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Institute for International Programs

Countrywide Mortality Surveillance for Action (COMSA) in Mozambique

The Countrywide Mortality Surveillance for Action (COMSA) – Mozambique aims to improve the lives of Mozambicans by producing and making available publicly continuous annual data on mortality and cause of death at national and subnational levels for use by the government and stakeholders in health programs, policy decision-making, and resource allocation. Mozambique is one of the few countries in sub-Sahara Africa that has met the Millennium Development Goal four by reducing its -under-five mortality (U5MR) by over two-thirds by 2015. Under-five mortality was estimated at 79 deaths per 1000 in 2015. Reaching the newly set target under the Sustainable Development Goals (SDG) of U5MR at least as low as 25 by 2030 will require greater efforts in health program strategies but also precise, accurate and timely measurement of mortality and cause of death to inform these programs. Similar to most low-income countries, Mozambique does not currently have a functioning CRVS system that is able to produce complete and high-quality mortality for monitoring recent trends in mortality and cause of death. Mozambique currently relies on national household surveys such as the Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS) to measure mortality but these sources are not able to generate recent and timely mortality data. For example, in DHS and MICS, child mortality estimates are calculated on the past five years preceding the survey for national level estimates and on the past ten years for provincial level estimates. These rates are not reflective of recent program implementation effects. Furthermore, the surveys do not produce estimate below provincial levels. Innovative approaches are urgently needed to support countries to effectively monitor levels and trends in mortality as well as cause of death.

The COMSA investment aims to address these measurement and monitoring challenges by supporting the government of Mozambique to develop and implement a sample registration system (SRS) of births and deaths, with cause of death assessment in the total population using verbal autopsy. The project puts a particular emphasis on cause of death in children under-five through a link to the Child Health and Mortality Prevention (CHAMPS) that uses an innovative approach of cause of death determination that relies on minimally invasive tissue sampling (MITS) and testing. Over a period of three years, COMSA will achieve four primary outcomes: (1) A sustainable and country owned sample registration system (SRS) for mortality and cause of death surveillance enabling national and subnational comparison leading to action, (2) improvements in measurement of causes of death among children under-five through link with CHAMPS permitting the use of the pairs of VA and MITS results for validation of VA results and prediction of MITS based on VA in areas where MITS data are not available, (3) annual national and subnational mortality and cause-specific rates generated using directly the SRS data but also through sound statistical modelling, combining data from the SRS, the MITS and other available national surveys such as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Survey (MICS), leading to production of distribution of mortality burden that is used for action, (4) a sustainable system for mortality and cause of death data collection, analysis and use in place in Mozambique by the end of the three-year project, owned and run by the government, generating frequent national and subnational mortality and cause specific rates that responds to government’s and partners’ needs for program, policy planning, and resource allocation.

Partnership with government and in-country institution

COMSA is implemented through collaboration between the Institute for International Programs (IIP) and Mozambique government through the National Institute of Statistics, the National Institute of Health, the Ministry of Health, and the Ministry of Justice. The National Institute of Statistics is leading the execution of the project with technical and managerial assistance from the National Institute of Health. The project collaborates closely with the CHAMPS project implemented by the Center for Health Research of Manhica. A National Advisory Group is formed to advise on designs, link with other government initiatives and data use.  

Overall design, sample size and implementation strategy

IIP works directly with the National Institute of Statistics (INE) and the National Institute of Health to setup a representative nationwide sample of clusters for routine surveillance of pregnancies, birth outcomes (pregnancy loss, stillbirth, births) and deaths. All deaths, including stillbirths, are followed-up for verbal autopsy data collection.  The sample is stratified by province to allow production of mortality and cause of death estimates at provincial level and their comparison across provinces. In total, the SRS sample include 700 clusters with approximately 300 households each. This sample represents approximately 210,000 households, a population of 923, 000 and is estimated to achieve total annual under-five deaths of 2649, 1805 infant deaths and 9230 total deaths. Community Surveillance Assistants (CSAs) are recruited, trained, and deployed in each cluster to report all events on a continuous basis. The CSAs are identified by their communities themselves. Coordinators are trained and stationed in each province along with two to three verbal autopsy data collectors who will be on call to collect verbal data as deaths occur. Furthermore, we collaborate with the CHAMPS site at Manhica that will be responsible for carrying out MITS on selected deaths occurring at selected sites identified jointly with the COMSA team.  The Central and General hospitals in Zambesia are being considered to serve as COMSA-MITS site.  A total of 200 under-five deaths will be identified in these hospitals for the MITS. VA data will also be collected on these deaths. COMSA is being implemented in two phases.  Phase I starts in five Northern provinces (Zambezia, Tete, Cabo Delgado, Nampula and Sofala). At the end of the first year, the remaining six provinces will start implementation.

Data collection and analysis

The CSAs will work community key informants to identify vital events (pregnancies, births outcomes and deaths) on a continuous basis. Deaths identified will be notified to the VA data collectors who will follow-up for VA interviews. The CSAs will also help their community members in registering births and deaths at the local registrar office. They will notify the registrar office of these events. An electronic rapid data collection system will be established to allow CSAs to directly collect and upload data to a cloud-based server using pre-programmed smartphones. Similarly, verbal autopsy data collected will be uploaded to the server. These data will be accessible to project investigators for review, processing, and feedback. Analysis and summary of these data will be carried out on an on-going basis and released on a web-based server accessible to larger public. Link will also be made with the DHIS 2.

The COMSA SRS data will be used to calculate birth and mortality rates at national and provincial levels on annual basis. Recent annual neonatal, post-neonatal, infant and under-five mortality rates will be produced to allow progress assessment toward SDG 3.2. Data from verbal autopsy and MITS will be used to generate cause of death fraction and rates at national and subnational level. In addition to direct empirical estimates, we will combine COMSA and MITS data with other existing data such as the DHS, MICS and census in a Bayesian statistical modelling to derive robust national and subnational mortality and cause specific rates. MITS data will be used to validate and improve the accuracy of verbal autopsy cause attribution, thus allowing generation of better national and subnational cause of death data. A statistical tool will be developed to allow the country to carry out simple and complex analysis themselves, obtain and interpret the results.

Policy translation, sustainability, and government ownership

COMSA project is being implemented with sustainability, demand of data and data use strategy. This builds IIP’s existing strategy currently implemented under the National Evaluation Platform (NEP) with strong collaboration with the Ministry of Health (MOH) and the National Institute of Health. The government of Mozambique, through the MOH, National Institute of Statistics, and the National Institute of Health and the department of CRVS are engaged from the outset and lead the implementation of various components of the project. A national advisory committee is being setup and led by the Ministry of Health and the National Institute of Statistics. A continuous consultation process is established with the government to understand how to present the data, what relevant questions arising are and what types of analyses are most relevant for them. The COMSA data will be input in national systems such as the DHIS 2 and the NEP database. Data and analysis generated by the COMSA will be continuously uploaded on the project’s website as data become available, with open access. As the end of three-year implementation, it is expected that the government institutions involved will be capacitated to take over the continuous running of the system.

Funding

Bill & Melinda Gates Foundation

Investigators