A systems-change approach to addressing the mortality surveillance gap in Pakistan.

With a lack of cause of death estimation and an inadequate and fragmented Civil Registration and Vital Statistics system, Pakistan faces a significant gap in data on mortality. This poses significant challenges for health policy planning and monitoring. In this viewpoint, we draw on systems-change frameworks to examine and provide recommendations to improve mortality surveillance in Pakistan. We use the multiple cause diagram framework to understand the challenges and barriers to instituting a robust mortality surveillance system in Pakistan. We also examine current and future scenarios and what it will take to get to best future scenarios using the Theory of Change model. Through the multiple cause diagram mapping, we show that the poorly functioning mortality surveillance system in Pakistan is underlain by multiple complex and interrelated multisectoral challenges. However, a cost-effective, agile, and data-lean system of mortality surveillance can exist through strengthening already existing systems. This could be accompanied with context- and resource-sensitive use of different types of surveillance methods such as verbal autopsy tools implemented in the community and integrated into sample registration systems, as well as hospital-based surveillance in urban areas with government coordination. This can be achieved with cross-sectoral, cross-agency collaboration, capacity strengthening, and local stakeholder involvement.