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An indicator has been included in the UN sustainable development agenda to monitor progress in reducing deaths from conflict (SDG 16.1.2),5 and methods to estimate mortality have been developed and applied in some fragile and conflict settings.2 6 7 8 9 However, implementation has been hampered by incomplete coverage of births and deaths registrations, lack of greater global commitment to better capture mortality in conflict settings, and a shortage of capacity and funding to implement well conducted representative surveys or prospective surveillance to supplement incomplete civil registration. Furthermore, collecting data during conflict is hugely challenging because it is often unsafe and access to the relevant areas is poor. Support may be lacking to access or collect data if revealing the real death toll is undesirable to those involved in the conflict.3 10 The destruction of health facilities and infrastructure removes another source of death data,11 and survey respondents may be reluctant to provide information owing to fear of consequences.12 Finally, migration of people from conflict zones may create uncertainty about whether they have died or moved away.

onflict.3 10 The destruction of health facilities and infrastructure removes another source of death data,11 and survey respondents may be reluctant to provide information owing to fear of consequences.12 Finally, migration of people from conflict zones may create uncertainty about whether they have died or moved away. Prospective surveillance, routine health information systems, civil registration, and recording of vital statistics are sometimes poorly supported in settings where peace is fragile. In Sudan, for example, completeness of registration was 67% for births and unknown for deaths in 2014 (the latest available data).13 In the Central African Republic (2018-19) and Mali (2018), coverage was 45% and 87% respectively for births and unknown for deaths.13 Other methods therefore have to be used to estimate mortality,7 9 and these, particularly in the case of surveys, require financial resources.

aths in 2014 (the latest available data).13 In the Central African Republic (2018-19) and Mali (2018), coverage was 45% and 87% respectively for births and unknown for deaths.13 Other methods therefore have to be used to estimate mortality,7 9 and these, particularly in the case of surveys, require financial resources. Ukraine reported recording 100% of births and deaths (2017) and Palestine 90-99% of births and 70-79% of deaths (2020),13 but the completeness of births and deaths registrations may decrease as the conflicts continue. Differences in scope (for example, inclusion of only documented deaths, rather than both documented and undocumented), as well as methods (eg, use of population based methods v passive reporting such as body count), lead to different estimates that can be difficult to interpret and may prompt questions about the validity of estimates. Diversity in methods used and limitations in methods themselves, compounded by the politically charged nature of measuring conflict related deaths, have led to criticism of some estimates.10 11 For example, estimates of deaths in the Gaza conflict from the Ministry of Health were questioned (although independent analyses found no evidence of inflation).14 15

s in methods themselves, compounded by the politically charged nature of measuring conflict related deaths, have led to criticism of some estimates.10 11 For example, estimates of deaths in the Gaza conflict from the Ministry of Health were questioned (although independent analyses found no evidence of inflation).14 15 Governments, universities, non-governmental organisations (NGOs), and organisations focused on health, human rights, civil society, development, and humanitarian aid must work together to enable the implementation of existing methods for estimating mortality such as prospective surveillance, retrospective surveys, small area estimation, or capture-recapture analysis. The existing reliance on reactive, piecemeal estimation does not meet current needs. Actors must now define clear roles and coordinated contributions to advance timely and reliable estimation of mortality. Cross disciplinary discussions and existing initiatives16 17 to introduce and further validate methods, improve the quality of their implementation, and increase their use need to be sustained. The role of local partners needs to be enhanced and the independence and impartiality of the estimates safeguarded by making the data accessible to independent organisations, such as universities, with the expertise to analyse and interpret the results. Governments and development partners must invest in civil registration and vital statistics and other systems of prospective surveillance and must provide access to data so that independent parties can develop estimates and verify the reliability of the data. Reliable estimates of the burden of mortality from conflict can guide an evidence based response to crises. For this to happen, we need willingness to act on those estimates.18

spective surveillance and must provide access to data so that independent parties can develop estimates and verify the reliability of the data. Reliable estimates of the burden of mortality from conflict can guide an evidence based response to crises. For this to happen, we need willingness to act on those estimates.18 Recording the dead shows how much value we place on their loss.19 We cannot expect justice and accountability for those who die or are killed in these settings without having accurate data.