Facilitators, Barriers, and Lessons
Open Access DepositedIntegrated Mortality Surveillance in the United States, Colombia, and Zambia
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1.) Describe how CRVS and MS functions are organized in the U.S., Colombia, and Zambia
and 3.) Understand the facilitators and barriers to integrating the mortality surveillance systems and the CRVS in the U.S., Colombia, and Zambia. Methods
This study examined how integrated mortality surveillance systems (IMSS) operate in three contrasting contexts- the United States, Colombia, and Zambia- and how institutional, technical, and organizational factors beyond basic digitization enable timely access to mortality data for public health use. The specific aims were to
A total of 23 participants were interviewed in the United States (12), Colombia (6), and Zambia (5). Across the three countries, integration was found to be an institutional process rather than a purely technical one. In the United States, long-standing institutional maturity, standardized certificates, and incentive-based federal-state arrangements supported high levels of integration, though variability across jurisdictions remained. Colombia demonstrated how centralized stewardship and nationally managed digital platforms can reduce fragmentation and support more consistent data flows, while also revealing the importance of sustained inter-institutional coordination. In Zambia, integration was more catalytic and adaptive, relying on partnerships, community surveillance assistants, and verbal autopsy to extend mortality reporting in settings with limited routine registration. A sample registration system has been launched to fill the gaps in completeness and timeliness of mortality data. Across contexts, digitization improved timeliness primarily when combined with a clear governance framework, interoperability, data-sharing agreements, trained personnel, and feedback loops that reinforced data use. Common challenges included uneven subnational capacity, dependence on external funding, and gaps between legal mandates and operational practice. Conclusions
Reliable and timely mortality data are essential for public health decision-making, yet many countries continue to struggle with fragmented civil registration and vital statistics (CRVS) and public health mortality surveillance (PHMS) systems. While digitization is widely promoted as a solution, less attention has been paid to how broader digital ecosystems, governance arrangements, and institutional practices shape the integration and performance of mortality surveillance. Objectives
2.) Assess the degree and outcome of systems integration between each country's CRVS and mortality surveillance functions using the Centers for Disease Control and Prevention (CDC)’s Theory of Change (ToC) for integrated mortality surveillance framework
Background
A qualitative, multi-country case study design was employed to understand the phenomenon of integration of the CRVS and PHMS systems in the three countries. Semi-structured key informant interviews were conducted with national and subnational stakeholders involved in in CRVS, mortality data systems, and mortality surveillance. Interviews were complemented by document review. Transcripts were coded and analyzed using a reflexive thematic approach guided by CDC’s ToC, enabling cross-country comparison while preserving contextual specificity. Findings
The findings suggest that strengthening mortality surveillance requires moving beyond stand-alone electronic systems toward integrated digital ecosystems supported by legal mandates, policies, governance, financing, and workforce capacity. Investments in interoperability, institutional coordination, and sustained domestic ownership are critical for ensuring that mortality data are not only collected, but are timely, accessible, and actionable for public health.
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