A Sathasivayyar

Buddhipani Y Perera

C Banduthillake

EM Gunesekera

Rajitha L Jayasuriya

Samath D Dharmaratne

WAAP Fonseka

World Health Organization

Population Health Metrics

English

PubMed

Springer - Publisher Connector

COMMENTARY Open Access
Opportunities and challenges for verbal autopsy
in the national Death Registration System in Sri
Lanka: past and future
Samath D Dharmaratne1*, Rajitha L Jayasuriya1, Buddhipani Y Perera2, EM Gunesekera2 and A Sathasivayyar2
Commentary
Analyses of cause of death (COD) statistics are funda-
mental for monitoring the health situation of popula-
tions and for planning suitable interventions. The
accuracy of national COD statistics is important for reli-
ably prioritizing health problems in order to decide
upon interventions and for resource allocation. The
completeness of registration in the Death Registration
System (DRS), which is a major component of the Civil
Registration System (CRS) of Sri Lanka, is above 90%
[1]. However, the quality of COD statistics are deficient,
with 30% of deaths categorized as being due to “signs,
symptoms, and ill-defined causes” [2]. Deaths coded to
these categories are of little use for decision-making.
There is considerable potential for verbal autopsy to
complement the DRS to improve the quality of COD
statistics in Sri Lanka [3].
In Sri Lanka, once a death occurs, it has to be regis-
tered before the deceased can be cremated or buried.
For deaths that occur outside hospitals, the relatives of
the deceased notify the Death Registrar (DR). The
majority of these notifications will not have a medically-
determined COD, and the Death Registrar determines
this by interviewing the relatives regarding events pre-
ceding the death.
For deaths that occur in hospitals, a COD is declared
by the medical officer who attended the deceased by fil-
ing a Death Declaration Form (DDF). Except for “sud-
den deaths,” the COD for three out of four deaths that
occur outside a hospital is given by the Death Registrar.
Sudden deaths (which are a small proportion of total
deaths) that occur outside a hospital are attended by an
Inquirer into sudden death or by a court of law. The
majority of the Death Registrars are lay people with
minimal or no training in how to decide on the prob-
able COD. Deaths that occur outside a hospital, in the
majority of instances, do not have a death declaration
made by a medical officer (A.Sathasivayyar. Assistant
Registrar General of Sri Lanka. 3-11-2010 - personal
communication).
Several studies conducted in Sri Lanka [1,4], have
highlighted the biases that are present in the DRS. They
point out that only 30% to 40% of the registered deaths
occur in a government hospital and that 80% of the
registration and certification of deaths is done by non-
medical registrars. A study carried out in 1996 to assess
the quality and coverage of death certification found
that 15.5% of the medical officers misclassified the
underlying cause of death. The study also found that the
use of ill-defined terms (e.g., cardiovascular arrest) was
frequent (76.4%), as was the use of abbreviations leading
to misclassification (26.4%) [1].
The Verbal Autopsy Questionnaire (VAQ), introduced
into Sri Lanka in 2006, has several important limitations:
only a limited number of diseases are included that
encompass very broad categories, such as high blood
pressure, heart disease, diabetes, kidney disease, paraly-
sis, wheeze, any fever and cancer; symptoms asked
about are limited; and the ability of the Death Registrars
to identify the correct disease using this VAQ is also
limited.
Nonetheless, the introduction of a VAQ with the sup-
port of policymakers is an important step towards
improving the quality of cause of death data in Sri
Lanka. This not only has sensitized the government to
the technique of verbal autopsy but users (i.e., Death
Registrars) now accept it as an integral part of their
function in certifying deaths and as an important step
towards improving data quality. The difficult part of the
policy change, establishing the system and ensuring that
the Death Registrars accept it, has already been
achieved. What is now needed is to improve it: to
* Correspondence: samath20@gmail.com
1Department of Community Medicine, Faculty of Medicine, University of
Peradeniya, Sri Lanka
Full list of author information is available at the end of the article
Dharmaratne et al. Population Health Metrics 2011, 9:21
http://www.pophealthmetrics.com/content/9/1/21
© 2011 Dharmaratne et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
restructure and expand the VAQ to include additional
items to help the Death Registrars to arrive at a prob-
able COD using the VAQ.
The Standard VAQ developed by the World Health
Organization (WHO), which is also being used in a
number of other countries for improving COD statistics,
is being translated and validated for routine use in Sri
Lanka. This innovation, particularly if combined with
automated methods for diagnosing cause of death, has
the potential to substantially improve the quality and
timeliness of critical cause of death information for pol-
icy and planning in Sri Lanka.
Acknowledgements
The authors would like to thank the Registrar General and his staff who
helped in the data collection. We also acknowledge all the others who
helped us in numerous ways to make this study a success.
Author details
1Department of Community Medicine, Faculty of Medicine, University of
Peradeniya, Sri Lanka. 2Registrar General’s Department, Colombo, Sri Lanka.
Authors’ contributions
SDD planned the study and data collection, analyzed and interpreted the
data, and prepared the manuscript. RLJ helped in the data acquisition and
helped in the preparation of the manuscript. The other authors were
involved in acquisition of data and manuscript preparation.
Competing interests
The authors declare that they have no competing interests.
Received: 11 February 2011 Accepted: 1 August 2011
Published: 1 August 2011
References
1. Fonseka WAAP: A study in the quality and coverage of death registration
in a district of Sri Lanka. MD Thesis, Postgraduate Institute of Medicine,
University of Colombo, Sri Lanka; 1996.
2. Vital Statistics. Department of Census and Statistics, Colombo, Sri Lanka;
2010 [http://www.statistics.gov.lk/].
3. World Health Organization: Verbal Autopsy Standards: ascertaining and
attributing cause of death. Geneva, Switzerland: World Health
Organization; 2007.
4. Banduthillake C: Epidemiology of maternal mortality in Sri Lanka.
Postgraduate Institute of Medicine, University of Colombo, Sri Lanka; 1997.
doi:10.1186/1478-7954-9-21
Cite this article as: Dharmaratne et al.: Opportunities and challenges for
verbal autopsy in the national Death Registration System in Sri Lanka:
past and future. Population Health Metrics 2011 9:21.
Submit your next manuscript to BioMed Central
and take full advantage of: 
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at 
www.biomedcentral.com/submit
Dharmaratne et al. Population Health Metrics 2011, 9:21
http://www.pophealthmetrics.com/content/9/1/21
Page 2 of 2


Opportunities and challenges for verbal autopsy in the national Death Registration System in Sri Lanka: past and future

Crossref

COMMENTARY Open AccessOpportunities and challenges for verbal autopsyin the national Death Registration System in SriLanka: past and futureSamath D Dharmaratne1*, Rajitha L Jayasuriya1, Buddhipani Y Perera2, EM Gunesekera2 and A Sathasivayyar2CommentaryAnalyses of cause of death (COD) statistics are funda-mental for monitoring the health situation of popula-tions and for planning suitable interventions. Theaccuracy of national COD statistics is important for reli-ably prioritizing health problems in order to decideupon interventions and for resource allocation. Thecompleteness of registration in the Death RegistrationSystem (DRS), which is a major component of the CivilRegistration System (CRS) of Sri Lanka, is above 90%[1]. However, the quality of COD statistics are deficient,with 30% of deaths categorized as being due to “signs,symptoms, and ill-defined causes” [2]. Deaths coded tothese categories are of little use for decision-making.There is considerable potential for verbal autopsy tocomplement the DRS to improve the quality of CODstatistics in Sri Lanka [3].In Sri Lanka, once a death occurs, it has to be regis-tered before the deceased can be cremated or buried.For deaths that occur outside hospitals, the relatives ofthe deceased notify the Death Registrar (DR). Themajority of these notifications will not have a medically-determined COD, and the Death Registrar determinesthis by interviewing the relatives regarding events pre-ceding the death.For deaths that occur in hospitals, a COD is declaredby the medical officer who attended the deceased by fil-ing a Death Declaration Form (DDF). Except for “sud-den deaths,” the COD for three out of four deaths thatoccur outside a hospital is given by the Death Registrar.Sudden deaths (which are a small proportion of totaldeaths) that occur outside a hospital are attended by anInquirer into sudden death or by a court of law. Themajority of the Death Registrars are lay people withminimal or no training in how to decide on the prob-able COD. Deaths that occur outside a hospital, in themajority of instances, do not have a death declarationmade by a medical officer (A.Sathasivayyar. AssistantRegistrar General of Sri Lanka. 3-11-2010 - personalcommunication).Several studies conducted in Sri Lanka [1,4], havehighlighted the biases that are present in the DRS. Theypoint out that only 30% to 40% of the registered deathsoccur in a government hospital and that 80% of theregistration and certification of deaths is done by non-medical registrars. A study carried out in 1996 to assessthe quality and coverage of death certification foundthat 15.5% of the medical officers misclassified theunderlying cause of death. The study also found that theuse of ill-defined terms (e.g., cardiovascular arrest) wasfrequent (76.4%), as was the use of abbreviations leadingto misclassification (26.4%) [1].The Verbal Autopsy Questionnaire (VAQ), introducedinto Sri Lanka in 2006, has several important limitations:only a limited number of diseases are included thatencompass very broad categories, such as high bloodpressure, heart disease, diabetes, kidney disease, paraly-sis, wheeze, any fever and cancer; symptoms askedabout are limited; and the ability of the Death Registrarsto identify the correct disease using this VAQ is alsolimited.Nonetheless, the introduction of a VAQ with the sup-port of policymakers is an important step towardsimproving the quality of cause of death data in SriLanka. This not only has sensitized the government tothe technique of verbal autopsy but users (i.e., DeathRegistrars) now accept it as an integral part of theirfunction in certifying deaths and as an important steptowards improving data quality. The difficult part of thepolicy change, establishing the system and ensuring thatthe Death Registrars accept it, has already beenachieved. What is now needed is to improve it: to* Correspondence: samath20@gmail.com1Department of Community Medicine, Faculty of Medicine, University ofPeradeniya, Sri LankaFull list of author information is available at the end of the articleDharmaratne et al. Population Health Metrics 2011, 9:21http://www.pophealthmetrics.com/content/9/1/21© 2011 Dharmaratne et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.restructure and expand the VAQ to include additionalitems to help the Death Registrars to arrive at a prob-able COD using the VAQ.The Standard VAQ developed by the World HealthOrganization (WHO), which is also being used in anumber of other countries for improving COD statistics,is being translated and validated for routine use in SriLanka. This innovation, particularly if combined withautomated methods for diagnosing cause of death, hasthe potential to substantially improve the quality andtimeliness of critical cause of death information for pol-icy and planning in Sri Lanka.AcknowledgementsThe authors would like to thank the Registrar General and his staff whohelped in the data collection. We also acknowledge all the others whohelped us in numerous ways to make this study a success.Author details1Department of Community Medicine, Faculty of Medicine, University ofPeradeniya, Sri Lanka. 2Registrar General’s Department, Colombo, Sri Lanka.Authors’ contributionsSDD planned the study and data collection, analyzed and interpreted thedata, and prepared the manuscript. RLJ helped in the data acquisition andhelped in the preparation of the manuscript. The other authors wereinvolved in acquisition of data and manuscript preparation.Competing interestsThe authors declare that they have no competing interests.Received: 11 February 2011 Accepted: 1 August 2011Published: 1 August 2011References1. Fonseka WAAP: A study in the quality and coverage of death registrationin a district of Sri Lanka. MD Thesis, Postgraduate Institute of Medicine,University of Colombo, Sri Lanka; 1996.2. Vital Statistics. Department of Census and Statistics, Colombo, Sri Lanka;2010 [http://www.statistics.gov.lk/].3. World Health Organization: Verbal Autopsy Standards: ascertaining andattributing cause of death. Geneva, Switzerland: World HealthOrganization; 2007.4. Banduthillake C: Epidemiology of maternal mortality in Sri Lanka.Postgraduate Institute of Medicine, University of Colombo, Sri Lanka; 1997.doi:10.1186/1478-7954-9-21Cite this article as: Dharmaratne et al.: Opportunities and challenges forverbal autopsy in the national Death Registration System in Sri Lanka:past and future. Population Health Metrics 2011 9:21.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDharmaratne et al. Population Health Metrics 2011, 9:21http://www.pophealthmetrics.com/content/9/1/21Page 2 of 2

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Opportunities and challenges for verbal autopsy in the national Death Registration System in Sri Lanka: past and future

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