An Intersectoral Approach to Hypertension Care: Solutions for Improving Blood Pressure Control in São Paulo, Brazil.

BACKGROUND: Hypertension is the leading risk factor for cardiovascular diseases (CVDs) and a major public health issue worldwide. In Brazil, it affects approximately 52.5% of the adult population. We describe the solutions package and the impact of a population health initiative in São Paulo city, following the CARDIO4Cities approach for the management of cardiovascular risk. METHODS: Using a design thinking approach, interventions were developed with a coalition of local and international stakeholders to address needs of patients, healthcare professionals, and the health system. The resulting solution package was checked to comply with guidelines for non-communicable disease and hypertension management. Clinical impact was measured by extracting the hypertension cascade of care-monitored, diagnosis, treatment, and control-from medical records. RESULTS: Under the leadership of the municipal health authorities, nine solutions were piloted and scaled across the city. Solutions conform with local and international best-practices. Between October 2017 and December 2021, 11,406 patient records were analyzed. Results showed a 40% increase in monitored patients (patients with at least one blood pressure, BP, measurement); reduced proportions of patients diagnosed among those with available BP measurements (72%-53%) and treated among diagnosed (93%-85%); and an improvement in controlled patients among those receiving treatment (16%-27%). CONCLUSIONS: The solution package described in this study was correlated with increased BP control. The implementation methodology and results add to the body of real-world evidence supporting population health implementation science in Brazil and beyond.

Development of the Systems Thinking for Health Actions framework: a literature review and a case study.

BACKGROUND: Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health. METHODS: A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study. RESULTS: The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan. CONCLUSION: The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions.

Assessing the design of road traffic death information systems in Iran: A participatory systems approach.

AIM: To describe and analyze the information architecture and information pathways of the road traffic death recording, registration and reporting system in Guilan Province, northernIran. METHODS: We used Business Process Mapping, a qualitative approach. This participatory and iterative approach consists of a document review, key informant interviews, development of a process map and a participatory workshop with key stakeholders to illuminate and validate the findings. We classified the tasks performed in the system into three phases: (1) Identification and recording; (2) Notification and registration, and (3) Production of statistics. RESULTS: We identified 13 stakeholders, with operating and influencing roles in the process of identification, registration and production of statistics about road traffic deaths in Guilan province. The three main sources of road traffic death statistics are the Ministry of Health and Medical Education, the National Organization for Civil Registration and the Forensic Medicine Organization. Our results reveal a highly fragmented system with minimal cross-sectoral data exchange. Each stakeholder operates in a silo resulting in delays and redundancies in the operating system. In the absence of an effective communication among stakeholders, the information exchange was dependent on the family of the deceased. These fragmented information silos alter the compilation of cause of death statistics and result in under-reporting and discrepancies in road traffic deaths figures. CONCLUSIONS: Designing a comprehensive road traffic information system that provides accurate and timely information requires an understanding of the information flow and the entangled web of different stakeholders operating in the system. Participatory systems approaches such as process mapping can assist in capturing the complexity of the system and the integration process by facilitating stakeholders' engagement and ownership in improving the design of the system.

Did COVID-19 Policies Have the Same Effect on COVID-19 Incidence Among Women and Men? Evidence From Spain and Switzerland.

Objective: This study aimed to investigate how COVID-19 prevention policies influenced the COVID-19 incidence in men and women. Methods: We conducted a retrospective longitudinal study using the Swiss Federal Office of Public Health and the Spanish Ministry of Health surveillance data for February 2020-June 2021 to explore sex and age differences in COVID-19 cases and testing. The female-male incidence rate ratios (IRR) were estimated for each week of the pandemic. We complemented our analysis with qualitative information on relevant containment measures in each country. Results: In Switzerland and in Spain, there was an excess of cases in women of 20-59 years old and 80+. This excess of cases was significant during the waves of the pandemic in both countries. In Switzerland, the biggest difference was observed for the age group 20-29, reaching an excess of 94% of cases compared to men during the first wave of COVID-19 (March-May 2020). The excess of cases in women was greater in Spain than in Switzerland, where it reached 159% for women aged 20-29 during the first wave (March-June 2020). In both countries, the age groups 60-79 had a significant excess of cases in men during the pandemic. Conclusion: COVID-19 public health policies affect men and women in different ways. Our findings highlight the importance of gender-sensitive responses to address a public health crisis.

From Public Health Policy to Impact for COVID-19: A Multi-Country Case Study in Switzerland, Spain, Iran and Pakistan.

Objectives: With the application of a systems thinking lens, we aimed to assess the national COVID-19 response across health systems components in Switzerland, Spain, Iran, and Pakistan. Methods: We conducted four case studies on the policy response of national health systems to the early phase of the COVID-19 pandemic. Selected countries include different health system typologies. We collected data prospectively for the period of January-July 2020 on 17 measures of the COVID-19 response recommended by the WHO that encompassed all health systems domains (governance, financing, health workforce, information, medicine and technology and service delivery). We further monitored contextual factors influencing their adoption or deployment. Results: The policies enacted coincided with a decrease in the COVID-19 transmission. However, there was inadequate communication and a perception that the measures were adverse to the economy, weakening political support for their continuation and leading to a rapid resurgence in transmission. Conclusion: Social pressure, religious beliefs, governance structure and level of administrative decentralization or global economic sanctions played a major role in how countries' health systems could respond to the pandemic.

Addressing the Evidence Gap in the Economic and Social Benefits of Civil Registration and Vital Statistics Systems: A Systematic Review.

Objectives: Considering the aspiration embedded in the Sustainable Development Goals to Leave No One Behind by 2030, civil registration and vital statistics systems have an essential role in providing reliable, up-to-date information to monitor the progress. Thus, the aim of this systematic review is to compile empirical evidence on the benefits of a functioning civil registration and vital statistics system. Methods: Selected databases were systematically searched until 2019. Key experts were also contacted for relevant literature. The review process was managed with the software EPPI-Reviewer and followed standard methods for systematic reviews. Results: A total of 18 studies were included. The findings revealed that having birth, death, and/or marriage registration, and vital statistics were associated with access to rights and protection, positive impact on economic and health outcomes, and increased access to education. Conclusion: The present review supports the idea that systemic approaches strengthen civil registration and vital statistics systems due to the cumulative effects of vital events' registration. Ensuring appropriate systems for civil registration will have an impact not only on the individuals but also on the generations to come.

Deconstructing design thinking as a tool for the implementation of a population health initiative.

BACKGROUND: The translation of evidence-based practices and rapid uptake of innovations into global health practice is challenging. Design thinking is a consultative process involving multiple stakeholders and has been identified as a promising solution to create and apply implementation strategies in complex environments like health systems. METHODS: We conducted a process evaluation of a real-world example, namely an initiative to innovate hypertension screening, diagnosis and care in São Paulo, Brazil. The parameters of the evaluation were informed by a specification rubric and categorization system, recommended for the investigation of implementation strategies, and the double-diamond conceptual framework to describe and examine the strategic architecture and nature of the design thinking approach, with particular emphasis on identifying potential areas of "value-add" particular to the approach. The retrospective evaluation was performed by an independent partner who had not been involved in the setting up and implementation of the design thinking process. RESULTS: The evaluation unveiled a dense catalogue of strategically driven, mostly theoretically based, activities involving all identified health system stakeholders including patients. Narrative reconstruction illuminated the systematic and coherent nature of this approach, with different resulting actions progressively accounting for all relevant layers of the health system to engineer a broad selection of specific implementation solutions. The relevance of the identified features and the mechanics used to promote more successful implementation practices was manifested in several distinct ways: design thinking offered a clear direction on which innovations really mattered and when, as well as several new dimensions for consideration in the development of an innovation mindset amongst stakeholders. It thereby promoted relationship quality in terms of familiarity and trust, and commitment to evidence-based enquiry and action. Design thinking was also able to navigate the territory between the need for intervention "fidelity" versus "adaptation" and provide the operational know-how to face familiar implementation hurdles. Lastly, it brought a new kind of skill set to the public health stakeholders that incorporated diplomacy, multidisciplinary approaches and management sciences-skills that are considered necessary but not yet widely taught as part of public health training. CONCLUSIONS: Design thinking is a sound and viable tool to use as part of an implementation strategy for engaging with health system stakeholders and successfully translating evidence-based practices and new innovations into routine practice, thereby addressing an important knowledge-practice gap and, more broadly, contributing to the strategic repertoire available to implementation science.

The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions.

INTRODUCTION: Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. METHODS: We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. RESULTS: The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. CONCLUSION: The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.

Assessing Determinants of Programmatic Performance of Community Management of Malaria, Pneumonia, and Diarrhea in Children in Africa: Protocol and Data Collection for a Mixed Methods Evaluation of Integrated Community Case Management.

BACKGROUND: Integrated community case management (iCCM) is a child health program designed to provide integrated community-based care for children with pneumonia, malaria, or diarrhea in hard-to-reach areas of low- and middle-income countries. The foundation of the intervention is service delivery by community health workers (CHWs) who depend on reliable provision of drugs and supplies, consistent supervision, comprehensive training, and community acceptance and participation to perform optimally. The effectiveness of the program may also depend on a number of other elements, including an enabling policy environment, financing mechanisms from the national to the local level, data transmission systems, and appropriate monitoring and evaluation. The extent to which these factors act upon each other to influence the effectiveness and viability of iCCM is both variable and challenging to assess, especially across different implementation contexts. OBJECTIVE: In this paper, we describe a mixed methods systems-based study protocol to assess the programmatic components of iCCM that are associated with intervention effectiveness and report preliminary results of data collection. METHODS: This protocol uses a mixed qualitative and quantitative study design based on a systems thinking approach within four iCCM programs in Malawi, Democratic Republic of the Congo, and Niger State and Abia State in Nigeria. Routine monitoring data are collected to determine intervention effectiveness, namely testing, treatment, and referral outcomes. Surveys with CHWs, supervisors, and caregivers are performed to collect quantitative data on their demographics, activities, and experiences within the program and how these relate to the areas of intervention effectiveness. Focus group discussions are conducted with these stakeholders as well as local traditional leaders to contextualize these data. Key informant interviews are undertaken with national- and district-level program stakeholders and officers knowledgeable in critical program processes. RESULTS: We performed 3836 surveys and 45 focus group discussions of 379 participants with CHWs, supervisors, caregivers, and traditional leaders, as well as 120 key informant interviews with district- and national-level program managers, health officers, and ministry officials. Policy and program documents were additionally collected for review. CONCLUSIONS: We expect that evidence from this study will inform child health programs and practice in low- and middle-income settings as well as future policy development within the iCCM intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33076.

Evidence From the Decade of Action for Road Safety: A Systematic Review of the Effectiveness of Interventions in Low and Middle-Income Countries.

Objectives: To evaluate the effectiveness of road safety interventions in low and middle-income countries (LMICs), considering the principles of systems theory presented in the Global Plan for the Decade of Action for Road Safety. Methods: We conducted a systematic review according to PRISMA guidelines. We searched for original research studies published during 2011-2019 in the following databases: Medline, Embase, PsycInfo, Scopus, Web of Science, Cochrane library, Global Health Library, ProQuest and TRID. We included studies conducted in LMICs, evaluating the effects of road traffic safety interventions and reporting health-related outcomes. Results: Of 12,353 non-duplicate records, we included a total of 33 studies. Most interventions were related to legislation and enforcement (n = 18), leadership (n = 5) and speed management (n = 4). Overall, legislation and enforcement interventions appear to have the largest impact. Few studies were found for road infrastructure, vehicle safety standard and post crash response interventions. Conclusion: Based on the currently available evidence, legislation and enforcement interventions appear most impactful in LMICs. However, many interventions remain understudied and more holistic approaches capturing the complexity of road transport systems seem desirable. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197267, identifier CRD42020197267.

The Need to Address Fragmentation and Silos in Mortality Information Systems: The Case of Ghana and Peru.

Objectives: We aimed to understand the information architecture and degree of integration of mortality surveillance systems in Ghana and Peru. Methods: We conducted a cross-sectional study using a combination of document review and unstructured interviews to describe and analyse the sub-systems collecting mortality data. Results: We identified 18 and 16 information subsystems with independent databases capturing death events in Peru and Ghana respectively. The mortality information architecture was highly fragmented with a multiplicity of unconnected data silos and with formal and informal data collection systems. Conclusion: Reliable and timely information about who dies where and from what underlying cause is essential to reporting progress on Sustainable Development Goals, ensuring policies are responding to population health dynamics, and understanding the impact of threats and events like the COVID-19 pandemic. Integrating systems hosted in different parts of government remains a challenge for countries and limits the ability of statistics systems to produce accurate and timely information. Our study exposes multiple opportunities to improve the design of mortality surveillance systems by integrating existing subsystems currently operating in silos.

A health systems resilience research agenda: moving from concept to practice.

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

The complexity of scaling up an mHealth intervention: the case of SMS for Life in Tanzania from a health systems integration perspective.

BACKGROUND: SMS for Life was one of the earliest large-scale implementations of mHealth innovations worldwide. Its goal was to increase visibility to antimalarial stock-outs through the use of SMS technology. The objective of this case study was to show the multiple innovations that SMS for Life brought to the Tanzanian public health sector and to discuss the challenges of scaling up that led to its discontinuation from a health systems perspective. METHODS: A qualitative case-study approach was used. This included a literature review, a document review of 61 project documents, a timeline of key events and the collection and analysis of 28 interviews with key stakeholders involved in or affected by the SMS for Life programme. Data collection was informed by the health system building blocks. We then carried out a thematic analysis using the WHO mHealth Assessment and Planning for Scale (MAPS) Toolkit as a framework. This served to identify the key reasons for the discontinuation of the programme. RESULTS: SMS for Life was reliable at scale and raised awareness of stock-outs with real-time monitoring. However, it was discontinued in 2015 after 4 years of a national rollout. The main reasons identified for the discontinuation were the programme's failure to adapt to the continuous changes in Tanzania's health system, the focus on stock-outs rather than ensuring appropriate stock management, and that it was perceived as costly by policy-makers. Despite its discontinuation, SMS for Life, together with co-existing technologies, triggered the development of the capacity to accommodate and integrate future technologies in the health system. CONCLUSION: This study shows the importance of engaging appropriate stakeholders from the outset, understanding and designing system-responsive interventions appropriately when scaling up and ensuring value to a broad range of health system actors. These shortcomings are common among digital health solutions and need to be better addressed in future implementations.

Estimating causes of death where there is no medical certification: evolution and state of the art of verbal autopsy.

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

Decentralization of birth registration to Local Government in Tanzania: the association with completeness of birth registration and certification.

BACKGROUND: In Tanzania only an estimated one-quarter of births are registered and certified. Birth registration uses a centralized system with geographic and cost barriers for families. A pilot decentralized birth registration system has been trialled in 11 of 26 regions, substantially increasing registration points, and enabling notification, registration and certification to occur in one step. OBJECTIVE: This study compares completeness of birth registration and certification and achievement of key birth registration milestones in two districts where the birth registration system decentralized and two districts with the existing centralized system. METHODS: Registration, notification, census and survey data were used to estimate birth registration completeness and quantify achievement of key registration milestones for births in 2012-16. These were compared between districts of Mbozi (decentralized in 2013) and Iringa (decentralized in 2016) and districts of Dodoma and Kibaha which remained centralized. RESULTS: For births that occurred from 2012 to 2016, completeness of birth registration/certification (by early 2017) was higher in districts that decentralized (Iringa 60%; Mbozi 52%) than remained centralized (Kibaha 36%; Dodoma 20%). Introduction of the decentralized system saw completeness for births registered within 12 months of occurrence increase in Iringa from 1% in 2014 to 67% in 2016, and in Mbozi from 15% in 2012 to 36% in 2013 before falling and subsequently increasing to 53% in 2016. In contrast, completeness in centralized districts did not increase. Although a higher proportion of births are notified in centralized than decentralized districts, registration and certification occurs for all notified births in decentralized districts but only one-third in centralized districts. CONCLUSIONS: Benefits of a decentralized system are more proximate registration points and the merging of notification, registration and certification steps. The findings, while demonstrating the immediate impact of the decentralized system on completeness, also show that continued efforts are necessary to sustain these improvements.

Thematic areas and complexity of integrated community case management (iCCM) design, implementation, and evaluation: protocol for a scoping review.

BACKGROUND: Integrated community case management (iCCM) is a community-based child health strategy designed to reduce deaths due to pneumonia, malaria, and diarrhea in low-income countries. Due to the integrated nature of the intervention and the diversity of its stakeholders and activities, iCCM is complex and comprises many systems elements. However, the extent to which studies examine these different elements is unknown. The purpose of this scoping review is to summarize the key areas of emphasis of the iCCM literature and assess the extent to which this takes into account systems complexity. METHODS: This study will be guided by Arksey and O'Malley's scoping review methodology. We will systematically screen MEDLINE, Web of Science, and the specialized platform Community Case Management (CCM) Central Library for published literature in English related to the design, implementation, and evaluation of iCCM. Two investigators will independently screen the full list of titles and abstracts for eligibility, followed by a full-text review of selected titles divided between investigators. Emergent themes will be categorized according to a thematic tool iteratively developed to guide the charting and analysis process. To compare the extent to which the literature assesses systems factors, we will compare our results with the iCCM Interagency Framework. We will use the Intervention Complexity Tool for Systematic Reviews (iCAT_SR) to assess how literature measures complexity. Results will be presented in narrative fashion, supplemented by interactive graphical interfaces. DISCUSSION: The results of this scoping review will identify the priorities and deficiencies of the analysis and evaluation of iCCM programs and may illustrate the need for systems approaches. Bottom-up emergent iCCM themes can help researchers, policymakers, and implementers target and better emphasize true priorities of iCCM. Understanding how complexity is considered and examined in iCCM may result in greater attention to this critical dimension of iCCM program assessment, resulting in the design and development of more robust and sustainable iCCM programs.

A systems approach to assessing complexity in health interventions: an effectiveness decay model for integrated community case management.

Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.

Better data for better outcomes: the importance of process mapping and management in CRVS systems.

BACKGROUND: Despite attempts to apply standard methods proven to work in high-income nations, nearly all civil registration and vital statistics (CRVS) systems in low- and middle-income countries are failing to achieve adequate levels of registration completeness or produce the high-quality vital statistics needed to support better health outcomes and monitor progress towards the 2030 Sustainable Development Goals. This suggests that, rather than simple technical issues, these countries are facing additional or different systemic challenges, including duplication of roles and responsibilities, inefficient methods of data collection, and a reluctance to change. APPLYING PROCESS MANAGEMENT: Process management is a valuable tool that strengthens the production of vital statistics by providing a visualisation of data flow from start to finish. It helps identify gaps and bottlenecks in the process, allowing stakeholders to work collaboratively to find solutions and target interventions. As part of the Bloomberg Philanthropies Data for Health Initiative at the University of Melbourne, 16 countries were supported in mapping the varied processes required in registering a birth or death. Comparative analysis exposed several limitations in the design of CRVS systems that hinder their performance - from 'passive' systems, to overly complex and fragmented system design, through to poor collaboration and duplication of efforts. CONCLUSIONS: The experiences from Myanmar, Papua New Guinea and Rwanda reported in this paper illustrate the benefits of process management to improve CRVS. While these three countries are at different stages of system development, each uniquely benefited. Process management is a useful tool for all CRVS systems, from the most rudimentary to the most developed. It can strengthen CRVS systems and improve the quality and completeness of vital statistics, resulting in more robust, reliable and timely vital statistics for health planning and better monitoring of the 2030 Sustainable Development Goal agenda.