Abstract
Introduction:
The National Mortality Register (NMR) of Panama is a key element in demographic analysis and in acquiring an updated picture of population health in Panama. The main objectives of this study are to characterize the NMR and to enumerate its strengths and weaknesses.
Methods:
We describe the history, processes, and structure of the Vital Statistics Section of the National Institute of Statistics and Census (the curator of the NMR database). In addition, we discuss publication punctuality, underregistration of the data, the proportion of registered deaths certified by medical doctors, and the top 5 causes of death according to the 80 groups of the International Classification of Diseases, Tenth Revision. We also examine works derived from the register's data, from the first publication on its website (2002) until 2019.
Results:
The NMR procedures were described. The web reports of the NMR were performed with a delay of between 1 to 2 years. The underregistration of deaths in 2002–2019 was 14.7%, and the national yearly proportion of deaths certified by medical doctors was always above 90%. Hard-to-reach areas had higher underregistration proportions and fewer deaths certified by medical doctors. Information extracted from the NMR supports several national and international reports, geographic information systems, and studies. The most common causes of death between 2002 and 2019 were noncommunicable diseases.
Conclusions:
The NMR is a robust official information system. However, hard-to-reach areas require improvement in terms of the NMR. The NMR is used for publishing official reports, writing studies, and updating reports on the current health status of Panama in a timely fashion following international guidelines.
Keywords: mortality register, Panama, vital statistics
Introduction
Vital records, including the mortality register, are used to perform a series of demographic analyses to calculate rates and projections to assess the current and future growth of a population. A mortality register is an essential component of a health information system.1 Mortality statistics contribute to assessment of the current picture of population health and the planning, execution, and evaluation of national development programs. The main objective of the National Mortality Register (NMR) of Panama is to compile, review, and publish mortality statistics using data from every person who died in Panama.
Panama is a tropical country located in the southern part of the Central American Isthmus with an estimated population of 4,445,505. Panama became a republic in 1903.2 Panama first had 12 administrative divisions (9 provinces and 3 indigenous territories) (Figure 1). In December 2013, the area within the province of Panama west of the Panama Canal was declared a new province named “Panama Oeste.”3 However, for the current report, we use the original geographic divisions.
Figure 1.
First-Level Administrative Divisions (Provinces and Indigenous Territories) of the Republic of Panama, 2014
Source: DIVISIÓN POLÍTICA DE LA REPÚBLICA DE PANAMÁ POR PROVINCIAS Y COMARCAS, AÑO 2010 (28). Ngäbe-Bugle, Emberá and Guna-Yala are Indigenous Territories (Comarca in Spanish).
The main objectives of this study were to characterize the NMR of Panama and to enumerate its strengths and weaknesses.
Materials and Methods
Using interviews with the officer of the Vital Statistics Section (VSS) of the National Institute of Census and Statistics (INEC, acronym in Spanish) and from the official documentation, we described the history and procedures of the NMR.
Strengths and Weaknesses of the Register
The punctuality of the NMR was assessed using the time between data generation and the published report extracted from the NMR website between 2002 (when the first report was uploaded online) and 2019. Although the website also shows reports from 2020 onwards, such information will be evaluated in future studies because of the unique impact of the COVID-19 pandemic.
Using the observed deaths and the census population as of July 1, a mortality table was prepared to evaluate life expectancy at birth. A hypothesis of expected life expectancy at birth in the year 2050 was formulated via Coale and Demeny model tables, and logit West Brass was used to obtain expected deaths, since this is the model used for the behavior of mortality in the countries of the Latin American region. The yearly national underregistration rates were calculated using the number of yearly registered deaths extracted from the reports from the NMR website and corresponding estimated deaths, which were calculated by the INEC Demographic Analysis Unit between 2002 and 2019.
The underregistration rate was calculated using the following formula:
 |
The national and provincial proportions of underregistration are reported for 2002–2019 in a similar fashion.
The national yearly proportions of deaths certified by medical doctors were assessed using official reports between 2002 and 2019. The national and provincial proportions of deaths certified by medical doctors are reported for 2002–2019 in a similar fashion.
We report the top 5 most common causes of death according to the Mortality Tabulation List 2 (80 groups) of the International Classification of Diseases, Tenth Revision (ICD-10)4 extracted from the most recent VSS official reports between 2002 and 2019 on its webpage.5
Routine official report information was described by VSS officers (FG/FI/AR). Other reports were also mentioned. A search of the latest literature using NMR data was performed using the Medline and Web of Science databases.
Ethical Statement
Anonymous secondary data were taken from the Mortality Registrars and from the publicly available web page; therefore, no ethics approval was required.
Results
NMR Characterization
Official national death statistics in the Republic of Panama have been published since 1907. Starting in 1942, official death statistics were published by the Directorate of Biostatistics and Health Education of the Ministry of Health and Public Works. Since 1952, these statistics have been published by the Subsection of Vital Statistics as a dependency of the Social Statistics Subdirectorate of the Direction of Census and Statistics within the Direction of Biostatistics and Health Education. Since 1964, the Subsection of Vital Statistics has been named the VSS. Since 1952, the VSS has published national official vital statistics tables in printed form.
In 2009, a new law (10/2009) was introduced with the aim of modernizing the National Statistics System and officially implementing the INEC as a dependency of the Contraloría General de la República (in English: National Comptroller General of Panama).6 The main aims of the VSS are as follows:
To establish the principles and rules that govern statistics-related activities in the Panamanian government.
To implement the INEC, the National Statistics System, the National Council of Statistics, and the Technical Consulting Committees and to rule regarding the National Statistics Plan to articulate its activities.
To establish the principles and to improve the duties of the National Statistics System for coordination regarding the participation and collaboration of governmental institutions. The National Statistics System, when needed, shall foster cooperation from private institutions and the public.
To foster the integration and development of the National Statistics System to satisfy citizens' rights to grant them access to public official information.
The VSS is within the INEC. The VSS and 8 INEC regional offices code death certificates. Table 1 shows the regional offices and their respective geographic areas covered by the NMR (Figure 1). There is an INEC regional office per province except for the Herrera/Los Santos regional office, which covers 2 provinces, mainly due to their geographic proximity. Coding of death certificates in the Province of Panama is performed by the VSS. The Ngäbe-Buglé Indigenous Territory districts are covered by the closest INEC regional office, the Emberá-Wounnan Indigenous Territory is covered by Darién, and the Guna-Yala Indigenous Territory is covered by the VSS (Table 1). The VSS is financed by public funds, with 20 people working full-time.
Table 1.
The Vital Statistics Section (VSS), the National Institute of Statistics and Census (INEC, Spanish Acronym) Regional Offices and Their Respective Geographic Areas Related to the National Mortality Register (NMR) of Panama
| Office | Geographic area covered |
|---|---|
| VSS (in Panama City) | Panama Province and Guna-Yala Indigenous Territory |
| INEC regional office | |
| Bocas del Toro | Bocas del Toro Province and the following Ngäbe-Bugle districts: Kankintú, Kusapin, Jirondai, and Santa Catalina |
| Coclé | Cocle Province |
| Colón | Colon Province |
| Chiriquí | Chiriqui Province and the following Ngäbe-Bugle districts: Besikó, Mironó, and Nole Düima |
| Darién | Darien Province and Emberá-Wounnan Indigenous Territory |
| Herrera/Los Santos | Herrera and Los Santos provinces |
| Veraguas | Veraguas Province and the following Ngäbe-Bugle districts: Müna and Ñürúm |
| Panama Oeste | Panama Oeste Province |
The procedures of the NMR performed by the VSS closely follow the Principles and Recommendations for a Vital Statistics System, Revision 3 (PRVSS)7 and the Code of Good Practice in Statistics for Latin America and the Caribbean.8 Both are international standards to foster high-quality vital statistics systems.
Death registration is possible nationwide due to interinstitutional coordination and collaboration among the Ministry of Health, the Civil Records Department of the Electoral Tribunal, the Legal Medicine and Forensics Sciences Institute, and the VSS.
Until 2008, each death was independently recorded by 2 institutions, the VSS and the Civil Records Department of the Electoral Tribunal, using 2 different forms. Currently, the Unique Clinical Death Report Form, a standard form, is used by every institution for recording deaths and related information. To point out the historical relevance of this standard form, we extracted information from official reports preceding 2008, shortly after 2008, and the most recent information.
The original paper form of the Unique Clinical Death Report Form is collected by the Civil Records Department of the Electoral Tribunal within a week after the event. A hard copy of the form is also collected by either the corresponding INEC regional office or by the VSS within a 15-day period. Then, the Unique Clinical Death Report Form is coded and sent via the web to the Death Subsection of the VSS. Since 2015, the INEC regional offices and the VSS have validated the coded data from the form using other sources (described below). Then, the hard copies of the standard form stored in each INEC regional office are sent monthly to the Control and Promotion Subsection of the VSS.
The main cause of death is classified according to book I of the ICD-10 and according to 4 shortened lists of ICD-10 codes of the 103, 80, 6/67, and 51 death groups since 1998.4 Contributory causes of death are also classified according to the ICD-10 codes since 2016.
The Control and Promotion Unit of the VSS receives, reviews, validates, and cross-checks the coded web data sent by each INEC regional office. Every 6 months, a report is produced to assess delayed death certificates. Delayed death certificates (less than 1%) are archived for a monthly in-depth review.
The information that feeds the NMR is stored in 3 data-bases: (1) as hard copies of the death certificates stored in the Civil Records Department of the Electoral Tribunal; (2) in crude electronic form stored in the National Information Technology (IT) Department of Contraloría; and (3) as a clean database curated by the VSS. Before 1996, the VSS published mortality statistics using paper-based death certificates and mortality aggregated data provided by the National IT Department of Contraloría. Since 1996, the VSS has published mortality statistics using data extracted from the database they curate. Between 1996 and 2000, the clean database was stored in Visual Basic FoxPro format. Currently, the clean database is stored in a Microsoft SQL Server version 06.01.7601. The other 2 databases are backups of the NMR.
As shown in Table 2, the NMR contains variables that correspond to the direct and indirect themes of the deceased person and the death event according to the PRVSS. For example, the death date is recorded as the day, month, and year.7 The report of the direct themes of the PRVSS in the death certificate is also required under articles 58 to 70 of Law 31/2006.9 Among these variables, the name, unique personal identification number (assigned to each person who is living or who has lived in Panama), birth date, and sex are considered direct themes of the deceased person.7
Table 2.
List of Variables Included in the National Mortality Register
| Variable | Description |
|---|---|
| Name | Name of the deceased |
| Day of death | Date of death |
| Month of death | Month of death |
| Year of death | Year of death |
| Sex | Sex of the deceased |
| Age | Age of the deceased |
| ID number | Identification number of the deceased (Panamanian ID or passport if the deceased was born outside Panama) |
| Security Number | Security number of the deceased |
| Main cause of death | ICD-10 code of the main cause of death |
| Main cause of death description | Main cause of death text description |
| Cause of death A Part I | ICD-10 code of the cause of death A Part I |
| Cause of death A Part I description | Cause of death A Part I description |
| Cause of death B Part I | ICD-10 code of the cause of death B Part I |
| Cause of death B Part I description | Cause of death B Part I description |
| Cause of death C Part I | ICD-10 code of the cause of death C Part I |
| Cause of death C Part I description | Cause of death C Part I description |
| Cause of death Part II | ICD-10 code of the cause of death Part II |
| Cause of death Part II description | Cause of death Part II description |
| List 80 | 80 group list of ICD codes for the main cause of death |
| List 51 | 51 group list of ICD codes for the main cause of death |
| List 667 | 6/67 group list of ICD codes for the main cause of death |
| List 103 | 103 group list of ICD codes for the main cause of death |
| Occupation | Eleven occupation groups of the deceased:
|
| Civil Status | Civil status of the deceased:
|
| Deathplace Province | Province where death took place |
| Deathplace District | District where death took place |
| Deathplace Corregimiento | Corregimiento where death took place |
| Geographical area | Geographical area where the death took place:
|
| Death in hospital | Whether the death occurred in a hospital or not |
| Residence Province | Province where the deceased lived |
| Residence District | District where the deceased lived |
| Residence Corregimiento | Corregimiento where the deceased lived |
| Certification code | Person who certified the death:
|
| Medical certification | Death certified by a medical doctor (physician or medical examiner) |
| Medical details | The name of the medical institution where the death took place, if available |
ICD-10, International Classification of Diseases, Tenth Revision.
There are several quality parameters of a death register. According to the PRVSS, it is recommended to cross-validate the data derived from the NMR with independent sources that also document the death event.7 Since 2016, the VSS regional offices and the VSS have carefully cross-validated the age, sex, and unique identification number of the deceased person using the Identification Verification System curated by the Civil Records Direction of the Electoral Tribunal. However, if the deceased person was not a Panama national and did not have a Panamanian identification number, the passport number is used instead. Data stored in the NMR are also cross-checked yearly with the National Integrated System of Criminal Statistics curated by the Panamanian Ministry of Public Security.10
Strengths and Weaknesses of the Panama NMR
The time between the generation of the data and the web-based reports in the study period was a year, except for the following reports that took 2 years: 2002 and from 2007 up to 2012 (Table 3).
Table 3.
Publication Year of the Panamanian National Mortality Register (NMR) Reports on its Website, 2002–2019
| NMR report | Publication year |
|---|---|
| 2002 | 2004 |
| 2003 | 2004 |
| 2004 | 2005 |
| 2005 | 2006 |
| 2006 | 2007 |
| 2007 | 2009 |
| 2008 | 2010 |
| 2009 | 2011 |
| 2010 | 2012 |
| 2011 | 2013 |
| 2012 | 2014 |
| 2013 | 2014 |
| 2014 | 2015 |
| 2015 | 2016 |
| 2016 | 2017 |
| 2017 | 2018 |
| 2018 | 2019 |
| 2019 | 2020 |
The yearly national underregistration rate reached a maximum of 19.0% in 2011 and a minimum of 10.2% in 2008 (Figure 2).
Figure 2.
Yearly Underregistration of Deaths of the Panamanian National Mortality Register (NMR), 2002–2019
Sources: Registered deaths are shown on the National Mortality Register website; yearly expected deaths were provided by the Demographic Analysis Unit of the Panamanian National Institute of Statistics and Census (INEC) as described in the main text.
The national underregistration rate from 2002–2019 was 14.7% (Figure 3). The provinces with proportions of underregistered deaths during 2002–2019 higher than the national value were Chiriquí (17.8%), Comarca Guna Yala (17.4%), Coclé (25.5%), Veraguas (26.0%), Comarca Ngäbe-Buglé (47.7%), Darién (47.9%), and Comarca Emberá (68.9%). The yearly national proportion of deaths certified by medical doctors was higher than 90%, with a maximum value of 96.7% in 2019 (Figure 4).
Figure 3.
Underregistration of Deaths in the Panamanian National Mortality Register by Province, 2002–2019
The underregistration of deaths in Panama Oeste is shown together with that of the province of Panama between 2014 and 2019. Sources: Registered deaths are shown on the National Mortality Register website; yearly expected deaths were provided by the Demographic Analysis Unit of the Panamanian National Institute of Statistics and Census (INEC) as described in the main text.
Figure 4.
Yearly Proportion of Deaths Certified by Medical Doctors in the Panamanian National Mortality Register (NMR), 2002–2019
Sources: The proportion of registered deaths certified by medical doctors was extracted from the Panamanian National Mortality Register website.
The proportion of deaths certified by medical doctors from 2002–2019 was 94.0% (Figure 5). The provinces that had proportions of deaths certified by medical doctors during 2002–2019 lower than the national value were Darién (89.7%), Herrera (88.3%), Coclé (88.1%), Veraguas (77.5%), Comarca Emberá (64.3%), Comarca Ngäbe-Buglé (59.1%), and Comarca Guna-Yala (28.8%). The VSS generates a monthly report to the Statistics Division of the United Nations (UN) with the national number of deaths and the national death rate. The VSS responds to a yearly questionnaire regarding detailed vital statistics by the same division of the UN. The Pan American Health Organization receives a copy of the NMR database curated by the VSS yearly.
Figure 5.
Proportion of Deaths Certified by Medical Doctors in the Panamanian National Mortality Register by Province, 2002–2019
The proportions of deaths certified by medical doctors in Panama Oeste and Panama are shown together between 2014 and 2019. Sources: Registered deaths are shown on the Panamanian National Mortality Register website; yearly expected deaths were provided by the Demographic Analysis Unit of the Panamanian National Institute of Statistics and Census (INEC) as described in the main text.
The VSS publishes an annual web-based report of the NMR called Vital Statistics Volume III: Deaths.11 This report includes mortality statistics published in at least 22 tables as suggested in the PRVSS.7
The NMR provides data for several health-related governmental institutions. For example, the Ministry of Health periodically publishes a report called “Analysis of Health Status” using data from the NMR and comparing with other sources.12 In addition, the Gorgas Memorial Institute for Health Studies has 2 geographic information systems to visualize malignancies and cardiovascular-related mortality using NMR data.13,14 Furthermore, several studies have used NMR data to assess the mortality and sociodemographic variables of several diseases.15-21 Others have used information extracted from the NMR to compare the Panamanian death rates with those of other countries.22-26 Panamanian insurance companies offering life insurance require actuarial technical notes that support their products using data extracted from official reports published by the VSS.27
During the study period, the annual leading cause of death nationally was malignant neoplastic diseases. The following second, third, and fourth yearly leading causes of death nationally varied among the following 3 groups: “accidents, self-inflicted injuries, physical assault and other violence,” “heart ischemic disease,” and “cerebrovascular disease.” The fifth leading annual cause of death in Panama was diabetes mellitus (Table 4).
Table 4.
Yearly Ranking of the Top Causes of Deaths According to the 80-Groups of ICD-10 in the Panamanian National Mortality Register, 2002–2019
| Ranking | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases | Malignant neoplastic diseases |
| 2 | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Stroke | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Ischemic heart diseases | Ischemic heart diseases | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Enfermedades cerebrovasculares | Ischemic heart diseases | Enfermedades cerebrovasculares |
| 3 | Stroke | Stroke | Ischemic heart diseases | Stroke | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Ischemic heart diseases | Ischemic heart diseases | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Ischemic heart diseases | Ischemic heart diseases | Enfermedades cerebrovasculares | Ischemic heart diseases | Enfermedades cerebrovasculares | Ischemic heart diseases |
| 4 | Ischemic heart diseases | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Stroke | Stroke | Stroke | Stroke | Stroke | Stroke | Stroke | Stroke | Stroke | Stroke | Ischemic heart diseases | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence | Accidents, self-inflicted injuries, assault and other violence |
| 5 | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus | Diabetes mellitus |
ICD-10, International Classification of Diseases, Tenth Revision.
Discussion
Herein, we provided a detailed overview of the current registration practices of the NMR. Eight INEC regional offices and the VSS code data from death certificates. All data received are carefully revised before adding them to the curated NMR database to produce official mortality statistics reports in a timely fashion.
Data extracted from the NMR have been used in several reports and studies. The leading cause of death between 2002 and 2019 was noncommunicable diseases, with small changes in the ranking of diseases.
The completeness of death registration data, accurate coding of the cause of death, and identification of the underlying cause of death are key issues for any national mortality registry.7 There is a lack of studies describing the NMR at a subnational level. Notably, other studies have compared the performance of the NMR with those of other countries, ranking it as good.23,24,26 One of the publications of the Global Burden of Diseases collaboration estimated that the NMR had >95% completeness in 2014.23
One of the advances of the NMR is recording the contributory causes of deaths since 2016. This novel advance might help researchers use the NMR database to clearly understand the chain of events leading to death when needed and to identify an outcome that might not be captured by the main cause of death.
Since 2014, the NMR results from the prior year have been published regularly. This follows the “timeliness and punctuality” principle of the Code of Good Practice in Statistics for Latin America and the Caribbean.8
One of the strengths of the NMR is that the VSS closely follows the PRVSS6 when it inputs and revises the data of the NMR database, which provides high-quality mortality statistics in Panama in a timely manner. The Panamanian identification number is unique, making it easy to link to other national registers. The VSS together with INEC regional offices review and crosscheck the information of each registered death event that occurs in Panama with independent information systems before adding the deceased person and the death information to the NMR and publishing a high-quality official mortality statistics report. The comprehensive PRVSS parameters of the NMR are a consequence of a close interinstitutional collaboration of the INEC, the Panamanian Health Ministry, the Tribunal Electorate, and Institute of Legal Medicine and Forensics Sciences in the last 10 years. Unfortunately, previous studies have shown that in a few other countries in the Americas, most deaths are not registered, particularly in Honduras, Haiti, and Bolivia.23,24 However, some weaknesses of the NMR include underregistration and the low proportion of deaths certified by medical doctors in hard-to-reach provinces.
Conclusion
The NMR is a robust official information system. The NMR provides high-quality information supporting reports, geographic information systems, and studies in a timely fashion. Although the NMR needs improvements in the data collected from provinces and indigenous territories that are difficult to reach, it plays a unique and critical role in providing health metrics for Panama.
Acknowledgments
Each author of this manuscript was financed with public funds. HKQ is a member of the Sistema Nacional de Investigación (National System of Research) of the National Secretary of Science and Technology (SNI, SENACYT, Panama).
We thank Mr. Raúl Angulo from the Demographic Analysis Unit, INEC for providing us with the national and provincial yearly death underregistration proportion data.
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