A spate of deaths from “fever” and “unknown causes” tore through rural India in April and May, coinciding with India’s second Covid-19 wave, new official data show. While deaths from clinically diagnosed respiratory infections surged too, the spurt of undiagnosed deaths points to the scale of potential undercounting of Covid-19 deaths in India.

The latest data from the National Health Mission’s Health Management Information System show nearly 3,00,000 more deaths in May 2021 compared to May 2019, which is more than 2.5 times India’s official Covid-19 death count for the same period.

Estimating undercounting

India’s official Covid-19 death toll is widely regarded to be an underestimate of the real toll. For reasons that are partly institutional and partly particular to the pandemic, official statistics are missing many Covid-19 deaths.

To estimate the scale of excess mortality during the pandemic, journalists and researchers have turned to data from India’s Civil Registration System to calculate the difference between deaths from all causes registered in 2020 and 2021, and those registered in 2019 and other pre-pandemic years, IndiaSpend reported in June. However, the data is incomplete and limited to officially registered deaths. We have been piecing together the true picture from the limited states for which data are available.

One other official source of data could provide further clues. The National Health Mission’s Health Management Information System is an administrative portal that aggregates data from around 2,00,000 health facilities across the country.

These are predominantly public facilities in rural areas, but also include some private and urban facilities. The health facilities include sub-centres (serving 3,000-5,000 people), primary health centres (serving 20,000-30,000 people), community health centres (serving 80,000-1,20,000 people), sub-divisional hospitals and district hospitals.

Each facility is supposed to upload monthly data on over 500 indicators to the National Health Mission’s Health Management Information System portal. However, states function at different levels of ability to provide health services and collect data.

Bihar, for instance, recorded under 17,000 deaths in 2019, while the Civil Registration System, tasked with registering all births and deaths, estimates that nearly 7,00,000 people died in the state that year. States such as Kerala, Tamil Nadu, Maharashtra and Gujarat, which had fewer actual deaths in 2019 than Bihar, recorded many more deaths than Bihar in the Health Management Information System portal.

These numbers, moreover, are far from showing the full picture. In a “normal” pre-pandemic year, for instance 2019, the Health Management Information System registered around 26,40,000 deaths, or less than a third of all deaths that would have taken place in the country that year when checked against Civil Registration System estimates. This is because the National Health Mission typically misses most deaths in urban areas and in private hospitals, an official associated with the Health Management Information System told IndiaSpend.

Yet, these limited Health Management Information System data show a big increase in deaths recorded within the National Health Mission system in April and May.

Every month on average in 2019, these facilities reported 2,00,000-2,20,000 deaths from across the country. In April, this rose to over 3,10,000 deaths for the first time in recent recorded history. In May, the number of deaths shot up further to 5,11,000, over twice the usual monthly deaths of any recent month, a 175% increase compared to May 2020 and a 150% increase over May 2019.

2.5 times higher toll

The break-up of recorded deaths by cause could be of particular concern. Of the over 4,92,000 adult deaths recorded in May (excluding infant, child and maternal deaths), over 2,50,000 were from “causes not known”. The biggest increases over a similar period in pre-pandemic times were in deaths from “fever” and “respiratory diseases”.

“In the absence of other information, these deaths should all be considered as Covid-19 deaths, particularly in a month like May where we will not expect deaths from malaria or similar vector-borne diseases that present with a fever,” Yogesh Jain, a public health physician in rural Chhattisgarh, and one of the founding members of the Jan Swasthya Sahyog group, told IndiaSpend.

While the data in the National Health Mission’s Health Management Information System miss much of what goes on in private hospitals, they give an insight into many patients in rural areas for whom a local government facility would usually be the first port of call, T Sundararaman, former executive director of the National Health Systems Resource Centre, a technical assistance body under the National Health Mission, told IndiaSpend.

Data on deaths in the Health Management Information System database is captured not just through deaths that take place at these facilities, but also through the wide network of auxiliary nurse midwives, who gather information on deaths at the village level from the community they interact with, said Sundararaman.

Health Management Information System data is also at odds with the official death toll from Covid-19. In May alone, the National Health Mission system showed over 3,00,000 more deaths than in normal months (May 2019), which is 2.5 times the official Covid-19 death toll of 1,20,072 in May 2021.

The numbers also show a significant increase in maternal mortality in May, particularly from undefined or unknown causes. The Health Management Information System records nearly 3,000 maternal deaths in May this year, an over 82% increase over maternal deaths reported in May 2019.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.