India's True COVID-19 Death Toll in 2021: Insights from Delayed Official Civil Registration Data

Excess deaths, defined as the difference between the total number of observed deaths and expected deaths (expected if pre-pandemic all-cause mortality trends continued), can offer a glimpse into the true impact of the COVID-19 pandemic. Based on 2021 death registration data, which India released in May 2025, we estimated that excess deaths in India in 2021 were 7.2 times greater than the reported number of COVID-19-related deaths (2.3 million excess deaths vs. 335,000 reported COVID deaths), and wide state-level variation in reporting fidelity. Without this observed death data, some epidemiological models estimated excess-to-reported COVID-19 deaths ratios, ranging from 4.4 to 11.9, during and shortly after the pandemic. The estimates from released data falls on the lower side of this range. Limited disaggregated data show that excess deaths per capita were significantly higher in men than women (2.2 vs. 1.3 per 1,000) and urban than rural areas (2.3 vs. 1.4 per 1,000). India's vital registration systems require modernization through automation and digitization through protocol standardization, real-time healthcare linkage, reporting incentives, and rural infrastructure investment. Robust mortality tracking enables rapid resource allocation to populations and conditions with the greatest need, providing lessons for pandemic preparedness that extend beyond COVID-19 to all public health challenges.