Status of Death Registration in HDSS sites of Uganda
Interviews with Subcounty chiefs and town clerks show low death registration rates, below 1% from January to December 2020 in all the four sub-counties and one town council where the study was conducted. The causes of death are not reported. The findings from the qualitative study in all the 3 HDSS sites confirm a low prevalence of death registration as elaborated below:
“Death registration was prominent in the 1980s. By then, it was a must that people had to report to the sub-county chiefs. But people nowadays do not register deaths at the sub-county offices due to various reasons, including distance, cultural norms, money, and religion. In the past month, we have buried many people, but we have not registered any.
(KII, Kyamulibwa Sub-county, Kyamulibwa HDSS).
The few death registrations recorded at the sub-counties are usually done more than three months after a death. This translates into delayed and late registration according to the ROPA 2015. This is further elaborated by one of the key informants thus:
“When a person dies, people do not immediately come to register the death. They come three months later or many years later to register a death especially to process powers of administration for the estate of the deceased. The death registration process is initiated by the family members by asking for a death confirmation letter from the chairperson of the Village to be brought to the sub-county chief. I confirm that the only time people come for death registration is when they are going to the administrator general”.
(KII, Nakigo Sub-county, Iganga-Mayuge HDSS).
Social norms and their contribution towards low death registration
The elderly are buried after 3-4 days of death while the young people are buried after 1-2 days.
An older person is generally buried after 3-4 days of death as they await children, relatives, and community members to gather. On the other hand, the burial of young people usually takes place 1-2 days after death. Older persons usually have properties that are distributed amongst the children of the deceased. Hence, local leaders are typically notified about the deaths because they are usually involved in affirming the property distribution of the dead. Even when an elderly dies, all community members cannot engage in economic activities such as cultivation until burial but rather gather at the deceased home and mourn the dead.
The funeral for a child is usually completed on the same day of death while for adults, it takes some days after burial. This time is usually given to find out some underlying information. For example, the last funeral rite for men is done after 40 days of death to cater for children in the inheritance sharing from wives of the deceased who could have been pregnant at the time of death. Funerals for children have limited activities including informing local leaders. When the funeral is completed on the same day of death, the majority of the people including the family are then preoccupied with their day-to-day chores and activities thereby diminishing the chances of reporting such deaths to civil registration authorities. More people attend burials for the elderly and the family is more likely to register deaths for the elderly as compared to those of the young ones as elaborated thus:
“When an elderly man dies, we do not go to the garden that day but instead congregate with the family of the deceased, days before and after the burial to comfort them. Many people attend the burial, and they come from as far as the towns. However, for young people, children, and women, few people attend. No one can even think of registering such a death, yet old men can be registered”.
(Participant, FGD with men, Bulamagi Sub-county, Iganga-Mayuge HDSS).
Traditional will-making and heir installation after the death of a family head
Traditional will-making before the death of a family head and installation of the heir does not require the processing of letters of administration for the property of the deceased and this consequently discourages death registration. The fact that clan or community members believe in the will read and implemented during “Kwabya olumbe,” i.e., the last funeral rite does not motivate the family members to register the death to the civil registration authority. A death certificate, in this case, is not a requirement before the installation of the heir by the family members. Indeed, even the property sharing among the relatives is based on the uncertified will left by the deceased. The majority of respondents mentioned that the heir installed after this ritual was recognized by all family and community members. Therefore, death registration is not a requirement to give powers of administration on the estates of the deceased to the heir. This is elaborated below thus:
“When the head of a family who has been sick for some time dies, he leaves a will with someone who is not from his family. This ‘will’ is supposed to be read on the burial day or some days after, giving inheritance details of the deceased and mentioning the heir. The heir is allocated a piece of land and sometimes a stool as a symbol that he has taken over leadership from the deceased. This gives the heir recognition and authority over the property of the deceased. Therefore, there is no need to register the death of the deceased to obtain powers of administration for the property since everyone acknowledges the heir installed after this ritual locally known as okwabya olumbe.”.
(Participant, FGD with men, Kyotera Sub-county, Rakai HDSS).
It is taboo to announce the death of infants and neonates in the community
Cultural taboos hinder family members from death announcements for infants and neonates in the community. Hence, the civil registration authorities and the community members are never notified about these deaths. Infants are usually buried on the same day of death by family members only. Neonates are not announced that they have died. If it is a girl, they cover her in a banana plant known as “Nakitedde” and a boy is buried under sour banana plantain called “mbidde.” Findings from an opinion leader in the HDSS community revealed that people are not informed and only women who have stopped giving birth attend such burial for neonates. This is due to the fear of transmitting bad omen to young women of reproductive ages. This hinders such deaths from being registered with the Civil Registration Authorities thus:
“We do not make death announcements for a child or a baby that dies before reaching full term. This makes death registration unlikely for such a death. A few close family members will get to know because it is considered insignificant. Only older women who have stopped giving birth are allowed to attend the burial. Women who are still giving birth are not allowed to bury”.
(LC1 Chairperson, KII, Kyotera Sub-county, Rakai HDSS).
Bride price payment determines where a woman is buried
Payment of bride price influences death registration among the Baganda and the Basoga tribes in the study area. The in-laws would halt the burial of a married woman in the husband's home if the bride price to marry her was not paid initially. The husband's family is forced to pay the bride price before burial. Else, the body is taken and buried at the home of the woman’s parents. A social norm of burying a woman to her parent's house after the bride price payment default discourages death registration. This is because parents may not want to get bothered anymore thinking about the death of their daughter. They cannot notify civil registration authorities about the death of their daughter. This is clarified by one of the respondents who cited that married women whose bride price had not been paid by the time of death were buried at their parent's home, a practice that hindered death registration:
“If a married woman dies before bride price has been paid, she has to be buried at her parents’ home. This is a very painful and shameful experience for the parents of the deceased. Many parents become remorseful and choose not to engage in activities that remind them of the death of their daughter. They don’t want to think of their children as dead, which death registration confirms”.
(Participant, FGD with women, Kyotera sub-county, Rakai HDSS).
Twins do not die but jump to the disappearance
Deaths of twins have low chances of being registered by the civil registration authorities due to cultural norms regarding such deaths as mere “jumping” or “disappearance” of a twin in the study area. A significant number of respondents stated that people could not go to the sub-county offices to make death notifications because it was not culturally acceptable for them to say that a twin had died. The implication of such is that the death of a twin does not attract interest from parents to register it with the Civil Registration Authority because they do not want to associate with the word “death of a twin” to avoid consequent impact on the living co-twin. Given that twins share a lot in common, the word “death of a twin" could have been avoided so that the surviving twin is not scared that he or she will die. When twins die, tradition requires them to be buried at night and not passed through the doors of the house but rather a hole is dug where the bodies are passed before taking them to the burial grounds. Again, this level of concealment diminishes the chances of death registration for twins. This is elaborated in the key informant interview thus:
“In this community, people do not say that a twin has died; they call it ‘kubuuka,’ which means that a twin has jumped. When someone says that a twin has died, the other twin can also die since they were produced together. Some say that he has gone to collect firewood. There is no way people can go to the sub-county chief and notify him that a twin has died. It would be opposing what we believe in”.
(VHT, KII, Kyamulibwa Sub-county, Kyamulibwa HDSS).
Suicide deaths are buried in secrecy
Suicide deaths are viewed as a curse to a family and can spread for generations as per the culture of the Baganda and Basoga tribes. Hence, such deaths are seldom registered with the civil registration authorities. Based on their culture, the residents of Bulamagi Sub-county, Iganga-Mayuge HDSS site consider life precious and believe that a person who commits suicide brings a curse to the family and has to be punished in a manner that prevents others from doing the same. Consequently, no family member is willing to register a suicide death with the Civil Registration Authorities. These views were expressed by a cultural leader saying:
“Suicide is a terrible thing in our culture. This is because someone has brought a curse in the family that can spread to all family members for generations. The deceased's body is beaten, and the rope used for strangulation is cut so that the body falls in a hole dug directly below. It is buried in whatever position it falls in, even if it is crooked. People are not supposed to arrange it because that is what the deceased wanted for him or herself. People are not supposed to mourn for such a death. Few people attend burials of people who have committed suicide. Their family members attend because they have no choice. No one can register such a death”.
(Cultural Leader, KII, Bulamagi Sub-county, Iganga-Mayuge HDSS).
Religious practices and low death registration
Religious leaders’ refusal to lead funeral prayers undermines death registration
Some religious institutions and leaders refused to lead funeral prayers for the dead, contributing to low death registration in the communities. Community members that were not involved in church or mosque activities, including paying tithe, attending prayers, often failed to have religious leaders pray for them when they died or their close relatives. These findings suggest that death registration status should not be conferred on those who deviate from the model of personhood–in this case, as articulated by the Church. The study respondents seemed to suggest that the dead whose identity is seen as being between faiths ends up between worlds in the afterlife. This makes them unworthy of death registration with Civil Registration Authority. A key informant mentioned that when priests fail to conduct funeral prayers for people who do not follow the rules put in place by Catholic Church, it increases grief and psychological torture to the family to the extent of foregoing death registration with the Civil Registration Authorities thus:
“I should say we do not conduct mass for people who act contrary to our faith. For instance, couples who die before being officially married in the church as well as converts from Catholicism to other religions like Islam and born-agains. It increases grieving and is psychologically torturing for family members when mass is not conducted. They can forego death registration because they feel that the deceased has not been decently put to rest. People will think that the deceased's spirit is still roaming on the earth and fear to refer to them as dead”.
(Religious Leader, KII, Nakigo Sub-county, Iganga-Mayuge HDSS).
Mixed religions bring conflicts that hinder death registration
Mixed religions bring about conflicts that undermine death registration. This is a result of mixed religions among community members. Study findings show that there were circumstances in the Nakigo sub-county of Iganga district where parents refused to attend the burial of their children because they had defected from Islam. As a result, both families were unwilling to register the dead with the civil registration authority, as elaborated thus:
“Family members can refuse to attend the burial of their children because of religious conflicts. For instance, a girl might be a Muslim and later becomes a Christian. The parents can even refuse to attend her burial and cannot register her death if they are the next of kin. This is because they did not approve religious conversion”.
(Participant, Female FGD, Nakigo Sub-county, Iganga-Mayuge HDSS).
Traditionalists do not seek medical treatment in health facilities but rather from shrines and witch doctors.
The study found out that the traditional religions did not seek medical treatment in hospitals and therefore resorted to traditional medicine in shrines and from witch doctors. Besides, traditionalists regularly attribute the cause of death to sorcery which hinders death registration and the medical examination of the cause of death. Even if someone dies of a motor accident, they will attribute the death to sorcery or ghosts. This consequently hinders death registration with the Civil Registration Authorities which is associated with post-mortem that is usually done in health facilities to establish the cause of death before registering the death. In light of the above, the study findings noted that a substantial proportion of the population takes sick people to traditionalists who perform rituals and later send them back home. In case of death of the sick at home, fewer efforts are put in place to register the dead with the Civil Registration authorities as elaborated thus:
“In cases where people die from the hospital, the family knows the cause of death. Some people who are not taken to hospital are taken to shrines where traditionalists tell them the root cause of the problem, perform rituals and send them back home. When they die at home, the family members are aware of the cause of death based on what the traditionalists told them. So, they just go ahead to bury the deceased. However, this decreases deaths at the hospitals where causes of death can be investigated, and the hospital staff fills out death notification forms before the discharge of the deceased as part of the death registration process”.
(Assistant Town clerk, KII, Kyamulibwa Sub-county, Kyamulibwa HDSS).
The Catholic Church registration of the dead is mistaken for Civil Registration
The study noted that the Catholic churches were fond of registering the dead and maintaining a death register for their members in the areas of jurisdiction. Findings revealed that religious registration of the dead by the Catholic church was mistaken with the official death registration by Civil Registration Authorities. As a result, some community members had not registered their dead with Civil Registration authorities because the catholic church took records of their dead to pray for them and administrative purposes. These records are never relayed to the Government’s Civil Registration Authorities which is perhaps a missed opportunity in death registration initiatives for Uganda. The catholic church uses catechists who record particulars of the dead and then feed it into the death registration book for the church. This scenario is elaborated below:
“The catholic church has religious heads in every parish locally known as the ‘Eitwale’ who register the death of every catholic that regularly attends mass. They have forms that record the death details, including the cause of death. A person who registers the death of their family member with the Eitwale cannot register with the sub-county chief because it is like double registration and wastage of time”.
(FGD Participant for women, Bulamagi Sub-county, Iganga-Mayuge HDSS).