India counts its dead, but can't say why: The case for universal medical cause-of-death certification

India has come close to counting its dead. In 2023, the Civil Registration System recorded 86.6 lakh deaths, 97.2 per cent of the number estimated to have occurred in the country. Nineteen states and union territories now register every death. The gap that remains is real but concentrated: Bihar registers 53 per cent of its deaths, Nagaland 32 per cent, Assam 69 per cent and Uttar Pradesh 80 per cent, and the 97.2 per cent itself is a ratio against a sample-based estimate, not a head count. Still, measured against where the country stood a decade ago, when a third of deaths went unrecorded, the counting problem has largely been solved.

The cause problem has not. A registered death is an entry in a ledger. It says that a person died, where and when. It does not say why. That second question is answered by a separate and far older obligation: the Medical Certificate of Cause of Death, which every doctor who attends a death has been required to issue, free of charge, since the Registration of Births and Deaths Act of 1969. On this count, the record is poor. Of the 86.6 lakh deaths registered in 2023, only 19 lakh, or 22 per cent, carried a medically certified cause. The counting gap is three per cent nationally. The cause gap is seventy-eight.

That figure has barely moved in a generation. It was 20 per cent in 2011. It was 19 per cent in 2016. It touched 23.4 per cent in 2021 and has drifted down since. Registration climbed from two-thirds of deaths to nearly all of them over the same period; certification stayed flat. India built the ledger and left the most important column empty.

The pattern of the gap tells us what is wrong. Certification tracks hospital deaths almost exactly. About 24 per cent of registered deaths in 2023 occurred in a medical institution; about 22 per cent were certified. The scheme, in practice, is a hospital-death scheme. Three out of four Indians die at home or on the way to care, and for most of them no doctor records what killed them. Even where medical attention was received during the final illness, fewer than half of deaths were certified. The Registrar General's own report concedes that the scheme covers "only selected hospitals, and that too mostly from urban areas".

The geography is stark. Goa certifies every death. Puducherry certifies nine in ten. Uttar Pradesh, Assam and Bihar, three of the most populous and highest-burden states in the country, certify fewer than six in a hundred. These are also the states that still miss a fifth to a half of their deaths at registration, so the two gaps compound: the states that most need to know why their people are dying know the least. And the numbers can swing without any change in mortality: certified deaths in Uttar Pradesh fell from 1.28 lakh in 2022 to 71,000 in 2023, and in Assam from 24,000 to under 9,000. A system that halves in a year is reporting-driven, not death-driven.

Even the certificates that exist often say nothing. In 2023, 11.9 per cent of medically certified deaths were coded to "symptoms, signs and abnormal clinical findings", the chapter of the international classification reserved for cases where no disease is named. That share was 9.7 per cent in 2021. It is rising. A review in the Indian Journal of Medical Research of 20 studies covering more than 17,000 Indian death certificates found the mode of death, typically "cardiopulmonary arrest", written in place of the cause in anywhere from 9 to 86 per cent of certificates, and the underlying cause wrong in up to 99 per cent. Every heart eventually stops. Writing that down explains nothing.

None of this is a mystery of medicine. It is a failure of training and incentive. Certifying cause of death in the WHO format, with an underlying cause leading through a sequence to the immediate cause, is a skill. It is taught briefly, if at all, in the undergraduate curriculum, and every intervention study in the IJMR review found that a short structured course cut major errors sharply. Doctors are not careless; they were never taught. Nor is there any consequence for not certifying. The 2023 amendment to the Act, in force since October that year, made certification mandatory for every medical institution regardless of ownership. It also retained the penalty for a practitioner who neglects to issue a certificate: a fine that "may extend to fifty rupees".'

The cost of the gap is that India governs its health from samples and models. The national cause-of-death profile, which tells us that non-communicable diseases now account for 56.7 per cent of deaths and cardiovascular disease alone for 31 per cent, comes from the Sample Registration System's verbal autopsies, not from the registry. Sample data can describe a region. It cannot tell a district collector how many people in her district died of stroke last year, whether that number is rising, and whether the hypertension programme is making any difference. Every state now runs population-based screening for hypertension and diabetes. None can yet measure the outcome that matters, because the outcome is recorded on a form that three-quarters of the time is never filled.

The moment is right to close the gap, because the reach of the system has changed. For most of the life of the 1969 Act, the nearest doctor to a village death was hours away, and Form 4A, the certificate for a death outside a hospital, stayed unused for a reason. That is no longer true. Every primary health centre now has a medical officer, and the network of Ayushman Arogya Mandirs has placed a trained health worker within walking distance of most villages, with a referral line to that doctor. A death at home can now be reported by the community health officer, reviewed by the primary health centre doctor with a short structured interview of the family, and certified on the same form the hospital uses. Certification at village level has become an administrative choice, not a logistical dream.

There is a larger reason to make that choice now. The Prime Minister has set the country the goal of Viksit Bharat, a developed India by 2047. Development is measured in many ways, but one marker separates every developed health system from the rest: it knows what its people die of, and it knows it from a registry, not a survey. Mortality data is the foundation of epidemiology. Certified cause of death, aggregated across a district, is what tells a health system whether stroke is rising, whether diabetes is killing people younger, whether a cluster of deaths in one block points to an outbreak or a contaminated water source, and whether the programmes it funds are changing any of this. Every disease-control target India has set for the next two decades, from hypertension and cancer to tuberculosis and road injuries, will be judged by deaths.

Universal medical certification is the instrument that makes those deaths visible in the places where they happen. A developed India cannot be built on estimates of its own mortality.

This will not happen without money, and it is worth being plain about that. Certification has stayed flat for a decade partly because no budget owns it. It sits between the Registrar General, who compiles the data, and the Health Ministry, whose doctors produce it, and neither line carries a dedicated allocation for training, software, supervision or the district cells that check quality. The result is a system that runs on the goodwill of overworked medical officers. Compare what it would cost to fix with what it would protect. India spends thousands of crores a year on programmes for hypertension, diabetes, cancer, tuberculosis and road safety. Not one of those programmes can currently show, from the registry, whether it is reducing deaths. A national line for cause-of-death certification, funded through state programme implementation plans, would cover a short certified course for every practising doctor, electronic certification in every hospital, verbal-autopsy support at primary health centres, and a mortality-data cell in every district. Against the sums already committed to the programmes it would evaluate, that is a rounding error. It is the cheapest investment in Indian public health that no one has yet made, and every rupee spent on disease control without it is spent blind.

The rest of the fixes are known and inexpensive. Cause-of-death certification should be a certifiable competency in the MBBS curriculum and a condition of registration with the National Medical Commission, examined the way any other clinical skill is examined. Every hospital, public or private, should be required to submit its certificates electronically to the state registrar as a condition of empanelment under public insurance schemes, and the audit framework that the Health Ministry, ICMR-NCDIR and WHO released in 2022 should be run and its results published. For the majority who die at home, states should make the primary health centre doctor responsible for Form 4A, supported by a simple verbal autopsy collected by the community health officer through the digital registration portal, so that a home death receives a probable cause the way it already receives a certificate. And every state should publish its share of ill-defined certificates as a quality indicator, in the same way it publishes its registration level.

India has done the hard part. It has found nearly every death, and it has put a doctor within reach of nearly every village. What remains is to ask, of each death, the only question that turns a number into knowledge. A country that counts its dead, and means to be a developed one by 2047, should not have to guess why they died.

Dr Om Prakash Bera is a senior public health and policy specialist, and Dr Pradeep Aggarwal is a senior public health specialist and an additional professor at All India Institute of Medical Sciences, Rishikesh.

The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.