Getting the Numbers That Matter for Public Policy

(Photo by iStock/pixelfusion3d)

In 2007, a group of researchers and I wrote about the “scandal of invisibility” of unregistered births and deaths affecting millions of people, especially in low- and middle-income countries. In the years since, this problem has become more widely known as people more deeply understood the importance of civil registration and vital statistics (CRVS) to sound public policy. This culminated in 2015, when the United Nations (UN) set ambitious Strategic Development Goal (SDG) targets to provide legal identity, including 100 percent birth registration and 80 percent death registration by 2030.

Worldwide, we have seen some progress. Yet the agenda remains largely unfinished. According to the World Bank, about four in 10 people over the age of 15 in the world still have no official record or proof of their existence, whether their death, birth, or present life (for example, a driver's license). Globally, one-third of all deaths are unreported—and a majority of those that are recorded lack reliable information about the cause of death, leaving us in the dark about mortality in many low- and middle-income countries.

The time is now to do more. The potential benefits of strong CRVS systems touch on many domains of life, from improved access to health care and education, to the right to vote, and ultimately to data critical for policy making in health and other sectors. When governments possess robust statistics about their people, they can more accurately count their populations, apportion resources based on sound data, and take action in the face of health challenges and trends in mortality.

To achieve universality and truly leave no one behind, registration services must serve even remote, marginalized, or vulnerable populations. Furthermore, distrust of providing personal information to government must often be overcome; the population needs to know that their information will be protected. Government must navigate the extremely high level of cyber security that is necessary to protect individual registration and identity data in the digital age, taking on challenges such as encryption, safe storage and backup, reliable software vendors, and legal and ethical access to people's information. Breaches, such as the 2018 data leaks that compromised up to a billion records in India’s Aadhaar system, damage trust as well as the system’s efficacy.

Truly functional CRVS systems have become an important goal for many governments. The way forward is attainable through smart collaborations and with the right resources. Ongoing assistance from strong regional programs led by the UN Economic Commission for Africa and the UN Economic and Social Commission for Asia and the Pacific represent important advances in this regard. Nonprofits also have a role to play, helping to accelerate progress in civil registration largely through advocacy at the global, national, and local levels. Other natural allies should include organizations concerned with mass displacement of people during refugee or other humanitarian crises, as the lack of identity documents in such dire circumstances can make individuals particularly vulnerable. And the global health community—public and private donors, international and local NGOs, and for-profit companies—should be in the vanguard of establishing robust CRVS systems.

To guide the efforts of advocates for strong CRVS systems, here are six insights from recent work funded by Bloomberg Philanthropies, the World Bank, the Centre of Excellence in CRVS, and others:

1. Coordination among government agencies can expedite progress. CRVS systems are by nature complex. Their ownership is usually distributed across not only a country's registration authority, but also ministries of health, justice, interior, and national statistics. Experience has shown that effective national steering committees produce the best results when comprised of these stakeholders, including one entity, perhaps the president or prime minister’s office, possessing the clear authority to convene the committee.

In Bangladesh, for example, the Office of the Registrar General and the Ministry of Health and Family Welfare coordinated their efforts and began to enforce an existing mandate for frontline medical workers to assist with the civil registration of births and deaths during household visits. Now community health workers help families register vital events in a way that requires minimal effort on the family’s behalf and places the responsibility for the registration of births and deaths in the hands of government authorities. Called the "Kaliganj model," this approach has been adopted for national scale. In just a few years in the areas it was implemented, the model led to an increase in completeness of birth registration from 50 percent to 83 percent and death registration from less than 10 percent to 90 percent.

Another example of this kind of intersectoral collaboration comes from Sri Lanka, where a CRVS Steering Committee has recently been convened and includes a receptive set of stakeholders from Ministries of Health, National Policy and Economic Affairs, Public Administration, Home Affairs, and Justice.

2. An improved legal and regulatory environment sets the groundwork for widespread impact. A CRVS system derives its legitimacy from a set of laws and regulations. This legal framework charters it as the sole foundational means to establish legal identity for citizens and residents. That, in turn, is the basis for access to protections and entitlements. In some countries, CRVS legal frameworks date from the colonial era and have little relevance to contemporary human rights or the needs of modern states to collect data using information technology. For example, an outdated law may not require registration of the "native population;" there may be no provision for the digitization of systems specified as paper-based under the law; or the law may bar data sharing between government ministries and the CRVS system. By assembling a team of lawyers and CRVS experts and comparing existing laws and legislation to current best practice in CRVS, areas requiring legal and regulatory reform can be identified.

As a result of this type of review, governments—including those of Rwanda and Tanzania—established new births and deaths acts starting virtually from scratch. They developed new regulations governing the application of international standards to their own processes and removed barriers to citizen participation, such as a legally required registration fees for reporting and registering vital events. These changes are critical for women and their children, who suffer most from the exclusion, lack of opportunity, and constraints brought about by non-registration of vital events. Non-registration of a child’s birth can pose obstacles that leave them more vulnerable to labor exploitation or child marriage. Non-registration of marriage puts a bride at a great disadvantage should the marriage dissolve. And non-registration of a husband’s death can mean a widow is unable to assert inheritance rights.

3. Bringing client-friendly registration services closer to the people can increase registration numbers. Inquiries into low registration completeness have revealed that barriers such as distance to registration offices and limited office hours have discouraged many from registering vital events. Many registration systems in low-income countries, such as Bangladesh, Rwanda, and Tanzania, have historically placed the burden on families to travel long distances to register a vital event at an authorized office or registrar, which are often located in city centers. However, making offices more accessible through large expansions of brick and mortar locations can prove both time consuming and costly.

To solve the challenge of reaching people in faraway places, a number of countries have enlisted their frontline health workers, social workers, or other government employees to take the lead on collecting vital statistics. This removes the onus of reporting from individual citizens. In the previously mentioned countries of Bangladesh, Rwanda, and Tanzania, community health workers have used tablet computers to report all births and deaths to registration authorities. Other countries, such as the Solomon Islands and Colombia, are experimenting with engaging religious and community leaders. In an effort to close the registration gap in traditionally underserved areas, the Colombian government recently expanded its Colombia Rural Vital program, which relies on local health directorates, trained community leaders, and the country’s extensive cell phone coverage to use text messages for reporting vital events.

4. Partnerships with hospitals lead to more accurate and accessible reporting of births and deaths. In most countries, the health sector represents the single largest potential source of data on births and deaths and the best, if not only, source of cause-of-death data. But in many low- and middle-income countries, hospitals have rarely taken active steps to ensure the formal registration of vital events occurring within their walls, leaving this task to parents and surviving family members. To address this issue, Rwanda in 2019 required its government hospitals to register births, deaths, and causes of death; today, more than 80 percent of deaths occurring in health facilities are registered through the civil registrar at their premises. In Ghana, the Ministry of Health and the Registrar General began sharing data on vital events in 2018.

When it comes to understanding causes of death, the collection of data is just the start. It still needs to be of high quality and analyzed, aspects of the process with which countries at every income level wrestle. As of today, data from most low- and middle-income countries is fair at best and frequently unavailable, according to the World Health Organization (WHO). Generating such data with consistency and accuracy requires the use of a standard medical death certificate, a standard process to fill it out, and agreed-upon rules and codes for assigning the underlying cause of death. Using and providing training on these global tools presents the most promising route to producing mortality data of sufficient quantity and quality for policy and planning.

5. Conducting verbal autopsies yields new insights on community cause of death patterns. In countries where most deaths occur outside of the hospital setting, verbal autopsies—interviews with surviving family members about the deceased—should be routinely conducted. This is the only way to reliably determine community patterns of mortality in such settings. The purpose of the verbal autopsy is to identify the leading causes of death at the population level. Because establishing and maintaining a verbal autopsy system is complex, it is optimal to use a representative population sample large enough to yield reliable national or sub-national estimates and small enough to effectively manage.

How does it work? Once a death has been registered, someone speaks with family members and caregivers of those who died. The interview aims to identify the symptoms experienced by the deceased in the period before death that can be reliably reported by laypeople. The response patterns to these questions are then correlated with causes of death using computer algorithms. Large numbers of interviews are needed to reliably assess the leading causes of death where there is no doctor. Interviewers are usually trained health workers, though on occasion non-governmental organizations are enlisted.

6. Embracing technology can allow for easier data collection and speedier analysis. Advances in technology make it possible to count every human life, even people in remote areas. In Peru, digital certification of cause of death is approaching 100 percent in 370 hospitals sharing a national information network. The data are automatically assigned a WHO mortality code and analyzed for use in policy and program decision making. This has led to better consistency and quality of death certificates and made data available to policy makers in weeks, not years. In Bangladesh, Colombia, Ghana, Rwanda, and Tanzania, governments are exploring the use of tablet computers to record births and deaths. In Tanzania and Morocco, verbal autopsy interviews are carried out via cell phone. Smartphone apps that aid doctors in assigning the correct cause of death are now used in Sri Lanka and Brazil, and training is reinforced through e-learning in Rwanda, Mumbai, India, and China. This ensures the maximum quality and utility of the data. In all of these cases, governments have not only leveraged low-tech solutions, but also taken care to rethink and redesign business processes that correct the inefficiencies of outmoded paper-based systems.

While it took decades for the global development community to focus on the role of CRVS, recent investments in national CRVS systems are proving that change is feasible in a relatively short time in countries where the problem is most acute. With the growing momentum and political will to meet the SDGs, extra care must be taken to ensure that the benefits—and basic rights—provided by CRVS are made available equally to all. Learning from the successes of Peru, Rwanda, Bangladesh, and so many other countries, together we can launch a decade of action to count the uncounted and improve health outcomes worldwide.

Read more stories by Philip Setel.