I am Amanda Glassman is senior fellow and executive price president at cdc. Today we will be talking about death and data in low and middle Income Countries from covid19 and all other causes. Accurate complete and timely data on mortality probably the single most powerful policy tools we have today to mitigate the Economic Impact of covid19 but what is also clear is that we have not collectively built the systems necessary to record peoples death in ways that enable more and to protect livelihoods. This failure does not only spawn individual experiences that creates unnecessary suffering. How is it possible to assess whether Subsaharan African countries are winning the fight against covid if a large share of total deaths and noncovid years go unreported or how to judge the trajectory of pakistan during covid19 if no mortality data of any kind is being ripped ported in the Public Domain according to dub a joes 2019 mortality report. Today will be talking about one strategy and mortality measurement to report on deaths in realtime. Systems cant rely on what deaths of the community are left at the camp are good examples of countries to start off with better data but struggled to produce accurate and timely data and will be focusing on the big picture. What can we do to develop modern systems to accurately record deaths in realtime the weather Innovative Strategies are effective or would he like to see from the global conducive to support low and no income government attack and we visit the issue further as it deserves . We are lucky to be joined today by four world experts in the field the Vice President for Civil Registrations vital strategies the adviser of the brazilian government on these issues for vital strategies semi era osmolik they director general for data and analytics for impact at the World Health Organization was Just Launched their own Data Initiative and Aaron Nichols who leads global Civil Registration and Vital Statistics improvement at the west centers for disease control. Lets get started and i will turn it over to you. Thank you so much all of you. Thanks amanda and if youll give me one moment to share my screen. And put us into live mode here, presentation mode. Okay, good morning and good afternoon or evening good evening and thank you for joining us here. This is an important topic and it really goes to the heart of the adage adage of know adage of no europe but then i can know your response which is a phrase that was coined over a decade ago but how do we know the covid pandemic. We believe every country should know the scope and scale of the pandemic in realtime to the greatest extent possible to shape the datadriven response and here we have our w. H. O. Global dashboard. It does represent deaths and confirmed cases due to covid19 but we need to be careful in terms of understanding and interpreting these numbers and understanding the measures particulate dessa mortalities and data that comes from lowland and sometimes in middleIncome Countries. As amanda indicated this presentation is going to focus on one measure of excess mortality that we fill captures the full scope and scale of the poll of the pandemic. It should be no news that sense the early days of the pandemic there have been shortages and concerns overtesting over its scope and its scale. Since early days there have been worries overtesting capacities throughout Subsaharan Africa not to mention from countries like the united states. Lets look at the implications of this testing context a little more closely when it comes to interpreting big numbers. One point i would like to make is testing a system like it is actually an essential service in the context of the pandemic. In the lancet recently in the absence of the vaccine or highly effective treatment widespread g transmission and death. I think this is something with which we can all concur and yet the reality on the ground particularly in low and middleIncome Countries is highly variable and its actually often inadequate and has been inadequate in relation to the need. Given the scarcity testing has tended to be focused on symptomatic cases of hospitals or to identify cases in clinical settings. The question here then is what are the invocations for that scope and scale for the defection of the total burden of the pandemic and as we have seen from this clipping from the guardian. Com this undercounts cases in the Community Meaning that w. H. O. Warned that it could be the tip of the iceberg in terms of the actual number of cases being detected. But what about death . The key picture that im trying to paint for you today is what a murky picture we have because we do not have the data in hand in many places. The w. H. O. Dashboard tallied over 960,000 confirmed covid deaths as of this past wednesday but again we need to unpack a little bit those numbers that are coming from countries that lack both robust and resilient Vital Statistics and Civil Registration programs and the cause of death data systems usually rooted in the Health Sector that are not yet capable of delivering and providing timely data on the cause of death. In those kinds of context there to issues that arise in particular. The first pertains to getting the covid19 death numbers right themselves. We are just trying to get covid19 debts and how do we get it . Thats going to depend on the adaptation, not adaptation but the adoption of important guidance issued by the World Health Organization in terms of how to correct a certified and code a covid19 death either suspected or confirmed. This guidance which i have looked at and get a little complicated when it concerns comorbidities for example where there is covid president of comorbidity. The upshot is all of this guidance need to be disseminated, adopted and manifest in the practices of coding positions in order to have a robust measure of covid mortality. The second issue however that i want to call attention to is with an exclusive focus on covid deaths and mortalities namely deaths that occur in locations far away from hospitals where they cannot be certified and the stark reality in her opening remarks. We leave out those deaths that arise from disruptions to overextend Health Systems and we leave out death that occurs because people delay seeking hospital care for fear of infection or if they fear they might be in the good are being separated from families and then taken away. It also often excludes emergencyroom death for those broad index of hospitals who are not often counted in hospital tallies. All of these forces are acting in many places where the majority of deaths as amanda pointed out even before the pandemic were occurring at home. In many african contexts for example this really contributes to a murky picture. We only have hypotheses at the moment about the syndication that we have may be comparatively fewer or unexpectedly low cases at the moment of covid19 and covid19 deaths occurring during the pandemic i should say across much of the continent. Is this really a factor of limited Testing Program so we dont have a window into the pandemic . Might the virus had come early already in because Surveillance Systems were not in place we might have missed the arrival of the virus . It may have later attenuated arrival and because less mortality because of competing causes of death at an older age in particular and also there may be a mitigating sense of the residential patterns of the population. Some combination of these factors in the answerer when we need to think in terms of parsing out mortality by cause particularly at the Community Level it becomes enormous and complex. This brings us then to the idea of access to mortality. We think the this complementary measure is really simple and fairly comprehensive way of capturing in a timely manner the full human cost of the pandemic. Im going to explain this mortality in two parts for the first part of measuring is to focus on the enumeration of all deaths now regardless of cause by age sex and location. We are tracking today that current levels of mortality. The second piece of measuring excess mortality is to establish a baseline of expected death for the same at the epidemiologic week and the same location to your go or an average of the Previous Year and a measurement of the gap between todays observed mortality and that is then expected in fact what we call excess mortality. This mortality can be attributed not only to covid direct we but also to the causes of death as the results of the sorts of factors that i outlined a moment ago. These graphs may be somewhat familiar and we have a graph from switzerland by age group on the right and on the left published by the economist. Major deaths are using access mortality visualizations such as those or these two to represent the pandemic. Thats all well and good but again bring us back to our main concern here what about places on the globe that are not being able to routinely and resolutely report the data particularly from immunity. At the moment at least 13 countries and there are more there are more everyday many with the support of philanthropies and other partners are leveraging existing sources of data or creating new ones to measure finality in part they are relying upon the technical package that we have. In partnership with World Health Organization leadership with Cdc Foundation and cdc leadership and regional partners in africa and asia. This technical package is assisting countries along the spectrum of system readiness if you will. I will show up graph from brazil one of the countries thats producing rapid mortality surveillance and the point i would like to say here and youll hear more about brazil surely rapid mortality surveillance was actually an innovative use of existing public data. Brazil and other countries such as colombia and even peru have the availability of data and have had to make fairly minor innovations i could say compared to where else we have been working in order to establish the rapid mortality surveillance and the measures of rapid mortality that rapid mortality surveillance can produce. Visiting a little bit to a discussion of lowIncome Countries what they find is that in these settings systems dulac high coverage and completeness and a lack of timeliness. This makes solutions for coming up with ways of measuring incident deaths more complex slower to implement and more resource intensive. With the notable exception of south africa i think this is generally the case in much of africa and somewhat Southeast Asia where governments have a need to measure the mortality from the community because theres such a such a Big Community mortality burden that exists regardless of the pandemic and eligibility in order to form a complete picture. In such circumstances are early experience has shown that the communitybased surveillance piece of the Technical Work that needs to be accomplished has been a bit more challenging than getting facilitybased surveillance up and running but in that regard strategies have been working with a few countries including rwanda bangladesh and supporting others to leverage routine Health Systems, sorry routine Health Information systems and boost reporting of deaths to a weekly basis and this is mostly for those of you who are familiar with Health Information systems leveraging functionality within the District Health management system. Communitybased rapid surveillance in which deaths occurring are actively detected and reported on we are supporting the government of colombia and the government of bangladesh to undertake this work. In colombia at the intention is to reach remote and harder to access parts of the population in parts of the country and in bangladesh where leveraging an expanding model of vital event notification to be able to identify deaths on a more rapid basis than those previously been the case under the Registration System there. As we are beginning to support countries to produce this data of course the question arises about their youth. In addition to the advocacy and serving as a corrective for misinformation excess mortality data can be viewed in conjunction with other data to assess geographic disparities for example or perhaps even to chart the lagging because mortality is a lagging indicator but a least impact of Public Health and social him matters that ideally have an impact on both a number of cases and hence the number of deaths that are observed. If indeed there is available cause of death data it may be possible to understand the excess mortality more in terms of the specific causes of death that comprise it. Certainly the majority will be covid and suspected covid but the quotient that is left over the additional excess due to other causes may be due to some important system break downs in the Health System and knowing the specific causes can be of help to pinpoint action for dressing those situations. And lastly and this is more significant than it may seem and i think we may have had the opportunity to discuss this further they can shore up death registration during the pandemic as rapid mortality surveillance that can shore up the pandemic and in fact we are working with at least one country intending to undertake rapid mortality surveillance for precisely this reason in addition to getting a handle on the pandemic. Summing up i just want to point out that we know that knowledge is key to the response that a focus on solely covid19 diagnoses and deaths are necessary and we have to unpack it but in a position to understand the true magnitude of the pandemic and measuring mortality is one very familiar and it leaves relatively straightforward thing to do in order to fill the space knowing the epidemic in terms of crucial statistics. I would argue it adds to the urgency of. Covid19 crv s. Improvement. These are i believe the longterm solutions for a resilient system that can indeed meet the needs of future Public Health emergencies and the directors Civil Registration services in kenya summed it up nicely at. And these are the words i will leave you with. She said we have also realized the need for a brazilian crv a system in an emergency such as covid19 to meet the needs not only of the population but vulnerable and marginalized populations in the country. With that i would like to conclude and thank you and hand it back to amanda. Thanks so much. Thank you philip. Its a great overview to get us kicked off. In doing work in brazil looking at this excess mortality measurement and i hope we not only find out that the findings from brazil but also how youve seen it used in policies. Thank you amanda. Good morning or good evening to everyone. Thank you philip for helping with the presentation on excess mortality in brazil. We have talked about methods and how we did this and the Health Department and ongoing work on excess mortality. It is the data source where were we combined the two data sources we have mortality information and get that Historical Data and history in 2015 and 2020. We use Natural Causes of death and crvs data. We compared with the cbr is from 2019 and we had each age group and we applied it to you can see on the right that deaths between the blue line in the red line. This is 2020 in the red line is existing so we had quite a correction when it was needed. Thats how we did this. We used it was our reference and small areas we beat the average. So excess mortality, weeks with values below the projected baseline were disregarded. We have levels of analysis states, sex and age, two age groups and to obtain the excess death we used it the most desegregated age and sex by state or by country. So in brazil we dont have exactly raised could we use the definition in the census and using statistics data. We have a redistribution of missing data by skin color but we work with categories of white lack and pardos, and a mix of a population and analysis by brazil has the consortium of the Health State Department in blue which is the mortality for 2020 and the Historical Data. In red we had the excess mortality. We have the correction applied with death [inaudible] you can see we started in the middle of march peaking at the end of may in beginning of june and it starts to decline because of [inaudible] we dont believe its going down so fast and we are discussing it with the administration. Next, please. It is an example of different phases in brazil. We call it a late pandemic. We just use bolivia and you see it starts to peak in june and the peak of excess mortality and the end of july. This is still going on in the region. On the right you see an early epidemic because they are big surges in the Southeast Region so you see increases in midmarch peaking in the middle of june and now we feel its not so clear here but its starting to increase again access mortality because mortality speaking again. We have following other states closely as well. And the last few numbers and the right resented so members of excess mortality and the most populous states in the country with a higher number and excess mortality deaths in the state and on the right we see 74 of an increase in the amazon states. Amazon states were surprising. They have got it early in the beginning of march and it peaked quickly and in the most remote areas would have the same regions. It starts in the north than the southeast and also you can see our last date in argentina. Its a small increase in excess mortality. From the south to the countryside and now its moving to the south in brazil. It shows very well. Who is dying . The cant see many more men dying compared to women with a 27 increase compared to women 18 that some states we have 57 increase in the north region. So its a huge difference among men and women and also in the age group right here under 60 years old and in the orange 60 or more. The impact in the group that we expect mortality was on the average 20 but in some regions we are higher and also more balanced with the elderly and people under 60. Also we are reaching the entire population. We will see in the next slide please, black and brown people and i took four or five states for presentation. Some ongoing work. We have vulnerable populations and this kind of analysis could help them. People have to higher of excess mortality and we have ongoing work. The first aid here is sal Powell Powell sao paolo. With 60 of the population of white but you see the excess mortality in the lack and brown its 2 compared to 11 among the white population. In other states you can see it similar. More black and brown people are dying than whites dying with excess mortality. When we move to the right thats 30 to 59 years old we can see in sao paolo state we had 42 excess mortality among black and brown group compared to 24 of the white population in this age group. They are the states have more violence in this age group of 30 to 59 years old. We are discussing with the states how to focus on this population the more vulnerable population and how can we use the excess mortality to get a better picture of the impact of state funding. So the excess mortality dashboard that deals states by state has been used for decisionmakers and researchers discussing how to use this. [inaudible] National Newspapers showing we have debates every week on the excess mortality dashboard. But the cause of the people who would die anyway. So this kind of thing, it has the excess mortality. We just dont know. So people are dying. This disease, they could die with it. But there is excessive mortality. That is exactly sometimes the number of causes of deaths. It is very close. In and around 80 percent now. Were still working on this. For us, as to asking for more. [inaudible]. The next one. Here is the mortality rates. And now, in comparing the two. By the state using this chart as well. And here, because there is a comparison lower rate here. We realize that we need to correct these layers. Because the way the pandemic moves through here. [inaudible]. So now we have the correct information. How to do this correction. To do this kind of correction. So this is what i had to show you. We wanted to show you the mortality rates. Thank you so much doctor. Its really interesting and particularly, completely obvious implications of this data for Health System response for geographical focus. Far reaching vulnerable groups. And if patients are very clear. So thank you so much for the presentation. Lets turn to Aaron Nichols. Obviously have been working on this on global perspective but also your sitting up in with the center of disease control. What your view on the state of the system stage and what else do we need to do better on. Good day everyone. My name is Aaron Nichols. On a small team focusing on registration. Improvements and situated cdc. And the National Center since 2015. And we have partnered with vital strategies and who. To support one of the growing number of initiatives over the last ten 15 years have focused on improving registration Vital Statistics. And lower to middle Income Countries. So as well laid out. In our challenges that we are trying to tackle throughout this initiative. So this ongoing momentum who may improvements is this triple demand for more timely data. Surveillance throughout the cdc are looking at what data is available across a multitude of existence platforms. In thinking about how these platforms can be leveraged to compile mortality information. Unique openness and integration and conversions of the efforts. They made us to lasting change. If i could beat the vet academic for minute. Registration is the continuance permanence and universal recording of the occurrence. So in this case, we focused on death or mortality. Some registration is a source of mortality information because of these inherent characteristics of the system. Unlike surveys which is a oneoff or intermittent and only a sample of the registration. And by law, and provides a solid basis for everyone to participate in the system. In the Health Sector has always recognize the value of mortality data and therefore one of his most regulated uses right in the engagement with other sectors including registration officials that are typically and with the affairs that is required to achieve a comprehensive mortality program. It is linked to Civil Registration. This engagement often requires more time and attention in coordination and vertical disease Surveillance Systems. They have traditionally been able to give. And so we know have a parallel interest of the improvement in mortality surveillance. Culture a little bit more background about the work of our team. And how we have pivoted with the arrival of the covid19. And what we are thinking about as we look ahead in that phase. As a partner of the data for health initiatives. Our teams have been supporting the mortality surveillance data. It is development and implementation. We are hoping to coordinate multiple partners to support a comprehensive program with rapid mortality surveillance components. About uganda and bambi upgraded its coordinating a community of practice focus on me medical Death Investigation. Is been used for sharing covid19 debts certification guidelines among the global forum of medical examiners. To help identify probable cause when theres no physician to verify that printer team also works with who, and the Reference Group and for covid1e compile the guidance on the use of proxy in the context of the covid19 and were now coordinating an av and evaluation to assess within the new questions can identify a probable covid19 debts. And frankly supporting you as cdc covid19 response our team is working to integrate mortality surveillance. In response to the increased demand for information on mortality. So i have two slides to show hero quick. There we go. We developed the slide to show the various potential forces of mortality information across platforms. The cdc supported activities among these include the mortality prevention surveillance and initiative or champ. With a funded by the foundation. In mortality surveillance works through the u. S. Government support. With the any possible information, there are any opportunities. Bringing these together and useful manner requires coronation and support for team to working to provide. The next slide please. The second slide we see a stark contrast among countries on it complete lack of information on positive. The countries slide have no data available. Its makes the information paradox. And what we need the information the most, is just not available. Then as we are showing on the first light, we do have any potential forces we do have an opportunity now to bring them together for optimal use. So looking forward, working on implementation package for comprehensive surveillance programs. One that for example she posted by National Public institute. Together with our colleagues across cdc, or sporting efforts to coordinate and integrate Health Information systems such as this one. To clarify roles and responsibilities across the agencies. And to facilitate and secure data sharing across all stakeholders the nieces mortality information. And these efforts, our regional partners including tomato, the cdc surveillance programs, the un economic commissions through africa and you and economic Institutions Commission for asia and pacific. They play critical and complementary role in advocating at the highest level of government. In providing important coronation among the relevant government agencies. So in short on this pandemic is underscore the need for harmonizing mortality Surveillance Systems are heated and we build a home for rapid mortality efforts within a cover has a program that is backed by a continuous pulse rate and universal structure. It is in the registration of Vital Statistics and ultimately supports human rights. That is all for me. Im glad to be part of this farm and looking forward to discussion. Thank you aaron. And thank you also for sharing the slides that show there is a lot that has been done and as you can see is directed to a specific population or centers for diseases and together we have to have this optimized. Back to you to reflect on how easy that is or not. What kinds of things that you think might make it easier. And at the World Health Organization, the doctor here to reflect a little on this issue from her perspective and some new ideas in terms of building rapid mortality surveillance moving forward. Goahead doctor. Thank you amanda. Can you hear me. Great. So everyone. Hello to all of the analysts and colleagues. And all of the listeners. Thank you for having me for who to have a discussion on this very important and timely topic. Matters. Finding reliable actionable data is very important. I will make a few points here. Twelve of these 17 svgs and 67 out of 234 indicators rely on good wellfunctioning registration. It is the bedrock. Today we are reporting 973,000 deaths. Due to covid19. We know this is the number that is recorded and we also had a discussion that this may be an under report because the death reporting is also lagging. There are also other reasons for underreporting. What am told is 73 percent registered. And only 50 percent of deaths are registered. Only half of the 194 Member States report on only 80 percent of deaths of the seniors and older. In only one third of the countries accurately report the debts. Civil we have seen today, in the midst of the pandemic, is a reflection of the longstanding problem. And thats with the solutions that the partners the cdc and any experts around the world have come together and established a mechanism of rapid mortality surveillance. In their area sounded countries report certified deaths. Were getting reports from countries through the surveillance mechanisms. And as philip mentioned, there are debts that are at of the facilities in the communities. And that is where the problem is. We have the tools. The building is going to take time for the capacity. But also i think that from the Partner Organizations need to commitments. Care of all of the un entities, and the countries in these different ministries of Health Ministries of justice, ministries of interior. There is often the responsibility of death certification and causes of death ice with different ministries. So that is also an inherent problem that we are facing. I think coordination amongst all partners, led by bloomberg philanthropies and. And five Partner Organizations including the bho is an impressive effort. Has to be skilled at speed. They recognize that we as a Global Community to invest in countries that have doubled up. As well as other countries that are facing the problems. And this is apparent. Counting the dead which is a fact we are having problems. Also not to forget every death that is being reported, there is a person behind. Often we forget that. So i just thought we should take a moment to recognize the lives that we are using. And more importantly being able to account for for those. And improve our response in a way that would have an impact because as you said amanda, flying with her eyes closed and being blinded or shooting in the dark. Solutions in the work that is underway is already mentioned by erin and others. What we have done rapidly is introduced directly to with the members to report on certified deaths. On a weekly of highly biweekly basis by age, and by broader causes. And the doctor, who also infrequently says, we cannot make progress. If we cannot measure progress. So this has been established and we are working with countries to support the countries to report in a rapid matters we we can gather the certified deaths. His work in progress. Weve got a very positive response from a number of countries where hoping in the next month or so we should have a majority countries reporting. The second point is the who hosts a global database. Its a unique database approved by Member States and it dates back to the 1950s. As reported by age. And also bisects for his unique database. What we have done is scaled it up and launching the revised database for the public in a couple of months. Third, given the challenges that you have heard, who has also prioritized this is a Flagship Initiative within the division of data and delivery for impact. The full data picture to drive and make who a Data Driven Organization the flagship of the doctors Transformation Initiative of who. The wto has not been transformed sentence and inception and out has gone to a massive reengineering so that we are responsive in embracing partnerships and being able to support countries in a coordinated way bringing the partnership and Technical Assistance together. So in this regard, a month ago who along with partners, launched a technical passage for data. And we were greeted 92 in interventions. In each of the letters stands for serving surveillance population. Civil registration optimizing information systems. Reporting data in a transparent way in calling for investments into the data systems. And finally, actionable data enabling uses of data to drive policies and programs and improve those. And ultimately have a measurable impact in the lives of the people that we are serving. So this is a package that has been launched. And going forward, each of the countries have done their own assessment of where they stand for each of these elements. This will be launched in november and then we know where each of the countries are so that we can make targeted interventions and support in every aspect of the countries requesting the support. Coming back to covid19 again. We have also established the secretary between who and the un division of statistics. To start quantifying the direct and indirect impacts of covid19. The network is going to be challenged we do not have all of the deaths quantified. And that is where the rapid mortality surveillance comes into play. And its an important area of work. How we make it happen. We can say it is only one country here to countries there are five countries here. We do not have time. Nine and a half years since and to 2030. So any are relying on root causes of death. And death information. So the question here is, are we going to repair and fill the gaps, fix the problems and save another nine years. Or, we rapidly with a sense of urgency, given that we have tools now. We have partners, and we can make this happen. We know what we can do. So i think that is the question prayed and that is the message i would like us to take away. In who along with any partners that have been mentioned with the un agencies and bilateral as well as national governments, planning to have and maintain in march at the Un Commission to again make a renewal call to action with some concrete actions so that we can address once and for all these data gaps. By the end of 2021. Its very ambitious. But we must be able to come back next year and say, x number of countries with good causes of death for the root causes of death have been reported but also that there sustained capacity that is in our countries. Centers of excellence that have been established in the countries. It is possible. We speak of the providences in bangladesh. We need to see this rapidly and quickly. We discovered separated and as soon as possible. So that, i think we are open and who to work with everyone. I look forward to coming together and leap forward so that we address this problem and find a solution which we already have. It is a matter of getting to work and taking a measurable difference. Thank you. Amanda thank you. This is one of the areas where we do kind of know what to do. Of course week should test the relative prospect of the various things. But we are faced with an opportunity. And i hope to see her can we invest as much in this court data to get out of covid19 plus plus plus. As we do in other areas. We have something to offer. Not just money but no, and the experiences. Let me ask you a followup question on the issue of context of these continuous permanent universal systems that erin spoke with us about. We have an analytical approach of this mortality is a way of using existed in existing data to see what is happening. We have problems of classification of deaths from this novel disease. Because of general weaknesses in the system and Health Facilities in the classified debts. Can you maybe, we will start with philip and will go back to the group. If you could reflect on what kind of innovations that you seen. Of course the standard person in the private sector looks at us in the field and says, why are we just reporting a recording of paper. It buys and sells low. Why cant we do it in real time. You think it would be easy enough to do. To collected directly from the populace. Some cases, the Health System is reporting deaths. In other cases, the offices are responsible. If i understood your perspective of it. Other fixes other thieves seen work that are promising. Sure. I think there are systemic and Technological Innovations is an easy way of having these things to begin with. For the sake of our brief discussion here. Lets think about technological information. In precisely the ones you identified. Moving towards systems and positive death that leverage the why or why the use of the systems. But automate data entry. And generate the automated cause of death to the application, theres an automated cause of death assignment virus. And then introduces much more system consistency. And so forth into the coding a positive death. So automation drug cause of death attribution system. So in terms of systems connections targeted and limiting my remarks just to the registration and cause of death. In terms of death registration, making sure that the Health Sector, Civil Registration links is functional the systems are interoperable and events that occur within are notified to the Civil Registration authorities for later followup to registration. In the context of covid19. I will wrap up here. Im sure there are other innovations that might calling to identify. Group one that jumps out to me is the innovation of taking a surveillance viewpoint in the surveillance model that you havent Something Like programs integrated disease response which are very widespread platforms in africa. Adding in their way of collecting all incident that. And squeeze on rex to the system for detecting Community Debts in a way that siu badly needed to get on Community Burden of mortality because as you been saying, some eight deaths occurred there. Thank you so much. s thank you. To work with global surveillance. [inaudible]. They have their own data. So the cause of death and also working with unilateral. They dont have any research. [inaudible]. Thats exactly why. They dont have anything. They dont have life insurance. Even in the mortalities. They have to pay a fee to have essentials. So how to work with the situation or how to make it much more kind of the civil rights. The family should know the reason of the death. When is the cause of the death. People want to know. They want to know why. Why my beloved died. What is the cause. So if you could work with the community. The common interest, it will come. They will do this work. The reporting the deaths. So when you start this type of surveillance, everyone knows what it is. [inaudible]. They can help in these kinds of surveillance. And i agree that it is possible. And you can do it, if you cannot do it. [inaudible]. Technology available and we have experience as well. International interest in the countries. So it is possible to move this quickly. We believe its possible. And then we could move this quickly. A group effort. Amanda thank you and also for reminding us, what is the incentive that any individual has to report that is actually occurred that youre not working and health facility. Thats a really important piece of the puzzle. And their simple things that can be done to involve the people. And to make that information relative to them in their lives. It so thank you for those comments. Erin, did you want to reflect a little bit of this question of the systemic and Technological Innovations that phyllis talked about. Erin i think of philip and fatima very much agree with. I think that covid19 is really forced us to see and test the limits of what we can do with support via the virtual platforms. I think weve really seen the benefits that those can bring when we are trying to bring this new technical product and Technical Area and supporting the workforce. And in participating in it. I mentioned earlier that a community of practice, that fatima supported. So those are medical examiners that are responsible for doing autopsies and Death Investigation often there by country but also taking place out of the Health Facilities. Maybe suspicious debts but often there is only one small handful in the country working very much in isolation. It in this very much a field that is benefited by being collaborative in nature. To be using virtual platforms to give these folks a chance generate and review difficult cases. Rather than the mainstream news and the challenges that we have in the certified covid19 debts. This really been a great contribution to improving this cause of death information around the world. In general and in relation to the covid19 specifically. Another example that philip mentioned was the iris coding information. And you can do it in provisional ways in surveillance purposes in complaint and full practice and for officials but it can be quite complicated and often have to be reviewed manually then give back to needing special expertise and experience. So we been able to facilitate by monthly remote online sessions for coders in india. As a focusing on advanced cases. Soon we can link up with experts that have extensive experience and they can continue to develop their knowledge on this. So think the scenario that we thought would be very helpful. Speech of thank you. We have talked about mobile phone service is another, lots of researchers are in the business of the mobile phone surveys. How useful are they for mortality incidents. [silence]. I think are still on mute. Can you just let. Can you hear me now. Yes. I will make three points. People, technology and partnership. With regard to people. I think there is no replacement with any technology. We have to invest in building the capacity and providing the incentive. There is an attraction to this topic that is left behind. The field of crps training and good medical causes of death certifications in the medical, courses etc. Is being done but not at the skill. Investing in peoples extremely important. I think now we dont need to travel. No need to take flight and be in a hotel room under the workshop. This can be training anytime and anywhere. With mentor ship. From people who have done it. Had incentives to the mentors as well. So i community that is really prioritizing and investing in infusion. In the second is we have seen now as a result the sheriff is the result of covid19. A lot of innovations. A lot of tools, allowing private partner sector partners. They have come up with good solutions. So we the tools in the technology. And iris was mentioned. And we have the digital 11. The launched updates to 4 inches two days ago here. Mobile phone surveys. Very important costefficient way of gathering information. We are launching the World Health Data collection platform. Multi platform data collections. With Technical Support and consultation with all of the partners. Mobile phones is a very easy and affordable and efficient way to gather information. And technology is another very important resource. Especially Health Facilities etc. And then takes artificial intelligence. But when we have the data in one place. That is important for unit and they can be automated. Hundred analyzing forecast etc. So we have the technology in the tools at our disposal. I feel that sometimes winter, why cant there be an amber alert when theres a death in the community. Our methods are ready from Community Health workers in other areas. We should innovate and use those experiences for this purpose. And finally, we cant do it alone. We cant be fragmented. Partnership, publicprivate partnership. At all levels here. But think again, with an approach on the standards will be extremely important for you so that we dont keep reinventing the wheel. And going in different areas. In us making the impacts that the area demand this. Our last point is the combination of people, innovation, Technology Tools and partnerships. Hopefully, we can solve the puzzle. Amanda a grade. Let me ask the audience. Their welcome to writing the questions on twitter, perhaps text. I think those are the ways. If you want to submit questions, we can submit them. That we can address them. Have a question. The community has asked for this before. This is community of funders. Theres a lot of these ongoing activities. Theres a lot of these earmarked money Firm Specific diseases. Cards deployed. He reflect a little bit on the obstacles you see getting to better coordination of what we might be able to do about it. Of course we all wanted to work out. Well so although the real world is hard to get everyone to move in the same direction. Giving it your reflections on that. Off the top of my head. I would stand back and view these things,. Distant perspective. What i see is a couple of things. When you see progress. I do see a change in the kind of support for the strengthening. Now compared 210 years ago or more when you First Published call for addressing the disability scandal as we named it at the time. Similar certainly is progress. I think only find somewhere able to make progress on the backs of were hitched to another wagon. So even the global Financing Facility really falls under the roof of internal and child health. And there are precious views that the number philanthropy are straight up data strengthening. And for using this data to have an impact importantly were at least as importantly. I would say then, there are 243 strategic alliances that we see our vs communities need to make. What is to the enormous enterprise of Identity Management systems that are beginning to proliferate throughout the world. The relationship of establishing legal identity for Identity Management in the subject of the un of a High Level Panel at the united nations. They pointed out in fact the crv is, the foundational system for the establishment. That is the seed into the ivy system by death of an individual whos in the system needs to retire record. In certain moments of should be a relationship with the id community. In the other big driver is government targeted one of the drivers his improvement i think from the idea that we can avoid the break of gross expense upgrading or order registration role if we have proper Civil Registration and Identity Management systems in place. Rather than recreating once every election cycle party i have seen certain investments coming from that space. Split between that id systems, governance communities. Also very much womens rights gender issue. So allies in that space i think are a natural source of alliance for partnership. So thats very nicely pointed out. Thank you. Amanda and for measures of the quality in general rights. I think the team is presentation shows how important it is for equality. Give any thoughts on results made an enormous amount of progress on this. What were the ingredients. He the leadership come from. What would you say has worked well and less well. We take the country in the perspective details. How we process this. People, the surveillance, and any demands. What is more important. [inaudible]. The National Community as well. How to include them. They offer data. What we have had to get the information. So how to movement. Not just the public policy. Trying to move all of the interest from the community. Maybe, the importance of the deaths. But its important to them. To know the cause of the death. We want to know. Certainly we want to know. It is to their interests. They were healthy the public policy. So there much more interested to work with and communicate. Any debts in the community. Because they have small cemeteries. Creating a life of the people. [inaudible]. You dont talk to your people. Or create an most removed areas. They will not increase. It will work with this read. [inaudible]. If we can move this but weve created this alliance and is natural. As such as people with the position and then the government. But also people with interest at the Community Level. They want to move this. They want to do it. If you create this, we can move it. Create this kind of so how can we have ideas of what we think about this or that. [inaudible]. Because of the death. In relations to their own communities. People want to know. His foundational. Sustainable. Amanda some really vital and important point. Its especially true, any countries are federal countries where, and this is the classic local function. To register death. Russ would you do that. Making that all Work Together creating to get people engaged rated what would appeal. How could we really do this. We blame the people. How can we move this together. Not to have the solution isolated. Amanda absolutely. Dishonest a technical solution. As you pointed out. Erin, do you have any thoughts on this. And i love your slide and im going to come back to it again and again. He has a lot of different initiatives. But you do. Interoperability but. Amanda in the u. S. Government, what should we hope for in terms of support to these kinds of things. Dont answer that erin. But just, what you think might work erin. Erin from a lot of innovative technological more advanced contributions. But im going to Say Something that is equally as simple as it is challenging for investors maintaining the Attention Span on this space for a minute. It is keeping with the urgency of the Public Health data and then he said that when theres a crisis. They offer the sustainability with crs. And this is for the investments. But given all of the challenges that everybody is laid out today come the need for coordination, the under nature. The different names of people have when theyre looking at mortality data. Somebody has to keep the focus on that bigger system change. And providing the Situational Awareness of where the advancements are being made. When the funding is available for this or that aspect. In making sure efforts are complementary. But even if its a matter of getting on the phone and people have a lot of great ideas people get busy and we all have a gazillion meetings right now. Theres no followup. Keeping that conversation going. Taking notes to remember when everybody committed to Holding People accountable the great ideas we can talk about on phone call. Within they get lost lost just keeping that momentum going. Something is really valuable what philip mentioned was having this initiative or we have this luxury almost twos simply focus on the registration. A been a component of it. And although cdc first became engaged with the philanthropies on it, is my former supervisor who hired me do this work. Hes been around for over 40 years. He saw the improvements in the space i thanks for working on before the surveys came round. And he said are interesting in investing in this. What you think. Must be would be thrilled. Talking about this area of responses and how much time do you princess something that happens immediately. So i think the work to keep these and keep showing the benefits of demonstrating the value is an area that is helpful for committing to. Amanda you have any reflections on the nalco back to philip rea. [silence]. I cannot hear you. Can you hear me now. Its. Amanda yes. Sorry about that. Concrete actions now. Thats important. Commencement of the highest levels of the International Un agency now. And also the highest levels in the country. Ministries and health injustice and ministries of interior. Collaboration and commitment and next time or x months, we will have x percent of the deaths and causes of deaths recorded and reported departed this is a matter of everyone said it, is human rights and any other areas. Commencement, the focus should be in the countries of all the multilateral organizations. We need champions. Champions as communities, champions as people, jim instance country. We needed to have them who can also do the start of funding in the country so there are people who can be recredited. And made into champions. We have budgeted hundred Million Dollars for improving serious. Most of the countries that has information that is needed. With all of the money going into the country with standards tools that we already discussed that should be available so i think an investment by multi laterals and government partners. 100 million over the course of the next two years. That should close the gap. And coming back, the commitment continues and the concrete actions is monitored for accountability. It would have countries that would have better information and we have champions. So we have a pipeline. A cattle of leaders who will carry this forward. Hopefully the technology will catch up in countries where we are making progress and were not yet there. But there are some superstar examples that we can take from and replicate. So the bottom line, if we can if we can get we can fix. Amanda just to be clear, do you have hundred Million Dollars in the make for this purpose right now. Now, we have a proposal we are working with the partners to bring in and leverage of partnerships. And bring in the various organizations now at the stage. Given the covid19 response and Recovery Party to because we cannot build that better. If we leave this gaping gap. We have already said, 12 of the 17 that rely on the Civil Registration and statistics. Just that the responsibility of one. It is again, coming together. So that is the proposal that we are working towards. I will be hoping that we together. This is a responsibility countries have. Speech of yes. Being bold. In helping. Amanda if not now, when prayed so philip, who is doing but in all that brings me think about the new administration in the u. S. Government. What would you hope to see in terms of the level of experts, financially in terms of organizational faces. Might recognize recognize. What you think is important. Given observation. Of course the emphasis on preparedness now and the Global Health security that is appropriate. This is also the bedrock of that is also been under appreciated element of preparedness in my view. So he had a magic wand what would you hope to see. Phillip thats exactly where i would start is what you just indicated. I do believe the Civil Registration is the bedrock of global security. And what i would like to see is really more on the u. S. Government side, the kind of inter one government approach that has characterized responsiveness to things like malaria and hivaids. And with the rbs when we are talking with those who are coming up from a rights perspective, protecting women and others from trafficking. And from under aged marriages child labor exploitation. Those who are forced on the outside. But those also social services to the countries that are starting to connect to the registration of vital events. The legalized entities and legally established persons are thereby available or have availability to access those social services. So education. I mentioned the Election Commission on government issues before. I think all of these u. S. Government entities that are concerned with those aspects of International Affairs and those aspects of Global Development have a definite stake in the strengthening of the crps systems and i would love to see the kind of multiplayer lift anything not only does it speak when a kind of total social fact it is but how it does have a ton everything from the most fundamental of human rights to the most important and Vital Statistics use to understand and plan an impact of Important Health programs. And have that acknowledgment be reflective and various sources of support. When they may ultimately be an easier lift and trying to continue to say the Health Sector as a sharp end of the stick to try to motivate others. There. Amanda thank you. Think we have reached the end of our session. One of client out that youve been working on the systems for a long time. If doing social services more efficient and some from a gender equality standpoint. It would be great now we could look at it from the perspective of generating more specifics in creating a cross that world talking about. I hope that we can come together in this area. And sees the moment that we have. I really think audio for participating in the conversations princeton great. The stateowned party to thank you tell of your mind for joining this session. Thank you a lot. Trump telling us not to worry, that the virus will disappear. That americo is coming. Joe biden saying we need a plan. A national strategy. The president is willing to lead. Willing to be a role model for our nation. 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