Regulation of Electronic Cigarette Use in Public and Private Areas in 48 Countries Within the WHO European Region: A Survey to In-country Informants

BackgroundThe objective of this study is to describe the legislation regulating the use of electronic cigarettes (e-cigarettes) in various places in European countries.MethodsA survey among experts from all countries of the World Health Organization (WHO) European Region was conducted in 2018. We collected and described data on legislation regulating e-cigarette use indoors and outdoors in public and private places, the level of difficulties in adopting the legislation, and the public support and compliance. Factors associated with the legislation adoption were identified with Poisson and linear regression analyses.ResultsOut of 48 countries, 58.3% had legislation on e-cigarette use at the national level. Education facilities were the most regulated place (58.3% of countries), while private areas (eg, homes, cars) were the least regulated ones (39.6%). A third of countries regulated e-cigarette use indoors. Difficulty and support in adopting the national legislation and its compliance were all at a moderate level. Countries’ smoking prevalence and income levels were linked to legislation adoption.ConclusionsAlthough most WHO European Region countries had introduced e-cigarette use legislation at the national level, only a few of the legislation protect bystanders in indoor settings.Key words: e-cigarettes, ENDS/ENNDS, secondhand exposure, legislation, FCTC     

Reaching the global tuberculosis control targets in the Western Pacific Region

PROBLEM: In 1999, a tuberculosis (TB) crisis was declared in the Western Pacific Region. APPROACH: In response, WHO established the Stop TB Special Project, which sought to halve 2000 levels of TB prevalence and mortality by 2010 through first reaching the global 2005 TB targets. LOCAL SETTING: Particular issues in the region were low political commitment, inadequate numbers of staff (particularly of adequately trained staff) and a wide variation in TB burden between countries. RELEVANT CHANGES: WHOs leadership (especially the commitment of its Regional Director) and building of regional and national partnerships strengthened political and donor commitment. This accelerated the implementation of regional and national TB control plans, allowing the region to reach the 2005 targets for TB control. LESSONS LEARNED: The experience in the Western Pacific Region demonstrated that WHOs leadership was pivotal in generating the political commitment necessary to accelerate actions on the ground. The regions investment in building partnerships and a motivated workforce was an important contribution towards achieving the 2005 global TB targets.     

Waiting for common-law solutions for the most vulnerable populations’ healthcare access

Background

The state of populations’ health is linked to their access to quality healthcare. Best achieving this primary condition – a health, social and humanitarian condition – is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited.

Coordination as a best practice from the polio eradication initiative: Experiences from five member states in the African region of the World Health Organization

BackgroundAs part of the efforts to eradicate polioviruses in the African Region, structures were put in place to ensure coordinated mobilization and deployment of resources within the framework of the global polio eradication initiative (PEI). The successes of these structures made them not only attractive to other public health interventions, but also caused them to be deployed to the response efforts of other diseases interventions, without any systematic documentation. This article documents the contributions of PEI coordination units to other public health interventions in the African Region of World Health OrganizationMethodsWe reviewed the contributions of PEI coordination units to other public health interventions in five countries in the African Region.ResultsThe analysis identified significant involvement of PEI coordination structures in the implementation of routine immunization programs in all the countries analyzed. Similarly, maternal and child health programs were planned, implemented, monitored and evaluation the Inter-Agency Coordination Committees of the PEI programs in the different countries. The hubs system used in PEI in Chad facilitated the efficient coordination of resources for immunization and other public health interventions in Chad. Similarly, in the Democratic Republic of Congo PEI led coordination activities benefited other public health programs like disease control and the national nutrition program, the national malaria control program, and the tuberculosis control program. In Nigeria, the polio Expert Review Committee effectively deployed the Emergency Operation Center for the implementation of prioritized strategies and activities of the National Polio Eradication Emergency Plan, and it was utilized in the response to Ebola Virus Disease outbreak in the country.ConclusionsThe PEI-led coordination systems are thus recognized as having made significant contribution to the coordination and delivery of other public health interventions in the African Region.     

Implementation of tuberculosis preventive treatment among people living with HIV,South Sudan

ObjectiveTo describe an intervention to scale up tuberculosis preventive treatment for people living with human immunodeficiency virus (HIV) in South Sudan, 2017–2020.MethodsStaff of the health ministry and United States President’s Emergency Plan for AIDS Relief designed an intervention targeting the estimated 30 400 people living with HIV on antiretroviral therapy across South Sudan. The intervention comprised: (i) developing sensitization and operational guidance for clinicians to put tuberculosis preventive treatment delivery into clinical practice; (ii) disseminating monitoring and evaluation tools to document scale-up; (iii) implementing a programmatic pilot of tuberculosis preventive treatment; and (iv) identifying a mechanism for procurement and delivery of isoniazid to facilities dispensing tuberculosis preventive treatment. Staff aggregated routine programme data from facility registers on the numbers of people living with HIV who started on tuberculosis preventive treatment across all clinical sites providing this treatment during July 2019–March 2020.FindingsTuberculosis preventive treatment was implemented in 13 HIV treatment sites during July–October 2019, then in 26 sites during November 2019–March 2020. During July 2019–March 2020, 6503 people living with HIV started tuberculosis preventive treatment.ConclusionLessons for other low-resource settings may include supplementing national guidelines with health ministry directives, clinician guidance and training, and an implementation pilot. A cadre of field supervisors can rapidly disseminate a standardized approach to implementation and monitoring of tuberculosis preventive treatment, and this approach can be used to strengthen other tuberculosis–HIV services. Procuring a reliable and steady supply of tuberculosis preventive treatment medication is crucial.     

Development of a road map to scale up the uptake and utilization of influenza vaccine in 22 countries of Eastern Mediterranean Region

BackgroundThe aim of this project was to develop a road map to support countries in Eastern Mediterranean Region in developing and implementing evidence-based seasonal influenza vaccination policy, strengthen influenza vaccination delivery program and address vaccine misperceptions and hesitancy.MethodsThe road map was developed through consultative meetings with countries’ focal points, review of relevant literature and policy documents and analysis of WHO/UNICEF Joint Reporting Form on immunization ((JRF 2015–2020) data. Countries were categorised into three groups, based on the existence of influenza vaccination policy and national regulatory authority, availability of influenza vaccine in the country and number of influenza vaccine doses distributed/ 1000 population. The final road map was shared with representatives of all countries in Eastern Mediterranean Region and other stakeholders during a meeting in September 2021.ResultThe goal for next 5 years is to increase access to and use of utilization of seasonal influenza vaccine in Eastern Mediterranean Region to reduce influenza-associated morbidity and mortality among priority groups for vaccination. Countries in the Eastern Mediterranean Region are at different stages of implementation of the influenza vaccination program, so activities are planned under four strategic priority areas based on current situations in countries. The consultative body recommended that some countries should establish a new seasonal influenza vaccination programme and ensure the availability of vaccines, while other countries need to reduce vaccine hesitancy and enhance current seasonal influenza vaccination coverage, particularly in all high-risk groups. Countries are also encouraged to leverage COVID-19 adult vaccination programs to improve seasonal influenza vaccine uptake.ConclusionThis road map was developed through a consultative process to scale up the uptake and utilization of influenza vaccine in all countries of Eastern Mediterranean Region. The road map proposes activities that should be adopted in the local context to develop/ update national policies and programs.     

Implementation of WHO Recommended Policies and Interventions on Healthy Diet in the Countries of the Eastern Mediterranean Region: From Policy to Action

Non-communicable diseases (NCDs) are responsible for almost two-thirds of the deaths in the 22 countries and territories of the WHO Eastern Mediterranean Region and unhealthy diets are a major contributor. Prevalence of overweight and obesity has increased among adults, adolescents and older children in recent decades. Among countries with the highest prevalence there are signs that the increase is slowing down or even that prevalence is declining. There has been no increase in the prevalence rate in younger children, although the absolute number of children under five years affected by overweight has increased. This review summarizes prevalence data and examines current implementation of regulatory, fiscal and voluntary measures to promote healthy diet across the Region. The last decade has seen a step up in such action. Ten of the Region’s countries have policies relating to trans-fatty acids and they are increasingly implementing specific regulatory measures. Thirteen countries had fully or partially implemented national salt reduction policies by 2019. Only four countries had adopted policies relating to aspects of marketing food to children by 2019, and concrete action in this area is still lacking. Eight countries have introduced taxes—sometimes at a rate of 50%—on carbonated or sugar-sweetened beverages. In order to meet the agreed global and regional goals relating to nutrition and diet-related NCDs, countries will need to build on this progress and scale up action across the Region while intensifying efforts in areas where concrete action is lacking.     

Improving the estimation of the tuberculosis burden in India

Although India is considered to be the country with the greatest tuberculosis burden, estimates of the disease’s incidence, prevalence and mortality in India rely on sparse data with substantial uncertainty. The relevant available data are less reliable than those from countries that have recently improved systems for case reporting or recently invested in national surveys of tuberculosis prevalence. We explored ways to improve the estimation of the tuberculosis burden in India. We focused on case notification data – among the most reliable data available – and ways to investigate the associated level of underreporting, as well as the need for a national tuberculosis prevalence survey. We discuss several recent developments – i.e. changes in national policies relating to tuberculosis, World Health Organization guidelines for the investigation of the disease, and a rapid diagnostic test – that should improve data collection for the estimation of the tuberculosis burden in India and elsewhere. We recommend the implementation of an inventory study in India to assess the underreporting of tuberculosis cases, as well as a national survey of tuberculosis prevalence. A national assessment of drug resistance in Indian strains of Mycobacterium tuberculosis should also be considered. The results of such studies will be vital for the accurate monitoring of tuberculosis control efforts in India and globally.     

Salt Reduction Initiatives in the Eastern Mediterranean Region and Evaluation of Progress towards the 2025 Global Target: A Systematic Review

This study aims at identifying national salt reduction initiatives in countries of the Eastern Mediterranean Region and describing their progress towards the global salt reduction target. A systematic review of published and grey literature was conducted. Key characteristics of strategies were extracted and classified according to a pre-defined framework: salt intake assessments; leadership and strategic approach; implementation strategies; monitoring and evaluation of program impact. Salt intake levels were estimated in 15 out of the 22 countries (68%), while national salt reduction initiatives were identified in 13 (59%). The majority of countries were found to implement multifaceted reduction interventions, characterized by a combination of two or more implementation strategies. The least common implementation strategy was taxation, while the most common was reformulation (100%), followed by consumer education (77%), initiatives in specific settings (54%), and front of pack labelling (46%). Monitoring activities were conducted by few countries (27%), while impact evaluations were lacking. Despite the ongoing salt reduction efforts in several countries of the region, more action is needed to initiate reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluations of ongoing programs. Such efforts are vital for the achievement of the targeted 30% reduction in salt intake.     

A mapping and synthesis of tools for stakeholder and community engagement in quality improvement initiatives for reproductive,maternal, newborn,child and adolescent health

BackgroundStakeholder and community engagement promotes collaboration and gives service users an opportunity to actively participate in the care they receive. Recognizing this potential, The Network for Improving Quality of Care for maternal, newborn and child health aimed to identify tools and operational guidance to integrate stakeholder and community engagement into quality improvement (QI) implementation.MethodsA mapping, consisting of a literature review and an open call through email and listservers, for implementation tools was conducted. Materials were included if they provided guidance on stakeholder and community engagement aligned to the Network''s QI framework comprising seven phases. Screening of tools was done by two reviewers.ResultsThe literature search and the call for tools returned 197 documents with 70 tools included after screening. Most included tools (70%) were published after 2010. International organizations were the most frequently cited authors of tools. Only 15 tools covered all seven phases of the QI framework; few tools covered the more ‘technical’ phase of the QI framework: adapting standards and refining strategies.ConclusionThe quantity of tools and their varied characteristics including types of stakeholder and community engagement processes across the QI framework confirms that engagement cannot be captured in a ‘one‐size‐fits‐all’ formula. Many tools were designed with a generic focus to allow for adaption and use in different settings and sectors. Country programmes looking to strengthen engagement approaches can take advantage of available tools through an online portal on the WHO website and adapt them to meet their specific needs and context.Public InvolvementProgramme implementers provided tools and resources during data collection.     

The WHO Tailoring Immunization Programmes (TIP) approach: Review of implementation to date

IntroductionThe WHO Regional Office for Europe developed the Guide to tailoring immunization programmes (TIP), offering countries a process through which to diagnose barriers and motivators to vaccination in susceptible low vaccination coverage and design tailored interventions. A review of TIP implementation was conducted in the European Region.Material and methodsThe review was conducted during June to December 2016 by an external review committee and was based on visits in Bulgaria, Lithuania, Sweden and the United Kingdom that had conducted a TIP project; review of national and regional TIP documents and an online survey of the Member States in the WHO European Region that had not conducted a TIP project. A review committee workshop was held to formulate conclusions and recommendations.ResultsThe review found the most commonly cited strengths of the TIP approach to be the social science research as well as the interdisciplinary approach and community engagement, enhancing the ability of programmes to “listen” and learn, to gain an understanding of community and individual perspectives. National immunization managers in the Region are generally aware that TIP exists and that there is strong demand for the type of research it addresses. Further work is needed to assist countries move towards implementable strategies based on the TIP findings, supported by an emphasis on enhanced local ownership; integrated diagnostic and intervention design; and follow-up meetings, advocacy and incentives for decision-makers to implement and invest in strategies.ConclusionsUnderstanding the perspectives of susceptible and low-coverage populations is crucial to improving immunization programmes. TIP provides a framework that facilitated this in four countries. In the future, the purpose of TIP should go beyond identification of susceptible groups and diagnosis of challenges and ensure a stronger focus on the design of strategies and appropriate and effective interventions to ensure long-term change.     

Informing evidence-based policies for ageing and health in Ghana

ProblemGhana’s population is ageing. In 2011, the Government of Ghana requested technical support from the World Health Organization (WHO) to help revise national policies on ageing and health.ApproachWe applied WHO’s knowledge translation framework on ageing and health to assist evidence based policy-making in Ghana. First, we defined priority problems and health system responses by performing a country assessment of epidemiologic data, policy review, site visits and interviews of key informants. Second, we gathered evidence on effective health systems interventions in low- middle- and high-income countries. Third, key stakeholders were engaged in a policy dialogue. Fourth, policy briefs were developed and presented to the Ghana Health Services.

Local setting

Ghana has a well-structured health system that can adapt to meet the health care needs of older people.

Relevant changes

Six problems were selected as priorities, however after the policy dialogue, only five were agreed as priorities by the stakeholders. The key stakeholders drafted evidence-based policy recommendations that were used to develop policy briefs. The briefs were presented to the Ghana Health Service in 2014.

Lessons learnt

The framework can be used to build local capacity on evidence-informed policy-making. However, knowledge translation tools need further development to be used in low-income countries and in the field of ageing. The terms and language of the tools need to be adapted to local contexts. Evidence for health system interventions on ageing populations is very limited, particularly for low- and middle-income settings.     

Strengthening national laboratory health systems in the Caribbean region

Abstract

The President's Emergency Plan for AIDS Relief (PEPFAR) programme for the Caribbean Region was established in 2008 to address health system challenges, including fragile laboratory services and systems. The laboratory component of this programme consisted of several phases: assessment of laboratory needs of all 12 countries engaged in the programme; addressing gaps identified during the assessment; and monitoring and evaluation of the progress achieved. After one year of PEPFAR collaboration with national governments and other partners, laboratory services and systems greatly improved. Some of the milestones include: (1) the accreditation of a public laboratory; (2) improved access to HIV diagnosis with faster turnaround time; (3) establishment of capacity for platforms for DNA PCR, viral load and HIV drug resistance; (4) development of the laboratory workforce; and (5) establishment of a framework for implementation of sustainable quality management systems for laboratory accreditation. The progress recorded in strengthening laboratory health systems after one year of initiating this collaboration shows that with a rigorous initial assessment, programme design and intervention and strategic partnership, national laboratory health systems can be greatly enhanced to support programme implementation. Continued collaboration and country leadership is critical to create an integrated and sustainable laboratory network in the Caribbean.     

Implementing Health Policy: Lessons from the Scottish Well Men's Policy Initiative

BackgroundLittle is known about how health professionals translate national government health policy directives into action. This paper examines that process using the so-called Well Men''s Services (WMS) policy initiative as a ‘real world’ case study. The WMS were launched by the Scottish Government to address men''s health inequalities. Our analysis aimed to develop a deeper understanding of policy implementation as it naturally occurred, used an analytical framework that was developed to reflect the ‘rational planning’ principles health professionals are commonly encouraged to use for implementation purposes.Methods and materialsA mixed-methods qualitative enquiry using a data archive generated during the WMS policy evaluation was used to critically analyze (post hoc) the perspectives of national policy makers, and local health and social care professionals about the: (a) ‘policy problem’, (b) interventions intended to address the problem, and (c) anticipated policy outcomes.Results and conclusionsThis analysis revealed four key themes: (1) ambiguity regarding the policy problem and means of intervention; (2) behavioral framing of the policy problem and intervention; (3) uncertainty about the policy evidence base and outcomes, and; (4) a focus on intervention as outcome. This study found that mechanistic planning heuristics (as a means of supporting implementation) fails to grapple with the indeterminate nature of population health problems. A new approach to planning and implementing public health interventions is required that recognises the complex and political nature of health problems; the inevitability of imperfect and contested evidence regarding intervention, and, future associated uncertainties.     

Frequency of Four-dimensional Oral Health Problems across Dental Fields – a Comparative Survey of Slovenian and International Dentists

ObjectivesTo compare the frequency of patients’ oral health problems and prevention needs among Slovenian and international dentists with the aim to validate the four oral health-related quality of life (OHRQoL) dimensions across six clinical dental fields in all World Health Organization (WHO) regions.MethodsAn anonymous electronic survey in the English language was designed using Qualtrics software. A probability sampling for Slovenia and a convenience sampling strategy for dentist recruitment was applied for 31 countries. Dentists engaged in six dental fields were asked to categorize their patients’ oral health problems and prevention needs into the four OHRQoL dimensions (Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact). Proportions of patients’ problems and prevention needs were calculated together with the significance of Slovenian and international dentists’ differences based on dental fields and WHO regions.ResultsDentists (n=1,580) from 32 countries completed the survey. There were 223 Slovenian dentists (females: 68%) with a mean age (SD) of 41 (10.6) years and 1,358 international dentists (females: 51%) with a mean age (SD) of 38 (10.4). Pain-related problems and prevention needs were the most prevalent among all six dental fields reported by dentists; Slovenian (37%) and 31 countries (45%). According to Cohen, differences between Slovenia, the broader European Region, and 31 countries were considered non-significant (<0.1).ConclusionAccording to the dentists’ responses, the frequency of patients’ oral health problems and prevention needs are proportionate between Slovenia and 31 countries, regionally and globally. The four OHRQoL dimensions can be considered universal across all dental fields.     

Predicting localised measles outbreak potential in Australia

IntroductionAustralia has achieved measles elimination as announced in March 2014 by the WHO Western Pacific Regional Committee, based on several lines of evidence. However, despite strong national evidence for elimination, there remains substantial regional variation in vaccine coverage, has resulted in recent outbreaks and potential for increased frequency in the future.MethodsIn this study, we apply a multiple cohort model of measles immunity, stratified by age and local geographic area to predict trends in the measles reproduction number R. In addition, we use branching process models of outbreak risks to predict state-level probabilities of the occurrence of measles outbreaks over the next 20 years.ResultsOur results suggest increasing risks of large measles outbreaks over this period, in particular in the states of Queensland and New South Wales. In addition, there is wide variation in predicted R values by smaller geographic areas, although uncertainty in age-specific immunity limits the precision of our results.DiscussionOur predictions align with observed outbreaks in Australian states and suggest our approach to determining future outbreak risks could be applied more widely in elimination or near-elimination settings.     

Evaluation of the National Tuberculosis Surveillance System in Sana’a,Yemen, 2018: Observational Study

BackgroundTuberculosis remains a public problem that is considered one of the top causes of morbidity and mortality worldwide. The National Tuberculosis Control Program in Yemen was established in 1970 and included in the national health policy under the leadership of the Ministry of Public Health and Population to monitor tuberculosis control. The surveillance system must be evaluated periodically to produce recommendations for improving performance and usefulness.ObjectiveThis study aims to assess the usefulness and the performance of the tuberculosis surveillance system attributes and to identify the strengths and weaknesses of the system.MethodsA quantitative and qualitative evaluation of the national tuberculosis surveillance system was conducted using the Centers for Disease Control and Prevention’s updated guidelines. The study was carried out in 10 districts in Sana’a City. A total of 28 public health facilities providing tuberculosis services for the whole population in their assigned catchment areas were purposively selected. All participants were interviewed based on their involvement with key aspects of tuberculosis surveillance activities.ResultsThe tuberculosis surveillance system was found to have an average performance in usefulness (57/80, 71%), flexibility (30/40, 75%), acceptability (174/264, 66%), data quality (4/6, 67%), and positive predictive value (78/107, 73%), and poor performance in simplicity (863/1452, 59%) and stability (15%, 3/20). In addition, the system also had a good performance in sensitivity (78/81, 96%).ConclusionsThe tuberculosis surveillance system was found to be useful. The flexibility, positive predictive value, and data quality were average. Stability and simplicity were poor. The sensitivity was good. The main weaknesses in the tuberculosis surveillance system include a lack of governmental financial support, a paper-based system, and a lack of regular staff training. Developing an electronic system, securing governmental finances, and training the staff on tuberculosis surveillance are strongly recommended to improve the system performance.     

Inequalities in full immunization coverage: trends in low- and middle-income countries

ObjectiveTo investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.MethodsIn May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.FindingsIn each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.ConclusionMost low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.     

Collect Once,Use Many Times: Attaining Unified Metrics for Tuberculosis Preventive Treatment for People Living With HIV

The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO’s list of 15 core indicators for program management and are also required by the US President’s Emergency Plan for AIDS Relief’s Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. “Collect once, use many times” is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.     

Estimating mortality using data from civil registration: a cross-sectional study in India

ObjectiveTo analyse the design and operational status of India’s civil registration and vital statistics system and facilitate the system’s development into an accurate and reliable source of mortality data.MethodsWe assessed the national civil registration and vital statistics system’s legal framework, administrative structure and design through document review. We did a cross-sectional study for the year 2013 at national level and in Punjab state to assess the quality of the system’s mortality data through analyses of life tables and investigation of the completeness of death registration and the proportion of deaths assigned ill-defined causes. We interviewed registrars, medical officers and coders in Punjab state to assess their knowledge and practice.FindingsAlthough we found the legal framework and system design to be appropriate, data collection was based on complex intersectoral collaborations at state and local level and the collected data were found to be of poor quality. The registration data were inadequate for a robust estimate of mortality at national level. A medically certified cause of death was only recorded for 965 992 (16.8%) of the 5 735 082 deaths registered.ConclusionThe data recorded by India’s civil registration and vital statistics system in 2011 were incomplete. If improved, the system could be used to reliably estimate mortality. We recommend improving political support and intersectoral coordination, capacity building, computerization and state-level initiatives to ensure that every death is registered and that reliable causes of death are recorded – at least within an adequate sample of registration units within each state.