A study by the Indian Council of Medical Research has found that India still lacks reliable information on the medical causes behind most deaths, raising serious concerns about health planning, disease surveillance, and policy priorities.
The findings, published in the journal Scientific Reports, show that despite improvements in death registration, only a small proportion of deaths in India receive a Medical Certification of Cause of Death (MCCD) - the process through which a doctor officially certifies the medical reason leading to death. The absence of such data leaves large gaps in understanding disease burden and weakens evidence-based public health decision-making.
The study is the first comprehensive analysis to examine MCCD reporting patterns across all Indian states and Union Territories over a 15-year period, highlighting deep regional disparities and systemic shortcomings in India’s mortality data system.
What the study highlights
Despite accounting for about 18 per cent of the global population, India continues to lag behind in the medical certification of causes of death. According to the 2020 report from the Office of the Registrar General of India, only 22.5 per cent of deaths had a medically certified cause of death. This means that in nearly eight out of ten deaths, the underlying medical cause was not formally certified by a doctor.
"Reliable cause-specific mortality statistics are crucial for defining health priorities, public health programs, allocating resources, designing and implementing policies to improve healthcare quality and accessibility," the study highlights, while adding that "For a country that accounts for 17.8% of the world’s population, the existing MCCD-rate of 22.5%, with only a 2.5% improvement over the past decade, is strikingly concerning."
This slow pace of improvement is concerning, as it is happening despite expansion of healthcare services and institutional care. Between 2006 and 2010, only 15.33 per cent of deaths received MCCD. This increased to 20.91 per cent during 2016–2020, reflecting some progress in death registration and certification practices, though far from adequate given India’s population size and disease burden.
Regional disparities in cause-of-death certification
The study documents stark regional differences in MCCD across India, and a distinct North-South divide too. "Southern states, like Tamil Nadu, Karnataka, and Andhra Pradesh, demonstrate a consistent upward trend in MCCD-reporting, reflecting well-developed healthcare infrastructure and administrative efficiency," it says.
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Tamil Nadu recorded a sharp increase from 28.34 per cent to 43.46 per cent, making it one of the strongest performers. Karnataka and Andhra Pradesh have maintained consistently high MCCD levels. Kerala, despite progress, continues to record comparatively lower MCCD rates than other southern states.
However, North India recorded the lowest regional average, with only 13 per cent of deaths receiving MCCD between 2015 and 2020. While Punjab and Himachal Pradesh showed consistent improvement, Haryana and Uttar Pradesh continue to lag, with incomplete reporting and persistent data gaps.
Among Union Territories, Lakshadweep recorded the highest MCCD rates, with 94–95 per cent of deaths receiving a medically certified cause. Puducherry and Chandigarh followed, each reporting nearly 70 per cent MCCD coverage.
Delhi has also shown gradual improvement, with Medical Certification of Cause of Death increasing from 57.46 per cent to 59.71 per cent over the study period.
Why do we not know the cause of death in many cases?
The lack of qualified doctors and access to healthcare is highlighted as a possible reason behind this. It says that while the doctor-population ratio as of December 2023 is about 1:834, which is better than the WHO guidelines of 1:1000, this accounts for both allopathic and AYUSH doctors. "However, AYUSH doctors and all allopathic hospitals are currently not included in the MCCD registry program," it says.
It also highlights a limited correlation between doctor-patient ratios and cause of death ascertaining. "States... with fewer doctors (0.14 per 1000 people), demonstrate lower MCCD-rates, while regions with a higher doctor density (0.35–0.50 doctors per 1,000) show moderate improvements in MCCD-rates," it says while adding that this is a "limited correlation" and "that merely increasing doctor numbers without addressing systemic challenges may not yield substantial improvements in reporting practices."
They also flag the density of hospitals as a possible reason. Some states "demonstrate better MCCD-rates, largely due to a significant portion of their populations residing in urban areas, which facilitates easier access to healthcare and certification processes," while other states "with lower MCCD-rates, struggle with underreporting, particularly due to a higher population in rural regions where access to certified medical facilities is limited, such as in Uttar Pradesh and Bihar."
"This underscores the importance of increasing hospital density and accessibility in rural areas, which are vital for improving MCCD-rates in states with lower reporting. Additionally, it is crucial to verify that such increases in hospital density and accessibility translate to active MCCD-reporting, as active hospital reporting has emerged as the greatest influencing healthcare variable affecting MCCD-rates among all clusters," it says.
Why it matters
Reliable medical certification of cause of death data is essential for understanding disease patterns, tracking health transitions, and shaping national and state-level health policies.
A World Health Organisation feature on mortality data systems in India highlights how strengthening cause-of-death documentation, including integrating verbal autopsies with MCCD, enabled Tamil Nadu to document causes for nearly all deaths in pilot districts, sharply reducing ill-defined causes and enabling data-driven planning.
Evidence from other health systems reinforces these concerns. A 2023 retrospective study examining underlying causes of death found that inaccurate documentation of the medical cause of death is common and can significantly distort mortality statistics.
“Approximately 80 per cent of the deceased patients had inaccurate data on the underlying cause of death,” the study reported, warning that such inaccuracies affect health system planning, research, and policy formulation. The authors called for formal training, auditing, and feedback mechanisms to improve the quality of cause-of-death certification.
Indian evidence echoes these findings. A 2024 scoping review examining errors in MCCD in India reported alarmingly high error rates. Major errors, including incorrect identification of the underlying cause or improper sequencing of events leading to death, ranged from 8.5 to 99.2 per cent. Minor errors such as missing details, abbreviations, and illegible handwriting were also widespread.
“The proportion of incomplete death certificates ranged between 12–100 per cent,” the review noted, adding that the absence of time intervals was among the most common certification errors.
The review concluded that training doctors in MCCD and integrating it into medical education is urgently needed, along with a uniform national system for auditing the errors.
“Efforts should focus on increasing the number of hospitals reporting MCCD, coupled with enhanced active reporting, particularly in underperforming states,” the ICMR study added, suggesting state audits, administrative incentives, and awareness campaigns as key strategies.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.