WHO’s excess Covid deaths and the need to invest in health information systems

The World Health Organization report on excess deaths from Covid-19 pegs deaths from India at 47 lakh, nine times more than the number reported in the country (4.8 lakh), between January 2020 and December 2021. In terms of sheer numbers, this is among the highest count of deaths not captured by the system; but as deaths in proportion to population (in 1,00,000) India is ranked in the early 30s.

What is the global death estimate?

The estimated global excess death toll is worryingly high, more than double the number reported to the WHO, at 14.9 million. Deaths reported to the WHO in the period stood at 5.4 million.

Podcast | Covid deaths: Why India must relook its numbers  Podcast | Covid deaths: Why India must relook its numbers  

How is excess mortality calculated?

Direct and indirect deaths from Covid-19 are categorised under excess mortality. In WHO’s words, “excess mortality is calculated as the difference between the number of deaths that have occurred and the number that would be expected in the absence of the pandemic based on data from earlier years.” It includes deaths associated with Covid-19 occurring indirectly - due to the pandemic’s impact on health systems and society.

For instance, those “attributable to other health conditions for which people were unable to access prevention and treatment because health systems were overburdened by the pandemic. The estimated number of excess deaths can be influenced also by deaths averted during the pandemic due to lower risks of certain events, like motor-vehicle accidents or occupational injuries,” the WHO explains.

Why is the Government of India contesting the report?

In the run-up to the report and after the final report was made public, the Indian government has been vocal in its objection to how the counting was undertaken. They have objected to the mathematical projections based on the Global Health Estimates (2019); they have objected to being categorised under tier 2 (where modelling was done due to inconsistent data from across the country), and they have protested the “one size fits all approach”. The Union Health Ministry maintains that the country’s Civil Registration System is robust and hass captured deaths from Covid-19.

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How have other countries fared when it comes to excess mortality?

Under-reporting of Covid-19 deaths has been quite universal, and public health experts say it is expected, given the unprecedented challenges of the time. At the WHO on briefing excess deaths, Stephen MacFeely (Director, Department of Data and Analytics) said that 6 out of 10 global deaths were unregistered, a telling number that underscores the need for countries to invest in health information systems. Over 80 per cent of the excess deaths are concentrated in South-East Asia, Europe, and the Americas. About 68 per cent of the excess deaths are concentrated in 10 countries.

Is there a takeaway for countries, including India, from this exercise?

The novel coronavirus was reported in China in November 2019 (some researchers suggest even earlier). The WHO called this a Public Health Emergency of International Concern in January 2020 – the WHO’s highest level of alarm that experts say should have come earlier, given reports of clusters of “pneumonia of unknown cause” from Wuhan, China. The world continues to live through the pandemic that followed, which leaves behind death and loss of livelihood in its aftermath.

This is not the last pandemic the world will see. So while India must record its reservations with the excess death study, it needs to look inwards at the absence of a system that captures not just deaths, but the public health reason behind the death, say veteran public health voices. This needs to be strengthened across all States, down to its remotest rural location. Multiple internal and external reports indicate that Covid-19 deaths are not captured fully. India needs to engage its best experts to identify the gaps and improve reporting of deaths, the medical cause behind them etc. This needs to be done in the interest of India’s public health, or else a valuable exercise will be lost in the din.

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