This chapter examines the relationship between data, statistics and records in the context of mortality statistics in The Gambia. The aim is to illustrate the complexities and practical challenges in acquiring reliable information as a basis for national development planning, as well as for measuring the achievement of the Sustainable Development Goals (SDGs), especially in low resource environments. The first section provides a brief overview of The Gambia’s economic challenges. The second deals with the complexities of birth and mortality data, how they are estimated and discrepancies between different data sources. It argues that, ultimately, accurate statistics can only be derived from verifiable data and that in the case of mortality statistics, reliable data must be based on the verifiable records of individual deaths captured as part of a prescribed process. The third section focuses on challenges for collecting reliable mortality statistics in The Gambia. The fourth section explains how The Gambia Bureau of Statistics (GBS) and the National Records Service (NRS) intend to address issues relating to the quality, integrity, completeness and ongoing availability of data, statistics and records. A concluding section suggests that if the two organisations could work together to maximise their strengths and resources, the quality and integrity of the data, statistics and records required to monitor the SDGs and support development planning in general could be significantly strengthened.

Background

The Gambia is a small country in West Africa with a population of less than two million. It occupies a long narrow strip of land on either side of the Gambia River, extending eastwards inland from the Atlantic Coast for approximately 210 miles/338 km. UNICEF and the World Bank estimate that 48 per cent of The Gambia’s population live below the poverty line (US$1.25 a day), with large disparities within the population in accessing basic social services.¹ Many of the poor depend on subsistence agriculture, while informal jobs, such as street selling, are predominant on roadsides and in urban areas. As the population has grown, many Gambians, especially young people, have moved from rural to urban areas or left the country to seek a better life. The Gambia relies heavily on its tourist industry and on remittances sent home from abroad.

Mortality rates in The Gambia

How are mortality rates calculated?

Obtaining accurate mortality statistics in The Gambia is not feasible at present, for significant practical reasons that will be explored later in the chapter. However, before examining the causes, it is useful first to look at some of the consequences of inconsistent statistics for the reliability of the available data. It is important to note that the World Bank, WHO and other international organisations constantly update their statistics and online information with new URLs. The information provided in the footnotes that follow was checked in August 2020.

Internet searches for The Gambia’s mortality rates tend to produce confusing results, which illustrate the problem. IndexMundi, ‘a data portal that gathers facts and statistics from multiple sources and turns them into easy to use visuals’, provides annual Gambian mortality rates per 1,000 for the years 2000 to 2017:² IndexMundi gives the source of these statistics as the CIA World Fact Book, a reference resource produced by the US Central Intelligence Agency. According to this source, the estimated death rate for 2017 (currently the latest year for which statistics are provided) is seven deaths per 1,000 population³ and shows a large drop (36 per cent) in the mortality rate between 2010 and 2011 (see table and highlighted figures below). All other years show a gradual overall reduction.

The World Bank, however, gives very different figures for the number of deaths per year per 1,000 population, rounded to two decimal places in the table below.⁴ In particular, the figures for 2010–11 are very different from those provided by IndexMundi:

The World Bank’s estimate for 2000 is 12 per cent lower than IndexMundi’s, whereas its estimate for 2016 is 13 per cent higher. In terms of estimated deaths for the population as a whole, the World Bank crude death rate of 8.67 in 2012 (when the population of The Gambia was estimated to be 1,857,181)⁵ provides an estimated 16,102 deaths for the whole population, whereas the IndexMundi death rate provides an overall death rate of 13,093, a difference of over 3,000 deaths, making IndexMundi’s figure 19 per cent lower. Still other sources give the mortality rate in a date range and show further disparities. For example, Wikipedia provides the ‘crude death rate’ as an average over six years, giving the source as ‘The Population Department of the United Nations’:⁶

The average death rates in these date ranges from the statistics provided by IndexMundi and the World Bank are again significantly different:

UNICEF demographic indicators give the crude death rate for 2012 as 9.8, which is significantly higher than the IndexMundi figure of 7.5 but, coincidentally, the same as the six-year average for 2005–10 provided by Wikipedia.

Finally, the World Health Organization’s African Health Observatory gives an adult mortality rate per 1,000 for 2008 as 276,⁷ which, taken at face value, further confuses the picture. Adult mortality refers to the probability that those who have reached age 15 will die before reaching age 60 (shown per 1,000 persons). A value of 276 means that of 1,000 persons who have reached the age of 15, 276 are expected to die before reaching age 60. Direct comparison between this statistic for ‘adult mortality rates’ and the ‘crude death rate’ used by other authorities would be difficult if not impossible, at least for the lay person.

The United Nations defines civil registration as ‘the continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events … provided through decree or regulation in accordance with the legal requirements of each country’.⁸ Reliable civil registration, including issuing relevant certificates, requires proof of such registration. Estimates of death rates can be derived from censuses and surveys, but only a well-developed and fully functioning civil registration system is able to collect this information on a continuous basis and to ensure that there are records of ‘vital events’, including deaths. Gambian mortality statistics have to be estimated because there is no systematic recording of deaths. Registration of deaths is not a legal requirement and is not feasible for many of the population. All the figures published by the World Bank, World Health Organization, UNICEF and other sources in The Gambia are, by necessity, estimates only.

Challenges for collecting reliable birth and death statistics in The Gambia

How are deaths recorded?

Although The Gambia is the smallest country in mainland Africa, some rural areas are still relatively inaccessible. Transport and communications are a problem for many Gambians, not only for the rural poor but for the urban population in the capital Banjul and the surrounding areas. The majority of the population are Muslims, and burials of the deceased take place as soon as possible, usually within 24 hours of the death. Introducing compulsory registration of births, marriages (many of which take place according to custom) and deaths would present huge challenges for a country with limited financial resources.

The Ministry of Health and Social Welfare is currently responsible for registering deaths in The Gambia, although, as noted, this is presently an unrealistic task for the country as a whole. Deaths are registered formally only for those who die in hospitals, where the cause of death is ascertained by a medical doctor. The Gambia has four public hospitals and a network of smaller health facilities throughout the country. Death certificates are only prepared by the Births and Deaths Registry Unit at Medical Headquarters in the capital, Banjul.⁹ As most deaths occur at home, formal registration of death is not common. The information available from registered deaths in the urban area does not enable the extrapolation of accurate national patterns of disease and mortality, especially among adults.

Deaths that occur in health facilities, such as clinics, are reported in the monthly health statistical reports through a national surveillance system. Where government health facilities have access to a power supply and the internet, the staff enter data in DHIS2, a web-based open-source information system.¹⁰ Facilities without internet access use a manual system to record data, which are then entered in the DHIS2 information system. Data from DHIS2 are consolidated in the government’s Health Management Information System and should be published on the Ministry of Health website.¹¹ Unfortunately, at the time of writing, there are no statistics available on the website. The data are reported to the World Health Organization and the West African Health Organisation (WAHO), an agency of the Economic Community of West African States (ECOWAS).¹² However, data from private health care facilities, accounting for 25–30 per cent of the country’s health care system, are not included in the surveillance and reporting system, though it is understood that they may be included in future. If conducted reliably by all health facilities, the surveillance system has the potential to provide more accurate national mortality statistics, but it is not clear to what extent or how they will include deaths occurring at home.

How are death rates estimated?

Systematic birth and death registration require an infrastructure (offices, equipment, systems, policies and standards) and the human resources needed to register the events. However, at present, in The Gambia, funding is inadequate to cover these costs. Without a civil registration system, death rates must be estimated from data collected by censuses, surveys and sampling. Organisations such as the World Bank derive data from reports gathered by in-country management units and other independent sources. The Gambia currently uses a combination of surveys (censuses) and sampling (using a sub-set of the population to derive information about the entire population) as illustrated below.

The most recent nationally representative demographic survey in The Gambia is the 2013 Population and Housing Census, which was conducted by the GBS in collaboration with the Ministry of Health and Social Welfare and the National Population Secretariat Commission. This was the fifth census to take place since The Gambia achieved independence in 1965 and the first to take place under the worldwide Demographic and Health Survey programme funded and supported by the United States Agency for International Development. The main objective of the survey was ‘to provide comprehensive data on fertility and mortality, family planning, maternal and child health and nutrition, as well as information on maternal mortality and domestic violence’.¹³

Over a three-month period in 2013, a total of 6,217 Gambian households were contacted: 10,233 women aged 15–49 and 3,821 men aged 15–59 were interviewed.¹⁴ Fourteen separate data analyses and reports were derived from the census data, including, reports on children, economic characteristics, education, housing and household characteristics, the elderly, mortality and access to ICT.¹⁵ The Mortality Analysis and Evaluation, published by the GBS,¹⁶ included reports of deaths in the households 12 months prior to the census, including sex and age at death. For every deceased female aged 15 years or older, further enquiry was made to establish whether the death occurred during pregnancy, while giving birth or within six weeks after the birth. Any death where there was an affirmative response to any of these three questions was classified as a pregnancy-related death. Women aged 12 years and over were also asked to state the total number of children they had ever given birth to, as well as how many were alive at the time of the census and how many had died.

The data gathered were used to estimate the infant mortality rate for the decade prior to the census as well as to develop an estimation of the crude death rate and the age- and sex-specific death rates experienced by the entire population. Various direct and indirect estimation techniques were used to provide reasonably acceptable mortality indicators for the country, although inevitably, as noted earlier in this chapter, there were discrepancies. The discrepancies, together with the fact that the survey is becoming outdated with time, have undermined the usefulness and relevance of the data. Plans to conduct a similar survey have yet to be developed and in any case, it is doubtful that the required resources would be secured.

The reliability of birth dates

Birth registration is an essential part of a functioning civil registration system and complements the registration of deaths. The existence of accurate and complete birth records facilitates the calculation of the ages of individuals at the time of their deaths. Most countries have mechanisms in place for registering births. However, the coverage, the type of information obtained and the use of resulting data differ, based on the country’s infrastructure, legal frameworks, administrative capacity, barriers to accessing services, availability of funds, accessibility to the population and technology for data management. Levels of registration vary substantially across countries due to these and other factors and to the availability of data on birth registration, which is highly uneven across countries.

In The Gambia, registration of births is a more common practice than is registration of deaths, but it is hampered by inadequate human and material resources, particularly at the health clinic level. Birth registration is supposedly mandatory, and a decentralised system operates at health facilities and outreach stations. Gambians are far more likely now than in the past to have a formal birth certificate, or they can apply for one if the original is lost, so the government and its development partners should have accurate birth statistics as a basis for planning. However, at present, there is no means of determining the reliability of The Gambia’s birth records.

Efforts to strengthen official statistics in The Gambia

The Gambia Bureau of Statistics

In February 2018, the Government of The Gambia launched a National Development Plan, 2018–2021.¹⁷ One area of focus is reducing maternal and newborn mortality. The Gambia’s second National Strategy for the Development of Statistics, 2018–2022, published in 2017,¹⁸ is aligned with the National Development Plan and the UN SDGs. The demand for improved statistics has grown across many subject areas. Timelier and more reliable statistics are seen as critical in informing policies and planning, in monitoring and evaluation of programmes and services, and more generally in public sector management. A key aim of the National Strategy for Statistics is to develop a civil registration and vital statistics system, including the official recording of all births and deaths.

The ability to capture these statistics reliably is crucially important for development planning and protecting citizens’ rights. It establishes legal identity and civil status and enables access to services such as health care, education and social protection; it contributes to timely and accurate estimates for effective planning and resource allocation; and it influences policy development and research and the ability to monitor and evaluate. In particular, it enables accurate monitoring of progress towards achieving the SDGs.

The strategy has six overarching goals:

Goals 4 and 5 are of particular interest for this chapter because of the focus on data quality and integrity.

The aim of strategic goal 4 (improved data production and dissemination) is to increase the frequency of data collection, conduct new surveys, develop civil registration/vital statistics systems, strengthen administrative records (including civil registration records) and assure proper data dissemination. The goal embraces the three main sources of official statistics across the national statistical service in The Gambia:

Recognising that The Gambia lacks an effective civil registration and vital statistics system, the GBS and the national statistical programme in general aim to scale up existing data management information systems and implement new systems where needed. In order to meet the increasing demand for statistics, the strategy states that ‘data production and dissemination should take advantage of using innovative statistical technologies employed in data management processes, such as mobile devices and advanced imagery technology’.¹⁹

The initiatives under strategic goal 5 (assured quality of data) are designed to enhance the quality of statistics through the development of a Statistical Compendium of Concepts and Definitions, a household sampling frame with a master sample, a business establishment sampling frame and a business registry. There are also plans for a metadata handbook and a customised National Quality Assurance Framework that adapts international classifications and nomenclatures to The Gambia’s needs.

These ambitious plans are commendable, but it remains to be seen whether they will be fully implemented, bearing in mind The Gambia’s lack of resources²⁰ and the fact that practices for gathering statistics are not coordinated at present. For instance, the national strategy notes that information management systems derive most of their data from administrative records and that these systems are ‘generally weak and require substantive development and improvement’. Furthermore, ‘the key suppliers of data require a lot of motivation in order to provide data and records for the compilation of the needed statistics’.²¹

The significance of records for mortality statistics and the contribution of the National Records Service

Weaknesses in information management systems that derive data from administrative records underscore the role records play in ensuring the quality and integrity of data and statistics for development planning. Their importance is often poorly understood and not well addressed in data quality initiatives that focus on improving the quality of processes generating data and statistics. Understanding the characteristics of records and the role they play is an important prerequisite to understanding the challenges that organisations face in managing their data and statistics.

Records are created by any given process for collecting, verifying or manipulating data and producing and disseminating statistics. Records document decisions concerning the design and management of the process as well as the reliability of the data and statistics themselves. When well-managed, records serve as evidence that the data and statistics were managed properly and that they have the required level of quality and integrity. In the case of death registration records, for instance, they tell the story of how, when, where and by whom a given death was identified and recorded, how data from the form capturing the data was verified and migrated to a master file or database, how it was manipulated and processed to enable statistics to be produced, how the statistics were published and disseminated, and how the data and statistics, not to mention the records themselves, were retained.

Based on their content, records can serve as sources of qualitative and quantitative data and can be used for multiple purposes beyond the evidentiary purpose that led to their creation. For instance, various records in the form of emails, correspondence, procedures and other documents may document and support the management of processes generating births and deaths data and producing statistics. These records, together with the forms and registries capturing the instances of births and deaths, serve, in themselves, as sources of data that can be used to produce a wide range of statistics. The quality and integrity of statistics are based on the quality and integrity of the data input to the statistics. This, in turn, reflects the quality and integrity of the processes for collecting, processing, analysing and maintaining the data and producing and reporting the statistics. The ability to demonstrate this quality and integrity is dependent on the availability of complete, authentic and accurate records.

In The Gambia, the NRS is responsible for facilitating the management of records across the government. Created as part of a series of records management reforms in the 1990s, the NRS controls standards and guidelines for records management in government records offices and carries out regular monitoring and training activities aimed at maintaining and strengthening the standards. All ministries and departments have ‘restructured’ records offices, and the NRS continues to restructure records in parastatals. Recently, a new National Records Service Act was drafted to strengthen, and to state explicitly in law, NRS responsibility for records in all formats, including data held in information systems in public offices. It would also make the NRS responsible for implementing policies and standards to support public records and data management. The Act has yet to be enacted, but in any case, the NRS will be responsible for records and recordkeeping systems created as part of any future civil registration and vital statistics system.

The significance of the NRS role is becoming ever more fundamental for national development as the government increases the use of new technology to create and manage its information and as the challenges of managing information in digital form become more apparent. Two examples of NRS contributions relate to the quality of government data and statistics in the areas of health on the one hand and finance on the other.

The first example, involving health data, relates to clinical coding or medical classification, which is the process of converting descriptions of medical diagnoses and procedures into universal medical code numbers in order to provide the raw data for analysis. Information about diagnoses and procedures, converted to codes, is usually taken from a variety of patient records, for instance, doctor’s notes, laboratory results and radiological results.²² In the past, records at The Gambia’s Royal Victoria Hospital (now the Edward Francis Small Teaching Hospital) were poorly managed, incomplete or inaccessible. Clinicians often had to treat patients without a full case history, which added to the difficulty of getting complete birth and mortality data.

The NRS introduced a unified patient record system that brought together the records of inpatient and outpatient episodes relating to the same individual. Patients were registered and given a unique patient number; their records were kept together by this number in a newly constructed registration block. The unified patient record system was also introduced at the Bansang and Farafenni Hospitals. The NRS team sought to capture and analyse statistical information about patients and treatments in the expectation that the new system would also improve clinical coding. The lack of resources and skilled staff has made it difficult to maintain clinical coding, but the potential contribution remains.

The second example relates to the integrated financial management information system (IFMIS) that the Ministry of Finance and Economic Affairs has been implementing in The Gambia in recent years. The aim has been to manage the government’s financial transactions, using the IFMIS human resources management module to manage civil servants. There is an opportunity to link this to reliable national registration data. Under the dynamic leadership of its director, the NRS has established an IT unit and is currently implementing an electronic records/content management system (compliant with international standards), initially for the NRS’s own records but with the aim of rolling out the system to four other pilot sites.

These and other examples demonstrate that the NRS should be a key player in strengthening the quality and integrity of the data and statistics used by the government. If records systems were linked to strengthening data for national development, they could provide valuable evidence needed to support statistical integrity. Without NRS input, the controls for managing records that document how decisions are taken and implemented in regard to statistics will remain weak, making it difficult to carry out effective audits and quality assurance. However, while the NRS could make an invaluable contribution strengthening data and statistics, it does not have the resources and the range of skills needed to play its potential role.

The benefits of shared responsibility for the quality of statistics

The NRS and the GBS share an important role in ensuring that the data, statistics and records supporting development planning are complete, accurate, authentic and reliable. As in many countries, however, they tend to work in isolation from one another, with the GBS focusing on data and statistics and the NRS on records. Each organisation supports its own set of policies, procedures, standards and practices, and the initiatives they manage are not coordinated. While each organisation is concerned about quality and integrity issues, they approach the issues independently based on media (data and statistics or records). They have yet to recognise that because the data, statistics and records generated by a given process, such as the process for registering births and deaths, are part of a comprehensive whole, their management needs to be coordinated.

Both organisations have strengths that can be brought to bear on a given process. The NRS team lacks resources, but it understands how records should be managed. The GBS understands data and statistics, and while it, too, is hindered by a lack of resources, its team understands how data and statistics should be managed. Both organisations have a vested interest in ensuring that the processes that generate the data, statistics and records are complete, well designed and reflect an appropriate level of quality and integrity. Much could be gained by both organisations if they could coordinate their human and financial resources to improve the quality and integrity of not only mortality data and statistics but development more generally across The Gambia. As joint leaders, they could draw in other relevant organisations, for instance those responsible for IT security and audit, as well as the users of the data and statistics. They could maximise scarce resources and present a set of unified strategies that would produce results of far greater impact and relevance than if each continues to work on its own.

Summary and conclusion

In the absence of a legal requirement to register all deaths and to create an official record of each death, mortality statistics must be estimates only. Official mortality statistics for The Gambia are based on estimates derived from periodic censuses and surveys. The most recent Population and Housing Census, conducted in 2013, provides the best available data for estimating the death rate in the year preceding the census and it is a basis for projections for the following years. Other methods of collecting death statistics, such as reporting by health facilities through a national surveillance system, do not provide complete nationwide coverage.

Independent sources have estimated a higher crude death rate than that provided by the GBS, implying that deaths in the year preceding the 2013 census were under-reported, that independent estimates were too high, or possibly a combination of both explanations. Statistics published by international organisations for The Gambia’s mortality rate vary widely, in some cases by up to 20 per cent. The GBS acknowledges that the country lacks an effective civil registration and vital statistics system, but compulsory civil registration, which could generate an accurate record of every birth and death, would require a huge investment in infrastructure and human resources.

At present, The Gambia lacks the funding and expertise to manage the quality, integrity and completeness of data, statistics and records to meet both current and future requirements. The GBS has established a strategic plan for addressing data quality issues, but it lacks the resources to execute the plan effectively. The NRS provides standards, common procedures, training and oversight for managing the government’s paper records and is currently piloting an electronic records management system that complies with international standards, but its role in setting policies and standards for data and digital information systems, including for preservation, is limited and its services and capacity remain a low priority for the government.

These two organisations, despite their statutory responsibility for the management of data and statistics on the one hand and records on the other, operate in isolation from one another. A working relationship between them, to formulate and agree standards for managing data and records as well as the content of information systems from which official statistics are derived, would maximise the use of limited resources and improve the quality of the data, statistics and records that the government needs to support national development planning and to monitor the achievement of the SDGs.