Are We Counting the Dead Right? A New Report Raises Alarms

India is gearing up for a fresh census after nearly 14 years. The last one was in 2011. This time, the government will count people based on education, income, caste, and language. But while we count the living, do we know how many have died? Has India kept track of its dead in the last five years? Do we know the causes? And what are the states doing about it?

A new report by the Registrar General of India answers these questions. It shows how deaths are being recorded—and where the system is failing.

India continues to struggle with counting its dead. The government reveals serious gaps in the country’s system of medical death certification. Many hospitals aren’t reporting causes of death, and large states like Madhya Pradesh show extremely low certification rates. The data shortfall became stark during the COVID-19 pandemic, when excess deaths far outnumbered official counts. Without accurate records, India risks failing to understand what is truly killing its citizens — and how to respond.

When a person dies in a hospital or during medical care, doctors have to issue a certificate stating the cause of death. This system is called Medical Certification of Cause of Death (MCCD). It helps the government understand which diseases are killing people and helps plan health services accordingly. The 2021 schedule of the Registrar General of India Report: This shows how 'well' the system is working across the country.

How do we keep the count?

The MCCD scheme works under the Birth and Death Registration Act 1969. This law requires doctors who treat patients during their final illness to issue death certificates free of charge. On the form, doctors can write down the sequence of events leading up to death and other health conditions that may have contributed to it.

Thirty-two states and union territories had officially launched this certification system as of 2021. However, the report underlines that not all hospitals in these states are still participating in the program.

National implementation status

There were 67,877 medical institutions with inpatient beds across India in 2021. Of these, 59,294 were supposed to be covered under the MCCD scheme, but only 33,645, a little over half, actually reported death certificate data. This means that only 57 percent of the covered hospitals are properly reporting certified causes of death.

 Certification success rates varied greatly across states. Some states, such as Goa, Delhi, and Punjab, achieved 100 percent reporting from their covered hospitals, while Jammu and Kashmir managed only 7.4 percent.

When looking at all registered deaths nationwide, only 23.4 percent received medical certification in 2021. This percentage is slowly improving from 20.7 percent in 2019 to 22.5 percent in 2020. But this rate of improvement is quite slow, and many states in India are lagging far behind in this regard.

 While some states performed much better than the national average, Goa and Lakshadweep certified 100 percent of their registered deaths.

Which diseases are killing Indians

According to certified death data, heart and circulatory diseases remained the biggest killer, accounting for 29.8 percent of medically certified deaths. Respiratory illnesses such as pneumonia and lung problems caused 12.7 percent of deaths, while infectious diseases contributed 6.1 percent. Cancer caused 4.5 percent of certified deaths, and injuries from accidents or violence contributed 4.3 percent.

 Interestingly, a category called “codes for special purposes” caused 17.3 percent of the deaths. This classification probably includes many COVID-19 deaths, as the pandemic peaked in 2021.

Situation in Madhya Pradesh

Madhya Pradesh presents a worrying picture of medical death certification. The state had 4,210 medical institutions with inpatient beds in 2021, but only 2,122 were covered under the MCCD scheme. Of these covered institutions, only 830 actually reported death certificate data. This means that only 39.1 percent of the covered hospitals in Madhya Pradesh were properly participating in the certification system.

The overall certification rate was particularly low in Madhya Pradesh. Of the 702,527 registered deaths in the state during 2021, only 58,323 received medical certification. This translates to only 8.3 percent of all registered deaths being medically certified, ranking Madhya Pradesh 32nd among all reporting states and union territories.

However, the situation is better when looking at the deaths of people who received medical care before they died. Of those who received medical attention during their final illness, 19.5 percent of their deaths were medically certified. While this is better than the overall rate, it still reflects significant gaps in the certification process.

The disease pattern in Madhya Pradesh largely mirrors the national trend. Heart and circulatory diseases were the leading cause of certified deaths at 31.7 percent, slightly higher than the national average. However, the state showed a higher percentage of deaths from unexplained causes, with 19.6 percent falling into the "symptoms and signs" categories, suggesting the challenges of diagnosis.

Respiratory diseases accounted for 9.1 percent of certified deaths in Madhya Pradesh, while diabetes and other metabolic diseases caused 8.2 percent. Infectious diseases were responsible for 3.3 percent of certified deaths, and cancer and injuries both contributed 3.1 percent.

Undercounting of COVID deaths

A separate analysis of death registration revealed a startling discrepancy in COVID-19 reporting. India registered about 25.8 lakh more deaths in 2021 than in 2019, but taking population growth into account, the actual increase was about 20 lakh. This is almost six times more than India's official COVID-19 death count of 3.3 lakh for 2021.

Madhya Pradesh was among the states with significant underreporting. The state had nearly 1.3 lakh excess deaths in 2021, 18 times more than the official COVID-19 death toll of about 6,900. This suggests that many COVID-related deaths were either not recorded or added to other causes.

Gujarat showed the worst discrepancy with nearly 2 lakh excess deaths, while the official COVID deaths were only a little over 5,800. West Bengal, Bihar, Rajasthan and Jharkhand also showed significant undercounting.

Challenges and way forward

The 2021 data highlights several significant issues with India’s death certification regime. Many hospitals are not participating in the MCCD scheme, and even among those that do, compliance is poor. States like Madhya Pradesh need to significantly improve both hospital participation and certification rates.

The COVID-19 pandemic exposed the weaknesses of this system, with massive under-reporting of deaths possibly related to the virus. This has serious implications for understanding the true impact of the pandemic and planning for future health emergencies.

To improve the system, states need to ensure that all medical institutions participate in the MCCD, properly train healthcare workers, and create better incentives for accurate reporting. Only then can India have reliable data on which diseases are affecting its population and plan appropriate healthcare responses.

Edited by Diwash Gahatraj

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