88351 World Bank | WHO Global Civil Registration and Vital Statistics Scaling up Investment Plan 2015–2024 May 28, 2014 Global Civil Registration and Vital Statistics Scaling up Investment Plan 2015–2024 May 28, 2014 World Bank WHO Acknowledgements T his Global Scaling Up Investment Plan was pre- The Canadian Department of Foreign Affairs, Trade and pared by the World Bank Group and the World Development is gratefully acknowledged for the financial Health Organization with input from several support it provided in developing the Global CRVS Scal- agencies and countries. The UN Economic Commis- ing Up Investment Plan 2015–2024. sion for Africa (UNECA), WHO, and the World Bank co-hosted a global consultative meeting on Civil Regis- Overall guidance was provided by Timothy Evans (Se- tration And Vital Statistics (CRVS) in Addis Ababa on nior Director, Health, Nutrition, and Population), Ni- April 28–29, 2014 to discuss and obtain input on a draft cole Klingen (Sector Manager, Health, Nutrition, and investment plan. The following agencies, together with Population) and Haishan Fu (Director, DECDG). The experts in the field of CRVS, contributed to the invest- ment plan through participation in the consultation1 or by providing separate contributions: 1 A list of participants is provided in Annex 9. African Development Bank (AfDB) Partnerships in Statistics for Development in the 21st Century (PARIS21) African Union Commission (AUC) Plan International Asian Development Bank (ADB) Secretariat of the Pacific Community Bill and Melinda Gates Foundation (BMGF) Statistics Norway Cambridge Economic Policy Associates (CEPA) United States Agency for International Development (USAID) Canadian Department of Foreign Affairs, Trade and Development (DFATD) United Nations Economic Commission for Africa (UNECA) Centers For Disease Control and Prevention (CDC) United Nations Economic and Social Commission for Asia and The Pacific (ESCAP) Center for Global Development (CGD) United Nations Economic and Social Commission For Western Asia (ESCWA) Inter-American Development Bank (IDB) United Nations Every Woman and Every Child Government Representatives and Experts from: United Nations High Commissioner for Refugees (UNHCR) • Bangladesh United Nations Children’s Fund (UNICEF) • Burkina Faso United Nations Statistics Division (UNSD) • Ethiopia United Nations Population Fund (UNFPA) • Mozambique World Health Organization (WHO) • Philippines World Bank Open Data Watch iv CRVS Scaling-up Investment Plan 2015–2024 World Bank’s CRVS Working Group was led by Samuel The findings, interpretations, and conclusions expressed Mills (Senior Health Specialist, HDNHE) and composed in this Global CRVS Scaling Up Investment Plan do of Amparo Gordillo-Tobar (Senior Economist, LCSHH), not necessarily reflect the views of the Executive Direc- Ana Milena Aguilar Rivera (Health Economist, HDN- tors of the World Bank or the governments they repre- HE), Bob Fryatt (Consultant, HDNHE), David Satola sent. The World Bank does not guarantee the accuracy (Lead Counsel, ICOIO), François Marius Lefebvre (Se- of the data included in this work. the boundaries, col- nior Financial Officer, CFPMI), James Neumann (Se- ors, denominations, and other information shown on nior Counsel, LEGPS), Mariana Dahan (Consultant, any map in this work do not imply any judgment on TWICT), Miyuki Parris (Operations Analyst, HDNHE), the part of the World Bank concerning the legal status Robert Palacios (Team Leader, HDNSP), Samia Melhem of any territory or the endorsement or acceptance of (Lead Policy Specialist, Transform Practice, TWICT), such boundaries. For more information contact, Sam- and Victoriano Arias (Program Assistant, HDNHE). uel Mills, email: smills@worldbank.org. The full Glob- Several World Bank management and staff provided in- al CRVS Scaling Up Plan is available on the following valuable inputs. The WHO team comprised Ties Boerma website: http://www.worldbank.org/en/topic/health/ (Director, Department of Health Statistics and Informa- publication/global-civil-registration-vital-statistics-scal- tion Systems) and Anneke Schmider (Technical Officer ing-up-investment CRVS, Health Statistics and Information Systems). Table of Contents Acknowledgements ������������������������������������������������������������������������������������������������������������������ iii Acronyms �������������������������������������������������������������������������������������������������������������������������������� ix Overview ��������������������������������������������������������������������������������������������������������������������������������� xi Section 1:  The Strategic Case ��������������������������������������������������������������������������������������������������� 1 What is Civil Registration and Vital Statistics (CRVS)? �������������������������������������������������������������������1 Why does CRVS matter? ����������������������������������������������������������������������������������������������������������������2 Identification ����������������������������������������������������������������������������������������������������������������������������2 Health information and vital statistics ��������������������������������������������������������������������������������������2 Birth registration ����������������������������������������������������������������������������������������������������������������������2 Registration of death and cause of death ����������������������������������������������������������������������������������3 Why CRVS will matter even more in the future ������������������������������������������������������������������������������3 The “Grand Convergence” in health �����������������������������������������������������������������������������������������3 Gender dimensions of civil registration and identification ��������������������������������������������������������4 Civil registration and data in times of crisis ������������������������������������������������������������������������������4 Harnessing new technology ������������������������������������������������������������������������������������������������������4 Section 2:  The Poor Performance of National CRVS Systems �������������������������������������������������� 7 Current state of CRVS ��������������������������������������������������������������������������������������������������������������������7 Birth registration ����������������������������������������������������������������������������������������������������������������������7 Death and cause of death ���������������������������������������������������������������������������������������������������������7 Why are CRVS systems in such poor shape? ������������������������������������������������������������������������������������8 Demand-side: lack of awareness and barriers to registration �����������������������������������������������������8 Supply-side problems and the CRVS “ orphan” ������������������������������������������������������������������������8 Lack of integration and coordination ���������������������������������������������������������������������������������������9 What progress has been made to strengthen CRVS? ����������������������������������������������������������������������10 Success stories �������������������������������������������������������������������������������������������������������������������������10 Public-private collaborations ���������������������������������������������������������������������������������������������������10 Statistical capacity �������������������������������������������������������������������������������������������������������������������11 Privacy and personal information ��������������������������������������������������������������������������������������������11 vi CRVS Scaling-up Investment Plan 2015–2024 Section 3:  The Opportunity to Transform CRVS ������������������������������������������������������������������� 13 Start with women and children �����������������������������������������������������������������������������������������������������13 Registration through maternal, newborn, and child health (MNCH) services ������������������������������13 Harness the data revolution �����������������������������������������������������������������������������������������������������������14 Build on regional leadership and global coordination ��������������������������������������������������������������������15 African Program for Accelerated Improvement of CRVS (APAI-CRVS) ����������������������������������15 Regional initiative to improve CRVS in Asia and the Pacific ���������������������������������������������������15 Eastern Mediterranean Regional Strategy for the improvement of civil registration and vital statistics systems ��������������������������������������������������������������������������������������������������15 Pan-American Health Organization Regional Plan of Action for Strengthening Vital and Health Statistics ���������������������������������������������������������������������������������������������������������15 Global coordination ����������������������������������������������������������������������������������������������������������������16 Key enabling factors for effective CRVS systems ����������������������������������������������������������������������������16 CRVS as a public good ����������������������������������������������������������������������������������������������������������16 Unique identifiers �������������������������������������������������������������������������������������������������������������������16 Information Communication Technology �������������������������������������������������������������������������������������17 Enterprise architecture design �������������������������������������������������������������������������������������������������17 ICT governance ����������������������������������������������������������������������������������������������������������������������18 Mobile technologies ����������������������������������������������������������������������������������������������������������������18 Incentives mechanisms �����������������������������������������������������������������������������������������������������������18 Synergies with identification and e-Governance initiatives ������������������������������������������������������18 Section 4:  The Scaling Up Plan ��������������������������������������������������������������������������������������������� 19 What will it take to deliver?  ����������������������������������������������������������������������������������������������������������19 National CRVS strengthening ������������������������������������������������������������������������������������������������19 International support for CRVS ����������������������������������������������������������������������������������������������20 Sharing knowledge and building the evidence base �����������������������������������������������������������������21 Financing needs ���������������������������������������������������������������������������������������������������������������������������22 Costing �����������������������������������������������������������������������������������������������������������������������������������22 Resource mobilization for CRVS ��������������������������������������������������������������������������������������������23 Financing mechanisms ������������������������������������������������������������������������������������������������������������������24 Option 1: Expand scope of existing funding mechanisms �������������������������������������������������������24 Option 2: Multi-donor trust fund to leverage IDA/IBRD funding for lending operations ������24 Option 3: Global Civil Registration and Vital Statistics Program ��������������������������������������������25 What will be delivered and when ��������������������������������������������������������������������������������������������������25 Goal and targets ����������������������������������������������������������������������������������������������������������������������25 Indicators �������������������������������������������������������������������������������������������������������������������������������25 Implementation ����������������������������������������������������������������������������������������������������������������������26 Monitoring and evaluation �����������������������������������������������������������������������������������������������������27 Risk and risk mitigation ����������������������������������������������������������������������������������������������������������27 Table of Contents vii Annexes Annex 1.  United Nations Definition of Vital Events ����������������������������������������������������������������������������31 Status of CRVS Maternal Death Estimates, Birth, Deaths, Quality of Annex 2.  Cause-of-Death Reporting ��������������������������������������������������������������������������������������������������33 Annex 3.  Country Case Studies �����������������������������������������������������������������������������������������������������������37 Annex 4.  National Statistical Capacity using World Bank Composite Indicator ����������������������������������49 Annex 5.  Legal and Regulatory Issues for CRVS ����������������������������������������������������������������������������������51 Annex 6.  Status of CRVS in 75 Countries Prioritized by the Commission on Information and Accountability ��������������������������������������������������������������������������������������������������������������55 Annex 7.  Global CRVS Group Terms of Reference ������������������������������������������������������������������������������59 Annex 8.  Costing of CRVS Scaling Up Plan ����������������������������������������������������������������������������������������61 Annex 9.  Participants at Global CRVS Consultation in Addis Ababa April 28–29, 2014 ���������������������67 References ����������������������������������������������������������������������������������������������������������������������������� 71 List of Figures Figure 1.  The CRVS systems ������������������������������������������������������������������������������������������������������������������1 Figure 2.  Estimated and reported deaths by income group, 2009 ����������������������������������������������������������8 Figure 3.  Brazil – Trends in birth registration ��������������������������������������������������������������������������������������10 Figure 4.  South Africa – Trends in birth registration ����������������������������������������������������������������������������10 Figure 5.  Birth registration – Compared to antenatal care and DPT1 immunization ���������������������������13 Figure 6.  CRVS enterprise architecture design �������������������������������������������������������������������������������������17 Figure 7.  Total CRVS development cost per five-year country plan ������������������������������������������������������22 Figure 8.  Per capita and per vital event CRVS development costs ��������������������������������������������������������22 Figure 9.  Country readiness for implementation ���������������������������������������������������������������������������������27 List of Tables Table 1.  Estimated financing gap for 2015–2024 scaling up investment plan �������������������������������������������������������������������������������������������������������������������23 Table 2.  Estimation of global CRVS development and recurrent costs for 73 COIA priority countries 2015–2024a �����������������������������������������������������������������������64 Table 3.  Main assumptions made to derive per-capita cost per activity in estimating global CRVS development and recurrent costs for 73 COIA priority countries 2015–2024 ������������65 Table 4.  Costs of developing CRVS and estimated investment gap CRVS (73 countries) 2015–2024 ����������������������������������������������������������������������������������������������������66 List of Boxes Box 1  Country investment plans: Quotes from country stakeholders ��������������������������������������������������37 Box 2  Lessons learned from establishing CRVS in Central and South America �����������������������������������38 Box 3  E-Governance and birth registration in Cape Verde �������������������������������������������������������������������39 viii CRVS Scaling-up Investment Plan 2015–2024 Box 4  Traditional leaders and birth registration in Senegal �������������������������������������������������������������������40 Box 5  Online and offline mobile birth registration in Uganda �������������������������������������������������������������41 Box 6  Modernizing the civil register in Albania �����������������������������������������������������������������������������������42 Box 7  Community health workers and birth registration in Bangladesh ����������������������������������������������43 Box 8  Automated Verbal Autopsies in the community in South Africa, Malawi, India, and Nepal ���������������������������������������������������������������������������������������������������������44 Box 9  Improving hospital mortality data in Mozambique ��������������������������������������������������������������������45 Box 10  Civil register links with maternal and child events in Philippines ��������������������������������������������46 Box 11  Strengthening vital statistics through inter-institutional efforts in Nicaragua ���������������������������47 Acronyms ADB Asian Development Bank IEC Information Education AfDB African Development Bank Communication APAI-CRVS Africa Programme on Accelerated iERG Independent Expert Review Group Improvement of Civil Registration LGU Local Government Units and Vital Statistics MDG Millennium Development Goal BCRS Barangay Civil Registration System MNCH Maternal Newborn Child Health COIA Commission on Information and MMEIG Maternal Mortality Estimation Accountability for Maternal and Inter-agency Group Child Health MDSR Maternal Death Surveillance and CPR Civil Population Registry Response CRVS Civil Registration and Vital Statistics NIS National Identity Systems EMRO Eastern Mediterranean Regional NSO National Statistical Office Office of the World Health OAS Organization of American States Organization PARIS21 Partnerships in Statistics for ESCAP United Nations Economic and Development in the 21st Century Social Commission for Asia and the PIN Personal Identification Number Pacific TFSCB Trust Fund for Statistical Capacity GCRVSP Global Civil Registration and Vital Building Statistics Program UNECA United Nations Economic HMIS Health Management Information Commission for Africa Systems UNFPA United Nations Population Fund HMN Health Metrics Network UNICEF United Nations Children’s Fund ICD International Classification of VA Verbal Autopsy Diseases WHO World Health Organization ICT Information and Communication WOMB Watching Over Mothers and Babies Technology Overview What is Civil Registration and the country as a whole and for local administrative subdi- visions. This provides more accurate information and the Vital Statistics? ‘denominator’ for assessing progress with plans across sec- tors for improving economic growth and reducing pov- Civil registration is defined by the United Nations as the erty. Accurate vital statistics and the ability to monitor “Universal, continuous, permanent and compulsory record- and respond to causes of death and disability underpin ing of vital events provided through decree or regulation in many global targets, including new commitments to uni- accordance with the legal requirements of each country.” versal health coverage and tackling the global epidemic of (UNSD). It is the act of recording and documenting of non-communicable diseases. vital events in a person’s life (including birth, marriage, divorce, adoption, and death) and is a fundamental func- Birth registration helps with the identification of pop- tion of governments. ulation health needs. Birth registration should take place “immediately” following birth, the standard measure be- Why does CRVS matter? ing within 30 days of birth. The move to high coverage health services for mothers and children makes universal The civil registry provides individuals with the documen- birth registration at or shortly after birth a realistic goal. tary evidence required to secure recognition of their legal It is also central to global efforts aimed at improving early identity, their family relationships, their nationality and childhood development. their ensuing rights, such as to social protection and in- heritance. It can help facilitate access to essential services, Death registration provides legal rights to the family, such as health, education, and social welfare and can for example, in conferring property or other individual contribute to activities such as gaining formal employ- or personal transfer rights to remaining family members. ment, exercising electoral rights, transferring property, Cause of death registration provides critical information and opening bank accounts. The lack of civil registration for health and development planning to improve the sur- during crisis or natural disasters can lead to statelessness. vival of children and adults. A current example of weak The arrival of new technology in resource-constrained CRVS systems is the lack of credible and coherent mater- environments has created opportunities for developing nal mortality statistics in areas where mortality is highest. more efficient information systems. Marriage and divorce registration is a largely unrecog- Unlike other sources of vital statistics, such as censuses nized part of well-developed CRVS systems. Having good and household surveys, the data from Civil Registration marriage and divorce registration are frequently required and Vital Statistics (CRVS) systems permit the produc- to obtain documents that can contribute to women’s abil- tion of statistics on population dynamics, health, and ity to inherit property and register their children in some inequities in service delivery on a continuous basis for countries, among other benefits. Registering girls at birth xii CRVS Scaling-up Investment Plan 2015–2024 and recording their marriages provides a legal backing What progress has been made to against early and forced marriage. strengthen CRVS systems? Some countries have seen remarkable improvements in Current state of CRVS CRVS systems in recent years, for example Brazil and South Africa. Good progress has been made in Latin In the past 10 years, there has been an overall increase in America and regional leadership is now showing prog- global birth registration rates of children under five from ress in Asia and Africa. The private sector has had a ma- 58 percent to 65 percent. However, more than 100 de- jor role to play in providing new solutions to improving veloping countries still do not have functioning systems access to and use of the CRVS system and for providing that can support efficient registration of births and other services. There has been significant progress in the num- life events like marriages and death. Around the world, ber of countries that now have National Strategies for almost 230 million children under the age of five are not the Development of Statistics. There has also been con- registered. Sub-Saharan Africa is home to 85 million of siderable learning on the need for secure and confiden- these children, while 135 million live in Asia and the Pa- tial sharing of personal information across government cific. Monitoring of data on birth registration rates for agencies. children under five is no longer considered useful and indicators are now required that help protect the rights of newborn children. This is an urgent area for consensus The opportunity to transform building, starting with routine monitoring of birth reg- CRVS istration rates within a year of birth. Progress with death registration has been much slower globally. In countries Start with women and children in most need of CRVS, up to 80 percent of deaths that occur outside of health facilities and two-thirds of all There is now an opportunity to overcome the many de- deaths globally are not counted. ficiencies in the CRVS system through global attention to improving the health of women and children. Scaled- up coverage of maternal, newborn, and child health Why are CRVS systems in such (MNCH) services, combined with the introduction poor state? of new technology, is providing many opportunities for strengthening CRVS, as illustrated by many pilot Many people are not aware of the importance of birth programs globally. Maternal and child health services and death registration for them and their families and the can be used as entry points to boost birth registration, implications that this has for access to core government such as by creating awareness among pregnant women services. In some countries, there are discriminatory laws, during antenatal care, immediate birth registration of practices, and attitudes that prevent birth registration. all institutional births, and ensuring all children who Simplifying the process and providing a vital event regis- are vaccinated at six weeks for DTP1 are registered. tration service within the existing structures with which National commitments to developing Early Childhood citizens interact can help to dramatically increase registra- Development services and registration at centers in or tion coverage. Lack of a political priority has resulted in near schools will be used for “mopping up” those not poorly managed, underfunded CRVS systems, deficient registered at birth. in full-time professional staff. Getting the civil registry, health and vital statistics systems to interact efficiently is a technical challenge requiring standards, protocols, data Harness the data revolution exchange, and institutional agreements across many gov- ernment departments. Modern technology has only pro- The full value of data from civil registries comes when they gressed piecemeal in many countries and there has been are properly integrated within government systems – for a proliferation of independent databases capturing differ- example with the statistical institutions, population regis- ent information about citizen records. ters, national ID systems, and voter registration systems. Overview xiii There are now opportunities to do this through 21st cen- The Scaling Up Plan tury CRVS systems that draw on the wide availability of information and communication technology (ICT) and What it will take to deliver innovations linking health records with civil registries. New internationally applicable CRVS standards are re- The global plan has three key components: quired for the use of unique identifiers, interoperability of information systems, and the various tools and devices • National CRVS strengthening: removing the barriers used to collect and transmit data. to birth registration, improving reporting of deaths and determining cause of death, strengthening CRVS institutions and ICT systems, strengthening Build on regional leadership and global national ID mechanisms, and improving the re- coordination sponse to deaths and vital statistics. • International support for CRVS: This will focus on Recent years have seen the start of important regional ini- strengthening international standards for CRVS, tiatives aimed at strengthening CRVS systems in coun- and preparing and sharing guidance based on coun- tries. These provide essential advocacy and accountability try experience. for change and create mechanisms to exchange and share • Sharing knowledge and building the evidence base: technical knowledge and expertise. A global coordination Analysis of barriers and programs of implementa- group has recently been established. tion research, together with rigorous impact evalu- ation, will share lessons on what works in different situations. Key enabling factors for effective CRVS systems Financing needs CRVS is more than the sum of its parts, and its develop- The costs in a number of recent country CRVS invest- ment requires a holistic approach, taking into consider- ment plans have been employed to estimate the addition- ation all events (including births, marriages, deaths, cause al financial resources needed to strengthen CRVS in the of death, and issuing IDs), their supporting information priority countries involved in the United Nations Com- systems, and associated legislation. The goal should be to mission on Information and Accountability on Women’s have one master CRVS system from which data can be and Children’s Health. accessed for different purposes while ensuring confiden- tiality and security. The total cost of scaling up and sustaining CRVS systems in the 73 countries is in the order of US$3.82 billion. This excludes India and China, as their size requires sepa- Information Communication Technology rate analysis. After excluding estimated domestic sources of funds, there is an estimated US$1.99 billion financing Well-functioning ICT infrastructure, including a reli- gap for the global scale-up plan over a ten-year period, or able power source, internet, and cell phone coverage, an average of US$199 million financing gap per year provides the enabling environment for developing for 73 countries. modern CRVS systems, which in turn provides the platform for interoperable CRVS information systems and databases. While ICT is not a silver bullet, it can Financing mechanisms provide a means to collect, store and retrieve data in a fast, cost-efficient and user friendly way. Recent ad- The key to success for establishing CRVS systems is strong vances have been made in areas such as enterprise ar- national leadership overseeing a country-led plan. The chitecture design and mobile technologies and many criteria for assessing the readiness of countries for inter- synergies can be found with ongoing efforts such as national support will include completed comprehensive for strengthening national identification systems (NIS) assessments; multisectoral costed CRVS plans including and voter registration. an indication of how much resources will be committed xiv CRVS Scaling-up Investment Plan 2015–2024 by government (budgetary allocation), existing support Goal: Universal civil registration of births, deaths and oth- from developments partners, and private sector, and fi- er vital events, including reporting cause of death, and ac- nancing gap. Financial sustainability will also have to be cess to legal proof of registration for all individuals by 2030 clearly articulated in national plans. A number of differ- ent international financing and governance models are under consideration. Implementation As of May 2014, of the 75 priority COIA countries, 25 What will be delivered and when have national CRVS plans based on comprehensive as- sessments of their CRVS (including three as part of the Assuming the required domestic and international re- regional PAHO CRVS framework). Over a ten year sources can be mobilized the following goals and targets period these efforts will grow so that all CRVS systems will guide the implementation of the global CRVS scal- have sufficient investments to ensure universal coverage ing-up plan. is reached by 2030. Targets 2020 2025 2030 Births in given year are registered 80% 90% 100% Children whose births are registered have been issued certificates 70% 85% 90% Deaths in given year reported, registered, and certified with key characteristics 60% 70% 80% Maternal and newborn deaths reported, registered, and investigated 80% 90% 100% Deaths in children under 5 reported, disaggregated by age and sex 60% 70% 80% Cause of deaths in hospitals reliably determined and officially certified 80% 90% 100% Countries have community assessments of probable cause of death determined by verbal autopsies using 50% 65% 80% international standards The Strategic Case 1 What is Civil Registration and vides a standardized format (Annex 1) and has recently reviewed its guidance on this subject (UN 2013). Var- Vital Statistics (CRVS)? ious institutions are responsible for ensuring these vital events are registered with the civil registry, and ensuring Civil registration is defined by the United Nations as that individuals receive the certificates confirming that the “Universal, continuous, permanent and compulsory the vital event has occurred (Figure 1). The civil registry recording of vital events provided through decree or regu- has two key objectives. The first is to be the preferred lation in accordance with the legal requirements of each source of data for the production of national and subna- country” (UNSD). It is the act of recording and docu- tional analysis and reports on vital statistics. The second menting of vital events in a person’s life (including birth, is to provide legal certification for individuals of a vital marriage, divorce, adoption, and death) and is a funda- event, which in turn supports the process of establishing mental function of governments. The civil registry stores legal identity, the production of national identification records of all vital events. The precise definition of vital documents, and the integrity of population databases events can vary across countries although the UN pro- and electoral rolls. Figure 1  •  The CRVS Systems Notification Certification Complimentary / interim sources Live birth Health service Death Civil Vital Population census Certifier of Registration Statistics Surveys Fetal death cause of death Sample registration Population Compilation ares Registers Processing Authorized Validation Marriage Principles Dissemination institutions . Compulsory Divorce . Universal Additional . Continuous administrative Annulments . Confidential Source: Judicial Courts . Police separation . Registries Judicial . Health information Adoption institutions National IDs National & Legitimation Electoral lists sub-national Recognition Passports etc statistics 2 CRVS Scaling-up Investment Plan 2015–2024 Civil registration and vital statistics (CRVS) systems are Health information and vital statistics composed of different parts: a system for the registration of vital events; a system for the production of certified copies of Unlike other sources of vital statistics, such as censuses these documents; a system of providing information that and household surveys, the administrative data provided allows issuing of passports and national identification docu- from CRVS systems permit the production of statistics ments, and a system for the production and dissemination on population dynamics, health, and inequities in service of vital statistics (WHO 2012). The various systems can be delivery on a continuous basis for the country as a whole governed by different legal frameworks but should have and for local administrative subdivisions. This is a key core strategies aligned and inter-linked. driver for developing CRVS systems. Birth registration helps with the identification of population health needs, and mortality registration contributes to a better under- Why does CRVS matter? standing of mortality patterns and the burden of disease in each population. Used together, birth and death data CRVS systems provides a critical platform to a significant can enable regular updates of population estimations and range of country planning and development needs. support planning efforts across sectors. This has many benefits including overall governance by having basic data on people being served by government, which is im- Identification portant, for example, for estimating population sizes for elections. Accurate ‘denominators’ allow accurate estima- Tracing the imprint of a person’s existence represents the tions of key measures such as income per capita, educa- first step in securing their right to life, freedom, and pro- tion needs, and assessments for disaster risk management. tection (Horton 2007, 1526). The civil registry provides individuals with the documentary evidence required to Improving vital statistics involves not collecting data on secure recognition of their legal identity, their family rela- a one-off basis, but establishing a sustainable and reliable tionships, their nationality and their ensuing rights, such system of data collection for producing nationally rep- as social protection and inheritance. This starts with the resentative vital statistics. A good example is the lack of legal identity that a birth certificate provides, and is fol- credible and coherent maternal mortality statistics in areas lowed, with the addition of biographic data, by issuance where mortality is highest (Annex 2a); available data can of identity documentation as and when necessary. Lack be difficult to reconcile in the absence of a credible CRVS of identity documents or legal identity can be connected systems. There are frequently differences of opinion in to poverty and vulnerability, as well as to the absence of countries on whether to use maternal mortality estimates transparent and efficient processes in public administra- from the census, household, or other sources used for esti- tion (Boekle and Harbitz 2009). Legal identity is proof mations. In addition, these national estimates often differ that a state recognizes and respects the lives of those it has from those modeled by WHO, UNICEF, UNFPA, the a responsibility to defend and develop. It enables access World Bank, and academia. Another difficulty is the wide to essential services, such as health, education, and so- confidence intervals of maternal mortality estimates de- cial welfare and can contribute to activities such as seek- rived from household survey data, which do not allow for ing employment, exercising electoral rights, transferring trend analysis. Given the factors above, a universal regis- property, and opening bank accounts. It is used in the tration of deaths with the cause of death would make it private sector, for example to access credit, and in the easier to track the level and causes of maternal and other public sector to provide identification cards, passports, deaths and to take the necessary actions to identify and and driver’s licenses. Many millions of people in low- and address causes of mortality. middle-income countries are being denied basic services and protection of their rights due to deficient CRVS and national identification systems (NIS). This includes uni- Birth registration versal health coverage, education and social protection schemes, humanitarian responses to emergencies and Universal birth registration is now enshrined in inter- conflicts, trade, and security. national human rights through the Convention on the The Strategic Case 3 Rights of the Child (Article 7). It is the continuous, to the calculation of population statistics and dynamics. permanent, compulsory, and universal recording with- The WHO International Classification of Diseases and in the civil registry of the occurrence and characteristics Injuries (ICD) is used as the global standard for classi- of births in accordance with the legal requirements of a fying causes of death in a comparable manner over time country. UNICEF has established a set of principles that and between populations. The latest version, ICD-10, should be followed, emphasizing that birth registration was released in 1994, and an eleventh revision is under should only be compulsory if certain characteristics are way (WHO 2010). Cause-specific mortality statistics, by established (UNICEF 2013). Birth registration should age and sex, for national and subnational populations are take place “immediately” following birth, the standard the backbone of public health decision making, planning, measure being within 30 days of birth (UNHCR 1990). and monitoring. Mortality data is collected using a stan- Data derived from CRVS systems normally refer to the dard Medical Certificate of Cause of Death with stan- proportion of live births that were registered within a dardized coding of the underlying cause of death. year or the legal time frame for registration applicable in the country. In the absence of functional CRVS systems, birth registration coverage is currently measured as the Why CRVS will matter even more percentage of children under age five (0 to 59 months) in the future with a birth certificate or whose birth was reported as registered with civil authorities at the time of the sur- The importance of CRVS will continue to grow in the vey. Birth registration at or shortly after birth is central future as both a critical enabler of improved country gov- to global efforts aimed at reducing infant mortality and ernance and planning and a means for improving devel- improving early childhood development (Giugale 2011). opment outcomes. Even when births are registered, the newborn may not obtain a birth certificate if the family have to return to the registration office to receive the birth certificate and The “Grand Convergence” in health do not see the value when there is significant distance, time and financial cost. Efforts to achieve universal birth Accurate vital statistics and the ability to monitor and re- registration should recognize the potential unintend- spond to causes of death and disability underpin many ed consequences if this is applied rigidly. For example, global health targets, including new commitments to birth registration can be checked at school entry, but this universal health coverage and tackling the global epi- should not be a requirement for entry to school or taking demic of non-communicable diseases. Current financing exams as this impinges on other rights. and ever-improving technical capacity in the world to- day could reduce child and maternal mortality rates to universally low levels by 2035 (Jamison and others 2013, Registration of death and cause of death 1898–1955). This would prevent an estimated 10 mil- lion deaths and lead to an estimated 11 percent increase Death registration is also identified in the UN Principles in economic growth, as measured in national income ac- and Recommendations for a Vital Statistics System (UN counts covering economic productivity. The importance 2013). It provides legal rights to the family, for example, in of CRVS will increase as countries expand their provision conferring property or other individual or personal trans- of services and as regional economic integration deepens fer rights to remaining family members. It is also central (ADB 2007). Additional gains would come from the in- to keeping the civil registry up to date. Some countries trinsic value of better health in and of itself. might have good death registration coverage but little or no information on causes of death because there are no These future investments, and the gains that come from processes or resources in place to determine these, such them, require reliable, complete, and timely informa- as verbal autopsy or in health facilities adequately trained tion to understand and measure three key domains of medical staff. Cause of death registration provides critical health—the determinants of health, health status, and information about infant, child, and adult mortality and the health system (WHO 2008). Good health informa- the burden of disease in communities, and contributes tion also makes health policy and planning more effective 4 CRVS Scaling-up Investment Plan 2015–2024 and efficient (Fryatt 2014, 950). However, such informa- basic numbers to help close data gaps in all these domains. tion is often not available in many middle-income and More importantly, it is a basic vehicle to increase women’s most low-income countries. Many problems arise from voice and agency and their ability to both contribute to using estimates to assess progress in achieving global and and benefit from development (UN Foundation 2014). national targets, and more reliable sources are increasingly being called for (Melamed 2014). For instance, as ma- ternal and child mortality rates decrease over time and Civil registration and data in times of crisis become rare events, the only way to accurately track prog- ress will be through complete CRVS systems which will A functioning CRVS system can support a stronger re- provide data on the full registration of births and deaths covery effort in the event of a crisis or natural disaster. among pregnant women and children. During emergencies, conflict, and disasters, routine CRVS systems, if present, often become non-functional with the destruction of records, hampering humanitarian Gender dimensions of civil registration and responses. The lack of civil registration during a crisis can identification lead to statelessness and in itself can be a strong reason to establish proper CRVS systems, as was recently acknowl- As already noted, birth registration is often required edged by the UN (UN General Assembly 2013). One of to access work and financial services later in life and is the main pillars of an effective humanitarian response is particularly important in societies where women have the establishment of CRVS type systems in times of emer- been denied access to such services, or where the male gencies (IDMC and UN OCHA 2008). New technology head of household has traditionally taken on this role can be more resilient than paper-based systems as it can for the family. In some parts of the world discrimination be more easily recovered following a disaster. It can also against women is a key factor behind non-registration assist the response; for example, when floods devastated of births (Plan International, 2012). Reporting of death Pakistan in 2010, the national office responsible for iden- may be key to inheritance and land rights as well as pro- tification used existing systems to roll out pre-paid relief tecting women and girls from abuse, exploitation, and cards to the 20 million flood victims within three days violence. (Uphadhya 2013). Likewise, archived and maintained CRVS systems were a critical component in the recovery Similarly, proof of marriage and divorce registration is effort after the recent typhoon in the Philippines. a largely unrecognized part of well-developed CRVS systems. Having good marriage and divorce registra- tion are frequently required to obtain documents that Harnessing new technology can contribute to women’s ability to inherit property and register their children in some countries, among The civil service workforce in many low- and middle-in- other benefits. Registering girls at birth and recording come countries in charge of recording vital events and their marriages provides a legal backing against early and preparing vital statistics are usually neither equipped nor forced marriage. trained for such tasks. Most CRVS systems have remained largely paper-based and manual. However, the arrival of Identity documentation is critical for individuals to exer- new technology in resource-constrained environments cise citizen rights and responsibilities and access entitle- creates an enabling environment for developing more ef- ments—precisely some of the most significant domains ficient and effective information systems. This technolo- with major gender gaps and gender data gaps. Individual gy was not present when CRVS systems were developed identity documentation expands women’s economic op- in OECD countries, so many low and middle income portunities by allowing women to acquire, claim, transfer, countries can “leap-frog” to more efficient systems. Good and dispose of physical and financial assets independent- practice is now being established on who should own ly. It also increases women’s independent access to services them, how these should be deployed to ensure accurate, and entitlements and expands women’s voting and politi- comprehensive records, and how these records should be cal rights and opportunities. Civil registry data yields the used and updated to the benefit of citizens. The Strategic Case 5 This requires careful design and not ad hoc projects. tifying civil registration authorities. This includes com- Building a well-functioning technology platform for munity-based vaccination program workers, commu- CRVS remains a challenge, given its multisectoral na- nity health workers, and village elders, some of which ture. There are currently too many lost opportunities, are highlighted in the case studies in Annex 3. Where where, for example data on births and deaths are being country context is similar, some models can be trans- captured in the routine health management informa- ferred across countries; however barriers and solutions tion systems (HMIS) of a country, but are not captured usually vary considerably across countries, and local as- in the CRVS records. Mobile phones and increased sessments are always the starting point to sustainable access to the internet are involving new groups in no- solutions. The Poor Performance of National CRVS Systems 2 Current state of CRVS tions, CRVS systems should be updated as close to the event (birth or death) as possible. This is an urgent area for consensus building, starting with routine monitoring Birth registration of birth registration rates within a year of birth. Check- ing for birth registration can provide useful incentives for In 2012, the Human Rights Council adopted a resolu- reducing delayed registration, but the lack of registration tion on birth registration as a human right. This follows should not be used as a means of preventing access to the mounting evidence on the need for individuals to essential services, such as enrolling in school. The Phil- have a legal identity if they are to be able to realize their ippines offers good practice in this regard, where a birth rights or obtain benefits and opportunities provided by certificate is checked for at enrollment, and if a child does the State. According to UNICEF estimates, in the past not have it then the school offers guidance on how to 10 years there has been an overall increase in global birth conduct a late registration. The child then has until grad- registration rates of children under five, from 58 percent uation to provide a birth certificate to 65 percent, with increases being most significant in East and Southern Africa (UNICEF 2013). However, Sub-Saharan Africa has the lowest levels of birth regis- Death and cause of death tration (see Annex 2b) and monitoring of data on birth registration rates for children under five is no longer con- Despite the importance of this data in informing health sidered useful. Indicators are required that help protect policies and programs, progress with death registration the rights of newborn children and ensure that they have has been much slower globally than birth registration, as access to the adequate nutrition and environmental stim- shown in Annex 2c. Up to 80 percent of deaths occur uli that are essential for early childhood development and outside of health facilities in low- and middle-income future physical and cognitive health. According to the countries and there is a lack of incentives for families, latest UN guidance, birth registration should be “imme- doctors, registries, and health services to register events diate” (where defined, this is usually 7–30 days); up to accurately. In 2012, WHO estimated that two-thirds 12 months is viewed as “late registration” and beyond 12 of all deaths globally are not counted, with low-income months is “delayed registration.” Children whose births countries being the most affected (Figure 2). are not registered will fail to be included in the CRVS systems if they die, leading to serious under-estimations An extension of the death registration data includes the of infant and child mortality. collection of information on causes of death, which, com- bined with birth and death information provides a com- The rules and definitions of birth registration need to prehensive set of vital statistics information for health and be updated to match our current knowledge of the re- broader development purposes. In a functioning CRVS quirements for a healthier population and the degree to system, each death would ideally have both death regis- which technology can play a role. As with all registra- tration information as well as cause of death information. 8 CRVS Scaling-up Investment Plan 2015–2024 Cause of death information is compiled in two primary tems are frequently difficult to access and to understand, ways: through the collection and coding of routine medi- so demand for better registration service is often low. Reg- cal certification records from health facilities; and through istration forms (birth, death, etc.) are often difficult to collecting information about community deaths through fill and need to be simplified and better designed as has sampled collections methods using verbal autopsy. happened in successful CRVS initiatives, such as in Brazil. There are often financial barriers to registration: obtaining Only 81 of 194 countries can report high-quality or me- identity documents, for example, often entails official fees, dium-quality data on deaths and causes of death (Annex fines for late registration, opportunity costs, transportation 2d) (WHO 2012). Alarmingly, 42 of the 46 African expenses, and bribes. For many poor families, it is simply member states cannot report credible death registration too costly both in terms of time and money. data, and of the 75 low- and middle-income countries prioritized by the Commission on Information and Ac- In some countries, there are discriminatory laws, practic- countability for Maternal and Child Health (COIA), es, and attitudes that prevent registration. For example, only 14 report figures on death registrations to WHO. the head of the household may be legally responsible for This means critical mortality information, such as deaths registering a child, and some countries specify that this of newborns, children, and mothers, or mortality from person must be male (Plan International 2012). Women HIV/AIDS, tuberculosis, and other diseases, are estimat- who are unmarried face particular obstacles, as do parents ed from very limited information. from minority groups. In addition to these barriers, indi- viduals may not bother to register vital events because they do not perceive any personal interest in so doing. Birth Why are CRVS systems in such registration in a country can, for instance, stand at 50 per- poor shape? cent while immunization coverage is 90 percent—moth- ers see an incentive for immunizing their children and are Demand-side: lack of Awareness and barriers willing to bring them to immunization centers, but fail to to registration report births to the local registration office because they do not see an immediate incentive for registration. Many people are not aware of the importance of birth and death registration for them and their families and the Simplifying the process and providing a vital event regis- implications that this has for access to core government tration service within the existing structures with which services. This lack of awareness extends to groups in the citizens interact can help to dramatically increase regis- community such as burial authorities, who can play an im- tration coverage. Meanwhile, the backlog of unregistered portant role in reporting deaths. Current registration sys- children can be reduced through registration at schools. Figure 2  •  Estimated and reported deaths Supply-side problems and the CRVS “orphan” by income group, 2009 35 There are different, often conflicting, legal frameworks governing each of the agencies in charge of CRVS ser- Number of deaths (millions) 30 25 vices, such as the health system, civil registry, and na- 20 tional statistics agency. Many countries have burdensome 15 procedures and non-standardized systems across a coun- 10 try, leading to confusion regarding what individuals need 5 95% to do or present. Supportive documentation may be re- 80% 1% 9% quested even if it is not legally mandated, such as birth 0 Low income Lower-middle Higher-middle High income registration requiring proof of parents’ citizenship. income income Estimated Reported Those involved in operating the CRVS systems may lack Source: World Health Statistics, WHO. the necessary skills. Some challenges, such as improving The Poor Performance ofNational CRVS Systems 9 data collection and accuracy of data entry, can be over- Lack of integration and coordination come by training existing staff. Others require special initiatives, such as expanding the size of the statistical The civil registry deals with individual, personalized, profession (Thabane and others 2008, 125–148) and set- transaction-level data, while vital statistics systems usu- ting up national and regional networks of civil registrars. ally focus on aggregated, anonymized data in relational Physicians, who are required by law to complete medical databases, data warehouses, or repositories using mul- certificates on cause of death, are often not aware of the tiple data sources (civil registry, census, surveys, etc.). importance of this responsibility and have inadequate Getting the civil registry and vital statistics systems to training. Capacity strengthening and awareness raising interact efficiently is difficult, and administrators derive are also required in ministries of health and national in- no benefit from linking to other parts of the govern- stitutions involved in surveillance, disease registries, large ment; it is just one of many functions that they have health facilities, national road safety commissions, po- to perform, which makes such linkages tenuous at lice, and health insurance authorities. best. There are often online and real-time access limitations Integrating the different components is also a technical in health facilities to the civil registry data repositories. challenge related to standards, protocols, and data ex- Electronic data inter-exchange limitations affect the change, often requiring institutional agreements across ability of health facilities to generate birth and death many government departments. The first challenge of certificates that include the underlying cause of death coordination is assigning clear responsibilities within properly coded according to ICD-10. Civil registration the CRVS systems and ensuring that there is no dupli- is too often just a passive collection of events and not an cation or gaps during the registration lifecycle. Some active seeking of new or more accurate collection data, basic activities, such as involving the national statistics a situation that is now changing with the use of other agency during the process of designing a new birth cer- networks such as health workers, village chiefs, and faith tificate form, can greatly enhance the effectiveness of the leaders. Use of mobile phones for registration is stimulat- CRVS system. Modern technology has only progressed ing a lot of interest, but this remains experimental with piecemeal in many countries. Meanwhile there has been as yet no nation-wide experience. Paper documents will a proliferation of databases capturing different informa- remain important for legal purposes, and most of these tion about citizen records, which are incompatible with countries will not have Information and Communica- one another, and often contain inaccuracies and incon- tion Technology (ICT) laws that allow electronic records sistencies in identifying citizens and their attributes. In to be used as evidence. such situations, laws covering privacy and the need for confidentiality are difficult to enforce. Lack of a political priority has resulted in inadequate pol- icies and poorly managed, underfunded CRVS systems, The CRVS databases are often neither connected nor in- deficient in full-time professional staff. Some CRVS sys- teroperable with any of the other management informa- tems, such as for birth registration and statistical capacity, tion systems in other agencies with which they need to have been the target of some international support, but interact (e.g. health, education, and social protection). there has been little support for strengthening the civil There is usually a lack of integration and interoperability registration system as a whole—it is seen as the donor between NIS and electronic medical records and HMIS. “orphan.” Collection of essential data, for example mon- Given that within governments, civil registration sys- itoring progress against the Millennium Development tems are the responsibility of a number of ministries Goals (MDGs), has focused more on interim measures or departments—health, interior, justice and statisti- and surveys, with inadequate investment in sustainable cal offices—coordination and communication among CRVS systems. Mobilization of resources and budgeting multiple agencies is key to performance, but difficult to for maintenance and operation of the civil registration achieve. This problem is also mirrored in the interna- system, in addition to recruitment and retention of quali- tional statistical systems, where efforts have been made fied professionals, are key to ensuring that accurate infor- to better support the needs of developing countries mation is maintained. (World Bank 2004). 10 CRVS Scaling-up Investment Plan 2015–2024 Brazilian Statistical Institute also made birth and death Figure 3  •  Brazil – Trends in birth registration statistics available on the internet within just one year (Danel and Bortman 2008). 100 90 South East 80 South Another example of success is South Africa, which has Centre West 70 also seen major improvements in birth registration in 60 Brazil recent years (Figure 4). Death registration has also im- 50 proved after the process was made a compulsory step be- 40 North East fore burial, and certification on the cause of death has 30 North improved following the training of certifying officials in 20 hospitals as well as the introduction of an automated cod- 10 0 ing system (Lehohla and Mathenge 2013). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: UNICEF Every Child’s birth right: Inequities and trends in birth registration. December Legally, institutionally, and administratively, civil registra- 2013. tion and vital statistics exist as two separate bodies—the first is a legal registry and the latter an administrative registry. Figure 4  •  South Africa – Trends in birth While the former is important for the latter, the legal reg- registration istry can function well on its own, whereas the administra- tive registry can be improved by timely input from the civil 100 90 registry. It is not a given that every country can develop a 80 fully integrated CRVS system, but this has been successful- 70 ly done, for example in Uruguay and Peru (IDB and World 60 Bank 2014). Regional experience has also been used to de- 50 40 velop a glossary for civil registration and for identification 30 (Harbitz and Benítex Molina 2010). 20 10 0 Public-private collaborations 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 The end products of functional CRVS systems are useful Source: UNICEF Every Child’s birth right: Inequities and trends in birth registration. December 2013. to the private and public sectors. The private sector has a major role to play in providing new solutions to the in- formation need of CRVS systems. One obvious example What progress has been made to is the expansion of mobile phone services to most parts of strengthen CRVS? Sub-Saharan Africa, with special initiatives aimed specifi- cally at sharing good practice and building interoperabili- Success stories ty. Groups such as GSM Association (GSMA), for exam- ple, have developed special initiatives for Africa to ensure Some countries have seen remarkable improvements that the benefits help both the industry and local health in CRVS systems in recent years. For example, Brazil services (Mobile World Live 2014). Another example of has made significant progress with birth registration, this is found in South Africa, where smart card technolo- overcoming many of the discrepancies across its states gy from the private sector is being used for identification (Figure 3). Brazil established civil registry units in ma- systems (South Africa.info 2012), and in India, where ternity hospitals and provided hospitals with a small pay- biometric technology for iris, fingerprint, and photos are ment incentive to register births. This was later expanded used in the country’s massive identification program (Gelb to electronic registration, and the country overcame chal- 2014). A common area of weakness, however, is among lenges with institutional coordination between the states private health and funeral service providers, who often and at the national level. The Ministry of Health and the need more encouragement to routinely report deaths. The Poor Performance ofNational CRVS Systems 11 Statistical capacity ability, on one hand, and the need to protect personal in- formation on the other (UN Joint Programme on HIV/ There has been longstanding recognition of the impor- AIDS 2006). The foundation rules for robust and sus- tance of statistics as a foundation for development. The tainable CRVS systems should be established in primary Partnership in Statistics for Development in the 21st legislation. Key principles should be taken into account Century (PARIS21) was set up in 1999 to reduce poverty in designing the legal framework for civil registries in- and improve governance in developing countries by pro- cluding the need for the following: moting the integration of statistics and reliable data in the decision-making process. There has been significant • Good governance arrangements: to support a holistic progress in the number of countries that now have Na- approach across the government agencies and insti- tional Strategies for the Development of Statistics with tutions responsible for civil registries, ensuring col- new, more user-friendly guidance recently launched. The lection and use of quality data in an efficient and World Bank’s composite indicator on statistical capacity effective manner; shows that since 1999, most low- and middle-income • Free flow of information: to ensure that accurate in- countries have improved their capacity. However, in formation is captured and disseminated in a timely Sub-Saharan Africa, the improvement is with respect to manner, supporting effective policymaking, efficient the periodicity of reporting statistics, with no significant resource allocation, and accurate evaluation and change in the other two capacity measures—method- monitoring; ological and sources of data (PARIS21). This demon- • Transparency: to ensure that registries are imple- strates that there is still considerable work to be done mented and managed pursuant to clear rules that (Annex 4). promote accountability for the fair handling and use of information; • Individual privacy rights: to protect individual priva- Privacy and personal information cy rights and permit individuals to access their per- sonal information and, where necessary, to challenge Sound public administration, the delivery of core govern- and correct any inaccuracies; and ment services, and the smooth functioning of commerce • Public safety and security: to support citizens’ identity all depend on robust means of personal identification. and civil status, without threatening the safety of in- The digitalization of registration systems are leading to dividuals who might be put at risk by the intentional new lessons on handling the risks (Plan International, or inadvertent disclosure of personal information. 2014). Secure and confidential sharing of personal infor- mation between government agencies is desirable for a range of reasons, but there is a tension between freedom A more detailed discussion and summary of emerging les- of information, transparency, and government account- sons relevant to CRVS are provided in Annex 5. The Opportunity to Transform CRVS 3 Start with women and children Registration through maternal, newborn, and child health There is now an opportunity to overcome the many defi- (MNCH) services ciencies in CRVS systems through global attention to im- proving the health of women and children (Government Scaled-up coverage of maternal, newborn, and child of Canada 2014). The move to universal access of super- health (MNCH) services, combined with the introduc- vised birth provides an opportunity, together with new tion of new technology, is providing many opportunities technology, for registering all births soon after the event for strengthening CRVS, as illustrated by the country and ensuring that women lacking adequate registration case studies in Annex 3. Birth registration coverage tends in the health system can now have their rights to govern- to lag behind coverage of antenatal care and DPT1 im- ment services acknowledged and guaranteed. The COIA munization, (Figure 5). Thus, birth registration can be recognized this opportunity and its first recommendation boosted by creating awareness among pregnant women stated that “By 2015, all countries have taken significant during antenatal care and having immediate notification steps to establish a system for registration of births, deaths, of births to ensure full coverage of essential services. This and causes of deaths and have well-functioning health infor- can be followed by immediate registration of all institu- mation systems that combine data from facilities, adminis- tional births, and follow-up of all children at the DPT1 trative sources, and surveys.” vaccinations at six weeks to ensure they are all registered. The first report of the independent Expert Review Group (iERG) released in 2012 on the COIA’s recommenda- tions noted 75 priority countries, which account for 98 Figure 5  •  Birth registration – Compared to percent of global maternal and child mortality (WHO antenatal care and DPT1 immunization, 2012). Of these 75, only 12 have over 90 percent cov- % coverage erage of birth registration and report to the UN with a 94.9 figure for death registrations. Uganda 2011 91.4 29.9 58.3 The global COIA oversight mechanism now reviews Nepal 2011 96.4 42.3 progress and has spurred significant interest and action in 73.1 many of the 75 countries targeted by the Commission’s Pakistan 2012–13 76.8 33.6 report. CRVS strengthening has become a central part 95.7 of discussions on the health of women and children. As Indonesia 2012 88.6 66.6 a result, dozens of countries have conducted CRVS as- sessments and several are developing national plans and 0 20 40 60 80 100 establishing multi-sectoral CRVS coordination mecha- Antenatal care DPT1 immunization Birth registration nisms (Annex 6). Source: Demographic Health Surveys. 14 CRVS Scaling-up Investment Plan 2015–2024 One area of particular interest for birth registration is the physician using the international form of the death cer- opportunity provided by the immunization of infants tificate, and in the community using verbal autopsies (PAHO 2012, vol. XXXIV). Given that the vast major- (WHO 2013). As well as providing data, the health sec- ity of newborns receive the BCG vaccine, and in some tor also gains from this closer link to CRVS, as better countries vaccinations are done at birth, health workers monitoring of births, deaths, and causes of death leads to have the opportunity to issue the child a vaccination card performance improvements. The early registration of all and remind the parents about registering their child. In pregnancies in antenatal services, for example, improves most countries, children also have at least five vaccination maternal outcomes. More complete registration and in- contacts by their first birthday. Inclusion of a space to vestigation of stillbirths, neonatal deaths, and maternal mark whether the child has been registered, either in the deaths, for instance by establishing maternal death sur- vaccination registers or in cards kept at health facilities, veillance and response (MDSR) systems, will provide the allows trained and sensitized vaccinators to remind par- required data on cause of death and lead to local correc- ents about birth registration and educate them on where tive actions and improved public health policy and re- to go to have their child registered. source allocation (WHO 2013). Messages on birth regis- tration can be integrated into personal communications Parental involvement is key. In Kenya, for example, dec- that the health workers undertake to educate mothers on laration forms are kept in health centers and parents are maternal and child issues, particularly during antenatal asked about the registration status of the child; if par- care and child immunization services. ents report that they have not registered the child, the health workers can have the declaration forms filled im- mediately, send them to the registrar, and the certificate Harness the data revolution can be obtained and delivered to the mother when she comes for her next visit. Additionally, birth registration Developing functional CRVS systems in all countries can be included in the list of incentivized indicators in will bring benefits to multiple settings and across many results-based financing programs. sectors, including to individuals, and in areas such as health, social protection, education, trade, and com- With the advent of computerized immunization registries merce. In fact, CRVS must be a critical part of the “data and unique identifiers, as in Latin America, health work- revolution” that has been called for by global leaders to ers also have an opportunity to register the child in an improve the quality of statistics and information avail- immunization registry while also updating the country’s able to citizens and governments (UN 2013). There are civil registry. This is made possible, in part, because the now opportunities to establish 21st century CRVS sys- same variables needed for birth registration—name, date tems that draw on the wide availability of information of birth, parents, etc.—are also included in birth and civil and communication technology (ICT) and innovations registry databases. Although the vital registration system around assigning unique identifiers and linking health requires that a newborn be registered within the short- records with civil registries. est possible time, children under age 2 are less likely to be registered than children age 2–4. This is because of The benefits will be broad and cover the two key outputs of the widespread practice of asking parents to produce a functioning CRVS systems—accurate statistics for plan- child’s birth certificate for school admission. A change of ning and development and establishment of the identity approach, linking birth registration to immunization as of individuals. Statistics facilitate the fight against poverty in Latin America, could result in a huge surge in regis- through quantifying outcomes and measuring progress to- trations, with the related benefits, over a relatively short ward the national and international development goals, as space of time. Similar opportunities exist for linking an- well as helping to build a more solid evidence base of suc- tenatal registration and maternal and neonatal death with cessful interventions (Okonjo-Iweala and Osafo-Kwaak updates to the civil registry. 2007). By focusing on birth registration and reporting of deaths in women of reproductive age, neonates and The health sector plays a unique role in reporting deaths infants, including cause of death data, all countries can and certifying deaths in health facilities by a trained strengthen coverage of essential health interventions and The Opportunity toTransform CRVS 15 remove the current “scandal of invisibility” in many low- now have an inter-ministerial coordination body on and middle-income countries (Setel 2007). CRVS. The Africa Symposium on Statistical Develop- ment had its ninth session in Botswana in January 2014, Legal identity proves citizenship and helps provide access focusing on CRVS for good governance. to State services or entitlements. It can also be a defense against exploitation or protracted hardship in times of emergency. As more children are routinely registered at Regional initiative to improve CRVS in Asia birth, and as the backlog of women receiving the identifi- and the Pacific cation documents they are entitled to is cleared, the many development benefits of proper identification will be real- Initiated in December 2012, the regional initiative in Asia ized. Civil registries and identification databases are often and the Pacific will be formalized at a Ministerial Con- developed separately, although attempts are being made ference in November 2014 when countries will have the to have them better linked. opportunity to endorse a regional action framework with national targets and a reporting structure for monitoring Experience from the many new approaches being tried in and accountability (UN ESCAP 2014). It is expected that low- and middle-income countries shows that the bene- the Ministerial Conference will induct a “CRVS decade” fits of fully functioning CRVS systems will not be real- for the region. The regional initiative is guided by an in- ized in the short term if each country has to do this on its tergovernmental Regional Steering Group (comprising own. New internationally applicable CRVS standards are representatives from 19 Asia-Pacific countries and 5 or- required in areas such as the use of unique identifiers, in- ganizations) that was established in December 2013; the teroperability of information systems, and the various tools initiative is supported by development partners such as and devices used to collect and transmit data. This will ESCAP, UNICEF, WHO, UNDP, UNFPA, UNHCR, speed up the move from paper-based to future ICT sys- ADB, SPC and Plan International. tems, and in the long term, improve the efficiency of many government administrations (Plan International, 2013). Eastern Mediterranean Regional Strategy for the improvement of civil registration and vital statistics systems Build on regional leadership and global coordination Following a review across members states, in September 2013, a regional committee from the Eastern Mediter- Recent years have seen the start of important region- ranean Regional Office of the World Health Organiza- al momentum of CRVS through initiatives aimed at tion (EMRO) together with more than seven partners in strengthening CRVS systems in countries. These provide the region agreed on the need for a regional strategy to essential advocacy and accountability for change and cre- guide and support countries with improving their civil ate mechanisms to exchange and share technical knowl- registration and vital statistics. To date, building on the edge and expertise. Accountability Framework momentum, every country in the Eastern Mediterranean region, with one exception, has completed comprehensive assessments and national African Program for Accelerated plans. A report on country rapid assessments has recently Improvement of CRVS (APAI-CRVS) been completed (WHO 2013). A permanent conference of Ministers, under the auspic- es of the African Union, oversees this regional effort, for Pan-American Health Organization Regional which the United Nations Economic Commission for Plan of Action for Strengthening Vital and Africa (UNECA) provides a secretariat and coordinates Health Statistics the implementation of APAI-CRVS in collaboration with regional partners. Experts have been trained to support This was adopted in 2008 and has been implemented CRVS strengthening, and most countries in the region with support from a regional partnership with the Or- 16 CRVS Scaling-up Investment Plan 2015–2024 ganization of American States (OAS), the Inter-Ameri- Key enabling factors for effective can Development Bank (IDB), UNICEF, and the World CRVS systems Bank (PAHO 2008). The World Bank also provided a detailed assessment of CRVS in most countries in the CRVS as a public good region in 2008 (Danel and Bortman 2008). In March 2010, the Latin American Network for the Strengthening A significant amount of learning has been taking place of Health Information Systems (RELACSIS) was created on what makes CRVS systems viable, notably, that they as an instrument to facilitate South-South cooperation must be seen as a public good in order for all members of toward improving the Health Information Systems in the society to benefit, regardless of whether they contribute to countries. A report on progress since 2008 was prepared creating or sustaining them (WHO/HMN 2013). CRVS in 2013 and the considerable lessons learned across the is more than the sum of its parts, and its development region are presented in Box 2 (Annex 3). requires a holistic approach, taking into consideration all events (including births, marriages, deaths, cause of death, and issuing IDs), their supporting information sys- Global Coordination tems, and associated legislation. The cross-sectoral nature of CRVS has attracted a large Good CRVS systems are user friendly and modular al- number of interested stakeholders to this growing glob- lowing different sectors and government departments al alliance. A Call for Partner Action on CRVS in April to engage over time. The business relationships of these 2013 called for global partners to align their efforts, and sectors with the civil registry need to be to be sufficient- “…deliver coordinated and sustained support to countries ly understood so that any changes can be carefully de- to achieve well-functioning CRVS systems” (WHO/HMN signed to strengthen flows of information and ensure that 2013). In addition to the numerous partnerships with- high-quality data is generated in a sustainable way. in countries and across regions, an increasing number of global players are taking on key roles. In March 2014, a When transitions to new systems are required, they must Global CRVS Group was set up to forge stronger alliances be carefully designed. All stakeholders must be involved, between key stakeholders in the area of CRVS. The secre- using good communications with users and business own- tariat will be provided by the UN Statistics Division. The ers. Strategies are required for dealing with legacy systems group aims to review status, progress, and challenges to to avoid duplicative processes. Incentives are required to support for national CRVS and to assist with coordina- keep the CRVS updated and of good quality, focused on in- tion (Annex 7). dividual citizens and the private and public sectors. CRVS systems must also be active in finding, collecting, and us- The main objectives of the group are to (a) converge ing data, and not acting as a passive recipient—in this way, strategic priorities and mandates towards a holistic ap- mobile devices and new technology can help enormously. proach to CRVS, creating an enabling environment for greater collaboration at the national, regional, and global Advocacy on CRVS as a public good is required to make this levels, and delivering as one; (b) exchange information a mainstream issue in the media and in the academic world. and coordinate global activities among members to com- As of now, many journalists or researchers write about birth plement CRVS momentum at the regional and national registration or mortality data as different things, not as part levels; (c) explore and leverage additional opportunities of the same system or institutions requiring strengthening. to accelerate the improvement of CRVS systems; and (d) advocate for the importance of CRVS as a development imperative. Unique identifiers But more must be done. With the post-2015 develop- The key to successfully integrating CRVS systems are ment agenda also likely to rely heavily on monitoring unique identifiers, or Personal Identification Numbers from CRVS data sources, coordination and investment (PIN) and ‘Primary Keys’, that allow for an exchange of by global partners are now critical. information while ensuring confidentiality and security. The Opportunity toTransform CRVS 17 Linking health information with broader data improve- the enabling environment for developing modern CRVS ment efforts in government provides opportunities for systems, which in turn provides the platform for interop- the health sector to benefit from the “unified identifica- erable CRVS information systems and databases. While tion coding systems” (e.g., national identification card ICT is not a silver bullet, it can provide a means to col- numbers) that many countries are developing. New rules lect, store and retrieve data in a fast, cost-efficient and and guidance are required on how to do this in a way user friendly way. Appropriate technology is required that that respects the obligations of different institutions and respond to the country context and needs. Experience is policies. Much can be learned from the history of using growing with innovative solutions such as electronic reg- unique identifiers in different settings. istries, mobile applications, open source and integrated ICT solutions, electronic coding, and verbal autopsy South Africa for example, mentioned earlier, is piloting the tools. National projects are, however, complex and sub- use of national IDs as the unique identifier in the health ject to failure; it is not unusual for them to require an system. The lessons from New Zealand may also be of wid- act signed by the Head of State. Some key lessons are er interest (Delany 2006). Their policy of universal health summarized below. coverage requires that every person residing in the country have access to health services, regardless of citizenship; the unique identifier therefore has to be different from that Enterprise architecture design used by the national identification system. The two sys- tems are linked however through confidential, inter-opera- Enterprise architecture (EA) is a methodology for sys- tional coding. If free universal health service coverage does tematically analyzing user needs (e.g. citizens, civil regis- not cover foreign visitors or migrants from other countries, trars, health planners, policy makers), mapping business additional policies and systems are required that respect processes (information/work flows), gathering and docu- international good practice (IOM and WHO). menting technical requirements to meet the needs, spec- ifications, and planning of ICT-enhanced solutions. De- signing and deploying these solutions requires data and Information Communication ICT standards, and ultimately operating and maintaining Technology these (interoperable) solutions, as shown in Figure 6. At its center are “backbone” connectivity and a central data Well-functioning ICT infrastructure, including a reliable warehouse and repository. A data warehousing approach power source, internet, and cell phone coverage, provides involves integrative thinking—for example, if a database Figure 6  •  CRVS enterprise architecture design Infant and maternal death information flows Birth and deaths notificatoin Birth and death Users records Causes of death CRVS Vital Integrated Heath statistics Information needs study, surveys sub-architecture Information Architecture information flows Population Usage across registries organizations Unique Data warehouse identification schemes ID cards issuance Backbone connectivity Technical and Application levels Social System level Source: World Bank. 18 CRVS Scaling-up Investment Plan 2015–2024 for issuing birth certificates is also used by Ministries of responsibility are important, but also provide commercial Home Affairs for issuing passport, there are additional in- opportunities—a birth registration event also represents a centives for keeping the databases up to date. sales opportunity: an incentive for the agents to visit more villages and meet more families more regularly. ICT Governance Synergies with identification and Effective governance mechanisms need to be designed, e-Governance initiatives including a holistic approach that involves all CRVS stakeholders and taking into account a country’s histor- Projects already strengthening different aspects of CRVS ical and institutional context. The governance arrange- and national identification systems (NIS) could be lever- ment should also allow for a modular approach so that aged as part of CRVS scaling up. These may have started components can be added or removed according to the in a different sector, for example strengthening statistical needs of the sectors involved. capacity, social protection, and national identification systems (World Bank 2013). The recent introduction of electronic patient records (EPRs) in many countries may Mobile technologies facilitate the transfer of information to the CRVS system; such links bring efficiency and need to be encouraged by The use of mobile technologies is expanding rapidly, linked donors and higher levels of government. Extracting data to the increasing penetration of mobile phone technolo- from EPRs will help eliminate the need to fill out ad- gies in previously remote and unconnected parts of low- ditional reporting forms for the CRVS systems and will and middle-income countries. They have the advantage of help to ensure data quality. Recent advances in digital potentially always being connected, always with the user, biometric identification technology, and their decreas- and secure. The reality on the ground is that many coun- ing costs, also provide more opportunities to expand and tries have many pilot mobile phone initiatives, in particu- strengthen CRVS and NIS (Gelb and Clark 2013). lar in the area of birth registration and maternal, neonatal, and child health. Thus, many countries are plagued by There are now a number of examples of countries plan- multiple pilot initiatives, each developing systems that are ning to link national identification systems with birth not interoperable. In order to capitalize on the potential, registration, for example in Botswana and Kenya. In Bo- it is critical to develop standards and agree on mechanisms tswana, the Omang (“who are you?”) system has databas- that are technically feasible and legally viable. es that interface with each other, under the purview of the Department of Civil and National Registration with of- fices at the district level. One of the essential prerequisites Incentives mechanisms for a person in Botswana to obtain an Omang card is the production of a birth certificate. Every birth that is reg- Incentives need careful consideration in the successful istered is provided with a unique Omang identification application of the ICT and mobile solutions, mentioned number, and the same number is printed on the birth cer- above. Close cooperation between all parties—pri- tificate. Similarly, the Omang database is updated as soon vate sector, government officials, civil servants, village as a death is registered. This linkage has resulted in in- chiefs—was a key element of the success of the pilots us- creased demand for birth certificates in the country. The ing mobile phones, as demonstrated in the case studies other important link that has been established as part of in Annex 3. Conditional cash transfers (CCT) have also the system is the requirement of the mother’s and father’s been successful, but raise questions regarding sustainabili- Omang identification number on the birth report form. ty (Robertson and others 2013, 1283–92). On the private This helps settle any issues relating to citizenship rights at operator side, contributions through corporate and social the time of birth. The Scaling Up Plan 4 Goal: Universal civil registration of births, deaths, and during routine post-natal care and immunization other vital events, including reporting cause of death, services, will become a national norm. For this to and access to legal proof of registration for all individ- happen, civil registration capacity needs to be em- uals by 2030 bedded within institutions such as hospitals, health centers, traditional ceremonies and religious institu- tions where, for example, baptism or naming cere- What will it take to deliver?  monies take place. This starts with creating aware- ness during antenatal care, so that there is immediate National CRVS strengthening registration of all institutional births, preferably with the provision of an identification number. At Rapid and comprehensive assessments of CRVS will be the six-week DTP1 vaccination, health personnel or used to develop national costed plans for strengthening community health workers check and register the CRVS systems. These assessments will be accompanied by infant if necessary. Care should be taken, however, inclusive, national multisectoral governance arrangements not to recreate the past problem of having too many to oversee and coordinate a sustained effort to develop registration centers, each with very low workload, and maintain CRVS systems (Box 1). Special initiatives leading to reduced quality and lack of uniformity. will be required to improve access by persons from mar- Registration at centers in or near schools will be ginalized groups, and provide registration support for used for “mopping up” those not registered at birth. illiterate citizens. National information, education, and Community approaches could also be used, such as communication (IEC) campaigns are important in cre- providing notification of births using ICT and Short ating awareness but need to be complimented by national Message Service (SMS) through community health communication programs aimed at changing behaviors workers or other village cadres. so that individuals actually declare and register vital events, • Improve reporting of deaths and determining with the impact assessed through repeated knowledge, cause of death attitudes, and practices (KAP) studies. While births and Reporting of deaths and cause of death in hospitals, deaths might be a priority, it is important that registration should be the norm, as the HMIS is increasingly of other vital events (such as marriages and divorces) ben- linked to the civil registry, with the automated pro- efits from the strengthened, interoperable CRVS systems. duction of death certificates and reporting of cause Countries will develop their own priorities, but some com- of death. Pre-service and in-service training of phy- mon areas might include the following: sicians on cause of death reporting and the use of using standardized death reporting form will need to become mainstream, with refresher trainings linked • Remove barriers to birth registration to continuing professional development and the Registration of all births and birth outcomes of many online resources. Continuous training of phy- mothers at the time of birth, or shortly afterward, sicians, coders, and analysts will encourage routine 20 CRVS Scaling-up Investment Plan 2015–2024 notification and registration of deaths along with the sure that government services and benefits are made cause of death, accompanied by automated mecha- accessible in a secure and cost-effective manner. nisms for ICD coding linked to financial or other Mobile phones can become the preferred delivery incentives. platform for social services, such as conditional cash In the community, many groups may be able transfers. The names of deceased persons have to be to play an increasing role in reporting deaths and removed from ID databases through linkage with should be encouraged to do so by removing any dis- death reporting systems. incentives such as extra registration fees charged by • Improve response to deaths and vital statistics morticians and burial service providers. Routine use Ensuring the routine collection and response to of verbal autopsies will not be possible in most coun- vital event information on maternal and neonatal tries. All countries, however, should be performing death is now a global priority and should help em- verbal autopsies in samples of the population to bed quality improvement techniques into health determine the burden of disease and the effectiveness services. This should lead to progressive expansion of public health interventions. Linking such systems and reviews of responses to other causes of death to the CRVS will remain a key topic for operational where this is not already taking place. Priority needs research. This will require extra work, and may re- to be given to training, online courses, and qual- quire dedicated non-medical staff so as to not bur- ification systems for staff involved in registration, den already over-committed local health workers. and for statistical clerks, medical schools, and phy- • Strengthen national CRVS Instiututions sicians on ICD coding, including the use of auto- Relevant legislation, policies, and regulations mated techniques. Strengthening national statistical on CRVS, in line with international standards, agencies should continue through the NSDS pro- will be required. CRVS institutions will need to cess, including quality assurance mechanisms, and be strengthened through improvements to infra- promoting the use of vital statistics to make deci- structure, human resources, and specialist skills. sions in areas of social, economic, and health policy, The realization of the need for centralized, integrat- through regular summaries, policy briefs and pub- ed CRVS systems will lead to new organizational lic, web-based access. models in government that need to be documented and shared. Business processes will be strengthened through modernized ICT solutions for integrating, International support for CRVS digitizing, and automating CRVS systems, with validation mechanisms to reduce duplication. Safe- A global, collaborative effort is required with the specif- guards will be required to protect confidentiality, ic mandate of improving CRVS systems by bringing all to secure registration information, and to avoid the relevant parties together more effectively. Currently, fraud or corrupt use. Certificates are the “products there is no single body within the international architec- of the CRVS system” in the eyes of the public, and ture that has a specific responsibility in the area of civil the certificate service may need to be strengthened registration and vital statistics, so a collaborative effort is to enhance public and political support for CRVS required, which would focus on the following: systems as a whole. • Strengthen national identification mechanisms • Improve International CRVS standards Identity management has become a fundamental International standards for tools and devices could component of modern-day government operations, help simplify and standardize birth registration, in both the developed and developing world. The death registration, determining cause of death, and linkages between CRVS and ID services are strong data collection, analysis, and dissemination. This and should be reinforced. Strengthening ID systems would include standards for the use of mobile tech- will not benefit CRVS systems unless they are con- nology, data management and analysis, and new ceived together, or national ID requirements are technologies. considered when designing CRVS systems. Secure Model legislation and regulations for the col- identity applications using new technology will en- lection, management, and use of information would The Scaling Up Plan 21 promote effectiveness and help protect individuals. be harmonized), and analyzing causes of death, in- Updated rules and definitions of birth registration cluding from external injury (WHO 2013). (for example, within days rather than weeks of the Iris software, from the German Institute for event) need to be explored. Medical Documentation and Information’s Iris In- An open sourced births and death certificate stitute, is being used for the automated coding of module could allow all health facilities to process multiple causes of death and for the selection of births and death registrations in electronic/modu- the underlying cause of death, with routine checks lar format, linked to appropriate quality validation required to minimize errors (through the WHO and verification. This would help provide incentives CoDEdit Tool). for quick on-site registration. New developments in ‘cause of death’ reporting, including ICD, provide Sharing knowledge and building the an opportunity to simplify the cause of death cod- evidence base ing system. Standards and good practice examples are re- The role of implementation research quired to link CRVS with other national systems The rapid expansion of new approaches and new commit- (e.g. national identification systems, population reg- ments to strengthening national CRVS systems is leading isters, electoral rolls, national pension systems, elec- to many research questions that would be best approached tronic medical records systems). This would include through multi-country collaborations (Abouzahr and oth- standards for interoperability of CRVS databases ers 2014). Some examples are (i) increasing mobile no- and other management information systems (such as tification of vital events through services such as child health, education, social protection). health days, immunization campaigns, and post-natal and Existing global and regional structures for over- neonatal care and how to link this to the registration and seeing and supporting work on CRVS will be used issuing of certificates; (ii) improving cause of death reg- to establish accountability frameworks and timelines istration and quality of cause of death data (for instance, for establishing national CRVS systems. This would synthesis of key lessons learned from OECD countries); be linked to strengthening financing and providing (iii) using birth certificate unique identifiers for CRVS advocacy and technical support to strengthen na- databases and other national systems (health, child pro- tional efforts to establish CRVS systems and a stan- tection, national identity, education, elections, humani- dard set of indicators for monitoring and evalua- tarian, judiciary and statistics); (iv) engaging community tion of CVRS systems. workers, Traditional Birth Attendants, and pharmacists • Guidance for strengthening CRVS through mobile SMS technologies; (v) establishing pro- There are a number of guides and tools for devel- grams of South-South cooperation and establishing oping different aspects of the CRVS system. These public-private partnerships; (vi) use of biometrics; and include guides on rapid and comprehensive CRVS (vii) birth registration as one of the incentivized indicators assessments (WHO 2010) to help the authorities in results-based financing programs. obtain a clear and comprehensive understanding of the strengths and weaknesses of their CRVS sys- tems and generate the evidence base for corrective Evaluation and sharing of lessons learned action. Several resources are available to support Monitoring of progress and sharing of knowledge will strengthening of the overall CRVS system (WHO take place in national and international forums and web- 2013; UNECA 2012) and for specific components based knowledge hubs. Evaluation of the development such as birth registration (UNICEF 2013; Plan In- of CRVS systems and its various components will take ternational). place following careful design with evaluation experts, us- Guidance exists for strengthening the response ing rigorous impact evaluation methods where possible. to complex areas such maternal deaths and HIV The development of new knowledge will also include the related deaths. There are a considerable number of impact and unintended effects of new technology and in- tools for strengthening coding of disease (WHO centives for increasing birth and death registration and of 2010), verbal autopsy (WHO 2012; IHME soon to penalties for late registration or non-compliance. 22 CRVS Scaling-up Investment Plan 2015–2024 Financing needs The costing exercise developed provides estimates for four cost categories: (a) development costs (incremental Costing costs or additional funds for establishing and strength- ening CRVS systems); (b) incremental recurrent costs for This exercise aims to estimate the additional financial re- maintaining CRVS systems; (c) international support to sources needed to reach the implementation plan targets CRVS, including sharing knowledge and strengthening with the overall goal of universal civil registration of births, the evidence base; and (d) monitoring and evaluation. deaths, and other vital events, and access to legal proof of registration by 2030. It also provides order-of-magnitude estimates of the incremental costs from 2015 to 2024 to Country strategic investment plans stimulate discussion and planning of support for nation- Detailed cost estimates have been drawn from the five al implementation plans. This work builds on the coun- countries that have undertaken in depth costing exercis- try-specific costing exercises and the cost structure devel- es as part of the development of CRVS investment plans oped by the Health Metrics Network. A summary of the (Figure 7). The costs in each plan were disaggregated into work is provided in Annex 8. fixed/start-up/capital costs and variable/operating costs2. The total costs (without inflation adjustment) vary from under US$30 million in countries with existing capacity, Figure 7  •  Total CRVS development cost rising to over US$365 million in Ethiopia, which only per five-year country plan (US$ million)a established a National Vital Events Registration Agency in October 2013. 400 365 350 Placing the investment in a population context, the coun- 300 try costs translate into a range of under US$1 per capita 250 in countries such as such as the Philippines and Bangla- 200 desh, to between US$1 and US$4 in Mozambique and 150 116 Ethiopia (Figure 8). The cost per vital event (births and 100 deaths) ranges from under US$2 to over US$13. 30 30 40 50 0 Mozambique Philippines Bangladesh Kenya Ethiopia Cost of CRVS scaling up and financing gap Source: National CRVS Investment Plans, WHO 2014. The estimated development costs (incremental costs * The total for Bangladesh excludes biometric costs. or additional funds for establishing and strengthening CRVS systems) in the 73 COIA countries during the period 2015–2024 is US$2,281 million or US$0.90 per Figure 8  •  Per capita and per vital event capita (Table 1). CRVS development costs $14 The estimated recurrent costs of running CRVS sys- 13.02 11.94 tems (with the assumption that this increases as more $12 CRVS systems become established) during the period $10 2015–2024 is US$1.201 billion. Furthermore, the cost $8 of the international support required, including to devel- $6 4.26 3.98 op international standards and tools, generate knowledge, $4 2.69 and develop an evidence base, was estimated at US$0.228 1.99 1.90 $2 1.18 0.31 0.26 $0 2 Philipines Bangladesh Mozambique Kenya Ethiopia Fixed/start-up/capital costs refers to both fixed costs for cap- Cost per capita Cost per vital event (annual) ital investments and one-time development costs needed for the CRVS system. Variable/operating costs refers to ongoing Source: National CRVS Investment Plans, WHO 2014. costs of operating and maintaining the system The Scaling Up Plan 23 billion (10 percent of the total development cost), with that governments make the required investment and that an additional US$0.114 billion (5 percent of the total international partners mobilize sufficient expertise and development cost) for monitoring and evaluation. short-term investments to get CRVS systems on track to a sustainable future. The country costing exercises also allow for a provisional estimate of the expected commitment of resources from domestic sources, including the government and other Domestic budget in-country sources, estimated at US$1.829 billion in the The global estimate of costs has included an analysis of 73 countries. After excluding estimated domestic sources budgets for developing and sustaining a CRVS system. of funds, there is an estimated US$1.99 billion financing This analysis provides an indication of the expected bud- gap for the global scaling up plan over a ten-year period, get that will be required to maintain CRVS systems in or an average of US$199 million financing gap per year the medium and long term in countries that are part of for 73 countries. the CRVS scaling up. In addition to the capital outlay and initial development costs, the analysis includes esti- mates of the staffing that the country should be prepared Resource mobilization for CRVS to commit as part of its engagement on the development and long-term operation of CRVS systems. Long term Underling the development of effective CRVS systems sustainable financing of CRVS systems will be required is the growing recognition of their fundamental impor- from domestic sources, and ensuring governments build tance to the development of any country. High-income up their own resources and budgets to sustain CRVS sys- countries that have an effective civil registration system tems is a critical success factor in this global plan. providing client-orientated services and vital statistics that are accurate, comprehensive, and accessible have developed their capacities over many decades, moving Country assistance from paper-based to automated systems, often at great In supporting the development of national CRVS sys- cost. Low- and middle-income countries now have the tems, the principles of aid effectiveness will be applied opportunity to benefit from this experience and move to ensure national ownership and transparency in the more quickly from paper-based systems to new ICT arrangements. Given that long-term sustainability is an systems that are much less costly to maintain. In short, essential element in the development of the CRVS, co-fi- this means there is the potential to move over a relative- nancing and joint investment will be the basic principle ly short time from old, high-cost, inefficient systems to for joint action, leveraging investments already under future low-cost, highly efficient systems. Such a change way in different sectors—health, social protection, and will require capital investment and the development of governance. Networks of regional technical support and adequate new administrative capacity. However, the eco- cross-country exchange of experience will need to contin- nomic arguments should be sufficiently strong to ensure ue to expand according to demands in country. There are Table 1.  Estimated financing gap for 2015–2024 scaling up investment plan (US$ million) 2015–2019 2020–2024 10 year total Financing Gap Development costs 1,140 1,140 2,281 1,604 Recurrent costs a 408 793 1,201 49 International support to CRVS including knowledge 228 114 114 228 sharing, and strengthening the evidence baseb Monitoring and evaluationc 57 57 114 114 TOTALs 1,720 2,104 3,824 1,995 Notes: a Recurrent costs increase as more CRVS systems are established (34 percent of total in first five years, and 66 percent of total in next five years) b 10 percent of total development cost distributed evenly c 5 percent of total development cost distributed evenly 24 CRVS Scaling-up Investment Plan 2015–2024 also useful lessons to be learnt from OECD countries that be effective. Expanding their scope could be less have developed their CRVS systems over many decades. expensive in terms of administration, compared to setting up a new financing mechanism. In addition, additional resources channeled through these in- Financing mechanisms struments would have a good chance of leveraging other programs, for example IDA/IBRD support, in Various options are being considered to assist Govern- each institution. The main disadvantages are that the ments in priority countries to fill the financing gap for scope of support is currently not working across all of strengthening CRVS systems. No matter what model is the sectors involved the CRVS system and changing chosen for the international financing and governance the mandate may not be possible owing to existing arrangements, the key to success will be country-level institutional rules. These institutions, however, will political commitment and leadership. In countries, an be key partners in taking forward the global scaling assessment of the readiness for investment will guide in- up of CRVS and will remain major stakeholders and ternational investments that must be aligned with one contributors. integrated, costed CRVS plan based on a clear institu- • Governance: The governance of existing instruments tional framework, on lessons from past experience, and could be reviewed to accommodate new stakeholders the existence of a functioning coordination mechanism. interested in strengthening CRVS systems. A Glob- Cross-sectoral coordination will include financing mo- al CRVS Program steering committee, which would dalities agreed with relevant government line ministries, be the decision-making body of the CRVS scaling development partners, and the private sector. The differ- up effort, could be established to provide oversight ent international financing and governance models are of global investments in national CRVS strengthen- as follows. ing efforts. A Global CRVS Technical Coordination Group would include a small team at the World Bank for day-to-day coordination of CRVS work Option 1: Expand scope of existing funding and would build on the community of practice that mechanisms has already been established. As there are stakehold- ers in the existing instruments, the change in gover- • Description: A number of funding mechanisms in nance could be lengthy. different institutions could expand their scope of operations to include strengthening national CRVS systems. UNICEF has extensive experience with Option 2: Multi-donor trust fund to leverage strengthening birth registration as part of its work IDA/IBRD funding for lending operations on maternal child health services and the rights of the child. It has published extensively on this and • Description: The World Bank Group (WBG) trust shown the impact through its own experience. The fund portfolio responds to the need for flexible and World Bank has an existing Trust Fund for Statis- customized development solutions for both recipi- tical Capacity Building (TFSCB), which has been ents and donors though its Global Partnership and in action for over ten years following the PARIS21 Trust Fund Operations. Trust funds administered event in 1999 with the explicit aim of building and by IBRD and IDA complement and leverage the strengthening the capacity of national statistical sys- WBG’s operations. They allow for the scaling up of tems in developing countries. Again, this has shown activities, notably in fragile and crisis-affected situa- to be effective in supporting many successful projects tions; enable the WBG to provide assistance when in different settings and has established links with its own ability to lend is limited; pilot innovations regional and national institutions that deal with civil that are later mainstreamed into the Bank’s opera- registration and national statistical agencies (Snorra- tions; and leverage the Bank’s operations both in son and others 2010); World Bank 2013). IDA and IBRD. Similarly, other multilateral devel- • Appraisal: Both of these institutions provide im- opment banks (MDBs) such as the African Develop- portant support to countries, which has proven to ment Bank, the Asian Development Bank, and the The Scaling Up Plan 25 Inter-American Development Bank perform similar sectoral boundaries. The main disadvantage would functions at the regional level. be the need to set up new, additional administrative • Appraisal: Considering that the strengthening and processes and funding mechanisms with countries integration of CRVS and national identification and implementing entities. Such funding would systems require multi-sectoral approaches, the ad- need to have significant added value over existing vantages of a trust fund associated with IDA/IBRD systems, for example by focusing on improvements is that it could be linked to larger projects, such as in front-line services as well as incentivizing the in health, social protection, education, governance, more difficult reforms required for CRVS systems and public sector reform and might be more closely to be established. Also it would be challenging for aligned with national needs. This would provide an the new global program to leverage other organi- opportunity to leverage CRVS implementation on a zations’ operations as its administrative processes larger scale, and possibly faster than through other could be different. mechanisms. The disadvantage is that not all coun- • Governance: The Global CRVS Program steering tries will choose to have CRVS strengthening linked committee could be the decision-making body of the to IDA/IBRD operations. global program. A Technical Advisory Group could • Governance: A Global CRVS Program steering be established at the World Bank or another insti- committee could provide oversight of investments tution for day-to-day coordination of CRVS work. carried out through the multi-donor trust fund. The World Bank or another institution would serve Technical coordination could be provided by a small as the trustee of the Global CRVS funds mobilized team at the World Bank for day-to-day coordination for the scaling up plan. of CRVS work. What will be delivered and when Option 3: Global Civil Registration and Vital Statistics Program Goal • Description: This program involves the setup of a Universal civil registration of births, deaths, and other new global program, with its own funding instru- vital events, including reporting cause of death, and ment. It could be housed in any of the development access to legal proof of registration for all individuals banks. There is an abundance of good practice to by 2030 draw on, such as the Global Agriculture and Food Security Program (GAFSP). It is inter-sectoral and has quickly expanded to provide support in many Indicators low-income countries. The proposed new global program would aim to strengthen CRVS and pro- Inputs: mote integration of CRVS and national identifica- tion systems in low- and middle-income countries. • Annual percentage public budget allocation to It would mobilize additional resources from donors CRVS (per capita and as a percentage of total gov- and development partners to provide additional ernment expenditure) financing to help fill the CRVS gap financing in countries. Outputs: • Appraisal: The advantage of this approach is that the program and its related funding arrangement • Number of countries with national CRVS plans could be purpose built, and recent evidence, in- based on comprehensive assessments cluding from the World Bank, has shown that it • Number of countries with functioning national CRVS could be operationalized. The cross-sectoral nature committees high level and/or technical (a minimum, of strengthening CRVS would fit well with a glob- the representatives of the civil registration, health and al program given its scope of work across many statistics sectors) 26 CRVS Scaling-up Investment Plan 2015–2024 Targets 2020 2025 2030 Births in given year are registered 80% 90% 100% Children whose births are registered have been issued certificates 70% 85% 90% Deaths in given year reported, registered, and certified with key characteristics 60% 70% 80% Maternal and newborn deaths reported, registered, and investigated 80% 90% 100% Deaths in children under 5 reported, disaggregated by age and sex 60% 70% 80% Cause of deaths in hospitals reliably determined and officially certified 80% 90% 100% Countries have community assessments of probable cause of death determined by verbal autopsies using 50% 65% 80% international standards • Proportion of the population within a reasonable dis- • Percentage of all deaths registered in the given year tance of civil registration points (<30km) or regularly are accompanied by the issuance of an official death serviced (monthly) through mobile civil registration certificate that includes, at a minimum, the de- • Number of countries with legal framework for ceased’s name, sex, and age CRVS that meets international standards and • Percentage of maternal and newborn deaths reported recommendations and investigated by a medical practitioner • Number of countries with integrated or linked • Reduction in maternal deaths reported nationally in CRVS, HMIS and national identification systems line with post-MDG targets • Percentage of hospitals with registrars in situ actively • Percentage of deaths in children under five that are registering births and deaths registered nationally (disaggregated by age, sex, resi- • Medically certified deaths as a percentage of total dence (urban/rural) and administrative subdivision) deaths and registered deaths annually • Number of standard vital statistics tables provided to • Percentage of civil registration points that report late the UN Demographic Yearbook that use administra- (i.e. after scheduled date) tive data from civil registration as their primary source • Percentage of all registration offices linked by com- puters to central level • Time lag between data collection and publications Implementation (years) • Ill-defined causes of death as a percentage of all As of May 2014, of the 75 priority COIA countries, 25 deaths annually have national CRVS plans based on comprehensive as- • Functioning national mechanism for determining sessments of their CRVS (including three as part of the probably cause of death in the community regional PAHO CRVS framework) (Annex 6). These 25 countries are grouped as COIA I countries, the remaining Outcomes as COIA II countries (Figure 9). • Percentage of births that are registered, nationally As there will be limited resources to support all 75 priori- (disaggregated by sex, residence (urban/rural), and ty countries, those that are ready for international invest- administrative subdivision) ment will be prioritized. • Percentage of all births registered are accompanied by the issuance of an official birth certificate that includes, • A completed comprehensive assessment of their CRVS at a minimum, the individual’s name, sex, date and system, performed according to WHO standards; place of birth, and name of parent(s) where known • A costed plan for strengthening the national CRVS • Percentage of deaths that are registered nationally plans, including an indication of the resources (disaggregated by age, sex, residence (urban/rural) that will be committed by the government and by and administrative subdivision) in-country development partners; and • Percentage of registered deaths with causes of death • A national mechanism for ensuring cross-sectoral medically certified and reported monitoring—for example a national coordinating The Scaling Up Plan 27 committee or oversight by the Office of the Prime will include a results framework for monitoring of the Minister or cabinet. achievement of project objectives. A core set of indicators (inputs, outputs, and outcomes) will be incorporated into Work in countries will continue in collaboration with re- the results framework of country proposals, including the gional and in-country partners. Once the international fi- CRVS core indicators. nancing and governance mechanism is in place, agreement will be reached on how to approach countries for further investment and scaling up of their CRVS country plans. Evaluation This will take into consideration the balance required be- Each national CRVS plan and strategy will be expected tween rapid scale up of CRVS, as required to deliver on the to have a component focusing on monitoring and eval- ambitious targets, and the need to ensure a comprehensive uation of progress, agreed in-country with the national approach and the use of limited technical support in a few inter-sectoral CRVS oversight committee. This will be countries, to ensure a sustainable impact across the CRVS complemented by a thematic or multi-country evaluation continuum. When the level of resources available interna- strategy for the scaling up plan that will be developed in tionally is clarified, a strategy for country engagement will close consultation with national and regional stakehold- be agreed upon with and communicated to national and ers, with technical support and guidance provided by im- regional stakeholders. It will be important to ensure that pact evaluation experts. expectations regarding international support are in line with the available technical and financial resources. Risk and risk mitigation Monitoring and evaluation Stakeholders: The scaling up plan involves a compli- cated set of stakeholders in local communities (family Monitoring members, health workers, local registration officials, vil- Regardless of the funding and governance model pro- lage chiefs), across government, the private sector, and posed, an oversight mechanism will be required to assess non-government partners working with local and nation- progress with the implementation of annual national al governments. There is a risk that the various disparate plans and the use of resources. Each country proposal efforts to strengthen CRVS systems as a whole will con- Figure 9  •  Country readiness for implementation Source: World Bank and WHO. 28 CRVS Scaling-up Investment Plan 2015–2024 tinue to be fragmented, made worse by different donors wins” that will give early momentum to the nation- and private operators developing pilot projects, without al CRVS investment plan, and will be prioritized to consideration of the need for interoperability, common ensure investments are not so diluted that they are data standards, and the broader architectural design of unable to show impact. the CRVS. The risks in local communities, in country, • Social and environmental: Increasing the need for cer- and internationally, will be mitigated by reinforcing the tificates to access services may work as an incentive to message that CRVS needs to be a holistic system if true register, but may also further exacerbate access issues value is to be achieved, and that incentives and funding for marginalized or vulnerable populations There is opportunities must make this possible. also a risk that the benefits of the CRVS plan will largely fall to higher-income groups, exacerbating Implementation: The risks of not learning from the past, inequities in the distribution of benefits. To miti- or from lessons learned in other countries, will be mitigat- gate this risk, the national projects will include some ed by an emphasis on implementation science, where the minimal analysis of groups that are socially excluded key questions to be resolved in the early implementation or at a particular disadvantage, so that special ini- stages will be used to design operational research along- tiatives can be targeted for them to ensure that they side implementation. In addition, inclusive oversight and derive maximum benefit from the CRVS scale-up. coordination mechanisms at the global, regional, and na- • Program and donor: The main risk in this area is the tional levels will help disseminate previous and ongoing potential for fragmented funding to continue, there- lessons. Where there are discreet interventions, such as by undermining the need for standards and interop- the application of new technology, experimental design erability. Extensive briefing and consultation will will be used, in line with evaluation good practice. be aimed at improving understanding, and existing global and regional structures will be used to oversee Project: investments. • Delivery and sustainability: Regular reviews of prog- • Design: The design of the global program has been ress against milestones and plans developed, and undertaken in a collaborative way to mitigate the owned locally, will help keep support for national risks of fragmented efforts. In countries, the need projects on track. The need for CRVS sustainabil- for a single CRVS design will be ensured through ity will also be addressed through careful consid- support for single CRVS scaling up plans, developed eration of long-term maintenance of staffing and using local evidence of what works in different con- infrastructure in the planning and funding of na- texts. Country investments will clarify the “quick tional efforts. Annexes Annex 1: United Nations Definition of Vital Events Annex 2: Status of CRVS Maternal Mortality Estimate, Birth, Deaths, Quality of Cause-of-Death Reporting Annex 3: Country Case Studies Annex 4: National Statistical Capacity using World Bank Composite Indicator Annex 5: Legal and Regulatory Issues for CRVS Annex 6: Status of CRVS in 75 Countries Prioritized by the Commission on Information and Accountability Annex 7: Global CRVS Group Terms of Reference Annex 8: Provisional Costing of CRVS Scaling Up Plan Annex 9: Participants at Global CRVS Consultation in Addis Ababa April 28–29, 2014 Annex 10: References Annex 1. United Nations Definition of Vital Events Live birth refers to the complete expulsion or extraction Divorce is a final legal dissolution of a marriage, that is, from its mother of a product of conception, irrespective that separation of spouses, which confers on the parties of the duration of pregnancy, which after such separation, the right to remarriage under civil, religious, and/or oth- breathes or shows any other evidence of life, such as beat- er provisions, according to the laws of each country. If a ing of the heart, pulsation of the umbilical cord or definite country recognizes registered partnerships, a legal disso- movement of voluntary muscles, whether or not the um- lution of a registered partnership refers to the legal final bilical cord has been cut or the placenta is attached. Each dissolution of such a partnership, according to national product of such a birth is considered live born (all live- laws, conferring the parties the right to re-enter into an- born infants should be registered and counted as such, ir- other partnership or marriage. respective of gestational age or whether alive or dead at the time of registration, and if they die at any time following Annulment is the invalidation or voiding of a marriage birth they should also be registered and counted as deaths). by a competent authority, according to the laws of each country, which confers on the parties the status of never Fetal death is death prior to the complete expulsion or having been married to each other. extraction from its mother of a product of conception, irrespective of the duration of pregnancy. The death is Judicial separation is the disunion of married persons, indicated by the fact that after such separation the fetus according to the laws of each country, without conferring does not breathe or show any other evidence of life, such on the parties the right to remarry. as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Adoption is the legal and voluntary taking and treating of the child of other parents as one’s own, in so far as Death is the permanent disappearance of all evidence provided by the laws of each country. of life at any time after live birth has taken place (post- natal cessation of vital functions without capability of Legitimation is the formal investing of a person with the resuscitation). status and rights of a person born in wedlock, according to the laws of each country. Marriage is the act, ceremony, or process by which the legal relationship of spouses is constituted. The legality of Recognition is the legal acknowledgment, either volun- the union may be established by civil, religious, or other tarily or compulsorily, of the paternity of a child born out means as recognized by the laws of each country. Coun- of wedlock. tries may wish to expand to cover civil unions if they are registered, in which case registered partnership usually re- Source: United Nations. “Principles and Recommenda- fers to a legal construct, registered with the public author- tions for a Vital Statistics System.” Revision 3 ities according to the laws of each country, which leads to legal conjugal obligations between two persons. Annex 2. Status of CRVS Maternal Death Estimates, Birth, Deaths, Quality of Cause-of-Death Reporting 34 CRVS Scaling-up Investment Plan 2015–2024 Annex 2. Status of CRVS Maternal Death Estimates, Birth, Deaths, Quality of Cause-of-Death Reporting 35 Annex 3. Country Case Studies Box 1  Country investment plans: Quotes from country stakeholders “…Very importantly, with the Philippines needing to urgently put itself on track to meet its target for maternal mortality, the government has intensified its commitment to improving the CRVS system.  It simply must know who, where and why mothers are dying and children are being born.” (Source: Philippines 2014 “Strengthening Civil Registration and Vital Statistics: A Case Study of the Philippines”) “For the future, Mozambique intends to continue expanding the coverage of CRVS.  Previous positive interventions in the sector are to be replicated throughout the country.  Regional and international experiences that showed best results are to be adapted to local circum- stances.  And a greater commitment to ICT will enable the country to create more flexible, reliable and efficient CRVS.” (Source: Mozambique 2014 ‘The Vital Statistics Journey: A Case Study of the Mozambique’) “As a country implementing a civil registration and vital statistics (CRVS) system for the first time, the focus of action in the next few years is preparing the groundwork for full implementation. … careful planning, designing and testing are being implemented in prepara- tion for developing a national system” (Source: Ethiopia 2014 “Establishing Vital Events Registration and strengthening: A Case Study of Ethiopia”) “…Digital registration provides an opportunity for less dependence on physical infrastructure and the opportunity to reach isolated populations.” Source: Bangladesh 2014. “Registering millions: Celebrating the success and potential of Bangladesh’s Civil Registration and Vital Statistics System”. 38 CRVS Scaling-up Investment Plan 2015–2024 Box 2  Lessons learned from establishing CRVS in Central and South America • Digitalization of the information contributed to faster compilation of the information and better quality control (Bolivia). • Improved civil registration directly influenced institutional social services (health, housing, education, and jobs) offered to special populations (Colombia). • The importance of having a champion to lead the implementation of new legislation supporting CRVS (Ecuador). • The importance of reinforcing civil registration within the country’s borders (El Salvador). • The need for and relevance of institutional coordination (Guatemala, Peru). • The importance of nominating well-known community leaders, in particular in rural indigenous or Afro-descendent populations, for the mobile units. Coordination with local offices helped to gain acceptance for registration (Honduras). • The need to improve civil registry offices with better technology to enhance the timeliness of service (Mexico and Panama). • The importance of marketing campaigns to educate the public about the value of the civil registry (Paraguay). Source: Consejo Latinoamericano de Registros Civiles, Identificación y Estadísticas Vitales.(CLARCIEV). Informe Pais. IX Encuentro del CLARCIEV. 23–26 Octubre, 2012, Guayaquil, Ecuador. Annex 3. Country Case Studies 39 Box 3  E-Governance and birth registration in Cape Verde Although Cape Verde ratified the United Nations Convention on the Rights of the Child (dated 1989) in 1991, the country was still witnessing very low birth registration rates, with large variations among municipalities. As a result of a project aimed at modernizing the public administration, Cape Verde computerized the entire CRVS system during 2007 and 2008. This allowed not only biometric enrollment and massive registration of births, especially in the remote, previously inaccessible areas of the country, but also enabled the issuance of birth certificates online. Some government agencies were concerned that the rapid pace of technological change might compromise the legal integrity of the existing system. Unanswered questions about privacy issues and the danger of security breaches persisted. The general public has also shown some concern about confidentiality issues. Major capacity-building and communication efforts were necessary to create an enabling environment to allow the system to grow as quickly and comprehensively as it has. Indeed, the consensus reached and the political support gained facilitated data collection and sharing among agencies. The results are encouraging: the national rates of unreg- istered children (aged 0 to 4 years) went from 39 percent in 2009 to 25 percent in 2010, and reached less than 10 percent in 2013. This is the highest birth registration level in West and Central Africa. The government is aiming for 100 percent birth registration in the years to come. For this purpose, mobile stations and enrollment kits have been installed in all major hospitals in the country and qualified personnel are continuously being trained. In addition, the government is adapting its legal and interoperability frameworks to allow for the development of new services and applications enabled by a well-functioning CRVS system, such as e-voting and e-taxes, increasing the overall value proposition of this public service. Sources: African Knowledge for Development Networks. “Rapport Sur L’état D’avancement De La Stratégie De La République Du Cap Vert — Résultats Sur L’enregistrement À L’état Civil Et Les Statistiques Vitales.” August, 2012. http://knowledge.africa-devnet.org/group/crvs United Nations Children’s Fund. A Passport to Protection: A guide to birth registration programming, UNICEF, New York, 2013. 40 CRVS Scaling-up Investment Plan 2015–2024 Box 4  Traditional leaders and birth registration in Senegal In Senegal, village chiefs are empowered by the State to register births. The Orange mobile birth registration solution was designed to make the most of existing methodologies and infrastructure, and the application was therefore tailored to meet the specific needs of village chiefs. • The solution chosen by Orange was a Java applet. This was considered to be more appropriate than an SMS-based solution because it offered more wide-ranging customization options and a better overall customer experience. • Mobile phones equipped with specific Java software have been distributed to 30 village chiefs. The chiefs are responsible for captur- ing information regarding births in their villages and transferring that information to the Senegal State Registrar. The registration office is equipped with a mobile phone in order to receive the information sent by village chiefs. • Once received, this information is checked and the birth is registered both physically in the registry and electronically in a database. A registration number is then sent back to the village chief, who communicates it to the parents. • This registration number means that the child has been registered. Using this number, parents can collect a birth certificate from the registration office at any time, provided they pay the corresponding fee. Results became evident very quickly because of the inherent inefficiency of the legacy paper-based system. Nevertheless, some areas of improvement have been identified, such as interoperability. Having subscribers of any and all networks able to use the same, interopera- ble solution would allow for the creation of a unified database of birth registration events. Source: GSMA Mobile Identity Team. “Mobile Birth Registration in Sub-Saharan Africa: A case study of Orange Senegal and Uganda Telecom solutions.” GSMA, Uganda Telecom, 2013. http://www.gsma.com/mobileidentity/wp-content/uploads/2013/05/Mobile-Birth-Registration-in-Sub-Saharan-Africa.pdf. Annex 3. Country Case Studies 41 Box 5  Online and offline mobile birth registration in Uganda Before the mobile birth registration solution was launched in Uganda, it could take several months for a child to be registered. As the whole procedure was paper-based, there were several barriers to effective child birth registration: • Distance and lack of communication channels • Lack of awareness of the need to register births • Administrative delays and process inefficiency • Cost and poverty obstacles In consultation with the development community, Uganda Telecom, the country’s major mobile operator, decided to become involved in the development of the Ugandan nation and its people by rolling out a mobile birth registration pilot. As part of the pilot, hospitals were equipped with a 3G connection, whenever necessary, to access a web-based application to register births. The registration agents (i.e. village chiefs, regional administrators) were given SIM cards mapped to their names, so as to be able to send USSD codes to register births occurring locally. Uganda Telecom used USSD codes on mobile phones and a web-based application on computers. USSD may be considered less user-friendly than a customized Java applet, but has the advantage of being able to work on any telephone. Frequent communication was set with the Registration Office, which validated each birth and sent a certificate to be printed in the hospital or the district office for distribution to the family. From a technical perspective, the solution is best adapted to developing countries’ context. For instance, in areas where the Internet connection is unreliable, Uganda Telecom devised an offline version that allows registrars to register births in an area where there is no Internet and synchronize with the online version later. This offline solution is currently in the final stages of being developed and tested. The results obtained have been very encouraging. Today, the company’s birth registration initiative is seen as a key means of demon- strating that mobile operators could contribute to development and the welfare of citizens. The next step is to extend the service to other mobile networks by encouraging the interoperability of systems. UNICEF is currently developing a USSD menu for MTN, another mobile network operator, which will send birth notification information to the Mobile VRS server. Source: GSMA Mobile Identity Team. “Mobile Birth Registration in Sub-Saharan Africa: A case study of Orange Senegal and Uganda Telecom solutions.” GSMA, Uganda Telecom, 2013. http://www.gsma.com/mobileidentity/wp-content/uploads/2013/05/Mobile-Birth-Registration-in-Sub-Saharan-Africa.pdf. 42 CRVS Scaling-up Investment Plan 2015–2024 Box 6  Modernizing the civil register in Albania The year 2008 was a milestone for the Albanian national civil register project. By the end of that year, all residents were entered into a digital national register with an online connection to all civil status offices throughout the country. It is used as the basis for providing voters lists, biometric passports, and producing national identification cards. A subsequent project focused on resolving two remaining problems—scanning the archive register books and transferring the data from the National Civil Register to third parties. By the end of 2010, the scanning project had completed the digitization of the register books and created an important archive that was accessible through all civil status offices across the country. The information is also accessible from the register to the national Institute of Statistics for producing register-based statistical information. One challenge involved the purchase of software; since this turned out not to be open source, there were limitations on how much the government and the Institute of Statistics could maintain and further develop it. Evidently, wider consultations at an earlier stage might have resolved this problem. Another lesson learned was the importance of involving more institutions from countries that have developed and maintained their own population registers so that they could provide advice based directly on their own experiences. Source: Statistics Norway, 2012 “How to Modernize a Civil Registration System - The Case of Albania,.” Documents 32/2012. https://www.ssb.no/a/english/publikasjoner/pdf/ doc_201232_en/doc_201232_en.pdf. Annex 3. Country Case Studies 43 Box 7  Community health workers and birth registration in Bangladesh The aim is to register all pregnant women and their children in a unified electronic system. The core technological aspect of this is the use of mobile devices for such registration at the community level by household health workers. The project uses two existing codes for the National Identification (NID) and Birth Registration Number (BRN). If these are not available, a temporary tracking number is generat- ed, thus imparting a degree of flexibility into the system. In 2004, the Government of Bangladesh enacted a new Birth and Death Registration Act. The Act and subsequent amendments and rules state that presentation of a birth certificate is mandatory in order to open a bank account, export and import licenses, connect to utilities, register a car, and obtain a national identification card. To obtain a birth certificate, within 45 days of birth, parents must provide proof of birth. However, 80 percent of live births occur outside of hospital facilities. Community EPI workers check for the birth certificate on the first day of immunization and enter the unique Birth Registration Number onto the EPI card. This information is then sent online to the local registrar and on subsequent immunization days, parents submit the Birth Registration Certificate to the EPI workers. Consultations were held with experts to develop minimum data sets for maternal, newborn, and child health (MNCH), and reviews were done of available MNCH-related instruments nationally and globally. Two sets of data were created: one for pregnant mothers and the other for children. This formed the foundation for work on digital design and software development aimed at collecting and processing data around individual name-based records, which would feed into the District Health Information Software 2 (DHIS2) being used by the Ministry of Health, Bangladesh and integrated with other ICT-based strengthening efforts by the Ministry of Health. One lesson learned was that the results may have been achieved more quickly had an existing open source application been used and customizes for the specific requirements, rather than trying to build applications from scratch. Source: WHO. “Move it: Report on Monitoring of Vital Events using Information Technology.” WHO 2013. http://www.who.int/healthinfo/civil_registration/crvs_report_it_2013.pdf. 44 CRVS Scaling-up Investment Plan 2015–2024 Box 8  Automated Verbal Autopsies in the community in South Africa, Malawi, India, and Nepal For the first time the development of WHO Verbal Autopsy (VA) standards have coincided with the refinement of an automated method for the interpretation of VA data. This is based on a long-established series of VA interpretation models developed over the past decade. It uses Bayesian probabilistic methods for a totally consistent and comparable source of cause-of-death data. Research on implementing the automated VA system is underway in South Africa, Malawi, India, and Nepal, and is expanding to Bangladesh and other countries. Experience to date shows that it is quicker and cheaper than traditional VA methods, it improves data quality and completeness, it is easy to use and secure, it is liked by field-workers, and the use of phones does not seem to be a problem even in remote areas. Challenges remain however, in remaining consistency with WHO questions in particular when translated versions are prepared. There is a need to have strong, well maintained trainer-of-trainer programs and funds secured to ensure long term maintenance and sustainability of the software. Source: Measure Evaluation. “SAVVY: Sample Vital Registration with Verbal Autopsy.” http://www.cpc.unc.edu/measure/tools/monitoring-evaluation-systems/savvy. Annex 3. Country Case Studies 45 Box 9  Improving hospital mortality data in Mozambique In Mozambique, prior to 2006, no routine data were available on cause of death and morbidity, and there were no representative civil registration data. In 2006, the Ministry of Health formally adopted the decision to use ICD-10 and standard classifications through the creation of a national committee for the implementation of standard classifications. A pilot was conducted in 2007 in one hospital using shortlists based on aggregated data, and in 2008, mortality registers were introduced. The mortality register allowed for the first national mortality analysis based on routinely collected data, although initially restricted to a hospital setting. There were further reforms initiated in the mortality system through the revision of the death certificate, introduced nationwide in 2009, and the introduction of SIS-ROH (Sistema de Informmacao de Saude – Registo Obitois Hospitalares), software designed to enable individual-based data management, including demographic data and data on hospitalization and cause of death. Building upon these ongoing processes of reform, in 2011, a project was initiated on the modernization of the national vital statistics system, which at that time was not implemented nationally and only covered deaths in hospitals. Capitalizing on existing initiatives was an important factor in the project’s success. An application was introduced that captured hospital deaths and permitted expansion of the system to allow extra-hospital deaths to be registered (that is, deaths registered by police stations and from declarations recorded by local community authorities). A later version of the application will be web-enabled and linked to scaling efforts and consolidation of data into a single database. The SIS-ROH software has improved with regular use and feedback from the users in selected hospitals. Simultaneously, there have been ongoing efforts to develop the capacity of nodal provincial staff, in both information technology and the use of SIS-ROH, so that they are able to provide technical support on the software to end users. It is hoped that the interest the project has generated will lead to a future national-level initiative for the computerization CRVS systems. Source: WHO. “Move it: Report on Monitoring of Vital Events using Information Technology.” WHO 2013. http://www.who.int/healthinfo/civil_registration/crvs_report_it_2013.pdf. 46 CRVS Scaling-up Investment Plan 2015–2024 Box 10  Civil register links with maternal and child events in Philippines The project was collaboration between the National Statistical Office (NSO) and the Department of Health and involved linking two existing monitoring tools: the Barangay Civil Registration System (BCRS) and Watching Over Mothers and Babies (WOMB). The WOMB system is an ongoing project of the department to enable registration and processing of maternal and child vital events, and for the generation and utilization of vital statistics at the local levels. The BCRS was developed by the NSO for use at the Local Government Units (LGUs) to support the process of civil registration by the local municipality. The BCRS also seeks to establish a database of social and demographic profiles of Barangay residents. The project supported the gathering of data on demographic profiles for all residents, including vital registration status. This involved supporting technical advances on BCRS, redesigning the data-gathering tools to facilitate data processing, and creating an online data- base at the national level for hosting authorized BCRS implementers. The project also aimed to increase awareness among the Barangay constituents of the importance of civil registration, as a part of their basic human rights, ensure interoperability between WOMB and BCRS, and improve quality and completeness of BCRS data. It also monitored the use of data with a view to improving the utilization of vital statistics for public health action. The project also performed an analysis of why births were not being registered: reasons varied from negligence to lack of awareness, with registration not being seen as part of the culture. Similar analyses were carried out of the status of marriage and death registrations and reasons for their non-registration. Source: WHO. “Move it: Report on Monitoring of Vital Events using Information Technology.” WHO 2013. http://www.who.int/healthinfo/civil_registration/crvs_report_it_2013.pdf. Annex 3. Country Case Studies 47 Box 11  Strengthening vital statistics through inter-institutional efforts in Nicaragua Nicaragua’s assessment of the vital statistics system drew attention to its problems, such as a weak legal framework, poor inter-insti- tutional coordination, a lack of access to and an insufficient number of civil registry offices, difficult connections due to transportation difficulties, the extremely low quality of data, and a lack of awareness of both the system and the importance of vital statistics. During the period May 2011 to September 2013, Nicaragua started a dialogue among the institutions involved in vital statistics registration in the country, with the Ministry of Health leading the process of integration to facilitate the connection and improve the timely reporting of births and deaths. In addition, authorities seized the opportunity to draft and place before the National Assembly legislation to create a legal framework for the civil registration of births and deaths. To reduce sub-registration, the institutions jointly embraced public education radio campaigns implemented with 43 radio stations in three languages: Spanish, English, and Miskitu. This activity facilitated registration in 118 com- munities, achieving a total of 253 children under 1, 4,451 children under 5 years of age, and 4,704 youth. In the same period, it was possible to carry out 19 workshops targeting municipal personnel and midwives, train 435 doctors on ICI-10 data, and review perinatal records on selected sites. Today, with a national legal framework in place and strong inter-institutional relations and commitment, resolu- tion of Nicaragua’s remaining challenges seems more feasible. Source: World Bank. Trust Fund for Statistical Capacity Building Program 2013. http://www.worldbank.org/en/data/statistical-capacity-building/trust-fund-for-statistical-capacity-building. Annex 4. National Statistical Capacity using World Bank Composite Indicator Composite indicator of three dimensions: statistical methodology; source data; and periodicity and timeliness Country 1999 2009 Change Country 1999 2009 Change Afghanistan 11 33 +22 Lao PDR 46 61 +15 Angola 31 34 +3 Lesotho 57 60 +3 Azerbaijan 46 77 +31 Liberia 13 32 19 Bangladesh 56 65 +9 Madagascar 59 61 +2 Benin 47 48 +1 Malawi 54 64 +10 Bolivia 63 70 +7 Mali 46 61 +15 Botswana 51 47 –4 Mauritania 50 60 +10 Brazil 78 77 –1 Mexico 68 81 +13 Burkina Faso 62 58 –4 Morocco 69 77 +8 Burundi 29 56 +27 Mozambique 62 62 0 Cambodia 43 72 +29 Myanmar 40 42 +2 Cameroon 36 64 +28 Nepal 51 72 +21 Central African Republic 43 46 +3 Niger 57 56 –1 Chad 52 49 –3 Nigeria 47 57 +10 China 61 54 –7 Pakistan 62 82 +20 Comoros 34 49 +15 Papua New Guinea 44 43 –1 Congo, Dem. Rep. 34 29 –5 Peru 75 81 +6 Congo, Rep 26 54 +28 Philippines 66 86 +20 Côte d’Ivoire 63 62 –1 Rwanda 42 66 +24 Djibouti n/a 35 n/a Sao Tome and Principe n/a 55 n/a DPR Korea n/a n/a n/a Senegal 67 67 0 Egypt, Arab Rep. 74 83 +9 Sierra Leone 24 49 +25 Equatorial Guinea n/a n/a n/a Solomon Islands n/a 30 n/a Eritrea 33 29 –4 Somalia 14 23 +9 Ethiopia 57 78 +21 South Africa 61 78 +17 Gabon 33 38 +5 South Sudan n/a n/a n/a Gambia 39 62 +23 Sudan 32 43 +11 Ghana 48 59 +11 Swaziland 43 64 +21 Guatemala 44 84 +40 Tajikistan 44 77 +33 (continued on next page) 50 CRVS Scaling-up Investment Plan 2015–2024 (continued) Composite indicator of three dimensions: statistical methodology; source data; and periodicity and timeliness Country 1999 2009 Change Country 1999 2009 Change Guinea 64 50 –14 Tanzania 63 59 –4 Guinea-Bissau 43 39 –4 Togo 47 53 +6 Haiti 32 41 +9 Turkmenistan 36 43 +7 India 74 79 +5 Uganda 55 61 +6 Indonesia 75 82 +7 Uzbekistan 36 64 +28 Iraq 21 37 +16 Vietnam 50 61 +11 Kenya 61 54 –7 Yemen, Rep 41 47 +6 Kyrgyz Republic 58 89 +31 Zambia 76 59 –17 Zimbabwe 66 46 –20 Source: World Bank Bulletin Board on Statistical Capacity. http://data.worldbank.org/data-catalog/bulletin-board-on-statistical-capacity. Annex 5. Legal and Regulatory Issues for CRVS CRVS legal and regulatory to instances of mistaken identity or unjust treatment; (ii) risks of unjust inferences caused by collecting or link- challenges ing data originally intended for different purposes; and (iii) risks of “function creep,” where data collected for one Sound public administration, the delivery of core govern- purpose is gradually used for others to which the individu- ment services, and the smooth functioning of commerce al concerned has not consented. Modern technology may all depend on robust means of personal identification. accentuate or help agencies manage these risks, depend- Government agencies also require accurate and reliable ing upon what technology is used and how it is deployed. vital statistics (population and health measures, among Unlike with paper-based records, digitized information others) in order to deliver services efficiently and effective- can be stored, sorted, manipulated, and redistributed at ly and to plan for the future. Sharing of personal informa- high speeds and minimal cost. Technology now makes tion between government agencies is desirable for a range it possible to combine information held across multiple of reasons. Information sharing can help the government databases, allowing for individual profiling among other provide better and more efficient services through coor- uses. The move toward the use of biometric features also dinated service delivery, detect wrongdoing, or take joint raises acute privacy issues. The inclusion of DNA or fin- action against social problems. Civil—or public—regis- gerprint information, for example, as part of a civil reg- ters are often open to the public for many of the same istry or identification scheme requires specific regulation reasons, including to improve economic efficiency and to under the primary enabling law. promote transparency and accountability, among others. However, the nature and range of information collect- A robust legal framework should promote the free flow ed under a civil registry—or personal identification— of information, balanced against the need to protect in- scheme may raise concerns about the potential for abuse dividual privacy, personal information, and other pub- if strong privacy protections are not included as part of lic interests governing access to public registers. Some the legal and regulatory enabling environment. The in- countries have established a single public agency that is formation on civil registers may include personal infor- responsible for administering privacy and freedom of in- mation that is sensitive or which could lead to harm if it formation laws—in effect an entire government clearing is disclosed or combined with other personal data. There house for complaints, oversight, advice, and reporting for is a tension between freedom of information, transparen- freedom of information and privacy matters. In other cas- cy, and government accountability, on one hand, and the es, countries have chosen to build on existing institutions need to protect personal information on the other. and agencies that are involved in collecting, using, and disseminating data. Under either model, the imperative The privacy and related issues regarding the collection is that all public agencies should be required to deal with and use of personal information on civil registers may be personal information in a manner that protects personal grouped into three broad categories: (i) risks of injustice, privacy. These obligations may be specified in individual including incorrect or inaccurate data, which may lead (sector-specific) laws or by way of a single overarching 52 CRVS Scaling-up Investment Plan 2015–2024 freedom of information and privacy law, depending on deal responsibly with personal information is an import- local issues. Where multiple agencies are involved, steps ant factor in ensuring proper administration and user should be taken to reduce the potential for regulatory in- take up of the scheme. If the government allows, or does consistency and overlap, which can lead to uncertainty not restrict, the use of the information for other purpos- and increase compliance costs for the government, indi- es, citizens may be harmed or feel aggrieved by the loss viduals, and businesses. of privacy. This is damaging both to good public admin- istration and the ability of the government to promote the use of the civil register. If citizens no longer trust the Protecting individual privacy government to keep personal information confidential, it rights may lead to information being withheld, or wrong or in- accurate information being supplied. While public records often comprise generic information such as name, address, birth date, etc., privacy risks are still Legislation should provide for the protection of personal present. Harm may be seen in the so-called “aggregation information and privacy, including data security. Mea- effect”—in combination, otherwise innocuous informa- sures to ensure confidentiality and protect against misuse tion may paint a portrait of personalities, activities, and are critical, among other reasons, to promote trust and individual attributes—greatly increasing an individual’s confidence in the system—maximizing the likelihood vulnerability to dangers such as identity fraud, stalking, or that the public will support and comply with obligations harassment. In addition, to the extent that a civil registry, to provide complete and accurate information in a timely public database, or document may evolve into an identi- manner. The law should contain privacy protections that ty system or gather intimate personal information (e.g., reflect the following basic principles: personal health data), stringent protections are needed to protect against the potential for abuse. Civil registers may • Collect only what is necessary for the purpose—an ef- also include information that creates special risks to indi- fective way of promoting good privacy practice is to vidual dignity in certain circumstances. For example, some collect only the minimum amount of personal infor- causes of death may result in embarrassment if they are mation that is necessary to meet a clearly defined and included on a register of deaths. In other cases, there may articulated purpose; be safety concerns about personal identifying information, • Ensure individual control—individuals should have including names and addresses, being publicly available, control over how their personal information is man- including in the context of domestic violence protection aged and used; orders, stalking, and harassment, or identity theft. • Use or disclosure for purpose—the registry should minimize the risk of individuals being surprised as Citizens are accustomed to filling in forms that ask for to how their personal information is managed, in- their personal information, frequently for inclusion on cluding by ensuring personal information is gener- public registers. It is usually given for specific purposes ally only used or disclosed for the purpose for which (recording births and deaths, recording marriages and di- it was collected; vorces, voter registration, buying and selling land, motor • Ensure transparency—a high degree of transparency vehicle licensing, company registration, buying/selling should accompany both the implementation and shares, etc.). Often, there is no choice but to provide the operation of the registry, including openness on how information—the registration may be compulsory (in the the system handles personal information and permit- case of vital statistics, for example, births and deaths) or if ting individuals access to their personal information the person wants or needs to carry out a certain activity. and, where necessary, the ability to challenge and While it is often assumed that the information is used correct any inaccuracies; and only for purposes relevant to its collection, this may not • Secure handling of personal information—an element be the practice. Revelations that personal data has been of enhancing privacy will be measures that improve misused or used in ways not originally expected or antici- how securely personal information can be handled, pated can lead to public discord or undermine confidence whether while in storage, during transmission, or in the registration process. Trust that the government will during use. Annex 5. Legal and Regulatory Issues for CRVS 53 Legal reform and development vide less certainty. It is important therefore that rules for the protection of individual privacy should be provided for CRVS for in primary legislation and not by way of subordinate The foundational rules for a robust and sustainable civil instrument. The UN Handbook, Civil Registration and registration and vital statistics system should be estab- Vital Statistics Systems: Preparation of a Legal Framework, lished in primary legislation. Legislation is essential to No. 71 (1989), includes a “model civil registration law” ensure registration is complete and accurate, to provide which is intended to assist with the development and re- for compulsory registration and impose deadlines, and to form of legislation for civil registration and vital statistics. permit the imposition of sanctions for non-compliance. Its guidance may be summarized as follows: Legislation may also be required to provide for the public funding that is needed to establish and operate a civil reg- General provisions istration system. Government policy is the starting point for the development of any new legislation. The process • Defines the vital events covered by the law (live of converting policy into legislation is complex and of- births, marriages, deaths, divorces, stillbirths and fe- ten time consuming. It requires political decision making tal deaths, adoptions, etc.). on questions of policy and technical expertise to lead the • Defines the jurisdiction and territorial application of consultation process and to draft the legislation. Among the law (and prescribed under a chapter dealing with other matters, it is necessary to ensure that any new law the sphere of competence of the civil register). is consistent with any applicable constitutional or “supe- • Provides for compulsory registration and penalties rior” legislative provisions, the existing statute book, and for non-compliance, deadlines for registration, who applicable international law. A range of issues must be must register the event, and documentary evidence considered, including the following: needed for registration. • Prescribes the legal effect of registration and official • the relationship between primary legislation and documents. subordinate regulations and rules; • Describes statistical obligations and mandates cer- • institutional arrangements, providing for clear tain collaborations among government agencies. functions and powers for the government agencies • Prescribes protections for individual privacy and involved; confidentiality. • monitoring investigative and enforcement powers; • funding mechanisms; Registration infrastructure • accountability and oversight mechanisms, such as appeal and for administrative review; and • Prescribes the structure, administrative organiza- • transitional and savings arrangements. tion, and functions of the civil registration service, including the appointment process and authority Subordinate laws may deal with a broad range of topics, of registrars, and intra-governmental coordination including technical rules and prescribing general forms. obligations. Depending on the jurisdiction, subordinate laws may also proscribe certain conduct and prescribe fees and penal- Entries in the civil registers ties, although the permissible usage of subordinate in- struments—rules and regulations—varies. In every case, • Prescribes the process for entering all vital events however, it is important to consider whether the contem- into the registers, the forms to be used, and the pro- plated subject matter is appropriate for inclusion in a sub- vision of official certificates. ordinate instrument, whether it is authorized by the em- powering statute and whether its promulgation satisfies Registration of births, marriages, divorces, and deaths any statutory conditions precedent. While regulations and rules are attractive because they may be made quick- • Details how particular life events should be reg- ly under delegated authority without submission to the istered, including what characteristics should be law-making body, for these same reasons, they also pro- included. 54 CRVS Scaling-up Investment Plan 2015–2024 • Provides instructions on handling information, in- • Article 24, International Covenant on Civil and Po- cluding storage and dissemination for statistical litical Rights (1966) reporting. • Article 12(2), International Covenant on Economic, • Provides for the verification of all evidence to be in- Social and Cultural Rights (1966) cluded on official certificates. • United Nations Human Rights Council Resolu- • Describes how to issue various permits. tion, “Birth registration and the right of everyone to recognition everywhere as a person before the law” Amendment of registration records (2012) • Provides a mechanism for correcting errors, includ- Protection of individual privacy rights ing errors that may be corrected administratively and errors that may be corrected only with a court order. • Recommendation of the Council Concerning Guidelines Governing the Protection of Privacy and Proof of registration Transborder Flows of Personal Data (September 23, 1980) • Provides for the preparation of certified copies of reg- • OECD Guidelines for the Security of Informa- istration papers and access to information. tion Systems and Networks: Towards a Culture of Security (adopted as a Recommendation of the Statistical reports OECD Council at its 1037th Session on July 25, 2002) • Provides for the preparation of statistical reports, data • APEC Information Privacy Framework (endorsed by management, error checking, and dissemination. APEC Ministers in Chile, November 2004) • Article 12, Universal Declaration of Human Rights Inspection and penalties 1948 • Article 17, International Covenant on Civil and Po- • Sets forth provisions to ensure transparency and ac- litical Rights of December 16, 1966; entry into force countability of the system. March 23, 1976) • Guidelines concerning computerized personal data Funding arrangements files (A/RES/45/95) • Article 8, Charter of Fundamental Rights (as signed • Prescribes for the payment of service fees for certain and proclaimed by the Presidents of the European registry services. Primary registry activities are pro- Parliament, the Council, and the Commission at the vided free of charge (promoting the universality of European Council meeting in Nice on December 7, the system). 2000) • EC Directive 95/46/EC of the European Parliament The WHO assessment framework, “Improving the Quality and of the Council of October 24, 1995 (the Data and Use of Birth, Death and Cause-of-Death Information: Protection Directive) Guidance for a Standards-Based Review of Country Practices,” • EC Directive 2002/58/EC on privacy and electronic may also be referred to for guidance on the legal and regula- communications of July 12, 2002 tory framework necessary to support the introduction and • EC Regulation 45/2001 on the protection of indi- operation of a robust civil registration and vital statistics viduals with regard to the processing of personal data system. Additional guidance may also be found from the by the Community institutions and bodies and on following international instruments (non-exhaustive): the free movement of such data of December 18, 2000 CRVS • European Council Framework Decision 2008/977/ JHA of November 27, 2008 on the protection of • Universal Declaration of Human Rights (1948) personal data processed in the framework of police • Declaration of the Rights of the Child (1959) and judicial cooperation in criminal matters Annex 6. Status of CRVS in 75 Countries Prioritized by the Commission on Information and Accountability Country COIA CRVS Rapid CRVS Comprehensive CRVS Strategic Plan CRVS Political Commitment country Assessment Assessment / Committee Afghanistan Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Angola Yes Planning assessment Civil Registration Minister – Health Ministers in 2014 Azerbaijan Yes Yes Bangladesh Yes Yes Completed National CRVS Plan and Likely in 2014 through UNESCAP Costed investment Plan process Benin Yes Civil Registration Minister – Health Ministers in 2014 Bolivia Yes Country works within Health Ministers through PAHO PAHO Regional Committee Regional Committee framework since 2008 Botswana Yes First completed and new National CRVS Plan Civil Registration Minister – Health one underway Ministers in 2014 Brazil Yes Country works within Health Ministers through PAHO PAHO Regional Committee Regional Committee framework since 2008 Burkina Faso Yes Completed National CRVS Plan and Civil Registration Minister – Health Committee Ministers in 2014 Burundi Yes Yes Planning assessment Civil Registration Minister – Health Ministers in 2014 Cambodia Yes Yes Completed National CRVS Plan, Likely in 2014 through UNESCAP National CRVS Steering process Committee Cameroon Yes Civil Registration Minister – Health Ministers in 2014 Central African Yes Civil Registration Minister – Health Republic Ministers in 2014 Chad Yes Civil Registration Minister – Health Ministers in 2014 China Yes Yes Planned in 1–3 provinces Likely in 2014 through UNESCAP process Comoros Yes Yes Civil Registration Minister – Health Ministers in 2014 (continued on next page) 56 CRVS Scaling-up Investment Plan 2015–2024 (continued) Country COIA CRVS Rapid CRVS Comprehensive CRVS Strategic Plan CRVS Political Commitment country Assessment Assessment / Committee Congo, Rep. Yes Civil Registration Minister – Health Ministers in 2014 Côte d’Ivoire Yes Civil Registration Minister – Health Ministers in 2014 DPR Korea Yes Yes underway Likely in 2014 through UNESCAP process DPR Congo Yes Yes Civil Registration Minister – Health Ministers in 2014 Djibouti Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Egypt Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Equatorial Yes Civil Registration Minister – Health Guinea Ministers in 2014 Eritrea Yes Planning assessment Civil Registration Minister – Health Ministers in 2014 Ethiopia Yes Yes Completed National CRVS Plan, Civil Registration Minister – Health National Committee and Ministers in 2014 Costed investment Plan Gabon Yes Civil Registration Minister – Health Ministers in 2014 Gambia Yes Civil Registration Minister – Health Ministers in 2014 Ghana Yes Underway Civil Registration Minister – Health Ministers in 2014 Guatemala Yes Country works within Health Ministers through PAHO PAHO Regional Committee Regional Committee framework since 2008 Guinea Yes Civil Registration Minister – Health Ministers in 2014 Guinea-Bissau Yes Yes Civil Registration Minister – Health Ministers in 2014 Haiti Yes Country works within Health Ministers through PAHO PAHO Regional Committee Regional Committee framework since 2008 India Yes Yes Likely in 2014 through UNESCAP process Indonesia Yes Yes Completed National CRVS Committee Likely in 2014 through UNESCAP process Iraq Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Kenya Yes Completed National CRVS Plan Civil Registration Minister – Health Ministers in 2014 Kyrgyz Yes Yes Completed Republic Lao PDR Yes Yes Completed National CRVS Plan, Na- Likely in 2014 through UNESCAP tional CRVS Committee process (continued on next page) Annex 6. Status of CRVS in 75 Countries Prioritized by the Commission on Information and Accountability 57 (continued) Country COIA CRVS Rapid CRVS Comprehensive CRVS Strategic Plan CRVS Political Commitment country Assessment Assessment / Committee Lesotho Yes Planning assessment Civil Registration Minister – Health Ministers in 2014 Liberia Yes Completed National CRVS Plan, Na- Civil Registration Minister – Health tional CRVS Committee Ministers in 2014 Madagascar Yes Yes Civil Registration Minister – Health Ministers in 2014 Malawi Yes Planning assessment Civil Registration Minister – Health Ministers in 2014 Mali Yes Civil Registration Minister – Health Ministers in 2014 Mauritania Yes Civil Registration Minister – Health Ministers in 2014 Mauritius Yes Functioning system Civil Registration Minister – Health Ministers in 2014 Mexico Yes Country works within Health Ministers through PAHO PAHO Regional Committee Regional Committee framework since 2008 Morocco Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Mozambique Yes Completed Underway, Costed Indica- Civil Registration Minister – Health tive Investment Plan Ministers in 2014 Myanmar Yes Yes Planned Likely in 2014 through UNESCAP process Nepal Yes Yes Completed National CRVS Committee Likely in 2014 through UNESCAP process Niger Yes Civil Registration Minister – Health Ministers in 2014 Nigeria Yes Civil Registration Minister – Health Ministers in 2014 Pakistan Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister; The Federal Planning commission is the CRVS Champion Peru Yes Country works within Health Ministers through PAHO PAHO Regional Committee Regional Committee framework since 2008 Philippines Yes Yes Completed National Plan, committee Likely in 2014 through UNESCAP and Costed investment process Plan Papua New Yes No Planned for 2014 Commitment to develop Endorsed at Pacific Health Ministers Guinea plan and committee is firm Meeting 2013 Rwanda Yes Yes Planning Civil Registration Minister – Health Ministers in 2014 São Tomé and Yes Civil Registration Minister – Health Principe Ministers in 2014 Senegal Yes Yes Underway Civil Registration Minister – Health Ministers in 2014 Sierra Leone Yes Yes Civil Registration Minister – Health Ministers in 2014 (continued on next page) 58 CRVS Scaling-up Investment Plan 2015–2024 (continued) Country COIA CRVS Rapid CRVS Comprehensive CRVS Strategic Plan CRVS Political Commitment country Assessment Assessment / Committee Solomon Yes Yes Completed National CRVS Plan and Ministers – Health and Finance Islands Committee Somalia Yes Yes Underway CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister South Africa Yes Yes Functioning System Civil Registration Minister – Health Ministers in 2014 South Sudan Yes Planned Civil Registration Minister – Health Ministers in 2014 Sudan Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Swaziland Yes Underway Committee Civil Registration Minister – Health Ministers in 2014 Tajikistan Yes Yes Planned for 2014 Togo Yes Civil Registration Minister – Health Ministers in 2014 Turkmenistan Yes Yes Uganda Yes Planned Civil Registration Minister – Health Ministers in 2014 Uzbekistan Yes Tanzania Yes Underway Committee Civil Registration Minister – Health Ministers in 2014 Viet Nam Yes Yes Planned Likely in 2014 through UNESCAP process Yemen Yes Yes Completed National CRVS Plan CRVS Regional Strategy endorsed by Eastern Mediterranean Regional Committee – Health Minister Zambia Yes Yes Completed National CRVS Plan and Civil Registration Minister – Health Committee Ministers in 2014 Zimbabwe Yes Civil Registration Minister – Health Ministers in 2014 Annex 7. Global CRVS Group Terms of Reference Draft April 2014 The formation of a global CRVS group was discussed on March 3, 2014 in New York at a UN Statistical Commis- sion side event on global partners for CRVS. The initial Background meeting brought together key regional and international stakeholders all active in the field of CRVS. The meet- The Global Civil Registration and Vital Statistics Group is ing agreed on the need to establish a global mechanism a group coming together to forge stronger alliances among whereby members can make positive contributions to the key stakeholders in the area of civil registration and vital improvement of CRVS, in light of their respective areas statistics (CRVS) to enhance the effectiveness and sus- of expertise and concern. tainability of the support that they provide to countries (http://unstats.un.org/unsd/demographic/CRVS/Global- CRVS.html). With growing recognition of the value of Objectives CRVS to human rights, good governance, and develop- ment planning, monitoring and evaluation, there has been The main objectives of the group are to: renewed interest in strengthening national CRVS systems. CRVS is also emerging as an essential underpinning of the • Converge strategic priorities and mandates toward post-2015 development agenda. a holistic approach to CRVS, creating an enabling environment for greater collaboration at the na- At the regional and global levels, many efforts continue tional, regional, and global levels, and delivering to be made to advocate and support the improvement as one of CRVS systems. Intergovernmental regional organiza- • Exchange information and coordinate global activi- tions and development banks have been active in raising ties among members to complement CRVS momen- awareness and urging governments to commit to the issue tum at the regional and national levels through the adoption of declarations or resolutions. Indi- • Explore and leverage additional opportunities to ac- vidual UN agencies and other international stakeholders celerate the improvement of CRVS systems have been working toward improvement of CRVS, how- • Advocate for the importance of CRVS as a develop- ever, their efforts were largely uncoordinated and posed ment imperative challenges for improvement of CRVS in a holistic and integrated manner. Hence, close communication and co- ordination of activities among stakeholders at the glob- Tasks/Activities al level are key to the systems’ improvement. The global community must act together by aligning its actions in The tasks and activities of this group will focus on com- providing sustainable support for regions and countries bining efforts and work toward global improvements in to achieve well-functioning CRVS systems. CRVS. Specific tasks are as follows: 60 CRVS Scaling-up Investment Plan 2015–2024 I. Review and update the activities and programs to Chair: The chair will be elected for one year and will improve CRVS among members rotate among member organizations. The chair works II. Identify opportunities, challenges, and emerging closely with UNSD in planning and implementing ac- needs and share best practices, innovations, and re- tivities. search to advance CRVS in countries III. Create a knowledge platform for sharing informa- tion, research, best practices, and lessons learned Organization of work IV. Form task teams to address specific issues related to CRVS, as necessary The group will work through regular meetings and ex- changes of emails.  An annual meeting will take place in New York, close to the dates of the meeting of the United Membership Nations Statistical Commission (usually in early March). Additional meetings can be convened on an as-needed Members are international and regional intergovern- basis, to be timed immediately following the major glob- mental organizations, committed to the advancement of al/regional meeting on CRVS.  UNSD will maintain the CRVS programs, represented by senior staff. Members website, where the information on the group’s activities need to be active in the deliberations and activities of the can be shared and updated. group. The participation of relevant INGOs and other stakeholders may be invited to meetings of the group. Expected duration Organization The work of the Group is ongoing.  This TOR will be reviewed as needed. Secretariat: the United Nations Statistics Division (UNSD) serves as the Secretariat of the Group. Annex 8. Costing of CRVS Scaling Up Plan Objectives systems); (b) incremental recurrent costs for maintaining CRVS systems; (c) international support to CRVS, in- This exercise aims to estimate the additional financial re- cluding sharing knowledge and strengthening the evi- sources needed to reach the implementation plan targets dence base; and (d) monitoring and evaluation. with the overall goal of universal civil registration of births, deaths, and other vital events, and access to legal proof of registration for all individuals by 2030. It also provides or- Country strategic investment der-of-magnitude estimates of the incremental costs from plans 2015 to 2024 to stimulate discussion and planning of support for national implementation plans. This work, As noted above, cost estimates have been drawn from the which is ongoing by the World Bank and partners, builds five countries that have undertaken detailed costing ex- on the country-specific costing exercises and the cost ercises as part of the development of CRVS investment structure developed by the Health Metrics Network.3 plans. The costs in each plan were disaggregated into fixed/start-up/capital costs and variable/operating costs.4 The total costs (without inflation adjustment) vary from Methodology under US$30 million in countries with existing capacity, rising to over US$365 million in Ethiopia, which only Two approaches were employed: a “bottom-up” approach established a National Vital Events Registration Agency and a “top down” approach. The approach used for the in October 2013. bottom-up assessment of costs was to estimate the ad- ditional investment required to fulfill the country op- The country costs translate into a range of under US$1 erational plans for developing the CRVS system in five per capita in countries such as the Philippines and Ban- countries where data was available—Bangladesh, Ethi- gladesh, to between US$1 and US$4 in Mozambique opia, Kenya, Mozambique, and the Philippines. In the and Ethiopia. The cost per vital event (births and deaths) top-down approach, aggregated and per capita costs per ranges from under US$2 to over US$13. activity were derived from the bottom-up assessment and used as a reference for other countries with similar char- acteristics. Population estimates from the UN Statistics 3 Division were used to estimate the aggregated need and CEPA provided analytical inputs from the country-specific cost per activity. investment plans to the global costing and financial estimates for strengthening CRVS 4 Fixed/start-up/capital costs refers to both fixed costs for cap- The costing exercise developed estimates for four cost cat- ital investments and one-time development costs needed for egories: (a) development costs (incremental costs or ad- the CRVS system. Variable/operating costs refers to ongoing ditional funds for establishing and strengthening CRVS costs of operating and maintaining the system. 62 CRVS Scaling-up Investment Plan 2015–2024 Total CRVS Development Cost per Five-Year a. High investment need (countries with low registra- Plan (US$ million)a tion requiring capital investment): Defined as coun- 400 tries lacking basic infrastructure/equipment, a legal 365 350 framework, designs for outreach systems (mobile 300 and health facility registers), and data warehouse and 250 systems coordination. 200 b. Moderate investment need (countries with basic 150 infrastructure, but with low or moderate birth reg- 116 100 istration coverage): Defined as countries with a legal 50 30 30 40 framework approved but lacking implementation, partial population coverage, outreach programs de- 0 Mozambique Philippines Bangladesh Kenya Ethiopia signed but not implemented, traditional or obsolete ICT infrastructure in warehouses or points of collec- Source: National CRVS Investment Plans, WHO 2014. tion (ICT computerizing—automation of both reg- a The total for Bangladesh excludes biometric costs. istration and certification services and digitizing re- cords), potential for ID registration integration, and national integration of the vital statistics component. Per Capita and Per Vital Event CRVS Devel- c. Low need investment (countries with a basic to opment Costs moderate level of infrastructure in place, high birth 400 registration coverage, but with quality and timeliness 365 350 issues): Defined as countries with issues regarding 300 quality of information in particular cause-of-death 250 recording, vital statistics analysis and use, and coun- tries needing to extend registration coverage to very 200 remote areas/excluded populations (indigenous, mi- 150 116 grants, refugees etc.). 100 50 30 30 40 0 Mozambique Philippines Bangladesh Kenya Ethiopia Cost of CRVS scaling up Source: National CRVS Investment Plans, WHO 2014. The estimated development costs (incremental costs or additional funds for establishing and strengthening CRVS systems) in the 73 COIA countries during the period Country categorization 2015–2024 is US$2,281 million, or US$0.90 per capita (Table 1). The costs comprise 59 percent fixed/start-up/ Seventy-three COIA countries are categorized into three capital costs (i.e. both fixed costs for capital investments groups of investment need (high, moderate, and low), and one-time development costs needed for the CRVS with a total of six subgroups, based on the available data system) and 41 percent variable/operating costs (i.e. on- on birth registration (under one year of age) and death going costs of operating and maintaining the system) (Ta- registration coverage, and the quality of cause-of-death ble 2). The assumptions made to derive per-capita cost data. It is assumed that countries with very low birth per activity are found in Table 3. registration and no data on death registration have low capacity and thus will require high investment, while The estimated recurrent costs of running CRVS sys- countries with high coverage and relatively high death tems (with the assumption that this increases as more registration coverage will need lower investment. China CRVS systems become established) during the period and India were excluded due to inadequate comparable 2015–2024 is US$1.201 billion. Furthermore, the cost data and their very large population size. The activities of international support required, including to develop included in each of the three groups are as follows: international standards and tools, generate knowledge, Annex 8. Costing of CRVSScaling Up Plan 63 and develop an evidence base, was estimated at US$0.228 investment plans are available (Bangladesh, Ethio- billion (10 percent of the total development cost), with pia, Kenya, Mozambique, and the Philippines). In an additional US$0.114 billion (5 percent of the total de- terms of data availability, this is a clear limitation, al- velopment cost) for monitoring and evaluation (Table 1). though it does offer insight into a range of countries with different levels of CRVS system development The country costing exercises also allow for a provisional (from no system at all to almost functional systems), estimate of the expected commitment of resources from and experiences across regions, although there is no domestic sources, including the government and other information on countries from Latin America and in-country sources, estimated at US$1.829 billion in the the Caribbean or Central Asia, among others. 73 countries (Table 4). • Comparability of national CRVS costing plans. The main inputs for the costing exercise are extracted After excluding estimated domestic sources of funds, from five recent but dissimilar country-specific stra- there is an estimated US$1.99 billion financing gap for tegic plans. Although every national plan aimed to the global scaling up plan over a ten-year period, or an strengthen the country’s CRVS system, each country average of US$199 million financing gap per year for plan is different in two ways. First, they differ in the 73 countries. The following assumptions were made in set of activities they incorporated, reflecting diverse deriving the financing gap estimate for sustainable devel- national priorities and needs. For example, the plans opment of country CRVS systems: vary in terms of the ICT solutions proposed (ehealth, electronic registration systems, and even biometrics), a. For low-income countries: (i) Governments will infrastructure requirements, etc. For instance, while finance 20 percent, 40 percent, 60 percent, and the plan for the Philippines comprises improvements 80 percent of the variable/operating costs in years to cause-of-death data, Ethiopia’s does not. Second, 2015, 2016, 2017, and 2018 and bear full costs from the country plans assume that universal (or a very 2019 onward; and (ii) Governments will finance 10 high percentage for) birth registration is possible percent of fixed/start-up/capital costs from 2015 to during the time period covered by the plan, regard- 2019 and 20 percent from 2020 to 2024. less of the state of the CRVS system. While this may b. For lower-middle-income countries: (i) Govern- be feasible in some countries with more developed ments will finance 20 percent, 40 percent, 60 per- CRVS systems (e.g. the Philippines), it is likely to be cent, and 80 percent of the variable/operating costs very difficult to achieve in other countries where the in years 2015, 2016, 2017, and 2018 and bear full CRVS system is not fully developed (e.g. Ethiopia). costs from 2019 onward; and (ii) Governments will • Estimated commitments and financing gap as- finance 25 percent of fixed/start-up/capital costs sumptions. As a result of a lack of data on current or from 2015 to 2019 and 50 percent from 2020 to previous commitments, domestic commitments per 2024. income group have been estimated. As such, there is c. For upper-middle-income countries: Govern- a high degree of uncertainty around them thereby re- ments will bear the full variable/operating costs from quiring careful interpretation. The exercise also does 2015 to 2024, 50 percent of fixed/start-up/capital not consider the speed and trends over time with costs from 2015 to 2019 and 75 percent of fixed/ which additional funds can be mobilized, and both start-up/capital costs from 2020 to 2024. incremental investment and recurrent costs may ex- tend the original implementation period. Additional Limitations recurrent costs depend on prior capital investments and may change over time. These initial estimates are provisional and have a number • Same cost for birth and death registration. The of limitations: costing exercise is not able to distinguish between birth and death registration costs based on the in- • Limited country and regional representation. formation outlined in the national plans. Death In addition to the scant information available for registration might be more costly than birth reg- current expenditures on CRVS, only five national istration when the provision of COD is included. 64 CRVS Scaling-up Investment Plan 2015–2024 Adjustment costs are therefore necessary to ensure having reached relatively high birth registration lev- that provision is made for COD improvements in els, have a low death registration level. target countries. • The costing excludes “broader” costs such as op- • Incomplete measure of death registration cover- portunity costs and costs to the public. Costs that age. Current CRVS levels or capacity is based pri- are not included in the analysis include opportunity marily on information for birth registration among costs; direct costs to the population, (e.g. transport children under five collected by surveys (DHS and and certification costs); and cost savings due to de- MICS) and compiled by UNICEF, but only 15 veloping regional tools and standards, improving out of 75 countries have data on death registration, registration and recording using ICT, and compar- therefore it is possible that the country classifications ing with other information instruments, as well as underestimate the need for countries that, despite revenue from the registration process. Table 1.  Estimated financing gap for 2015–2024 scaling up investment plan (US$ million) 2015–2019 2020–2024 10 year total Financing Gap Development costs 1,140 1,140 2,281 1,604 Recurrent costsa 408 793 1,201 49 International support to CRVS including knowledge 114 114 228 228 sharing, and strengthening the evidence baseb Monitoring and evaluationc 57 57 114 114 TOTALs 1,720 2,104 3,824 1,995 Notes: a Recurrent costs increase as more CRVS systems are established (34 percent of total in first five years, and 66 percent of total in next five years) b 10 percent of total development cost distributed evenly c 5 percent of total development cost distributed evenly Table 2.  Estimation of global CRVS development and recurrent costs for 73 COIA priority countries 2015–2024a Cost category/activity Total US$ million Cost per capita (US$) % of cost Total development costs $2,281 $0.9 100% Fixed/start-up/capital costs $1,341 $0.55 58.8% Development of legal/ regulatory framework $18 $0.01 0.8% Comprehensive assessment $4.8 $0.002 0.2% Infrastructure and equipment $542 $0.22 23.7% ICT (technology costs) $619 $0.25 27.1% Digitization of existing registration records $108 $0.04 4.8% Development of operational guidelines and procedures $49 $0.02 2.1% Variable/operating costs $939 $0.38 41.2% Capacity Building $210 $0.09 9.2% IEC (Advocacy and communication campaigns) $240 $0.10 10.5% Maintenance of technology and other infrastructure $186 $0.08 8.1% Data management $120 $0.05 5.3% Outreach activities to improve coverage $66 $0.03 2.9% System monitoring and enforcement costs $118 $0.05 5.2% Additional recurrent costs (including staff salary) $1,201 $0.5 100% Note: Total development costs include both fixed/start-up/capital cost and variable/operating costs. Recurrent costs estimates include. US$ 251 million for capacity building and IEC costs, US $491 million for maintenance of technology, data management, outreach activities and system monitoring costs.; $US411Million for salary and running costs estimated as 20 percent of total development costs for high and moderate investment need countries, and 10 percent for low investment need countries. Cost per activity assumptions are outlined in Table 3. a India and China excluded Annex 8. Costing of CRVSScaling Up Plan 65 Table 3.  Main assumptions made to derive per-capita cost per activity in estimating global CRVS development and recurrent costs for 73 COIA priority countries 2015–2024 Cost category Main assumptions and cost per activity applied Included in recurrent costs Incremental Fixed/ capital costs     Development of legal/ regulatory Average cost of US$250,000 for Bangladesh and Philippines, was used for the No framework 73 countries Comprehensive assessment Average cost of US$100,000 per country was assumed for the comprehensive No assessment for the 48 countries that are yet to undertake the assessment. Infrastructure and equipment US$0.30 per capita (US$24.2 million average for four countries with data) No was used for high and moderate investment need countries while US$0.05 per capita was used for low investment need countries. Cost estimated from Ethiopia’s costing excludes the cost of vital statistics infrastructure. ICT ( technology costs) US$0.30 per capita (US$24.5 million average for 5 countries with data) was No used for high and moderate investment need countries while US$0.16 per capita was used for low investment need countries based on data from the Philippines (US$15.0 million) Digitization of existing registra- US$0.04 per capita (US$2.4 million average for three countries with available No tion records data i.e. Bangladesh, Mozambique, and Kenya) was used for the 73 countries. Development of operational US$0.02 per capita (US$1.8 million average for 5 countries with data) was Yes guidelines and procedures used for the 73 countries. Incremental Variable/operating   costs Capacity Building High investment need countries—US$0.29 per capita average across five Yes. Decrease cost. High countries (US$25.4 million); moderate investment need countries—US$0.12 need $0.12 and the based on average from Bangladesh, Mozambique, and Kenya (US$9.1 million); moderate group $0.02 and low investment need countries based on Philippines US$0.02 (US$1.9 million). IEC (Advocacy and IEC is expected to be higher in the high investment need countries (US$.20) Yes. Average $ .052 per communication campaigns) with the per capita estimate based on Ethiopia. For the moderate and low capita for all investment need countries estimates, US$.052 was used based on the average for Bangladesh, Mozambique, Kenya, and Philippines. Outreach activities to improve US$0.02 per capita was used for high and moderate investment need countries Yes coverage (the average for Kenya and Philippines) while US$0.04 per capita was used for low investment need countries (the higher rate for the low investment need countries takes into account the difficulty in reaching marginalized populations). The high and moderate investment need countries will later experience high cost as they try to reach universal coverage by 2030. Maintenance of technology and 30 percent of technology cost was used based on the average proportion from Yes other infrastructure the available country data (29%–40%). Bangladesh was excluded as it was considered to be very low (0.07 percent) Data management US$0.05 per capita (US$1.2 million average for 5 countries with data) was Yes used for the 73 countries. System monitoring and US$0.05 per capita (US$5.7 million truncated average) was used for the Yes enforcement costs 73 countries. Note: The table summarizes the associated assumptions used to estimate average unit costs per activity and per CRVS level. Activity and aggregated cost for each country were estimated using per-capita costs as shown in the table. The last column indicates whether that category was included in the recurrent cost for the next five years (2020–2024). Categorization of CRVS activities and costs have been based on the available information in the investment plans and have required a degree of judgment given some incomplete/unclear information in the plans. Country in- vestment plans vary also in terms of the activities included so this exercise offered the possibility of standardizing the costs included in the estimate. In addition, each country investment plan has been developed independently and employs slightly different approaches to costing. Country plan costing has been adjusted for inflation for the country’s specific implementation period between 2014 and 2020. All country plans had a five-year time horizon except Ethiopia, which had a seven-year investment plan period. Currency exchange rate fluctuations have not been factored into the analysis. 66 Table 4.  Costs of developing CRVS and estimated Iinvestment gap CRVS (73 countries) 2015–2024 Additional estimated costs Cost reference Main estimate Estimated Country level Coverage Number of Development Recurrent investment need commitments Financial Gap category (level of need) Countries assigned range countries cost cost US$ million US$ million US$ million Low coverage High investment Eritrea, Somalia, Liberia, Afghanistan, 0–30% 20 929 488 1,417 759 659 (BR<=30) need Ethiopia, Chad, South Sudan, Papua New Guinea, Malawi, Angola, Swaziland, Guinea Bissau, Bangladesh, Tanzania, Uganda, Yemen, Pakistan, DRC, Nigeria, Zambia CRVS Scaling-up Investment Plan 2015–2024 Moderate Moderate Mozambique, Equatorial Guinea, 31–80% 34 905 438 1,343 637 706 coverage investment need Niger, Sudan, Nepal, Zimbabwe, (BR>30 & Guinea, Lesotho, São Tomé and BR<=80) Principe, CAR, Sierra Leone, Côte d’Ivoire, Gambia, Senegal, Mauritania, Benin, Burundi, Cambodia, Burkina Faso, Cameroon, Ghana, Botswana, Lao PDR, Bolivia, Togo, Kenya, Myanmar, Indonesia High coverage Low investment Madagascar, Solomon Islands, Congo 81–100% 19 447 275 722 434 288 (BR>80) need Rep, Haiti, Mali, Rwanda, Comoros, Morocco, Djibouti, Gabon, Philippines, Vietnam, Brazil, Peru, Mexico, Egypt, Iraq, South Africa, DPR Korea, Guatemala, Tajikistan, Azerbaijan, Kyrgyz Republic, Turkmenistan, Uzbekistan TOTAL       73 2,281 1,201 3,482 1,829 1,653 Note: Financial gap for development and recurrent costs, excludes international support and monitoring and evaluation financing needs. Annex 9. Participants at Global CRVS Consultation in Addis Ababa April 28–29, 2014 CO-HOST ORGANIZATIONS Canada DFATD Benjamen Yung Department of Foreign Affairs, Trade and Devel- benyamen.yung@international.gc.ca opment UN Economic Chukwudozie Officer in Charge, African Centre for Statistics cezigbalike@uneca.org Commission for Africa Ezigbalike Raj Mitra Chief, Demographic and Social Statistics rmitra@uneca.org Josephine Mareal- Officer in Charge, Office of Partnerships jmulimwengu@uneca.org le-Ulimwengu Salah Badr Manager, CRVS improvement Initiative sbadr@uneca.org Gloria Mathenge   gwaithiramathenge@uneca.org Gilbert Habaasa Fellow, Demographics & Social Statistics ghabaasa@uneca.org Kodzovi Senu Abalo Fellow, CRVS Secretariat kabalo@uneca.org Meaza Bekele Statistics Assistant meazab@uneca.org World Bank Samuel Mills Senior Health Specialist smills@worldbank.org Ana M. Aguilar Rivera Health Economist aaguilarrivera@worldbank.org Bob Fryatt Consultant, Health, Nutrition & Population bobfryatt@gmail.com Francois Lefebvre Senior Financial Officer flefebvre@worldbank.org James Neumann Senior Counsel, Legal Department jneumann@worldbank.org World Health Ties Boerma Director, Department of Health Statistics and boermat@who.int Organization Information Systems Anneke Schmider Technical Officer (CRVS), Health Statistics and schmidera@who.int Information Systems Mark Landry Regional Advisor, WPRO landrym@who,int Jyotsna Chikersal Regional Advisor, SEAR chikersalj@who.int Dag Roll-Hausen Technical Officer, WHO/HQ/HIS rollhansend@who.int. Lucille Nievera Philippines WHO Country office nieveral@wpro.who.int Eduardo Celades WHO Mozambique celadese@who.int (continued on next page) 68 CRVS Scaling-up Investment Plan 2015–2024 (continued) COUNTRY REPRESENTATIVES Ethiopia Nestanet Abera Lema Director-General, Vital Events Registration Agency netsanetvera@gmail.com Samiya Zakaria Director-General, Central Statistics Agency smaiyaz@ethionet.et Asmaru Berihun Commissioner, Women’s and Children’s Affairs, elaluberihun@yahoo.com Ethiopian Human Rights Commission Biratu Yigezu Deputy Director-General, CSA biratu_y@ethionet.et Mesoud Mohammed Assistant Director, Policy & Planning Directorate,   Federal Ministry of Health Noah Elias Director, Policy & Planning Directorate, Federal   Ministry of Health Hailemariam Teklu Senior Statistician, CSA   Daniel Lishanew VERA dldaniel361@gmail.com, lishanewd@yahoo.com Asfaw Mekonnen VERA asfawmekonnen@gmail.com Nikodimos Alemaayehu Specialist, Justice for Children nalemayehu@unicef.org Bangladesh Prof Dr. Abul Kalam Additional Director General (Planning & profakazad@gmail.com Azad Development), Directorate General of Health Services AKM Saiful Islam Project Director (Addl. Secretary), Birth and Death saislach@gmail.com Chowdhury Registration Project Anir Chowdhury Policy Advisor, Access to Information, Prime anir.chowdhury@gmail.com Minister’s Office Md. Nurul Karim Additional Secretary, Committee & Economic Wing nurul-karim96@yahoo.com Satya Ranjan Mondal Deputy Secretary, Statistics and Informatics sranjanmondal@gmail.com Division Syed Mohammad Director (Administration & Finance), NID musaarif21@yahoo.com Musa Registration Wing Election Commission, Bangladesh Prof Dr. Abul Kalam Additional Director General (Planning & profakazad@gmail.com Azad Development), Directorate General of Health Services AKM Saiful Islam Project Director (Addl. Secretary), Birth and Death saislach@gmail.com Chowdhury Registration Project Mozambique Sheila Santana Alfonso Permanent Secretary, Ministry of Justice sheila.santana.afinfo@minjust.gov.mz, shelasant242@yahoo.com.br Cidalia Baloi Head, Department of HSI, MISAU cidaliabaloi@gmail.com Cassiano Soda Director Estadisticas Demograficas, INE Chipembe Joao Carlos Mavimbe Ministry of Health, Mozambique jcmavimbe@misau. Gov.mz Angelo Paunde National Director DPC, GITEV Coordinator angelopawnde@gmail.com Carla Roda National Director of DPC, Ministry of Justice cguiLaze@yahoo.com.br National Director of Civil registration and Rotary Philippines Crispinita A. Valdez Director III, Information Management Service, cavaldez@co.doh.gov.ph Department of Health Aurora Reolalas Statistician V, Chief, Vital Statistics Division, a.reolalas@census.gov.ph Philippine Statistics Authority Burkina Faso Aimé Gérard Yameogo Directeur general de la modernization de l’état civil Aimegerard6@yahoo.fr (continued on next page) Annex 9. Participants atGlobal CRVS Consultation inAddis Ababa April 28–29, 2014 69 (continued) REGIONAL AND GLOBAL REPRESENTATIVES African Development Maurice Maubila Chief Statistician m.mubila@afdb.org Bank Genene Bizuneh gbizuneh@uneca.org African Union Yeo Dossina   dossinay@africa-union.org Rene N’guettia Kouassi Cambridge Economic Matthew Cooper Consultant Matthew.cooper@cepa.co.uk Policy and Associates (CEPA) Kaveri Kumar Managing Consultant Kaveri.kumar@cepa.co.uk CDC Sam Notzon Director, International Statistics Program, National fcn2@cdc.gov; Centre for Health Statistics Deblina Datta Global Immunization Division, Center for Global ddatta@cdc.gov Health, CDC IADB Haydeé Reyes Soto   haydeer@iadb.org Paris 21 Johannes Jütting PARIS21 Secretariat Manager Johannes.jutting@oecd.org Plan International Jennifer Martinesi Country Director Jennifer.Martinesi@plan-international.org Nicoleta Panta Advocacy Manager Nicoleta.panta@plan-international.org Project Consultants Carla Abouzahr CRVS Expert Carla.abouzahr@gmail.com Esperanca Nhangumbe Mozambique Project enhangumbe@gmail.com Purvi Paliwal Bangladesh Project purvipaliwal@gmail.com Yacob Zewoldi Ethiopia Project yzewoldi@gmail.com Ageazit Teka Ethiopia Project   Statistics Norway Vibeke Nielsen Senior Adviser, Division for Development Vibeke.nielsen@ssb.no cooperation. UN ESCAP Jonathan Marskell Consultant, CRVS, Statistics Division marskell@un.org, UN ESCWA Marwan Khawaja Chief Demographic and Social Statistics Khawaja@un.org UNFPA Richmond Tiemoko Population Dynamics Policy Advisor, UNFPA, tiemoko@unfpa.org ESARO UNHCR Monique Ekoko Deputy Representative, UNHCR Representation to ekoko@unhcr.org the AU and the ECA Liaison Officer Marouane Tassi tassi@unhcr.org UNICEF Cornelius Williams Regional Advisor cowilliams@unicef.org Mayke Huijbregts Chief, Child Protection mhuijbregts@unicef.org Kristen Wenz Child Protection Specialist, CRVS Focal Point kwenz@unicef.org EAPRO, Child Protection Djanabou Mahoude Child Protection Specialist dmahoude@unicef.org Mirkka Tuulia Mattila Child Protection Specialist mtmattila@unicef.org Milen Kidane Child Protection Specialist mkidane@unicef.org USAID Kathleen Handley Senior Advisor khandley@usaid.gov UN Statistics Division Keiko Osaki-Tomita Chief, Demographic and Social Statistics osaki@un.org References Abouzahr, Carla, M. 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