Dying to count: mortality surveillance in resource-poor settings

Reliable cause-specific mortality data constitute a crucial resource for health monitoring, service planning and prioritisation. However, in the majority of the world's poorest settings, systematic health and vital event surveillance systems are weak or non-existent. As such, deaths are not counted and causes of death remain unregistered for more than two-thirds of the world's population.For researchers, health workers and policy makers in resource-poor settings, therefore, attempts to measure mortality have to be implemented from first principles. As a result, there is wide variation in mortality surveillance methodologies in different settings, and lack of standardisation and rigorous validation of these methods hinder meaningful comparison of mortality data between settings and over time.With a particular focus on Health and Demographic Surveillance Systems (HDSSs), this paper summarises recent research and conceptual development of certain methodological aspects of mortality surveillance stemming from a series of empirical investigations. The paper describes the advantages and limitations of various methods in particular contexts, and argues that there is no single methodology to satisfy all data needs. Rather, methodological decisions about mortality measurement should be a synthesis of all available knowledge relating to clearly defined concepts of why data are being collected, how they can be used and when they are of good enough quality to inform public health action.