Context

The COVID-19 pandemic has exposed significant vulnerabilities and inefficiencies within health systems worldwide. In India, the official death count of around 533,000 has been widely questioned by researchers and international bodies. Analysis of data from India’s Civil Registration System (CRS) and Medical Certification of Cause of Death (MCCD) points to a large gap between official figures and the actual death toll. This makes it crucial to examine excess mortality during the pandemic years, highlight shortcomings in existing mortality tracking, and push for urgent reforms.

Excess Mortality: Revealing the True Impact

Excess mortality—deaths exceeding the expected baseline under normal conditions—has become a key measure for understanding the pandemic’s real toll.

• CRS data shows deaths rising from 7.64 million in 2019 to 8.11 million in 2020, and then surging to 10.2 million in 2021.
• This sharp increase suggests the actual COVID-19 death toll is far higher than official numbers.
• The World Health Organization estimates India’s pandemic deaths at about 4.7 million, a figure initially rejected by the government but increasingly supported by observed excess deaths.

Challenges in Medical Certification and Death Registration

Despite valuable insights from CRS data, its reliability is undermined by incomplete death registration and poor medical certification:

• In 2021, only 23.4% of registered deaths had medically certified causes, limiting accurate cause-of-death classification.
• In 2020, 45% of deaths occurred without any medical attention, up from pre-pandemic levels.
• Such gaps enable misclassification or under-reporting of COVID-19 fatalities.

A Kerala field study found increased cremations outside designated COVID facilities and only 22.8% of deaths with medically documented causes, highlighting systemic data flaws.

The Hidden Toll: Indirect Deaths and Systemic Disruption

Beyond direct COVID-19 fatalities, the pandemic caused many indirect deaths due to socio-economic disruption and healthcare challenges:

• Fear of infection, supply shortages, hospital bed scarcity, and lockdowns led to healthcare avoidance.
• Complications following infection and worsening chronic diseases also contributed.
• Kerala’s research attributed 34% of deaths to indirect causes and noted 9% possible misclassification.

Given Kerala’s relatively strong health system, these figures imply even greater undercounting in states with weaker infrastructure like Gujarat and Madhya Pradesh.

Structural Flaws in Mortality Surveillance

The pandemic highlighted major weaknesses in India’s mortality tracking systems:

• Civil registration was not designated an essential service during the 2020 lockdown, causing significant reporting delays.
• The National Family Health Survey-5 found nearly 29% of deaths from 2016–2020 went unregistered.
• Uneven medical certification and regional disparities further obscure true mortality figures.

These systemic flaws undermine data quality, weaken public health policy, and reduce preparedness for future crises.

The Way Forward: Reform and Inquiry

The stark gap between reported and actual deaths demands urgent reform:

• Policymakers should initiate a large-scale independent investigation into pandemic mortality, including integrating mortality questions in the upcoming Census and conducting retrospective surveys.
• India must strengthen death registration, enforce universal and timely medical certification, and improve public health data systems.

Such reforms are critical not only to accurately measure COVID-19’s impact but to build resilience for future health emergencies.

Conclusion

India’s pandemic experience has laid bare the deep deficiencies in mortality reporting. Under-registration, indirect fatalities, and data gaps have distorted the official picture, hiding the full human cost.

Going forward, transparent and comprehensive mortality surveillance must become a cornerstone of India’s public health framework. Addressing these shortcomings is essential—not only to honour the pandemic’s victims but also to better protect future generations from similar crises.