Mortality trends in Tonga: an assessment based on a synthesis of local data

BACKGROUND: Accurate measures of mortality level by age group, gender, and region are critical for health planning and evaluation. These are especially required for a country like Tonga, which has limited resources and works extensively with international donors. Mortality levels in Tonga were examined through an assessment of available published information and data available from the four routine death reporting systems currently in operation. METHODS: Available published data on infant mortality rate (IMR) and life expectancy (LE) in Tonga were sought through direct contact with the Government of Tonga and relevant international and regional organizations. Data sources were assessed for reliability and plausibility of estimates on the basis of method of estimation, original source of data, and data consistency. Unreliable sources were censored from further analysis and remaining data analysed for trends. Mortality data for 2001 to 2009 were obtained from both the Health Information System (based on medical certificates of death) and the Civil Registry. Data from 2005 to 2009 were also obtained from the Reproductive Health System of the Ministry of Health (MoH) (based on community nursing reports), and for 2005–2008, data were also obtained from the Prime Minister’s office. Records were reconciled to create a single list of unique deaths and IMR and life tables calculated. Completeness of the reconciled data was examined using the Brass growth-balance method and capture-recapture analysis using two and three sources. RESULTS: Published IMR estimates varied significantly through to the late 1990s when most estimates converge to a narrower range between 10 and 20 deaths per 1,000 live births. Findings from reconciled data were consistent with this range, and did not demonstrate any significant trend over 2001 to 2009. Published estimates of LE from 2000 onwards varied from 65 to 75 years for males and 68 to 74 years for females, with most clustered around 70 to 71 for males and 72 to 73 for females. Reconciled empirical data for 2005 to 2009 produce an estimate of LE of 65.2 years (95% confidence interval [CI]: 64.6 - 65.8) for males and 69.6 years (95% CI: 69.0 – 70.2) for females, which are several years lower than published MoH and census estimates. Adult mortality (15 to 59 years) is estimated at 26.7% for males and 19.8% for females. Analysis of reporting completeness suggests that even reconciled data are under enumerated, and these estimates place the plausible range of LE between 60.4 to 64.2 years for males and 65.4 to 69.0 years for females, with adult mortality at 28.6% to 36.3% and 20.9% to 27.7%, respectively. CONCLUSIONS: The level of LE at a relatively low IMR and high adult mortality suggests that non-communicable diseases are having a profound limiting effect on health status in Tonga. There has been a sustained history of incomplete and erroneous mortality estimates for Tonga. The findings highlight the critical need to reconcile existing data sources and integrate reporting systems more fully to ensure all deaths in Tonga are captured and the importance of local empirical data in monitoring trends in mortality.