A year since the deadly second wave of Covid-19 fuelled by the Delta variant swept through India and more than two years after the pandemic first broke out, its true toll in the country remains disputed. While the Ministry of Health and Family Welfare has defended the official count – 5,24,641 as on June 2 – the World Health Organization has said the real toll could be 10 times more.

The controversy over India’s Covid-19 toll has drawn attention to the country’s patchy mortality records. Even at the best of times, India only manages to capture 71% of deaths, according to the data from the fifth round of the National Family Health Survey for 2019-’21.

Further, deaths in India are not often medically certified, which is a process where a doctor fills out a detailed form to give cause-specific mortality of a dead person. Medical certification helps a country chart trends of diseases, assess burden, and plan public health policies.

In 2020, India certified only 22.5% of registered deaths, shows data from the Medical Certification of Cause of Death report, which is compiled and published by the Office of the Registrar General and Census Commissioner.

But one state remains an exception – Goa. Not only does the coastal state register 100% of its deaths, barring 2013 and 2015, when it certified 97.3% and 99.5% deaths respectively, it has managed to certify all registered deaths since 2011.

In 2020, it registered 14,601 deaths and had a medical certification of cause for each. Manipur, which certified 2,266 deaths, was the only other state to record 100% certification. Lakshadweep comes close with 99.7% of 342 deaths certified. Even states with better health infrastructure, such as Kerala, Tamil Nadu, Karnataka and Maharashtra, have less than 50% medical certification of deaths.

The roots of Goa’s records system can be traced back to when the state was under the colonial rule of Portugal that lasted until 1961.

How Goa does it

“Goa not only certifies, it also registers all deaths,” said Dr Madhu S G Ghodkirekar, Associate Professor in Forensic Medicine and Toxicology. According to Ghodkirekar, the colonial administration had made the registration of marriage, birth and death compulsory.

“It is a habit inculcated in people since then,” he said, adding that often, relatives would call the police or doctor if a family did not inform authorities of a death in the household.

Ghodkirekar said Goans require death certificates for inheritance procedures, insurance claims and social security, and the Christian-majority population is well educated about the importance of documentation.

Ajit Bacal, the sarpanch of Mandur village in north Goa, said churches, temples and burial grounds demand a cause of death certificate before they conduct the last rites. “The final rites will not be conducted without it,” said Bacal. “Even if a person dies in a house, a doctor is called to give the cause of death.”

This, perhaps, distinguishes Goa from other states where a crematorium may allow funeral rites in the absence of documents. Bacal said even the rural population is aware about the importance of a death certificate. “There is no money exchange at a crematorium or in church to avoid a death certificate,” said Bacal. “People themselves approach a doctor to certify death.”

How other states fare

Like Goa, the Union Territory of Daman and Diu too was under Portuguese rule till 1961 and death certification there hovers around 95%.

Union territories fare better than states when it comes to death certification. Lakshadweep, Manipur, most Union Territories have managed to medically certify more than 50% of recorded deaths. Andaman and Nicobar islands, Chandigarh, Dadra and Nagar Haveli, and Daman and Diu, Delhi, and Puducherry have more than 50% certification of deaths for the 2018-’20 period.

Tamil Nadu, Mizoram, Sikkim, and Maharashtra certify between 40-50% of registered deaths. The most populous state, Uttar Pradesh, certifies a mere 12.6% of its registered deaths, while Bihar accounts for the lowest – 3.4% of registered deaths in 2020 were certified, a decline from 5.1% in 2019.

In an email response to Scroll.in, Dr Prabhat Jha, Professor in Disease Control at the Dalla Lana School of Public Health in University of Toronto, said even the available data from the current Medical Certification of Cause of Death system is not “representative of the whole of India”.

“The MCCD [Medical Certification of Cause of Death] relies only on (data from) mostly urban hospitals in some states,” he wrote. “About 50% of all of India’s 10 million annual deaths continue to occur at home (more so in rural areas) where medical attention before death is not common.”

The Civil Registration System data from 2020, too, reflects these gaps in the medical certification of deaths. According to the report, of the total 81.2 lakh deaths registered that year, 36.5 lakh occurred in the absence of any medical attention. In 2019, 34.5% of the deaths took place in the absence of medical services.

Under the Registration of Births & Deaths Act, 1969, a medical practitioner must issue a cause of death certificate without charging any fees. On the ground, the practice varies since the fine for not filling out or refusing to fill out a certificate is just Rs 50 and no penal action is taken against doctors who do not certify deaths.

However, data from the 2020 Medical Certification of Cause of Death report showed that certification of the cause of death had increased to 54.6% for patients who died within a medical facility across India.

In some states and Union Territories, such as Arunachal Pradesh, Andaman and Nicobar islands, Dadra and Nagar Haveli and Daman and Diu, Goa, Lakshadweep, Manipur, Puducherry, and Tamil Nadu, all deaths that happened in a hospital were medically certified.

Crucial data, Covid-19 toll

Jha, in his email response, underlined that certifying deaths properly yields a minefield of data. “Accurate data on who dies from what helps identify new outbreaks/diseases (HIV, Ebola, COVID etc), monitors the success of existing control programs (such as child mortality reductions) and enables discovery of new risk factors,” he wrote.

According to Jha, who has also studied mortality in India during the pandemic and estimates a massive undercounting of Covid-19 deaths, the low tally is because of a poor registration process.

In its May 5 report estimating a massive undercounting of India’s Covid-19 death toll, the World Health Organization had slotted the country among tier-II nations, where data pertaining to deaths is not fully available and alternate sources have to be used to estimate mortality. The Indian government had faulted the methodology used by the WHO and also contested the tier-II label.

Jha said municipal corporations must make medical certification of the cause of death mandatory along with death certificates to increase the practice of certification.

“Various urban areas do not have requirements for a complete medically certified death certificate,” he said. In order to get a 100% coverage of medical certification of deaths, more deaths need to occur in hospitals instead of homes, he said. “This is still decades away,” Jha said.

Improving certification

While Goa has ensured 100% registration and certification of deaths, the state has had to work on improving the quality of the medical certification.

According to Dr Amit Dias, assistant professor, department of preventive medicine in Goa Medical College, said there have often been instances where the cause of death is incomplete or hastily written by doctors. At times, the handwriting is illegible.

“The [state] Directorate of Planning, Statistics, and Evaluation found it difficult to assess the correct cause of death due to incomplete information,” said Dias.

Y Durga Prasad, who served as Chief Registrar of Births and Deaths in Goa till May 31, also said that quality of medical certification of deaths was poor and in 2002, steps were taken to improve it.

According to Prasad, the directorate of planning, statistics and evaluation tied up with Goa Medical College to hold training workshops on medical certification for doctors.

Two forms, form 4 and form 4A, have to be filled up depending on whether a person died at a hospital, or outside. These forms seek details of the immediate cause of death, antecedent or underlying cause, and other medical conditions of the deceased.

Dias gave an example about the significance of the forms as well as in training doctors to fill them out properly. “If a person with cancer develops embolism and dies, the doctor has to mention this in detail. Else, actual disease trends may be missed,” he said.

Between 2002 to 2004, at least 750 doctors attached with the Goa Medical College and Directorate of Health Services were trained on how to fill form 4A and form 4. From 2004 till 2006, doctors with the Indian Medical Association, and homeopathic and ayurvedic doctors were trained as well.

Dias, who conducted these workshops, said that since citizens often consult ayurvedic and homeopathic doctors, training them became equally important. Between 2002 to 2015, 3,525 allopathic doctors, homeopaths and ayurvedic doctors in Goa have undergone training in certifying deaths, according to data shared by the Goa Medical College.

Post-2006, all interns who join hospitals after graduating, receive training in certifying deaths. Goa has only one medical college, making it easy to track interns. Now, every year, a fresh batch of interns is trained along with refresher workshops for doctors.

Goa’s data shows that currently, heart disease causes 35% deaths while 8.2% are due to respiratory failure. In 2020, 5.3% deaths were due to Covid-19.

According to the Medical Certification of Cause of Death report, Goa annually registers more than 13,000 deaths, which increased to 14,600 in 2020 during the pandemic. As of June 2, Goa had recorded a total of 3,832 deaths as a result of Covid-19.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.