Published Jan 26, 2026 | 7:00 AM ⚊ Updated Jan 26, 2026 | 7:00 AM
Representational image. Credit: iStock
Synopsis: India’s medical certification of deaths remains dismal at 22.5 percent, but southern states stand out. A 15-year study shows Tamil Nadu, Karnataka, and Andhra Pradesh leading with strong hospital participation, while northern states lag. Researchers stress that more hospitals don’t mean better data—active reporting does. Reliable certification is vital for health planning and policy.
While India struggles with a dismal 22.5 percent medical certification rate for deaths, southern states have quietly achieved what the rest of the country cannot—systematic, reliable tracking of how their citizens die. A new nationwide study has revealed that Tamil Nadu, Karnataka, and Andhra Pradesh lead the country in death certification, with participation rates from hospitals that dwarf those in northern and eastern states.
The study, published in Scientific Reports, analysed 15 years of data from 2006 to 2020 and found that southern India’s success isn’t about having more hospitals or doctors—it’s about getting the hospitals they have to actually report death data.
“South India region leads the country in overall improvement in MCCD reporting,” the study notes, with Tamil Nadu showing “a significant rise from 28.34 to 43.46 percent, making it one of the highest MCCD states in the southern region.” Karnataka and Andhra Pradesh follow closely with consistently high levels of certification.
The contrast with the rest of India is stark. Whilst Tamil Nadu reports over 40 percent of deaths with medical certification, Jharkhand manages barely 5 percent. While Karnataka maintains high standards, states like Uttar Pradesh and Haryana “lag behind with incomplete data reporting.”
The study, conducted by researchers from the Indian Council of Medical Research, identified the single most critical factor determining death certification rates: whether hospitals actually participate in reporting.
Using clustering analysis, researchers grouped India’s states and union territories into three categories based on their medical certification of cause of death (MCCD) patterns. The findings are revealing.
Cluster 1, comprising 23 states with an average MCCD rate of just 18 percent, has only 52 percent of registered hospitals actively reporting death data. These are predominantly northern and eastern states where “only 27.4 percent of hospitals actively reporting MCCD,” the study found.
In sharp contrast, Clusters 2 and 3—which include most southern states—have “over 80 percent of hospitals actively reporting MCCD” and achieve certification rates of 60-63 percent.
“The findings indicate that active MCCD-reporting is a major factor associated with MCCD rates,” the authors write, though they acknowledge that “other factors including healthcare infrastructure, state-specific healthcare policies, socioeconomic factors, and administrative management also influence MCCD-rates.”
Tamil Nadu exemplifies this institutional commitment. The state’s steady improvement over 15 years reflects not just better healthcare infrastructure but systematic administrative follow-through that ensures hospitals fulfil their reporting obligations.
One of the study’s most counterintuitive findings challenges conventional assumptions about healthcare infrastructure. The researchers found that simply having more hospitals doesn’t improve death certification—in fact, it can make things worse if those hospitals don’t report.
The multiple linear regression analysis revealed “a statistically significant negative association with the MCCD rate” for hospital density, with a coefficient of −70.77. “This counterintuitive finding likely reflects that, on average, only about 40 percent of hospitals currently report MCCD data,” the study explains.
The problem is particularly acute in Cluster 1 states, where nearly half of all hospitals registered for death certification simply don’t participate. “Cluster 1 demonstrated the highest number of non-reporting hospitals per 10,000 people (~ 0.19 or 48 percent of hospitals),” with each non-reporting hospital showing “a highly negative impact on MCCD reporting.”
Southern states, by contrast, have minimal non-reporting. Clusters 2 and 3 have “only 0.017 (~ 3 percent of registered hospitals) and 0.043 (~ 8 percent of registered hospitals) non-reporting hospitals per 10,000 people, indicating that even small lapses in reporting substantially reduce certification completeness.”
Interestingly, not all southern states perform equally well. The study notes that “Kerala, despite improvements, continues to have comparatively lower MCCD-rates compared to other southern states.”
This Kerala exception prevents any simplistic regional triumphalism and suggests that even within the successful southern cluster, administrative practices and enforcement mechanisms vary significantly.
The researchers don’t elaborate on why Kerala lags behind its neighbours, but the finding underscores that high certification rates require sustained institutional effort rather than automatically following from regional culture or economic development.
The study’s authors argue that southern states offer practical models for the rest of the country. “High-performing states and UTs, such as Goa and Lakshadweep, can serve as models for implementing best practices in reporting systems,” they write.
The key isn’t building more hospitals—it’s ensuring the ones that exist actually report. The regression analysis confirmed that “the number of hospitals actively reporting MCCD was found to be a strong positive predictor of the MCCD rate” with a coefficient of 397.54, whilst non-reporting hospitals showed a significant negative association.
“Addressing these disparities and leveraging insights from clustering and regression analyses can pave the way for a more efficient and equitable mortality surveillance system,” the authors conclude.
They recommend “state-level audits, financial or administrative incentives for hospitals to report MCCD, and public awareness campaigns highlighting the importance of accurate death certification” as concrete steps forward.
Accurate death certification isn’t just bureaucratic box-ticking. “Reliable cause-specific mortality statistics are crucial for defining health priorities, public health programs, allocating resources, designing and implementing policies to improve healthcare quality and accessibility,” the study emphasises.
Without knowing how people die, governments cannot effectively plan health interventions, allocate resources, or track emerging health threats. The study warns that “poor death certification undermines India’s ability to track non-communicable diseases, emerging health threats and regional health inequalities.”
For a country accounting for nearly 18 percent of the world’s population, the national MCCD rate of 22.5 percent—with “only a 2.5 percent improvement over the past decade”—is what the researchers call “strikingly concerning.”
Southern India’s success demonstrates that the problem is solvable. The region hasn’t achieved high certification rates through vastly superior resources but through administrative commitment and institutional follow-through. Tamil Nadu’s journey from 28 percent to 43 percent, achieved whilst maintaining over 90 percent hospital participation, offers a replicable model.
“Although this negative coefficient for hospital density does not mean that having more hospitals harms or reduces MCCD certification,” the authors clarify, “it suggests that simply having more hospitals will not improve MCCD rates unless they are actively engaged in the reporting process and consistently reporting.”
(Edited by Amit Vasudev)
