Weak death notification system

This theme relates to the perspective on how deaths are being notified. For deaths that occur outside health facilities, the nearest relatives or caretakers of the deceased are required by law to notify the authorities. This process triggers death documentation to the Tanzania Registration Insolvency and Trusteeship Agency (RITA) at the local level and puts a provision for issuing death certificates. However, many KI reported that the notification process does not take place in most rural areas. Most people who die are directly buried at home or on farms, contrary to designated burial areas which could have enforced the need for the notification process. If VA is conducted, they are often conducted weeks or months after the death has occurred and therefore responses to the VA interview may suffer recall bias and affect the overall quality of the VA document.

In most villages, the majority of the people die in their residences and are buried on farms or other rural dedicated properties/areas without formal notification to the responsible authorities. (CHW, Iringa Rural District)

Lengthy VA Questionnaire

This theme relates to perspectives on the length of VA questionnaire instruments. The length of time required to conduct a VA interview is among the barriers to the widespread implementation of VA in CRVS. About 67% of the KI were not happy with the length of the VA questionnaire or the time spent interviewing a single person. The VA implementation exercise in Iringa used the standard WHO 2016 VA questionnaire with 481 questions. MoH added 10 extra country-specific questions relating to health insurance coverage. This questionnaire was adapted and translated into Swahili to fit into the local context. An average of 45 min has been observed as required to administer one complete VA interview.

The VA interview guide is too long, sometimes it takes 1 hour to finish one interview (CHW, Iringa Municipal)

Poor data quality and inconsistent responses

This theme relates to the usage of VA data particularly in assigning the probable CoD. Despite built-in data quality control and question-by-question skip logic measures, some VA records were encountered with no or inconsistent responses. This includes, for example, missing age or unknown age information, inconsistent signs and symptoms for a given sex or age group and poor completion of the narrative section. Our results indicate that the inappropriate selection of interviewees may have contributed to this behaviour. This may happen when the family selects a respondent other than the designated one (a close relative who provided care to the deceased during the final days before death). CHWs noticed that some families selected a different person other than caretakers as they were expecting financial support from the interviewer or the government from the VA interview. Challenges were also observed when the caretaker was too old to recall important information which led to death.

Some of the local traditions do not allow women to speak on behalf of the family (National Task Force member).

These inefficiencies observed at a lower level compromise the quality of VA data.

Lack of clarity in the inclusion criteria

This theme relates to perspectives on who is supposed to be included in the VA interviews. It was not clear who should be included in the VA interviews. Either the residents of their locality or anyone buried in the locality. Furthermore, people who died at health facilities vs community. Notably, health facilities also report mortality statistics through routine health facility reporting channels. Reporting health facility deaths in the VA module could result in double counting in reports. In addition, different VA interviews provided contradicting information about the duration a person must reside in a specific location before their death to be considered a resident. The responses ranged from 3 months to 6 months.

Normally, we interview deaths that have occurred within the last one month. We allow the family to mourn for two weeks before we can engage for an interview. However, when we started this program, we were interviewing deaths that had occurred up to two months back (CHW, Iringa Municipal)

Poor commitment to roles and responsibilities

This theme relates to perspectives on the commitment of accountable personnel in VA implementation. Specific concerns regarding volunteering vs specific job accountability in VA implementation were raised by KI. Most positions, particularly VA interviewers (CHWs and Agricultural Officers), Ward Executive Officers (WEO) and other coordination positions, are often perceived as secondary commitments. In this perspective, several tasks are easily left behind or accumulated over time and result in attrition, where most of these positions pick other responsibilities and VA work remains undone.

This is an additional task that does not have any incentive, I have primary responsibilities which often require my immediate attention (WEO, Iringa Rural District)

Poor coordination

This theme relates to perspectives on the coordination of VA implementation. Documents review revealed different uncoordinated initiatives by the different stakeholders in the country including vertical programmes, government entities (the MoH, National Statistics Office, and the Registration Office) and local governments. The disconnection between death events, notification, registration, certification and ascertaining the COD. SAVVY implementation in Tanzania, Zambia and Malawi unanimously reported challenges stemming from poor coordination among public institutions. For instance, attempts to integrate VA data into routine CRVS were often unsuccessful due to a lack of interoperability among different national systems.

Poor financing mechanism

This theme relates to perspectives on finances in VA implementation. Some KI, mainly national task force members, expressed that poor financing mechanisms affect the efficiency of the VA interviews. During the VA implementation pretesting and demonstration phase, Tanzania commissioned pay for performance modality to incentivise and compensate for time effort. The approach was successful as more VAs were reached. However, the financial component relied on donor funds and, hence, was not sustainable. Furthermore, this modality motivated quantity but not quality. Interviewers were paid flat rates without considering transport costs and geographical coverage. When this modality was changed to a flat compensation within a defined period, other issues of quality and coordination arose. VA implementation in the Iringa suffers from low production of VA data as interviewers have not been receiving their tokens consistently. They tend to ignore reporting some of the deaths or visit the families of descendants until they have official duties in the area. This resulted in over 50% underreporting in most areas. Furthermore, limited resources for digital implementation such as poor internet connectivity and limited electricity to power digital devices also have been a barrier to VA implementation in LMICs.29

No or delayed feedback to VA implementers

This theme relates to perspectives on the dissemination of feedback to VA implementers. KI noted that the VA implementation lacked a feedback mechanism. Despite conducting event notifications for over a year, none had received feedback on their contribution. The KI and leaders of the local government authorities reported not having received any feedback on the number of VAs collected and analysis performed on the data. This means that they are hosting the VA exercise as couriers and thus unmotivated. Similar to many programmes at national levels or with global interest, little attention and resources are often put into disseminating results to local or to the ground where the data originate. Much of the focus and resources are narrowed and directed to influencing policies at the ministry or government level. It appears much easier logistically and financially to have one dissemination at the ministry level vs multiple dissemination at regions, councils or ward levels. In addition, the language starts to differ as you move down to different levels, and therefore this requires a different packaging or communication strategy.

We have been conducting VA interviews for years, but we have received no feedback or insights regarding the results of the analysis (CHW, Iringa MC)

Legislative procedures for death notification

The sustainable implementation of VA into routine CRVS requires proper governing structures and procedures. Without legislation, the VA will only be used as an ad hoc means. Countries should establish and supervise legislative procedures that bind the family members to report deaths to the relevant authorities. A CRVS legal framework should be established at the national level to bind coordination among responsible authorities. In Tanzania, the national VA programme is hosted by the MoH and has members from the National Bureau of Statistics, RITA, the President’s Office of Regional Administration, Local Government, and other stakeholders. However, there is no linkage between the implementation and data collection systems. To improve data efficiency and reduce data quality gaps, it is recommended that MoH and RITA should link their data systems and processes.

Stakeholder engagement

Stakeholder engagement is a cornerstone of quality VA data collection. It is observed that some families did not provide enough cooperation which eventually affected the quality of VA data. Most of the ongoing community engagements are limited to creating awareness, little attention is being paid to the feedback which has significant potential to create community ownership of the VA exercise. There is a need to conduct a thorough investigation using tailored approaches to engage communities with the intention of increasing awareness and acceptance of the unfamiliar nature of VA in the community.

Effective capacity building

Optimal VA questionnaire and quality control mechanism

The KI identified that the lengthy questionnaire is among the limitations of the current VA implementation. The questions should be reduced by removing questions that appeared repeated but asked differently. In addition, introduce a dynamic flow of questions to guide the VA interview administration. The MoH has emphasised the use of standard operating procedures and put emphasis on refresher training to continually support VA implementation at the ground level. Ultimately, this will contribute to reducing the duration of the VA interview and improve the overall VA implementation experience.

Sustainable financing mechanism

VA interviews are usually conducted by the CHWs who have other core responsibilities. The additional scope to conduct VA interviews needs to be financed. A healthy and sustainable approach would be to include the cost of VA interviews in local government financial plans. The KI also recommend the use of incentives such as support for children’s welfare, to attract communities to cooperate in VA interviews.

Integrating VA implementation in CRVS

Countries would need to design VA integration strategies and assess their impact on the overall CRVS to implement VA beyond research settings. Integration strategies should adopt an intersectoral approach, ensuring interoperability is at the forefront of considerations. There is considerable evidence that a few countries like Brazil,5 Uganda,23 Zambia24 and South Africa20 managed to integrate and use VA data into routine health systems.