Assessment of the cause of death registry in the occupied Palestinian territory: a qualitative study

Abstract

<h3>Background</h3> Decision makers use mortality data extensively. However, data quality—which depends on the accuracy of completion of the death notification form (DNF)—is inadequate in many countries, including the occupied Palestinian territory (oPt) where a cause of death registry was established in 1994. According to the National Health Information System Strategy (2013–15), issued by the Palestinian Ministry of Health in collaboration with WHO, the reporting of mortality data, including the DNF, needs to be improved in the oPt. The aim in this study was to assess and make recommendations for improvements in the reporting of mortality data to the cause of death registry, with the focus on hospitals and the DNF. <h3>Methods</h3> The study was undertaken in October, 2012, in the West Bank and Gaza Strip, both in the oPt, in collaboration with the Ministry of Health. An assessment team used qualitative methods for formal assessment of surveillance systems and registries as described by WHO and the Centers for Disease Control and Prevention, Atlanta, GA, USA. We held two start-up workshops with participants from key stakeholder institutions (16 in the West Bank and 19 in the Gaza Strip), and two focus group interviews (12 participants, Alia hospital, West Bank, and eight from different hospitals, Gaza Strip). We undertook in-depth interviews of two doctors from Rafidia Hospital, the director of the Palestinian Health Information Center who was in charge of the registry at a national level, and a district health director. The assessment team summarised and discussed all the findings and then formulated a total of 33 tasks organised into ten recommendations, which were reviewed by the Palestinian Ministry of Health, WHO, Norwegian Institute of Public Health, and Statistics Norway, both in Oslo, Norway, with final approval by the Palestinian Ministry of Health. All participants were informed about the aim of the assessment and how the information that they provided would be used. The assessment team did not have access to any confidential patient data or interview patients. <h3>Findings</h3> For the Palestinian cause of death registry, there were no formal definitions, quality documents, and standard operating procedures. Doctors had no guidelines for completing DNFs, with little training or supervision in the hospitals, few data quality checks were done, and there was a lack of quality-assurance systems at all levels. Only one person in the West Bank and one in the Gaza Strip assessed the DNFs and assigned the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) codes. Hospital doctors had inadequate understanding of how to apply the diagnoses, and there was no feedback of the results to the hospitals. Information was disseminated through a few tables in a yearly report. <h3>Interpretation</h3> Ten recommendations by the investigators for the improvement in the reporting of mortality data are: revise the DNF and develop guidelines; develop standard operating procedures to describe all aspects of the cause of death registry, including quality assurance systems and introduction of an electronic coding aid; identify a focal point doctor in each hospital to be responsible for all quality-assurance issues in relation to the DNF, including training of the hospital doctors; establish training programmes for hospital doctors; improve data output and feedback from the registry; synchronise flow of data with the population registry; and audit the quality of diagnoses in the cause of death registry. Assessments of other parts of this registry are further advised. About half of all deaths in the oPt occur in hospitals. Additionally, about half of the individuals who die outside of hospitals in the Gaza Strip (a quarter of the total number of deaths) are dead when they are brought to the hospital. <h3>Funding</h3> Palestinian National Institute of Public Health Project funded by the Norwegian Ministry of Foreign Affairs.