The Medical Certification of Cause of Death (MCCD) annual report, 2021, was a much-awaited one as 2021 was the year of the worst impact of COVID-19. As per data from this report and SRS 2021, the total number of registered deaths in India crossed 1 crore in 2021which is 21.6 lakhs more deaths than in 2020, a 27% increase over the previous year.
COVID-19 has returned to the headlines, with infections once again with a rise in number of cases in countries like Singapore and Hong Kong. The first and second waves of the pandemic left behind unparalleled trauma across nations, wreaking havoc on people’s lives across the globe, from a surge in various health conditions to the death of millions. The pandemic also imposed a massive financial burden on many families, with some losing their entire life savings and ending up in debt.
The trauma was no less intense in India, with the healthcare system facing unprecedented challenges and demands of the pandemic, exposing its structural weaknesses. Among the most critical challenges was the shortage of hospital beds, especially ICU beds, which left scores of patients untreated or stranded outside hospitals. During the second wave, oxygen shortages escalated with a staggering number of daily cases of over 4 lakh at the peak, which overwhelmed hospitals and frontline workers.
The state and central governments faced severe criticism, particularly during the second wave, for allegedly underreporting COVID-19 deaths. Despite official denials, images of overflowing crematoriums became grim symbols of the crisis and fuelled public outrage.
In such a context, accurate registration of deaths, together with their causes, and timely presentation of the same data are fundamental to understanding the true scale of deaths. This is also required for better future preparations and to address the reasons and issues that caused these deaths.
In this context, the Medical Certification of Cause of Death (MCCD) annual report, 2021 (referred as “MCCD report” hereafter) published by Office of Registrar General, India (ORGI), the nodal agency which maintains the medically certified deaths data, was a much awaited one various stakeholders and the common public. However, it was published only during May 2025, after a long gap of more than three years.
In this story, we look at the system of registration and medical certification of deaths, the trends over the last few years, especially focusing on COVID-19 deaths, with the data sourced from MCCD’s annual reports.
How are deaths accounted for and medically certified in India?
As explained in our previous stories (here & here), all births and deaths in India are required to be registered within 21 days of their occurrence through the Civil Registration System (CRS), under the Registration of Births and Deaths (RBD) Act. Additionally, the Medical Certification of Cause of Death (MCCD) scheme under the RBD Act mandates both registration and medical certification of all deaths. Therefore, only those deaths that are registered are considered under both these systems.
This implies that not all deaths occurring in India are registered or medically certified. The MCCD report itself acknowledges this limitation, stating, “The scheme of MCCD under Civil Registration System has been implemented in the States/UTs in a phased manner to provide data on medically certified cause of death. However, it has so far been implemented in the hospitals notified by the Chief Registrar of Births & Deaths. Thus, the scheme covers mostly those deaths, which occur in medical institutions. The coverage under the scheme in terms of percentage level of medical certification as well as the type of hospitals covered is not uniform across the States/UTs. Some of the States have notified only medical colleges and specialized hospitals, whereas in others, only district hospitals and Primary Health Centres (PHCs) have been brought under its ambit.”
It must therefore be noted that the coverage of medical institutions for death registration and medical certification is both limited and selective, confined only to those facilities officially notified. Even within these covered institutions, not all deaths are medically certified with confirmed causes. In other words, even if a death occurs within an ORGI-notified hospital, it does not guarantee that the cause of death has been medically certified.
The MCCD report highlights this gap with historical data. The proportion of medically certified deaths to total deaths registered was 14.7% in 1991. This figure rose to 20.2% in 2010, 20.7% in 2019, 22.5% in 2020, and marginally to 23.4% in 2021.
In other words, despite the significant toll and widespread damage caused by the global pandemic, which mandated proactive engagement in medical certification by ascertaining causes of death, there is no significant improvement in the medical certification of registered deaths.
Official Data shows over 6 lakhs COVID-19 deaths as of 2024; Registered COVID-19 related Deaths in 2021 increased by 156% from deaths in 2020
According to the 2021 MCCD report, the total number of COVID-19 deaths (classified under “Codes of Special Purpose”) in 2020 was 1.6 lakhs. This number increased by 156% to 4.1 lakhs in 2021. Further, as per a parliamentary reply dated 6 December 2024, the total number of COVID-19 deaths was at 49,600 in 2022, 2,600 in 2023, and 297 in 2024 (as of 6 December). Collectively, the total number of COVID-19 deaths in India from 2020 to 2024 amounted to 6.2 lakh.
To better understand the broader death scenario and the likelihood of excess deaths contributed from COVID-19 during 2021, we examined the number of deaths registered annually using MCCD data. The total number of registered deaths was about 64 lakhs in 2017, 69 lakhs in 2018, 76 lakhs in 2019, and 81 lakhs in 2020. Between 2017 and 2020, the average annual increase in registered deaths was approximately 4.3 lakhs. However, in 2021, there was a significant spike, with 21.6 lakh more deaths registered compared to 2020 — a 27% increase over the previous year.
This unprecedented increase becomes even more striking when viewed in the context of historical trends. Between 1991 to 2021, no other year recorded a comparable year-on-year (y-o-y) growth than 2021. The highest y-o-y increase before 2021 occurred in 2016, which saw a 17% increase over 2015, followed by 15% in 2002 and 13% in 2005 and 2014.
This stark deviation becomes even more evident when looking at the average annual growth rate in registered deaths over successive five-year periods. From 1992 to 1996, the average growth rate was 3%; it rose to 4% during 1997 to 2001, remained at 4% during 2002 to 2006, dipped to 2% from 2007 to 2011, increased to 6% during 2012 to 2016, and then sharply rose to 10% in the 2017 to 2021 period.
As per the MCCD report, in 2020, COVID-19 ranked third among the causes of medically certified deaths, contributing 8.9% of the total. By 2021, its share had nearly doubled to 17.3%, making it the second most reported cause of death in that year.
These figures point to the correlation between the surge in total deaths registered and the overwhelming impact of COVID-19, especially during 2021.
In 2021, 31 States/UTs saw an increase in Registered Deaths and 27 in Medically Certified Deaths
When compared across States and Union Territories (UTs), a total of 31 out of 34 (excluding Daman and Diu and Dadra and Nagar Haveli) reported an increase in the total number of registered deaths in 2021 over 2020 levels. This widespread increase contrasts significantly with the trends observed during the previous years from 2017 to 2020. During that period, the number of states/UTs showing an increase in registered deaths was 15 in 2017, 24 in 2018, 28 in 2019, and 26 in 2020. Notably, 21 out of the 31 states/UTs that witnessed an increase in 2021 recorded their highest-ever year-on-year (y-o-y) increase in registered deaths for the five-year period from 2017 to 2021.
A similar trend was observed in medically certified deaths. Excluding Jammu and Kashmir, which had not submitted MCCD data up to 2020, 28 out of the remaining 33 states/UTs reported a higher number of medically certified deaths in 2021 compared to 2020. Like the trend in total registered deaths, the y-o-y growth in medically certified deaths across these states/UTs also increased in 2021. In contrast, the number of states/UTs showing an annual increase in medically certified deaths was 26 in 2017, 23 in both 2018 and 2019, and 22 in 2020. Furthermore, 18 out of the 28 states/UTs that reported an increase in 2021 reported their highest y-o-y increase in medically certified deaths during the 2017–2021 period.
Uttar Pradesh and Gujarat among major states with higher registered deaths in 2021 over 2020
The highest increase in the number of registered deaths from 2020 to 2021 was observed in the state of Meghalaya, which recorded a 164% rise, from 2,230 deaths in 2020 to 5,896 in 2021. This was followed by Uttar Pradesh with a 55% increase, Nagaland with 51%, Gujarat and Chhattisgarh with 38% each, and Kerala with a 35% rise. If the less-populated states of Meghalaya and Nagaland (each with a population of less than one crore) are excluded, Uttar Pradesh, Gujarat, and Chhattisgarh emerge as the top three states with the highest increases in the number of registered deaths in 2021 compared to 2020.
In terms of medically certified deaths, the top five states showing the highest increase in 2021 over 2020 — excluding Manipur, which also has a population under one crore — were Haryana, Gujarat, Punjab, Uttarakhand, and Madhya Pradesh.
Even with incomplete data on registered deaths and medically certified deaths, it is clear that there were a significant number of excess deaths in 2021 than in the normal course. If the MCCD’s reported proportion of 17.3% of medically certified deaths being attributed to COVID-19 is extrapolated to include all uncertified deaths, the actual number of COVID-19 deaths in India would likely be much higher than the official figures.
Additionally, as highlighted in our previous stories, the share of deaths caused by Diseases of the Circulatory System (DCS) and Diseases of the Respiratory System (DRS) — both of which are strongly correlated and attributable to COVID-19 — was substantial. In 2020, DCS and DRS accounted for 32% and 9% of medically certified deaths, respectively. Combined with COVID-19, these three causes represented 51% of all such deaths. In 2021, the share of DCS and DRS was 29.8% and 12.7%, respectively. When combined with COVID-19 deaths, their collective share rose to about 60%.
Even the Sample Registration System Statistical (SRS) Report highlights that the crude death rate in India has risen sharply in India from 6 in 2019 to 7.5 in 2021.
