International Journal of Public Health
ORIGINAL ARTICLE
published: 14 December 2022
doi: 10.3389/ijph.2022.1604721
The Need to Address Fragmentation
and Silos in Mortality Information
Systems: The Case of Ghana and Peru
Daniel Cobos Muñoz1,2*, Carmen Sant Fruchtman1,2, Janet Miki 3*, Javier Vargas-Herrera3,4,
Sarah Woode5, Fidelia A. A. Dake6, Benjamin Clapham3, Don De Savigny1,2,3 and
Emmanuel Botchway7
1Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland, 2Epidemiology and Public Health Department,
University of Basel, Basel, Switzerland, 3Vital Strategies, New York, NY, United States, 4Departamento de Medicina Preventiva,
National University of San Marcos, Lima, Peru, 5Ghana Statistical Service, Accra, Ghana, 6Regional Institute for Population
Studies, University of Ghana, Accra, Ghana, 7Birth and Death Registry, Accra, Ghana
Objectives: We aimed to understand the information architecture and degree of
integration of mortality surveillance systems in Ghana and Peru.
Methods: We conducted a cross-sectional study using a combination of document
review and unstructured interviews to describe and analyse the sub-systems collecting
Edited by:
Jean Tenena Coulibaly, mortality data.
Félix Houphouët-Boigny University,
Côte d’Ivoire Results: We identified 18 and 16 information subsystems with independent databases
Reviewed by: capturing death events in Peru and Ghana respectively. The mortality information
Esso Emmanuel, architecture was highly fragmented with a multiplicity of unconnected data silos and
Félix Houphouët-Boigny University,
Côte d’Ivoire with formal and informal data collection systems.
*Correspondence: Conclusion: Reliable and timely information about who dies where and from what
Daniel Cobos Muñoz
daniel.cobos@swisstph.ch underlying cause is essential to reporting progress on Sustainable Development Goals,
Janet Miki ensuring policies are responding to population health dynamics, and understanding the
chiaki.miki@gmail.com impact of threats and events like the COVID-19 pandemic. Integrating systems hosted in
Received: different parts of government remains a challenge for countries and limits the ability of23 December 2021
Accepted: 24 October 2022 statistics systems to produce accurate and timely information. Our study exposes multiple
Published: 14 December 2022 opportunities to improve the design of mortality surveillance systems by integrating existing
Citation: subsystems currently operating in silos.
Cobos Muñoz D, Sant Fruchtman C,
Miki J, Vargas-Herrera J, Woode S, Keywords: cause of death, mortality surveillance, civil registration and vital statistics, mortality statistics, process
Dake FAA, Clapham B, De Savigny D mapping, social network analysis
and Botchway E (2022) The Need to
Address Fragmentation and Silos in
Mortality Information Systems: The Abbreviations: BDR, Births and Deaths Registry; COD, Cause of death; RENIEC, Registro Nacional de Identificación y Estado
Case of Ghana and Peru. Civil; CRVS, Civil registration and vital statistics; LMIC, Low and middle-income countries; SINADEF, Sistema Informático
Int J Public Health 67:1604721. Nacional de Defunciones; BDR, Birth and Death Registry; INEI, Instituto Nacional de Estadística e Informática; SIS, Seguro
doi: 10.3389/ijph.2022.1604721 Integral de Salud; MINSA, Ministerio de Salud.
Int J Public Health | Owned by SSPH+ | Published by Frontiers 1 December 2022 | Volume 67 | Article 1604721
Cobos Muñoz et al. Data Silos in Mortality Systems
INTRODUCTION information [12, 13]. Preliminary results of this study were
describe elsewhere in the form of a working paper [14].
Since the start of the COVID-19 pandemic in the year 2020,
substantial attention has been put on the count of deaths to
understand how the pandemic is evolving [1]. Many countries are METHODS
struggling to produce reliable estimates of the number of deaths
and their causes at a pace that can inform policy decisions. This is We conducted a cross-sectional study designed to map and
partly because their mortality information is segregated across catalogue information sub-systems collecting mortality data in
health, civil registration, and other sectors, and data are Ghana and Peru. Subsystems were defined as institutions or
incomplete, and frequently classified as being of low quality [2, 3]. information systems that were recording any information
The majority of low and middle-income countries lack a about a death event, including the cause of death. Subsystems
comprehensive birth and deaths registration system, with only were identified and described using enterprise architecture
45 percent of global deaths registered in official registers [4]. process maps [15]. In these maps, the sequence of activities
Improvement over the years has been slow [5–7], partly because required in the process to record the fact or the cause of death
of the difficulty of working across administrative silos in in each of the systems is described alongside the stakeholders
government. Deaths and their details can be recorded in implementing them. They also captured the different documents
multiple formal and informal information subsystems, such as (forms, and records) used in each system to record information
national identity agencies, social security services, civil about the death event, as well as a list of the data elements (e.g.,
registration, health services, health and demographic name, age, sex, cause of death) captured in the different
surveillance sites, mortuaries, coronial and forensic services, documents. The landscape of mortality information
burial administrative systems, police, insurance systems, subsystems and their business and information architecture
funeral homes, or cemetery records. These subsystems are was documented through a systematic document review and
sitting in multiple ministries across the government or private unstructured interviews between September 2018 and
sector with traditional administrative boundaries forcing them to January 2019.
operate in silos. Some of the informal mortality surveillance sub-
systems, such as funeral homes, are not regulated or monitored in Study Settings
some countries and the data collected by then is not captured by Peru and Ghana represent different states of CRVS system
formal mortality surveillance systems. As a result of this maturity in two very different contexts (Table 1).
fragmentation, none of these subsystems has a full picture of Peru has a long history of CRVS improvements, resulting in a
the complete mortality statistics of the population in the country functional and strong CRVS system [16] with a high level of
since they capture information from different and partially decentralization. The civil registration agency (RENIEC from the
overlapping population groups. Subsystems concerned with acronym in Spanish) or the municipal offices operate local civil
legal identity, civil registration, or health data, for example, are registration offices. At the time of the study, there were 54 registry
supposed to be nested within civil registration and vital statistics offices, 171 auxiliary registry offices, and 4,881 municipal
information systems [8]. However, these systems are often registries. The majority of the offices register events and issue
disconnected and not integrated, which leads to certificates using an electronic system named SIRCM. The system
underperforming information flows and inefficiencies in data also has auxiliary registry offices in hospitals and health centres to
management [9, 10]. bring registration services closer to users of the health sector.
The need for accurate and timely data to inform the response Municipal registry offices are local government offices that
to the COVID-19 pandemic has driven countries to develop register vital events and issue certified copies of death
short-term solutions to capture overall and cause-specific registrations [17]. Death events are reported in the health
mortality [11]. It has also exposed data systems that could system through either “SINADEF” (electronic system)or using
serve as opportunities to estimate excess mortality and the paper version of the MCCD (60% of deaths using the paper
understand its trends over time. As a first step towards system) [18, 19].
integrating mortality data sources to build comprehensive Still considered a low performing CRVS system, Ghana is
mortality surveillance systems, cataloguing all potential currently conducting a large-scale reform of their CRVS system as
information sources and understanding how they interact or a result of a comprehensive assessment conducted in 2014 [20,
overlap with each other will be essential. To our knowledge, 21]. Ghana ’s 10 regions are divided into a total of 216 districts
this is one of the first studies to explore the potential of integrating with 426 functioning Birth and Death Registration (BDR) offices
these sources of recorded death information into the wider CRVS across the country.
system. In this paper, we aim to understand the information The share of births and deaths captured by the CRVS system in
architecture of the mortality surveillance system and its degree of Ghana is low [19, 22] despite the fact that the Registration of
integration in two diverse lower middle-income countries, Ghana Births and Deaths Act 301 (1965) dictates that all births, deaths,
and Peru, before the start of the COVID-19 pandemic. We use an and foetal deaths must be registered. There is a low coverage of
enterprise architecture and systems thinking approach to vital events registration owing to a high degree of complexity and
understand how these systems operate, what their information bureaucracy in the CRVS operations, insufficient awareness
requirements are, and the technology used to host their among the public on the importance of having timely and
Int J Public Health | Owned by SSPH+ | Published by Frontiers 2 December 2022 | Volume 67 | Article 1604721
Cobos Muñoz et al. Data Silos in Mortality Systems
TABLE 1 |General characteristics of the civil registration and vital statistics systems in Peru and Ghana. The need to address fragmentation and silos in mortality information
systems: The case of Ghana and Peru, 2019.
Indicator Peru Ghana
Total Population in the country (2017) 31.2 million 28.9 million
Birth registration completeness 95%a 65%
Death registration completeness 70%a 23%
Level of decentralization of the CRVS system Decentralized Decentralized
Leading CRVS institution Civil registration authority (RENIEC) Births and Deaths Registry
Most recent year with published vital statistics 2021 [51] N/A
National Identity coverage (%) 99.3%a N/A
ahttps://www.inei.gob.pe/media/principales_indicadores/libro_bol_esp_24_4.pdf and https://www.inei.gob.pe/estadisticas/indice-tematico/poblacion-y-vivienda/
TABLE 2 | Overview of the institutions and actors included in the data collection researcher and DCM a male researcher, both from the Swiss
activities in Ghana and Peru. The need to address fragmentation and silos in Tropical and Public Health Institute, supported data collection
mortality information systems: The case of Ghana and Peru, 2019. activities in Ghana. In Peru, JM a female project manager for Vital
Strategies working within the mortality reforms and JV a male
Visited organisation Location
researcher at the Universidad San Marcos, and also involved in
City Council Accra, Ghana the mortality surveillance reforms, led the data collection design
RIDGE Hospital Accra, Ghana and JM conducted all interviews and workshops.
Accident and Emergency Centre (Public hospital) Accra, Ghana Face to face unstructured interviews with personnel from
Korle Bu mortuary Accra, Ghana
Imam (religious leader) Accra, Ghana different institutions were conducted. Researchers’ interview
Orthodox church Accra, Ghana notes were typed and organised into summaries after each
Private cemetery Accra, Ghana interview. Detailed information about the institutions that
Public cemetery Accra, Ghana were visited for unstructured interviews and document review
Private funeral home Accra, Ghana
MINSA Hospital Lima, Peru is compiled in Table 2.
ESSALUD Hospital Lima, Peru The forms and registers used to record the deceased
Hospital de las Fuerzas Armadas y Policiales Lima, Peru information were identified and blank copies of the
Private Clinic Lima, Peru registration forms were collected, if available. The nature
RENIEC Lima, Peru of the documentation was recorded in a pre-defined data
Cemetery Lima, Peru
OGTI-MINSA Lima, Peru collection tool in Excel®. Briefly, we captured general
INEI Lima, Peru information about the sub-systems, the data elements
Centro de Salud San Pablo de Tushmo Ucayali, Peru collected in each form, as well as the sender and receiver
Municipalidad de centro poblado de San Jose Yarinacocha Ucayali, Peru of each piece of information. Information subsystems were
Rural municipality—burial site Ucayali, Peru catalogued into producers or consumers of vital
statistics information depending on their primary role in
the system. We also reviewed the specific data elements
that each of these forms were capturing and these were
reliable vital statistics, limited geographical access for rural categorized as essential or non-essential. Essential
communities, limited funding, scarce human resources, and mortality data elements were considered to be the
direct and indirect registration cost for the users of the following 12 elements: Full name, Sex, Marital Status,
system [19]. Date of birth, Date of death, Age at death, Cause of Death
(COD), Name of medical practitioner certifying COD, Date
Data Collection of COD, Date of registration, Registration District and
The researchers in each country identified relevant subsystems Registrar name.
for mortality information systems at the national and local levels
within their routine activities in the mortality information Data Analysis
system. A snowball sampling approach was used to identify Researchers’ written interview notes were typed and
further unofficial information systems. The lead researchers in organised into summaries of each interview and
each country arranged face-to-face visits to each identified workshop. We synthesized the information using several
institution to conduct unstructured interviews and collect systems thinking tools and approaches. We developed
relevant documents. Twenty-two interviews were conducted in process maps [23] in Bizagi Modeler [24] and used
total, of these nine took place in Ghana and 13 in Peru. The standard Business Process Mapping Notation 2.0 [25] to
document review included 22 documents and forms from Ghana visualize the flow of information across subsystems and
and 42 from Peru. In Ghana, EB, a male director of the Births and the sequence of activities implemented by each institution.
Deaths Registry and SW a female statistician within Ghana One country-specific map illustrated all subsystems and their
Statistical Service led the data collection. CSF a female interrelationships.
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Cobos Muñoz et al. Data Silos in Mortality Systems
TABLE 3 | Characteristics of the different entities identified as part of the mortality information sub-systems in Peru (Adapted from Cobos et al. [14]. The need to address
fragmentation and silos in mortality information systems: The case of Ghana and Peru, 2019.
System type Name Level Role in the systema
Health services ESSALUD facility Local Producer
Military Force facility Local Producer
Private clinic Local Producer
Public facility Local Producer
Ministry of Health (MINSA) National Consumer
Government administration Morgue Local Producer
RENIEC local office Local Producer
Municipality Local Consumer
Burial system Local Producer
National Statistics Office (INEI) National Consumer
Justice system National Consumer
Military force central office National Producer
Comprehensive Health Insurance (SIS) National Consumer
Peruvian Government National Consumer
National Civil Registration Authority (RENIEC) National Consumer
National social security system (ESSALUD) National Consumer
Family Local Producer and consumer
Funeral homes and Cemeteries Local Producer
aRoles in the subsystem refer to the primary function of the institution in the system. Producers are actors participating in the collection and transmission of information about the vital event
and/or the generation and dissemination of vital statistics. Consumers are those actors whose primary interest is the use of either individual level data or aggregated statistics about vital
events.
The flow of information among the various subsystems ecosystem. These nodes represent the national headquarters
were visualized in an adapted Social Network Analysis of the leading institutions in each of the sectors involved in
diagram [26]; specifically, a “Force-directed graph” [27] generating vital statistics (e.g., health, police or civil
visualization in Power BI was used. In this diagram, nodes registration authority) and there are no links showing
(circles) represent the information subsystems and the arrows information sharing among them.
shows the flow of information between them, showing the Information exchange and interactions among subsystems
direction of the exchange. The two visualizations, the country- were greater at the local level. Two main nodes integrating
specific process map and the force-directed graph, analysed information in the system were identified: the family and the
the degree of integration and interconnections in the network local civil registration office (RENIEC office).
of sub-systems as well as the flow of information The family of the deceased has the highest number of
through them. incoming and outgoing information links in Peru. Even
though there exist information sharing among health
facilities and registration offices, the process maps
RESULTS describing the sequence of activities in the system show that
the family are demanded to complete the different
In both Ghana and Peru, several information subsystems were administrative tasks in person by visiting the multiple
identified in which the details of deaths were recorded and not offices (see Figure 1). The local RENIEC office also
shared with other systems. In these fragmented information functions as a major integration hub, receiving information
constellations, families were the only common connection from public and private health facilities using SINADEF for
between several of these information systems, leading to an medically certified deaths and pushing the information to
administrative burden for the families. some of the other systems.
In terms of administrative documentation, a total of
Peru 42 documents recording information about the death event
Of the eighteen information subsystems identified in Peru were identified across institutions. 36 documents recorded
(Table 3). Nine of them were functioning at the local level information on individual death events and six transmitted or
and collecting data for each individual vital event. The other stored aggregated figures. Most of them were exclusively paper
nine were national institutions primarily transmitting and storing forms including different versions being used different
aggregate information. institutions.
Figure 1 shows the design of the mortality surveillance Of the essential and non-essential data elements, none of
system in Peru. Several subsystem nodes are located on the the 42 forms collected all 12 essential elements. The necropsy
edge of the network, receiving information but not sharing report from the morgue was the document with the highest
this with any other system, which exposes a substantial degree number of essential and non-essential data elements
of fragmentation in the overall mortality inforamtion captured (n = 32).
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Cobos Muñoz et al. Data Silos in Mortality Systems
FIGURE 1 | Information architecture in Peru. Each node represents an institution involved in recording or transmitting information about death events. The size of
the node represents the number of incoming interactions in the network. The arrows represent the direction of the information flow. Green arrows represent interaction at
the local level, while black arrows represent interaction among national institutions. The need to address fragmentation and silos in mortality information systems: The
case of Ghana and Peru, 2019.
TABLE 4 | Characteristics of the different entities identified as part of the mortality information sub-systems in Ghana Peru (Adapted from Cobos et al. [14]. The need to
address fragmentation and silos in mortality information systems: The case of Ghana and Peru, 2019.
System type Name Level Role in the systema
Health services Health Facility Local Producer
Coroner Local Producer
Mortuary Local Producer
Pathologist Local Producer
Ghana Health Services (GHS) National Consumer
Government administration Police Local Producer
Birth and Death Registration (BDR) local office Local Producer
Judiciary system National Consumer
BDR national National Consumer
Funeral homes and Cemeteries Funeral home Local Producer
Mosque, Imam, Church Local Producer
Family Family Local Consumer
aRoles in the subsystem refer to the primary function of the institution in the system. Producers are actors participating in the collection and transmission of information about the vital event
and/or the generation and dissemination of vital statistics. Consumers are those actors whose primary interest is the use of either individual level data or aggregated statistics about vital
events.
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Cobos Muñoz et al. Data Silos in Mortality Systems
FIGURE 2 | Information architecture in Ghana. Each node represents an institution involved in recording or transmitting information about death events. The size of
the node represents the number of incoming interactions in the network. The arrows represent the direction of the information flow. Green arrows represent interaction at
the local level, while black arrows represent interaction among national institutions. The need to address fragmentation and silos in mortality information systems: The
case of Ghana and Peru, 2019.
Ghana 22 forms and registers were identified as recording
In Ghana, 16 information subsystems were identified (Table 4), information about the death event. Most documents (n = 20)
being 13 of them local subsystems recording data of each were designed to capture information for each death event
death event and three national systems primarily collecting including some of them information about the cause of
aggregate information about deaths in the country. When death. 17 of these documents were paper forms, four were
visualizing the information architecture of the system in a digital system, and one was supported by both systems. As
(Figure 2), the family, which is represented in the central occurred in Peru’s administrative data, most forms did not
node, acts as the main hub of the information ecosystem include all essential elements required to register a death.
around mortality in Ghana. In order the achieve the The registration book from BDR was the document that
registration of the death event, the family would need to had the most essential elements (n = 11), and only lacked
interact with health facilities, funeral homes, police in the date of birth.
some instances, BDR offices and local government officials.
In the worst-case scenario, families would have to
interact with up to eight different systems before they can DISCUSSION
complete all administrative and other procedures.
The BDR national database only captured those deaths in Our study shows that the mortality information systems in Peru
which the family physically attended a BDR office to formally and Ghana are similarly highly fragmented across different
complete the registration process. As a consequence, deaths institutional silos and they are strongly dependent on families
occurred outside health facilities which typically are not to register the death event. The implications are considerable as
medically certified by a trained physician, health facilities this contributes to a lack of completeness and inequities in death
deaths for which the family did not pursue registration or registration. Wealthier citizens from urban areas with access to
death recorded in the judiciary or police system (deaths due to the health system will be more likely to register deaths, leading to
intentional or unintentional injuries) will not find their way into a misrepresentation of people’s needs in vital statistics, as has
the BDR database. On the other side, a death event could be been seen with birth registrations [28].
recorded in multiple systems leading to duplication and The country systems portrayed in this analysis—one being a
inefficiencies. relatively well-performing system and the other a less mature
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Cobos Muñoz et al. Data Silos in Mortality Systems
CRVS system—were highly fragmented with a multiplicity of as a major challenge for data quality in health information
unconnected data silos. Mortality information silos systems in LMICs [46]. Modern database technology offers a
represented the parallel operations of the different clear opportunity to integrate these different information systems
subsystems involved in the wider mortality surveillance in Ghana and Peru, given in the current digitization efforts in
ecosystem. At the same time, having multiple actors both countries. Nevertheless, technology alone, will not solve
collecting information about deaths and causes of death can these challenges. Reforms will be required to understand the root
be seen as an opportunity if integrated with the mainstream causes of the inefficiencies to redesign the systems and create
system. Religious institutions, cemeteries, or funeral homes more integrated and complete systems.
could play a significant role in capturing information about The integration of different information systems within CRVS
death events in countries where neither the civil registration systems will not only be a technical challenge but a systems one
nor the health sector has a complete record of all deaths. They [47]. However, the integration alone will not solve the challenge
represent untapped opportunities for integration towards of increasing the completeness of mortality statistics. We
more complete mortality surveillance systems. Examples of believe it will be essential for countries to combine
the integration of non-traditional sources of mortality interventions and system redesign. In a previous study, we
statistics have been reported for HIV or during crises [29–31]. identified several ways to mitigate this weakness [40]. By
Despite the global consensus on the importance of vital redesigning death registration to be proactive, decentralized, and
registration, the completeness of CRVS systems is a concern less bureaucratic, it was possible to increase death registration
for most LMICs [28, 32–34], especially for death registration. coverage in Ghana and Tanzania. Acknowledging the systemic
Information about causes of deaths, when available, is of low challenges to integration will be of great importance if countries
quality in many settings and limits its use for public health incorporate additional information sources, like verbal autopsy,
policymaking [35]. This has been demonstrated during the into the routine CRVS. Verbal autopsy is the main resource low-
COVID-19 pandemic. Timely and complete mortality data for income countries are using to bridge the data gaps in registration of
COVID-19 is vital for countries to plan and implement COVID- deaths and cause of death in communities, especially in rural
19 control strategies and plans and to understand the impact it is settings [48, 49]. This will be a great opportunity but also a
having on different populations [36], yet a lack of such data has challenge, as it will increase the complexity of the information
affected countries’ ability to contain and control the pandemic systems. In countries choosing to implement verbal autopsy to
[37]. Addressing this gap is essential for the social and economic serve CRVS purposes, the integration of information will be
development of every country [38, 39]. essential.
Two of the fundamental root causes of the low vital event This study also emphasizes the challenges of developing
registration completeness in CRVS systems of LMICs are omnibus CRVS implementation software [50]. In Peru and
inefficient CRVS operations and systems passively waiting for Ghana, the existence of a large variety of forms and different
the family to complete the different administrative processes to data elements that were collected across the subsystems would
register vital events [35, 40]. The lack of integration of these make it challenging to develop national standard processes. Peru
systems and their passivity, where the system relies on families to and Ghana are now in the process of redesigning their CRVS
physically visit a location several times to register a death, has systems, and as they do so, this study has shown they will need to
likely hampered efforts to improve CRVS as a whole. Even in reconsider the architecture of their information systems. Local
well-performing systems like the one in Peru, where the two main efforts to develop IT applications and tools could help producers
subsystems (health and civil registration) are digital and already and consumers to rethink the rationale behind the data that they
sharing some information, there is a need for the family to move currently collecting and the use of the best mortality data sources.
to the relevant offices to complete the administrative process [41, This could allow them to leverage existing resources and increase
42]. This leads to bottlenecks in improving the system, as the the quality and coverage of their systems.
responsibility for registering deaths partially remains on the
individuals and families, who may not be able to complete the Conclusion
process. For instance, during COVID-19, an inability for people As countries struggle to collect timely and reliable mortality
to travel to offices, as well as factors like shorter office hours or statistics to combat COVID-19, mortality surveillance systems
disruptions in rural outreach for registrations, were challenges in are proving to be a great ally, as well as a pending task in many
multiple countries [43]. countries. With this study, we aimed to bring some clarity into the
The lack of integration of the systems in Peru and Ghana could mortality information gap by mapping all the subsystems
lead to inefficiencies and could enable double-counting, recording deaths. The study makes the case for further
undercounting, or other inaccuracies and inconsistencies. research in other contexts to piece together a path towards
Based on our results, the details of one death would need to integrated and efficient mortality surveillance systems.
be recorded up to seven times in different systems capturing The study showed that none of the multiple sub-systems
different data elements. As a consequence, none of the systems collecting information about death events in Peru or Ghana
would have the complete information about the death event and could provide a complete picture of mortality statistics
would be impossible to identify discrepancies. This fragmentation nationwide or for the different population groups in the
and incompleteness have also been reported for road traffic country. The different sub-systems are recording death
deaths in Uganda [44], HIV patients in South Africa [45] and events in partially overlapping population groups and our
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Cobos Muñoz et al. Data Silos in Mortality Systems
analysis reveals that integration across the various information contributed to the design of the study. JM participated in the
sub-systems would increase death registration completeness. design and implementation of the data collection and helped in
Globally, death registration is severely lacking [4]. The use of the interpretation of the analysis results. EB and SW led data
systems thinking tools, such as process mapping, should be collection in Ghana. FAAD supported data collection in Ghana
employed as an initial step to elucidating the fragmentation and contributed to drafting this manuscript. All authors have
and opportunities for harmonization across mortality read and approved the final version of this manuscript.
registration systems and various stakeholders, as has been
demonstrated in this study. More integrated, efficient, and
complete mortality registration systems are needed in many FUNDING
countries and contexts, but in doing so, digitalization needs to
be carefully designed in order to avoid replicating inefficient This study was funded by the Bloomberg Data for Health
paper systems in digital format. Initiative.
DATA AVAILABILITY STATEMENT CONFLICT OF INTEREST
All the data used in this study are available from the authors upon The authors declare that they do not have any conflicts of interest.
reasonable request.
ACKNOWLEDGMENTS
AUTHOR CONTRIBUTIONS
The authors thank Births and Deaths Registry, Ghana and
DM and CF contributed to the design of the study, participated Registro Nacional de Identificación y Estado Civil in Peru for
in the data collection activities in Ghana, led part of the agreeing to conduct this research, as well as all other
analysis and led the drafting of this manuscript. DS and BC organizations that participated in data collection activities.
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