SEA/RC67/9 - Covering every birth and death: improving civil registration and vital statistics (CRVS)

REGIONAL COMMITTEE Sixty-seventh Session Dhaka, Bangladesh 9–12 September 2014

Provisional Agenda item 8.1 SEA/RC67/9 28 July 2014

Technical matters: Consideration of the recommendations arising out of the Technical Discussions on “Covering every birth and death: improving civil registration and vital statistics” Civil registration is defined as the compulsory, permanent, continuous and universal recording of the occurrence and characteristics of vital events. Registration records are essential to establish legal identity and nationality, as well as to access services including health. Furthermore, vital statistics on births, deaths and causes of death (COD) are essential for population health assessment, monitoring of health progress, and health policy analysis. The correctness of the health indicators for mortality statistics would depend on the counting of every death and accuracy of COD data. Comprehensive assessments of civil registration and vital statistics (CRVS) systems, were undertaken by eight of the 11 Member States of the WHO South-East Asia Region, using the WHO tool. The findings showed inadequate coverage of birth and death registration, poor quality of COD data, incorrect coding of ICD-10 (International Classification of Diseases), lack of audits of civil registration data quality, and inadequate interagency coordination between key stakeholder ministries. The technical discussions on “Covering every birth and death: Improving civil registration and vital statistics” were held in the WHO Regional Office in New Delhi on 16–17 June 2014. During the discussions, the draft regional strategy on strengthening the role of health sector in improving civil registration and vital statistics was finalized (Annex 1). It consists of five strategic areas: (i) legal and organizational framework for CRVS; (ii) political commitment and intersectoral collaboration for national capacity-building, partnership, advocacy and outreach; (iii) birth and death registration: completeness and coverage; (iv) Recording causes of death, ensuring completeness and quality; (v) creating demand for health and vital statistics, enabling service delivery and planning through use in: (a) evidence-based decision-making and (b) linkage to other activities. The High-Level Preparatory (HLP) Meeting held in the Regional Office in New Delhi, India, from 14 to 17 July 2014 reviewed the attached working paper and made the following recommendations:

Actions by Member States: (1) (2) Comprehensive assessment of CRVS system should be undertaken as appropriate. Health sector-specific interventions such as but not limited to strengthening health systems and health information systems (HIS), training on listing causes of death under ICD-10 and on medical certification of cause of death (MCCD) should be accelerated. Verbal autopsy mechanism should be scaled up to determine the most probable cause of death occurring outside the health facilities, as appropriate. Health services should be linked to CRVS to promote registration of births and deaths.

(3) (4)

Actions by the WHO Regional Office: (1) (2) (3) WHO should provide technical support to Member States upon request to strengthen the CRVS system. The capacity of Member States should be built to develop a simple tool to capture COD and web-based computerized registration system with linkages to HIS. Technical support should be provided to countries upon request to develop national capacity for implementation of ICD coding.

The working paper and the draft Regional Strategy for Strengthening the Role of the Health Sector for Improving CRVS and the HLP recommendations are submitted to the Sixty-seventh Session of the Regional Committee for its consideration.

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Introduction 1. Civil registration is defined as the compulsory, permanent, continuous and universal recording of the occurrence and characteristics of vital events. Registration records are essential for establishing legal identity and nationality, as well as accessing services. Further, vital statistics on births, deaths and causes of death are essential for population health assessment and health policy analysis, such as for monitoring progress towards the Millennium Development Goals (MDG). National civil registration and vital statistics (CRVS) systems are the best sources for such data. 2. CRVS systems may comprise the following key stages1:      

recording of the occurrence of vital events (births, deaths, etc.) and associated characteristics; notification of the occurrence of vital events to individuals and families and to the appropriate registration authorities; formal registration of vital events through the civil registration system; issuance of certificates of birth, death, and causes of death to family members and relevant authorities; compilation, analysis and interpretation of vital statistics based on the information generated through registration and certification; and archiving of individual records for future use.

3. The health sector has a particularly strong need for functional CRVS. Unless every birth is counted, the denominator for almost all the health indicators would be incorrect. Similarly, the correctness of the numerator for all health indicators for mortality statistics would be dependent on the counting of every death and the accuracy of cause of death data. CRVS are the only way to obtain continuous, compulsory, cost-effective data on births, deaths and causes of death. Reliable vital statistics from civil registration systems can provide essential inputs to 42 of the 60 MDG indicators. It is, therefore, imperative to promote these systems in order to make intercensal population estimates more reliable and reduce data gaps and discrepancies. 4. The WHO Regional Office for South-East Asia has developed a regional strategy for strengthening the role of the health sector in improving CRVS to provide a unified direction and political support to prioritize it. Technical Discussions on Covering every birth and death: improving CRVS, were held in the WHO Regional Office on 16 –17 June 2014. A total of 78 participants attended with representation from ministries of health, civil registration and national statistics office from 10 of 11 Member States. Development partners, NGOs and research organizations were also well represented at the technical discussions – Asian Development Bank (ADB), UNICEF, UNESCAP, Plan International, Gates Foundation, Centre for Global Health 1

Using innovative approaches in the health sector to strengthen and modernize civil registration and vital statistics (CRVS) systems: guiding principles and good practices - Report of a technical meeting sponsored by the World Health Organization in collaboration with CIDA, UNICEF, USAID and the World Bank, Geneva, 17–18 December 2013.

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Research (CGHR), Central Bureau of Health Intelligence (CBHI, WHO-CC) of the Government of India, University of Queensland (UQ) and Cambridge Economic Policy Associates (CEPA). The draft regional strategy on strengthening the role of the health sector in improving CRVS has been finalized for endorsement by the RC. 5. The regional strategy focuses on health sector initiatives at regional, national and local levels towards achieving universal birth and death registration and better quality mortality statistics from routine CRVS systems. In practice, this could potentially be achieved through implementation of specific activities within the health sector, as well as through close collaboration and coordination of health sector activities with other sectors and national stakeholders in the CRVS system.

The role of the health sector 6. “Accurate vital statistics and the ability to monitor and respond to causes of death and disability underpin many global health targets, including new commitments to universal health coverage and tackling the global epidemic of noncommunicable disease…. This would prevent an estimated 10 million deaths…..” World Bank/WHO 2014 Global CRVS Scaling Up Investment Plan 2015–2024. 7. The health sector can play a critical role in accelerating the development and strengthening of the CRVS system. Currently, there is an increasing trend in occurrence of births in health facilities, or at least, with skilled birth attendants. Hence, for births, the majority of events can be adequately captured on occurrence by the respective health sector institutions or personnel, and notified to local registration offices. While deaths in health facilities could be directly notified for registration, deaths in the community are commonly brought to the notice of local health staff, given their close proximity to the community. Hence, there is potential for the health sector to act as key notifiers of deaths in the community for registration, as well as undertake more detailed enquiries to ascertain the causes of death. Further, there is a demand in the health sector for routine and reliable data on deaths by age, sex and causes of death, which can only be met by CRVS systems.

Current situation in South-East Asia 8. In general, civil registration of births and deaths is conducted in all countries of the SouthEast Asia Region (SEAR), within a broad legal and administrative framework. However, as in all countries, civil registration in the countries of the Region is put in place with the primary purpose of establishment of legal identity, including family relationships. Hence, where such legal documentation for births is not linked with accessing services or there are no financial incentives to register deaths, there is little motivation for the community to participate in registration; hence notification and registration are often not completed. In all countries of SEAR, the processes for compilation of vital statistics from civil registration need to be strengthened; at present, data from CRVS systems have uneven coverage and completeness, and the quality is poor, particularly in terms of recorded and coded causes of death. This vastly limits the utility of these data for health sector purposes.

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9. Since end-2010, comprehensive assessments of CRVS systems have been completed, using the WHO tool. Strategic plans for improvement of CRVS systems are being developed in eight of the 11 countries of SEAR: Bangladesh, Democratic People’s Republic of Korea, Indone sia, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste. CRVS comprehensive assessments are also planned for Bhutan, India and Myanmar. Further, the WHO Regional Office has also supported Bangladesh to develop a five-year investment plan for CRVS with prioritized activities along with costing, as part of an initiative supported by the Canadian International Development Agency (CIDA).

Conclusions and recommendations 10. Though multisectoral processes are required, strengthening the CRVS system as a whole can be complex and will take time. The health sector can move immediately to accelerate those parts of the CRVS systems that are its own responsibility. This includes notifications of births and deaths and ascertaining causes of death, which require considerable strengthening. In addition, the health sector can create demand through links with services such as immunization and UHC. 11. These goals are consistent with the UNESCAP Regional Action Framework and the World Bank/WHO 2014 Global CRVS Scaling Up Investment Plan 2015–2024, which identify the global goals as: universal civil registration of births, deaths and other vital events, including reporting causes of death, and access to legal proof of registration for all individuals by 2030. 12. The specific health goals of the regional strategy for strengthening the role of the health sector for improving CRVS, are:   

support the universal civil registration of births and deaths; provide relevant documentation related to notification and certification to facilitate the civil registration of births and deaths to all individuals; and produce accurate, complete and timely vital statistics, with a focus on causes of death based on civil registration data2.

13. The regional strategy for strengthening the role of the health sector for improving CRVS focuses on five strategic areas as listed below: Strategic Area 1: Strategic Area 2: Strategic Area 3: Strategic Area 4: Strategic Area 5: Legal and organizational framework for CRVS Political commitment and intersectoral collaboration for national capacity-building, partnership, advocacy and outreach Birth and death registration: completeness and coverage Recording causes of death, ensuring completeness and quality Creating demand for health and vital statistics, enabling service delivery and planning through use in: (a) evidence-based decision-making, and (b) linkage to other activities

2

Separate targets will be established for institutional and non-institutional causes of death.

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14. The health sector can play an instrumental role in supporting the creation of demand for registration where possible through linking with health services such as immunization or universal health coverage (UHC). 15. The formal registration of the important events in the lives of people is critical for the protection of rights, a core component of good governance and sound administration, and crucial for producing reliable statistics on the demographics and health of the population. The improvement of CRVS systems is thus imperative for sustainable and inclusive development and will be central to the achievement of the health and development agenda post-2015, including UHC. 16. The regional strategy for strengthening the role of the health sector for improving CRVS launches a collective intervention focusing on strengthening the role of the health sector across the Region to improve CRVS systems in ways that are efficient and evidence-based. 17. Partnership between stakeholders and development partners is a quintessential prerequisite for the successful implementation of this strategy at both country and regional levels. 18. The experiences of countries that have successfully embarked on efforts to improve CRVS systems demonstrate that although circumstances and starting points vary, there are common actions to be taken, which can happen in parallel and in an iterative manner.



REGIONAL COMMITTEE

Provisional Agenda item 8.1

Sixty-seventh Session Dhaka, Bangladesh 9–12 September 2014

SEA/RC67/9 Inf. Doc.1 28 July 2014

Technical matters: Consideration of the recommendations arising out of the Technical Discussions on “Covering every birth and death: improving civil registration and vital statistics” The attached document is the draft Regional Strategy for Strengthening the Role of the Health Sector for Improving CRVS.

Annex 1:

Draft Regional Strategy for Strengthening the role of the health sector for improving CRVS

Contents

1. 2. 3. 4.

Introduction ........................................................................................................................... 1 Role of the health sector in CRVS ........................................................................................... 3 Overview of CRVS systems in SEAR........................................................................................ 4 Vision, mission and goal of the regional eHealth strategy ........................................................ 6 4.1 Vision ............................................................................................................................ 6 4.2 Mission.......................................................................................................................... 6 4.3 Goal .............................................................................................................................. 7

5. 6.

The scope and key principles of the regional strategy ............................................................. 9 Strategic areas for strengthening the role of the health sector in improving CRVS ................. 10 6.1 Strategic area 1: .......................................................................................................... 10 6.2 Strategic area 2: .......................................................................................................... 12 6.3 Strategic area 3: .......................................................................................................... 15 6.4 Strategic area 4: .......................................................................................................... 17 6.5 Strategic area 5: .......................................................................................................... 20

7. 8. 9.

Monitoring and evaluation: Reporting and regional reviews ................................................. 22 Sub-regional country clusters ............................................................................................... 24 Key country actions.............................................................................................................. 27

10. Regional action .................................................................................................................... 28 11. Conclusions and the way forward ........................................................................................ 29

Annex: Targets of goal .................................................................................................................. 29

Acronyms CHWs COD COIA CR CRVS ICD ICT MCCD MDGs NGOs SEAR SRS UNESCAP UNICEF USAID VA VS WHO Community Health Workers Causes of Death Commission on Information and Accountability for Women’s Children’s Health Civil Registration Civil Registration and Vital Statistics International Classification of Diseases Information and Communications Technology Medical Certificate of Cause of Death Millennium Development Goals Nongovernmental Organizations South-East Asia Region Sample Registration System United Nations Economic and Social Commission for Asia and the Pacific United Nations International Children’s Emergency Fund United States Agency for International Development Verbal Autopsy Vital Statistics World Health Organization

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1. Introduction Civil registration is defined as the compulsory, permanent, continuous and universal recording of the occurrence and characteristics of vital events. Registration records are essential for establishing legal identity, nationality, and accessing services based on human rights. Further, vital statistics on births, deaths and causes of death (COD) are essential for population health assessment and health policy analysis, such as for monitoring progress towards the Millennium Development Goals (MDGs). National civil registration and vital statistics (CRVS) systems are the best source for such data. CRVS are governed by a legal mandate and involve a network of key stakeholders at different levels in the national administrative hierarchy. Despite the complexity of these systems, robust annual vital statistics are available from CRVS systems in many developed countries, and these data are widely used for national and subnational health policy and research. ‘The goal should be to have one master CRVS system from which data can be accessed for different purposes whilst ensuring confidentiality and security’ World Bank/WHO 2014 Global CRVS Scaling Up Investment Plan 2015–2024 There are three key national government stakeholders involved in CRVS systems. Firstly, a government agency usually within the Ministry of Home Affairs / Interior / Justice or local government is the nominated legal authority for implementation of registration of vital events, including births and deaths. Secondly, the health sector is a key stakeholder as a source for event registration as well as a key user of vital statistics, for health monitoring, health policy and research. Thirdly, the national statistics office (or similar institution) has an important role in the compilation and production of vital statistics. A fourth government stakeholder is the police department, for investigation of deaths from unnatural causes. Close intersectoral coordination between these key stakeholders involving institutions at various levels in the administrative hierarchy is imperative for the overall CRVS system to achieve its full potential in terms of providing registration services as well as compiling timely and reliable vital statistics. CRVS systems perform the following functions1:  recording of the occurrence of vital events (births, deaths, etc.) and associated characteristics;  notification of the occurrence of vital events to individuals and families and to the appropriate registration authorities;  formal registration of vital events through the civil registration system;  issuance of certificates of birth, death, COD to family members and relevant authorities;  compilation, analysis and interpretation of vital statistics based on the information generated through registration and certification; and  archiving of individual records for future use.

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Using innovative approaches in the health sector to strengthen and modernize civil and vital statistics (CRVS) systems: guiding principles and good practices - Report of a technical meeting sponsored by the World Health Organization in collaboration with Canada, UNICEF, USAID and the World Bank , Geneva, 17 –18 December 2013

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The health sector has a particularly strong need for functional CRVS systems. CR and VS are two very separate and important areas usually considered together as there is a lot of interdependency between the two areas and integration optimizes the benefits of both. The civil registration system creates a permanent record of vital events - birth, death, COD, adoption, marriage and divorces. birth death and data are most important for health policy and programming. The lack of reliable data has been a long-standing constraint for effective health planning and management particularly in efforts towards achieving the time-bound health targets such as the health-related MDGs. There is a need to strengthen approaches to monitoring of progress on MDGs. There is also an urgent need to adopt innovative means to obtain better vital statistics data from CRVS systems, and investment in these approaches will be essential over the next 3–5 year period. If every birth is not counted, then the denominator for almost all the health indicators is incorrect. If every death is not counted and the COD data is not accurate, then the numerator for all health indicators for mortality statistics is incorrect. CRVS systems are the only way to obtain continuous, compulsory and cost-effective data on births, deaths and COD. Currently critical health policy decisions rely on estimates. Globally one in three births are not counted, two in three deaths are not counted and 9 in 10 deaths in the Asia Pacific region are not recorded with reliable COD. Reliable vital statistics from civil registration systems can provide essential input to 42 of the 60 MDG indicators. This need will continue in the post-MDG period. It is, therefore, imperative to promote these systems in order to make intercensal population estimates more reliable at any point of time and reduce data gaps and discrepancies. The data from civil registration records form the basis of a country’s vital st atistics system. Vital statistics are used to derive the fundamental demographic and epidemiological measures that are needed in national planning across multiple sectors such as education, labour and health. Civil registration records are the best source of vital statistics. However, such systems are often weak and incomplete in developing countries. Therefore, it may be necessary, to use alternate data sources to generate vital statistics – such as, population census, household sample surveys, demographic surveillance in sentinel sites and sample registration systems. These alternate data sources are statistical means to generate measures of vital events, they are costly methods and in no way, provide a continuous, complete and cost-effective means to obtain real-time vital statistics. All births and deaths must be registered, and COD recorded, to produce accurate vital statistics and to generate health indicators.

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2. Role of the health sector in CRVS2 ‘Accurate vital statistics and the ability to monitor and respond to COD and disability underpin many global health targets, including new commitments to universal health coverage and tackling the global epidemic of non-communicable disease…. This would prevent an estimated 10 million deaths…..’ World Bank/WHO 2014 Global CRVS Scaling Up Investment Plan 2015–2024. The health sector can play a critical role in accelerating the development and strengthening of the CRVS system. Currently, there is an increasing trend in occurrence of births in health facilities, or at least, under skilled birth attendance. Hence, for births, the majority of events can be adequately captured on occurrence by the respective health sector institutions or personnel, and notified to local registration offices. While deaths in health facilities could be directly notified for registration, deaths in the community are commonly brought to the notice of local health staff, given the close proximity to the community. Hence, there is potential for the health sector to act as a key notifier of deaths in the community for registration, as well as undertake more detailed enquiries to ascertain the COD. Further, there is a demand for routine and reliable data on deaths by age, sex and COD, for health sector purposes, which can only be met by CRVS systems. The health sector has long been recognized as a contributor to CRVS. Its role is often described in terms of the activities of health institutions, which act as informants of the occurrence of births and deaths, and enable the certification of COD, by physicians. Information collected by health institutions are part of the delivery of health care is crucial in generating health statistics to guide public health policy and planning. Systems in many countries also use these health data and records to underpin the CRVS system processes, especially birth and death registration. The potential role of the health sector varies at each stage, as shown visually in Figure 1. The health sector role depends on country legal, institutional, and sociocultural circumstances. For example, in many countries, the registry office is located within health facilities in order to facilitate immediate registration of vital events. In some instances, the health sector is legally mandated to register births and deaths and deliver certificates. Recent innovations in mobile technologies offer opportunities to greatly strengthen aspects of CRVS systems, especially in relation to the recording of the occurrence of vital events at community level and notification to the registration authorities. Many of these innovations are being introduced through the health sector, both in facilities, and through the network of community health workers and informal health workers. Adherence to good practice principles as these innovations are introduced, will help ensure that innovations reinforce the CRVS system as a whole rather than remaining isolated, stand-alone interventions. While innovations can significantly improve systems, it is important not to see technological advances as a solution to all issues. Often, issues with coordination and legal frameworks need to be addressed before technology can make a real difference and pitfalls related to introduction of mobile technology (such as confidentiality) be avoided. 2

Using innovative approaches in the health sector to strengthen and modernize civil and vital statistics (CRVS) systems: guiding principles and good practices - Report of a technical meeting sponsored by the World Health Organization in collaboration with Canada, UNICEF, USAID and the World Bank , Geneva, 17 –18 December 2013

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Figure 1: Schematic description of involvement of different sectors in aspects of the CRVS system3 Health sector Promotion and community mobilization for registration of vital events Recording of the occurrence of vital events (births, deaths, etc.) and associated characteristics; Notification of the occurrence of vital events to individuals and families and to the appropriate registration authorities; Registration of vital events formally through the civil registration system; Issuance of certificates of birth, death, causes of death to family members and relevant authorities; Compilation, analysis and interpretation of vital statistics based on the information generated through registration and certification Archiving of individual registration records for future use. If legally mandated Civil registration authorities Statistical offices Individuals and families Communities and community leaders

3. Overview of CRVS systems in SEAR countries In the WHO South East Asia Region which comprises 11 countries, there is considerable diversity in terms of population size, geographical distribution, and socioeconomic status across countries. In general, civil registration of births and deaths is conducted in all countries of the WHO South-East Asia Region (SEAR), within a broad legal and administrative framework. However, as in all countries registrations are put in place with the primary purpose of establishing legal identity, including family relationships. Hence, where such legal documentation for births is not linked with accessing services, or there are no financial incentives to register deaths, there is little motivation for the community to participate in registration; hence notification and registration are often not completed. The first of the ten recommendations of the Commission on Information and Accountability for Women’s 3

Using innovative approaches in the health sector to strengthen and modernize civil and vital statistics (CRVS) systems: guiding principles and good practices - Report of a technical meeting sponsored by the World Health Organization in collaboration with Canada, UNICEF, USAID and the World Bank , Geneva, 17 –18 December 2013

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Children’s Health (COIA) is that by 2015 countries have made significant steps for improving their CRVS systems to register births, deaths and causes-of-death. All six countries of SEAR prioritized by the COIA have committed to implement the recommendations of COIA through developing roadmaps to implement the country accountability framework. CRVS has received special attention by the countries under their accountability framework. Since end 2010, comprehensive assessments of CRVS systems using the WHO tool have been completed or in the process of being completed in eight of the 11 Member countries: Bangladesh, Democratic People’s Republic of Korea, Indonesia, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste and strategic plans for improvement of CRVS system in these countries are being developed. CRVS comprehensive assessments are planned for Bhutan, India and Myanmar. While civil registration is implemented in some form in all countries in the SEAR, there are systemic weaknesses that result in non-registration of events, incomplete or inaccurate official documentation of reported events, inadequacies in ascertainment of COD, and inefficient data management processes, resulting in poor quality of vital statistics from registration records. In many countries of the Region, there is a low demand for civil registration on the part of citizens, as well as for vital statistics on the part of governments and other data users, which has led to gross inattention to CRVS operations in the entire Region. There is an urgent need to strengthen the registration processes to improve the capturing and recording of vital events in the Region, as well as establish streamlined processes for compilation of vital statistics from all registration units. The health sector has a critical role to play in this. In view of the key roles of the health sector in vital event capture, provision of detailed accurate information on key variables, and interests in vital statistics, the World Health Organization (WHO) has been closely involved in international initiatives to strengthen CRVS systems at the global and regional levels. Recent events include the following:     High-level meeting on CRVS in collaboration with UNESCAP in December 2012; Global Summit on CRVS in collaboration with Health Metrics Network in April 2013; Regional Steering Group for Civil Registration and Vital Statistics in Asia and the Pacific in December 2013; ( WHO is a member of the Steering Group) Technical consultation on health sector initiatives to strengthen CRVS, in collaboration with World Bank, UNICEF, USAID and the Canadian government, in December 2013; Countries in Asia and the Pacific, in the Statistical Commission resolution 69/15,4 requested further regional action to support the improvement of CRVS systems. In response, a regional action framework has been developed as a catalyst for governments and development partners to focus and accelerate their efforts to realize a shared vision and three CRVS goals during the decade, 2015- 2024.

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‘Implementing the Outcome of the High-level Meeting on the Improvement of Civil Registration and Vital Statistics in Asia and the Pacific’, ESCAP resolution 69/15, 2013.

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Following on from these initiatives, the WHO Regional Office for South East Asia is currently engaged in developing a regional strategy for specific health sector initiatives to strengthen national CRVS systems in all countries of the Region aligned with the Regional Action Framework on CRVS guided by the Regional Steering Group. CRVS needs to be prioritized as a development issue on the global post-MDG agenda. The time is now. The recent global focus on aid effectiveness and outcomes will remain more rhetoric without functional CRVS systems. Every birth and death should get counted and reliable COD should be recorded for every death. Addressing these shortcomings of national CRVS systems in the Region is a complex task. The diversity of countries and the variation in current operational status of national CRVS systems necessitates a country-specific approach to strengthening national CRVS systems. Nevertheless, formulation of a regional strategy which articulates common principles in CRVS development, key strategic objectives to be met, and a range of action areas to meet specific objectives will help guide essential development activities in the Region.

4. Vision, mission and goals Consistent with the Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific5:

4.1 Vision The shared vision is that all people in countries of SEAR benefit from universal and responsive CRVS systems that facilitate the realization of their rights and support good governance, health and development.

4.2 Mission To strengthen the role of the health sector to improve CRVS systems in the Region.

5

Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific, Preliminary draft: 25 June 2014s in Asia and the Pacific. Preliminary draft: 25 June 2014- The Regional Steering Group for CRVS in Asia and the Pacific, of which WHO is a member, will be responsible for providing regional oversight and guidance for the implementation of the Regional Action Framework, including acting as custodian for the decade, 2015 to 2024.

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4.3 Goal The health sector CRVS strategy goals are consistent with the three goals of the Regional Action Framework which are6: (a) Goal 1: Universal civil registration of births and deaths; (b) Goal 2: Provision of legal documentation of civil registration of births and deaths as necessary to all individuals to claim identity, civil status and ensuing rights; and (c) Goal 3: Production of accurate, complete and timely vital statistics (including on COD) based on registration records and disseminated. The specific health goals of this regional strategy are: 1. 2. support the universal civil registration of births and deaths. provision of relevant documentation related to notification and certification by the health sector to all individuals to facilitate the civil registration of births and deaths; and production of aaccurate, complete and timely vital statistics, with a focus on COD based on civil registration data7.

3.

These goals are consistent with the World Bank/WHO 2014 Global CRVS Scaling Up Investment Plan 2015–2024, which identifies the global goals as: universal civil registration of births, deaths and other vital events, including reporting COD, and access to legal proof of registration for all individuals by 2030.

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Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific, Preliminary draft: 25 June 2014s in Asia and the Pacific. Preliminary draft: 25 June 2014 7 Separate targets will be established for institutional and non-institutional causes of death.

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Figure 2: ‘The Regional strategy for strengthening the role of the health sector in improving CRVS’ is consistent with and resides as a specific subset of the Regional Action Framework and the Global CRVS- Scaling up Investment Plan 2015–2024. The set of targets associated with achievement of each of these goals are designed to enable monitoring and evaluation in ways that are objective, efficient, technically sound and time bound during the decade, 2015 to 2024 (See Annex)8. Countries set their own national target value for each target (either the percentage or the year, depending on the target) based on their current situation and national priorities, and in accordance with their comprehensive multisectoral national CRVS strategic plan for improvement, if one exists.

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Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific, Preliminary draft: 25 June 2014 in Asia and the Pacific. Preliminary draft: 25 June 2014

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5. The scope and key principles of the regional strategy The WHO SEAR regional strategy will focus on health sector initiatives at regional, national and local levels that will work towards achieving these goals. In practice, this could potentially be achieved through implementation of specific activities within the health sector, as well as through close collaboration and coordination of health sector activities with other sectors and national stakeholders in the CRVS system. The Regional Strategy is intended to guide and support the improvement of CRVS systems in the Region over the period 2015-2024. The strategy will cover the following scope of activities: a. Mobilisation of political commitment for health sector initiatives for CRVS development at regional and national level. b. Support for the design of national CRVS development plans aligned with a conceptual framework of CRVS systems, in order to enable long-term and sustainable improvements in national systems. c. Facilitation and coordination of financial and technical inputs from development partners, international agencies and academia to support activities aligned with specific strategic themes and/or related action areas for CRVS development, based on their respective program agenda in countries or technical expertise in specific topics. d. Provision of regional oversight through monitoring and evaluation of progress in CRVS strengthening over time and across countries in the region, and providing a platform for sharing of resources, experiences, and lessons from the field. The key principles advocated by the Regional Strategy for designing national health sector initiatives for CRVS development are: a. CRVS development activities should re-orient and/or strengthen existing procedures to include roles for the health sector, rather than establish new systems b. Health sector institutions should play an active role in design and implementation of reforms, in partnership and collaboration with other stakeholders / institutions including civil registration authorities and statistical organizations c. Close attention should be paid to all phases of the CRVS business process including the health sector activities in vital event notification, registration, COD ascertainment, and data processing, analysis and utilisation d. The processes of notification and registration should be decentralised to facilitate citizen participation, and reach out to remote, under-served populations, and thereby improve efficiency of registration e. ICT technologies and other innovations involving local personnel / institutions should be harnessed to improve efficiency of CRVS processes and production of outputs f. The health sector should support the creation of demand for registration where possible through linking with health services such as immunization or universal health coverage.

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6. Strategic areas for strengthening the role of the health sector in improving CRVS 6.1. Strategic Area 1: Legal and organizational framework for CRVS Objective 1.1 – Legislation in place (including its enforcement) for compulsory notification of births and deaths and recording of COD from the health system within stipulated time period Anchoring civil registration in a law supports the continuity, consistency, correctness and comprehensiveness of the CRVS systems. In the absence of a strong legal framework, concerned authorities may not collaborate to enforce existing registration rules and, as a result, systems are unable to achieve sufficient coverage of vital events to deliver useable vital statistics Even where Registration of births and deaths is conducted under a legal mandate. inadequate laws, regulations and standards are principal reasons for dysfunctional civil registration systems. In general, the laws and the regulations should be reviewed to assess the following key elements: a. b. c. d. e. f. g. Definitions of vital events; in this case births, stillbirths, deaths and COD Compulsory notification of births and deaths and recording of COD from the health system (public and private sector) within stipulated time period Specification of community health workers as notifiers of births, deaths and enumerators of VA Designated agency / official charged with registration responsibilities at national level Administrative hierarchy of birth and death registration and vital statistics systems from national to local level Reporting periods/exceptions / rules for delayed registration/fees for registration and legal documentation of birth and death registration Specific mention of rules and requirements for ascertainment and reporting of COD, including details on confidentiality of information and investigation of deaths from unnatural causes Recognition of the statistical function of civil registration data, and clear data sharing protocols

h.

Countries are encouraged to amend the regulations on civil registration, as well as health laws and regulations, to include specific mention of the role of the health sector institutions/personnel as notifiers of births and deaths and for COD ascertainment. Health-care workers could play the role of notifiers in births occurring inside and outside health facilities; however, the informants still remain the parents in case of births and next of kin in the case of deaths. In case of unnatural deaths, concerned authorities would play the role of notifiers.

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Objective 1.2 – Health contributes to the establishment of national CRVS coordination mechanism with multistakeholder representation and clear articulation of roles and responsibilities of all key stakeholders A whole-of-government approach with effective coordination between the different ministries and agencies such as the civil registration authorities, the health system, and the national statistical office, is essential. Organizational or administrative bottlenecks may make it difficult for people to register and delay the compilation of statistics or affect the quality of the data. The Regional Office will support countries to establish mechanisms to institutionalize intersectoral collaboration for CRVS. The health sector is encouraged to contribute to formation of a national CRVS coordination mechanism which reports to the highest level of government and includes representation of all levels of government involved in the CRVS system, such as a national steering committee. This steering committee could be established in the capacity of an overarching interministerial governance structure providing direction, oversight and mandate to the CRVS system in the country. Objective 1.3 – Health contributes to the development, adaptation and implementation of appropriate protocols for data confidentiality and data security to protect personal information and identity of individuals Data-sharing protocols need to be developed. Keeping in mind the need for data security and confidentiality, existing health frameworks and health data standards can be utilized to contribute to this process. Protecting confidential information of individuals is an ethical requirement and needs to be reflected in the law, so it is a legal requirement as well. Where individual citizen data is not required, only anonymous and consolidated data needs to be shared. The laws covering civil registration and cyber security need to adequately capture the scope and requirement of CRVS data, the health information system (HIS), the national population register, and all the associated databases. A disaster data recovery mechanism also needs to be developed and implemented. Objective 1.4 – Establishment and implementation of clear end-to-end business process for CRVS, describing the contribution of health. Countries need to devise clear business processes for supporting CRVS systems from a systems architecture perspective, describing health contributions to the procedure. The business process should span the entire CRVS process from recording the event, its notification and registering, and the issuing of the legal document surrounding the event, to its consolidation into vital statistics. Countries also need to review and adapt registration forms to align with international standards for legal and statistical purposes as well as guaranteeing national consistency. Governance should involve a holistic perspective to manage current and expected future components and ensure these various components act together, contributing to the overall strengthening of the system.

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This should describe the role of the health sector to the procedures of birth registration, death registration, recording of reliable ICD coding, generation of vital statistics from civil registration data and mechanisms to share and analyse information while maintaining confidentiality. Countries also need to review and adapt registration forms and procedures to align with international standards for legal and statistical purposes. Objective 1.5 – Galvanize political commitment in health to allocate adequate infrastructure and resources for CRVS

CRVS cannot be effectively and sustainably implemented through the efforts of one or two departments in charge of statistics, birth registration. For successful implementation of CRVS, a whole-of-government approach is a necessity. The multisectoral nature of CRVS operational operations creates challenges in focusing attention on overall system development. In recognition of this reality, as well as the potential catalytic role of the health sector, the Regional Strategy will promote the role of the national health sector in CRVS development in the Region, given its key roles in notification of births and deaths, as well as its interests in vital statistics. As part of the Regional Strategy, the CRVS advocacy campaign of the Regional Office will highlight the importance of vital statistics from CRVS systems in regional and national level health programme-specific committees, consultations, and conferences for the purposes of monitoring progress towards the MDGs, in targeting the emerging epidemics of noncommunicable diseases and injuries, and in monitoring family planning and population policies. Where possible it will also link demand to health services such as immunization and universal health coverage. This advocacy campaign should highlight the potential for contributing resources for raising demand and strengthening the CRVS system.

6.2. Strategic Area 2: Political commitment and intersectoral collaboration for national capacity building, partnership, advocacy and outreach Objective 2.1 – Support the comprehensive assessment of CRVS and development of a five-year national strategic and investment plan for improvement of CRVS including role required from health to strengthen CRVS Broad participation is a crucial factor in the eventual improvement of CRVS systems, as this will require effective collaboration between government departments in both the health and non-health sectors, and cooperation with nongovernmental organizations (NGOs) and other civil society groups. Countries would need to adopt country-specific approaches to address their needs or to cover other vital events. To identify strengths and weaknesses in the country’s CRVS system and to provide evidence for an improved strategy, countries are encouraged to undertake a comprehensive assessment of their CRVS system with participation of all key stakeholder ministries. WHO and the University of Queensland have developed robust tools for comprehensive and rapid assessment of CRVS in countries.

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Subsequently a five-year strategic and Investment plan for improving CRVS needs to be developed with prioritized activities fully costed, lead implementing agency, timelines and sources of financing. The comprehensive assessment also allows countries to compare their current CRVS systems with the CRVS standards developed by the United Nations Statistics Division and WHO. This assessment is aimed at producing the evidence needed to prioritize improvement activities, and to develop an improvement plan. Objective 2.2 – Advocacy and outreach to reach the population through use of health networks, with civil society, parliamentarians, citizens and media Countries are encouraged to use health networks to engage civil society, parliamentarians, citizens and media to undertake the following advocacy and outreach efforts to reach the unreached populations9: a. b. c. d. e. undertaking national campaigns or drives to create demand and to encourage individuals and families to declare and register vital events; national and subnational advocacy and outreach specifically directed to hard-toreach and marginalized population groups; identifying and removing barriers to registration, in particular those that impede access by persons from marginalized groups; undertaking advocacy focusing on the benefits of vital statistics, and on vital statistics theme for a national statistics day; reviewing incentives and penalties in relation to the civil registration of vital events and considering ways to make these more effective and avoiding unintended effects and adverse impact on the realization of rights, such as access to health and education; and including representatives of civil society, such as communities and nongovernmental organizations, on national CRVS steering, technical and coordination mechanisms.

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Objective 2.3 – Engagement in efforts for cross-cutting resource mobilization, both internally within the government sector and externally with development partners, for implementing CRVS strengthening initiatives CRVS systems are essentially government operations, with services for registration of vital events as well as compilation of vital statistics being resourced by the designated-government agencies. The basic infrastructure as well as human capacity for registration of the occurrence of births or deaths is available or can be established through from government resources. Regional and national advocacy campaigns should highlight the need for allocation of basic resources to decentralize vital event notification and registration processes. Donors often confound this problem by providing support to building individual systems/ processes, without looking into the issue of how these data will interface with processes of registration and generation of vital statistics. Such individual support leads to typically

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UNESCAP Regional Action Framework

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fragmented systems, because the different components are designed as silos, within a shortterm project framework with strong donor dependencies that encourage a limited focus10.   Development partners are encouraged to adopt an aligned “systems approach” to strengthen CRVS nationally and at regional level. Resources mobilized (both within government and from development partners) should be utilized for programmes that are sustainable, scalable and institutionalized as a part of a larger ecology of systems. The Regional Strategy advocates a role for the WHO Regional and Country Offices in mobilizing external and national resources including from the health sector for CRVS development activities. An important regional role is also to compile and share tools and resources, and create a forum for sharing best practices and lessons learned.

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Objective 2.4 – Establish interoperability between health information systems, CRVS, and other related systems Since CRVS by definition is multisectoral, a variety of actors are involved in the recording, notification and registering of vital events (citizens, health-care workers, doctors, police officers, clerics, and ministries of health, justice and home affairs, for example) and the use of its outputs (such as health authorities, tax authorities, social protection schemes and policymakers). In practice, CRVS systems tend to be fragmented and compartmentalized and different sectors are typically not able to access the same database and generate vital statistics from the civil registration system. Thus countries need to establish a CRVS system, wherein databases of different sectors are able to communicate and share data.11 However, enabling communication and sharing data is not enough – the different components must be interdependent in an ‘ecological’ framework that mutually incentivizes the production, sharing and consumption of quality data. 12 Countries are encouraged to establish interoperability of data on births and deaths being captured in the routine HIS and CRVS registration records. Creating such multisectoral linkages would be mutually beneficial for the participating sectors, WHO would provide technical support to countries to implement this.

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“Civil Registration and Vital Statistics 2013: challenges, best practice and design principles for modern systems. “A publication by WHO, HMN and HISP. 11 12 , “Civil Registration and Vital Statistics 2013: challenges, best practice and design principles for modern systems. “A publication by WHO, HMN and HISP. 12

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Objective 2.5 – Establish regional and national support for capacity-building on CRVS Countries are encouraged to address the need for capacity development at all levels of the CRVS system covering the entire cycle from notification of a vital event till the production of vital statistics. Capacity development activities should be institutionalized in order to ensure sustainability over the long term. In terms of human resources, CRVS systems depend on a sufficient number of qualified staff. Governments need to consider mechanisms for career development and appreciation well as ongoing training to enhance the skills of and retain staff. WHO will serve as a coordination and technical support resource for the Region. The Regional Office will work with the country offices and national technical partners engaged in specific CRVS development activities to coordinate and support capacity development in respective areas. For instance, specific regional training workshops will be organized to provide technical inputs in the methodology of CRVS review and design of national strategic plans. At another level, specific institutions could be identified at the regional level, to provide training and build capacity among national staff in specific elements such as ICD coding of COD.

6.3. Strategic Area 3: Birth and death registration- completeness and coverage Objective 3.1 – Mobilization and empowerment of health workers, including frontline health workers, midwives, community health workers and volunteer workers, and health facilities, as notifiers for births and deaths. In many countries of SEAR, networks of health facilities and community health workers have successfully brought service delivery to the door step of every citizen. Going forward utilizing the network of health facilities and community health workers will be instrumental to improving the quality and completeness of birth and death registration. Countries are encouraged to make every effort to improve laws to notify birth and death reporting by the health workers, volunteers and facilities, and improve field-level coordination between health sector and civil registration offices to boost the completeness of registration of births, deaths. For example, ensuring the community health worker has the mandate to report every birth or death. Objective 3.2 – Linking registration of births and death with services such as immunization, maternal, newborn and chilzd health care, and other services Linking registration of births and deaths with services such as immunization, maternal and child care would create an intrinsic value in registration of vital events for citizens. For example, Maternal Newborn and Child Health (MNCH) services already maximize the potential of existing health delivery platforms and points of contact and referral with Version 1.4

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families both within and outside of health facilities, such as immunization, maternal, newborn and child health care. By linking civil registration systems with these MNCH services at scale, countries would maximize the likelihood of capturing all vital events. Further, countries could create appropriate incentives to register births and deaths, for example, through public– private partnerships However, incentives should not be inconsistent with a child’s rights to other services. Objective 3.3 – Promoting the use of sustainable and scalable health innovations, including tracking maternal, newborn and child health, to contribute to strengthening and modernizing CRVS systems Countries are encouraged to use appropriate innovations, including in MNCH tracking, both to increase vital events notification and registration and bring benefits to individuals in terms of improved rights related to care, social protection and education for individuals and families, and entry to national identity systems. Countries are encouraged to utilize innovations, not limited to ICT, to move beyond paper-based systems and to strengthen the CRVS system. This includes developing guidelines and standards for use of ICT, drawing on examples in e-health, as well drawing on innovations and experiences from other countries to build functional systems. The focus should be on building sustainable, scaled solutions. For example, health facilities could use SMS to notify events or use of Internet. Innovations can be used to increased demand for registration services. Also, innovations include redefining business processes, improving capacity and mobilizing community health workers. Also, ICT innovations should be designed to preserve integrity by managing data securely and confidentially and in accordance with country and international requirements. Objective 3.4 – Development of a last-mile-coverage strategy to reach the unreached Registration points should be within a reasonable distance for the whole population, and measures need to be undertaken to facilitate civil registration in remote and hard-to-reach areas on a routine basis. This includes socially disadvantaged and marginalized populations, excluded migrant populations both within and across regions, as well as geographically isolated populations. Research should be carried out to identify and address context-specific practices for timely registration of births and deaths events, including culturally-sensitive practices which may delay registration. Also, the possibility of legal and policy barriers should be investigated. Examples include: adopting strategies such as ‘birth registration days’ or ‘child health days’ can help raise community awareness and increase demand for timely registration of vital events. Information and communication materials should be created targeting the specific audience. Many countries in the Region have successfully conducted doorstep mobile registration campaigns, to significantly boost birth registration within a short period of time.

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Such approaches can be utilized on a routine basis for reaching populations living in hard-toreach and remote areas. Consideration should be given to how special attention from the health sector can be given to marginalized populations, including stateless or other vulnerable populations.

6.4. Strategic Area 4: Recording cause of death, ensuring completeness and quality Processes of death registration and the associated vital statistics generation are seen to be generally poor in low- and middle-income countries, where much greater emphasis seems to be given to modernizing birth-related systems. This is probably because birth registrations are relatively trouble free, while death records are often not completed and information is legally challenging. The problem is further magnified when deaths take place outside the health facility, in the community or at home. There are limited examples of national systems that are integrated with death-related data coming from various sources such as hospitals, funeral homes or burial grounds. In addition to the challenge of coverage of data, death data also suffer in terms of quality because of the challenges in accurately determining, which is often left blank or completed as “other”. A key principle is that all deaths occurring in health facilities are medically certified by a trained physician using the international form of the death certificate and including the underlying COD, and notified to the registration authorities. The COD information should be sorted in statistical categories according to the International Classification of Diseases (currently the 10th Revision). Deaths occurring in the community that cannot be medically certified should nonetheless be notified and/or registered and information collected on mortality by age and sex for the whole population. In these cases, innovations to conduct verbal autopsy (VA) to determine probable COD can be introduced and can also be used to help formally notify that a death has occurred. The previous strategic areas stressed the importance of collaboration across sector and programmes in activities to strengthen CRVS. By contrast, the complete and reliable recording and certification of COD is predominantly a health sector responsibility. This is particularly true for deaths that occur in health facilities or deaths in the community for which the deceased person received formal health care prior to death. For non-facility deaths, likely COD can be ascertained using VA techniques. The health sector, through its wide network of community leaders, is in a good position to identify such deaths and work with communities to ensure that they are registered through the responsible authorities. The health sector is primarily responsible for investigating and conducting VA for deaths in the community. Collaboration with community leaders, funeral and religious authorities can increase the likelihood that all deaths are notified and registered.

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An essential challenge is to increase the completeness of reporting of deaths; a key intervention is to work more closely with both the health sector (especially CHWs) and with funeral authorities to report these deaths. It is also important to ensure that all reported deaths have information on the sex and age of the deceased. Distribution of COD by age and sex is information of immense public health value. Even community workers can provide this information; they do not need to be trained physicians. Physicians need to be trained to ensure they have the skills and training to correctly fill in the international form of the death certificate. All hospital deaths should be registered in civil registration system and a COD ascertained by a trained physician. VA can be introduced for deaths at community level. This can be based on experiences with sentinel surveillance and sample registration. It can be gradually extended to the whole population using a step-by-step approach. Objective 4.1 – For health facility deaths (public and private) recording accurate COD using ICD, including advocacy and training for physicians on medically certified using the international death certificate For deaths occurring in hospitals, the gold standard is that the attending physician should complete the international death certificate, with the underlying cause of death. The Regional Office would provide technical support on developing modules for training doctors on medical certification of cause-of-death and developing a quick reference guide on medically certified COD (MCCD)  Countries need to take necessary action to increase awareness among physicians of death- certification practices and improve their skills, both during medical pre-service training (in collaboration with medical training institutions), during professional development and on-the-job. Quality assurance procedures should include regular validation of COD certification in hospitals. ICD-10 should be included in undergraduate medical curriculum and internship; until this has been implemented, pre-service and in-service training for physicians on MCCD and ICD-10 should be included. Periodic COD audit and monitoring should be done on multiple COD by local medical committees or local health authorities.

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Objective 4.2 – For community deaths, use innovative approaches to implement VA to capture the most probable COD using sampling techniques or complete coverage (as required) through the community health worker networks Linkages should be established between relevant local stakeholders (health workers, registrars and others such as funeral directors or burial services) for the recording, notification for deaths that occur in the community or outside of health facilities. A multisectoral and collaborative approach with the health sector as a key contributor is required to capture information about as many of these deaths as possible.

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Introducing innovative approaches for determining COD among community deaths, such as mobilizing community health workers for conducting VA using standard international tools in encouraged. In countries with small populations, VA could be performed for all non-facility deaths.  For large populations, VA may be conducted on a nationally representative sample of all deaths occurring outside a health facility. However, where medical certification of COD can be obtained, this should take priority.  Countries are encouraged to use the WHO VA Instrument 2012, which is designed to be suitable for routine use. It can be used for physician assessment and with software that assigns the COD after training and providing logistics. Countries are also encouraged to adopt a “systems-approach” when using innovations. Innovations for both ICD coding and VA should be scalable both geographically and functionally and should be able to speak to the civil registration system.

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Objective 4.3 – For unnatural deaths, establish linkages to police data with the data collected from health facilities or communities Inaccurate reporting of deaths due to external causes is that in most countries deaths due to accidents and violence must be investigated by the police or coroner. Cooperation with the police department for unnatural deaths needs to be strengthened and formalized. In these cases, the COD may initially be registered as ‘not defined’ or ‘unknown’, pending the outcome of the investigation. It is common for significant delays in finalizing the data and the true cause of death may not be corrected in the vital statistics system. Countries need to make efforts to link police-reported data on deaths with the civil registration data. Objective 4.4 – Implementation of centralized ICD coding and automated coding using technologies such as the IRIS, including the capacity building of a cadre of national ICD coders The international standards for coding provide rules for selecting the COD most important or relevant to public health, that is, the underlying cause that gave rise to the chain of other conditions associated with the death 13 . Coding translates diseases, health problems, and procedures from text to alphabetic or numeric codes for storing, retrieving, and analysing. Highquality coding requires training and skills development for coders. 14 A core international curriculum has been developed for coders through a collaborative effort involving the WHO Family of International Classifications network (WHO-FIC Network).

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World Health Organization 2007 Strengthening practice and systems in civil registration and vital statistics: A resource kit, HISHub, NUMBER 19 | January 2012

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To maintain standardized and good quality ICD-coding practices the following must be borne in mind:

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Countries are encouraged to implement centralized ICD coding, at the national level to streamline quality, as opposed to at the lowest administrative levels; this is seen as the best practice internationally,. In many settings, coders only receive some elementary on-the-job training, which is insufficient to develop sound coding skills quickly and efficiently. All coders should undergo formal training for correctly coding death certificates. On-the-job training is also important, but training courses with standardized curricula are essential to ensure consistency of training and hence coding. Countries are encouraged to develop career paths, skills recognition, and formal qualifications for retaining trained coders. Automated coding can be done using technologies such as the IRIS.

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6.5. Strategic Area 5: Creating demand for health and vital statistics through use in evidence-based decision-making and linkage to other activities, enabling service delivery and planning. Objective 5.1 – Creating demand for evidence-based decision-making in health There is a need to ensure adequate uptake and utilization of vital statistics, particularly from the civil registration system, for health policy development and evaluation of health programmes. Hence, it is important for the vital statistics reports to be disseminated to a wide range of national and international stakeholders and donor agencies, through seminars, workshops and policy briefs. Although it takes time and political will to develop a culture of evidence-based decisionmaking, there are some practical organizational and behavioural interventions that can help improve the use of information. For example, countries need to promote a culture of evidence-based decision-making by:    increasing collaboration between data producers and users and encouraging better mutual understanding; taking measures to make vital statistics readily accessible to users, including through issuance of summaries, policy briefs, and availability of vital statistics on the web; linking data and information to actual budgets and developing indicator-driven planning to promote evidence-based decision making15

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sharing analysed information and feedback with the grass-roots level where the data is collected, awareness of the utilization of data will encourage those at the grassroots, to collect better quality data and recognize the gaps in the data; and making data more accessible to users by providing analytical summaries that present data using simple charts and maps.

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Objective 5.2 – Promoting the secure utilization of health information and civil registration records for the improvement of other administrative systems The possibilities that are being created through electronic databases and their interlinking represents not merely a simple automation of a paper-based birth or death registration system, but potentially ushers in a radical transformation of how the business processes around births and deaths registration takes place. 16 The CRVS system could potentially serve as the basis for developing interoperable systems to the benefit of all ministries. For example, where the context and law permits, some countries are moving towards developing interoperable administrative systems, including the national population register, which uses health and civil registration data to update demographic data of citizens. Objective 5.3 – Support or undertake innovative statistical techniques to generate interim vital statistics, including utilising incomplete civil registration data Countries are encouraged to make use of innovative techniques for statistical analyses in order to maximize the value of available data, enhance data quality, and take account of missing data and biases. Countries should assess the availability of human resources and analytical skills to undertake primary demographic and epidemiological analysis within the CRVS organizational setup; or else within scientific and research divisions within government or academic institutions within the country. Countries are encouraged to draw upon expertise in academic and research institutions, including crowd-sourcing of open data / big data (with secure access), to support enhanced analysis of available data and promote broader understanding of analytical techniques. The Regional Office will support countries to take an innovative role in collecting, compiling and producing statistics, especially in health facilities. The Regional Office promotes the use of multiple data sources to produce vital statistics in settings where available data are of limited quality. Objective 5.4 – Data should be fit for purpose, and of good quality to create demand. Data must be of good quality, and fit for purpose, in order to create and sustain demand for its use. 16

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A good practice would be for countries to regularly analyse data for quality and reliability by conducting assessments of coverage, completeness, consistency, and plausibility.    Mechanisms for data documentation and archiving should be established. Countries are encouraged to be transparent with users about data limitations; make them explicit in statistical reporting. Countries should develop a community of practice to ensure confidentiality is protected while not impeding data dissemination.

To enable better data management and quality, computerization of records at source should be promoted, to enable accurate data capture, archival, and availability of detailed information for statistical compilation. Computerization will require another level of data standards for data security and confidentiality. In addition, to ensure quality and fitness for purpose, countries are encouraged to compile and tabulate data according to established international standards developed by the UN.  Countries are encouraged to undertake the production and release of annual reports on vital statistics in the form of standard statistical indicators of fertility, mortality and COD by age and sex. Statistics should be produced at national and disaggregate to subnational level.

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7. Monitoring and evaluation: Reporting and regional reviews The goals and the indicators to measure progress of this regional strategy are aligned with the UNESCAP Regional Action Framework which should be endorsed by all Member States of the Region. the Regional Office is a collaborating partner on the development of the Regional Action Framework; therefore, it is proposed that the monitoring and evaluation framework of this Regional Strategy also be aligned with the reporting and reviews of the Regional Action Framework.

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Key dates for reporting and reviewing progression implementing the Regional Action Framework 2015 to 202417 are as follows: Year 2015 2016 2020 2021 2024 2025 Activity Members and associate members submit baseline report to the secretariat First regional review conducted Members and associate members submit mid-term report to the secretariat Mid-term regional review conducted Members and associate members submit final report to the secretariat Final regional review conducted

In order to facilitate reliable monitoring while respecting the need for flexibility to national circumstances, the reporting structure of the Regional Action Framework is as follows: (a) Baseline report: By the end of 2015, members and associate members, through the designated national focal point, will submit to the ESCAP Secretariat:      most recent nationally representative baseline data for each target; the national target value for each target; a progress report on CRVS improvement activities; the report of any comprehensive assessment conducted in the country, where available; and any national CRVS strategy, where available.

(b) Mid-term report: By the end of 2019, members and associate members, through the designated national focal point, will submit to the ESCAP Secretariat :     nationally representative data measuring progress towards each target, where available; a progress report on CRVS improvement activities; the report of any comprehensive assessment conducted in the country, where available; and any national CRVS strategy, where available.

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Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific, Preliminary draft: 25 June 2014s in Asia and the Pacific. Preliminary draft: 25 June 2014

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(c) Final report: By the end of 2024, members and associate members, through the designated national focal point, will submit to the ESCAP Secretariat:     nationally representative data measuring progress towards each target, where available; a progress update report on CRVS improvement activities; the report of any comprehensive assessment conducted in the country, where available; and any national CRVS strategy, where available.

8. The need for subregional country clusters The 11 countries of SEAR have considerable variation in terms of population size, geographical dispersion, and socioeconomic characteristics. However, there are several important common features across four subgroups of countries in SEAR in terms of attributes that could facilitate similar approaches to CRVS development. (See table below.) Among these attributes, the current status of CRVS in each country is an important element which determines the approach to be taken for development, in view of the long-term goal of achieving universal registration, as well as the more immediate goal of generating representative, timely and reliable vital statistics for health sector purposes. In this regard, national population size is also a critical determinant of the approach, and will necessitate a dual strategy in terms of systemic development towards universal coverage of civil registration, but an incremental sampling approach for compilation of vital statistics, particularly for COD. First cluster – Bangladesh, India, Indonesia, The first cluster of countries includes large populations comprising Bangladesh, India, and Indonesia . In general, implementation of a full scale vital registration with COD ascertainment in the entire population is a substantial challenge. Hence, for the purpose of vital statistics, India has operated a sample registration system since the past four decades, which generates annual vital statistics on fertility and mortality rates at the state level. However, this system needs to be strengthened in regard to the capture of COD at national and state levels. Similarly, Bangladesh and Indonesia are also currently establishing sample registration systems. In all three countries, the suitable approach would be to design organic CRVS reforms to strengthen notification and registration of vital events across the country, but invest resources to compile vital statistics and COD in robust and representative population samples at national, regional and provincial levels. There should also be routine monitoring of CRVS for the whole country, to assess the potential to expand the sample, and thereby obtain more robust data for detailed subnational and local demographic and epidemiological analysis. A notional road map could be proposed outlining the pathway towards complete coverage over the next three to four decades.

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Second cluster – Democratic People’s Republic of Korea, Sri Lanka and Thailand The second cluster of countries (Democratic People’s Republic of Korea, Sri Lanka and Thailand) implement vital registration systems with very high completeness of death registration, but low quality of COD ascertainment. In these countries, the approach lies in strengthening COD reporting; with periodic assessment of validity and other aspects of data quality, and application of findings to generate national and subnational mortality estimates. These periodic data quality assessments could identify the areas where further interventions are required to strengthen reporting of COD, and thereby improve the quality of national data from CRVS over one or two decades. Third cluster – Myanmar and Nepal The third cluster of countries – Myanmar and Nepal – have functional vital registration systems, but with patchy coverage and completeness, and only lay reporting mechanisms for capturing COD. There is an urgent need to undertake practical assessments of the operational status of CRVS systems, and design reforms to strengthen their functions. At first, it might be useful to pilot test CRVs reforms in a few sentinel districts, with a focus on ensuring coverage of the entire population, completeness of registration, and data quality including COD. The success of these initiatives could lead to development of strategies for expansion of reforms to the entire country, over the next two to three decades. Fourth cluster – Bhutan, Maldives and Timor-Leste The fourth cluster comprises countries with small populations – Bhutan, Maldives and TimorLeste. While the challenge in Maldives lies in dealing with geographic dispersion across many islands, a common issue with all countries is in dealing with human resources and infrastructure. However, a strategic approach could result in rapid development of comprehensive CRVS in these countries, within the period of a decade. In summary, addressing CRVS development in clusters of countries in SEAR offers several key advantages. Firstly, there is potential to discuss and develop a national strategic approach that could be shared with other countries in the cluster; which could extend to troubleshooting and problem-solving strategies. Secondly, capacity development strategies and resources could be shared and targeted to all countries within the cluster, given the shared approach to CRVS development. Such capacity development could also extend to providing a platform for sharing experiences. Finally, there is potential to develop a common set of timelines and targets, and thereby a monitoring and evaluation plan that could enable comparison of CRVS development between countries within the same cluster.

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Clusters of countries in SEAR according to characteristics of CRVS systems and key recommendations for action Countries (Population size)18 India (1236.68 million) Indonesia (246.86 million) Bangladesh (154.69 million) CRVS strengths Legal framework Human resources Bangladesh has a nationally representative SVRS. ICD-10-based hospital reporting is increasing. An initiative for electronic lifetime health record for rural population began. High completeness Efficient data compilation Limitations Administrative and accessibility challenges leading to patchy completeness; weak community awareness and barriers to access including costs. Lack of awareness and skills in certification.     Recommendations Public awareness campaigns. Removal of barriers to access. Collaboration with funeral authorities to report deaths. All deaths to be reported by age and sex with reporting by CHWs to registration authorities. Sample Registration system (SRS) with VA for all deaths and MCCD to provide state/province level data Scale up over 2–3 decades

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Thailand (66.78 million) Sri Lanka (21.09 million) DPR Korea (24.76 million)

Poor cause ascertainment Low utilization of data

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Train physicians to accurately certify COD. Introduce VA using WHO tools in collaboration with registration authorities. Implement VA and validation studies on periodic basis Analyse data using validation studies to generate periodic estimates for policy use Public awareness campaigns. Removal of barriers to access. Collaboration with funeral authorities to report deaths. All deaths to be reported by age and sex with reporting by CHWs to registration authorities. Strengthen / implement SVRS with VA for all deaths. In Myanmar and Nepal, first establish sentinel surveillance sites, to develop and test strengthened registration/ protocols In all three countries, scale up over next 5–10 years to achieve full coverage by incremental growth of SRS sample cluster size

Myanmar (52.79 million) Nepal (27.47 million)

Myanmar has a long history of data compilation Nepal has increasing CRVS coverage in past decade

Poor completeness in all countries. Lay reported COD, very limited implementation of MCCD for hospital deaths

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Countries (Population size)18 Maldives (0.33 million)

CRVS strengths Small populations Homogenous ethnicity ++High or complete CRVS coverage, high MCCD – 96% deaths in facilities in Maldives

Limitations Human resourcesHigh dependency on expatriate physicians who are employed short term Geographic dispersion 

Recommendations Complete CRVS coverage VA for deaths outside hospital; strengthen MCCD

Bhutan (0.74 million) Timor-Leste (1.11 million)

9. Key country actions The experiences of countries that have successfully embarked on efforts to improve CRVS systems demonstrate that, although circumstances and starting points vary, there are common actions to be taken, which can happen in parallel and in an iterative manner. The strategy will guide countries through the implementation of several key actions. These are listed below.

Key country actions MULTISECTORAL ACTIONS 1. Participate in a standards-based comprehensive assessment of current status, capacities and resources using the WHO-UQ tool. 2. Support the use of the results of the assessment to generate high-level political commitment and crosssectoral support for improving the CRVS system. 3. Participate in the establishment of and strengthen an existing national CRVS coordination and oversight mechanism with multistakeholder representation and clear articulation of roles and responsibilities of all key stakeholders and its functioning. Foster involvement of nongovernmental entities, including civil society representatives, and monitor progress. 4. Support the formulation of a five-year national strategic plan and investment plan for improvement of CRVS including requirements of all stakeholders, including setting targets for the key health goals. 5. Support mobilization of the resources needed, including human, technical and financial resources. 6. Support the implementation of the costed five-year national strategic plan for improvement of CRVS, document experiences and lessons learnt, and monitor and evaluate progress. HEALTH SECTOR ACTIONS 7. Accelerate health sector-specific interventions such as strengthening health systems and HMIS, training for ICD and; research in scaling up VA; creating demand through linking services to CRVS e.g. newborn care, immunization , UHC; community notification using technology.

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especially with regard to resource allocation and legislative review. Pathways and time-scales for the multisectoral national action plans will vary across countries depending on the current status of their CRVS systems, institutional, legal and administrative characteristics, and capacities and stage of development. The establishment of a national CRVS coordination and oversight mechanism to coordinate the assessment and the development and implementation of the strategic plan for improvement is of critical importance for ensuring sustainability and the attainment of measureable improvements. Each country would determine the precise nature and composition of the coordination body, using existing coordination mechanisms when possible.

10. Regional action The Regional Office has chosen to pioneer the work for the improvement of the CRVS systems as part of its focus on specific identified priorities for its work in the Region over the coming years. At the top of these priorities is the strengthening of health systems and the building of regional information capacities. Strengthening CRVS systems in the Region would have an enormously positive impact on the type and quality of information available to support health development activities in the Region. Action at the regional level for the implementation of this strategy will be initiated by the endorsement of the strategy by the WHO Regional Committee Meeting for the South East Asia Region. Other regional activities will be organized for mobilization of technical and other resources by WHO and partners to support country implementation of the strategy. Coordination between Member States and exchange of experiences and good practices will also be facilitated at the regional level. WHO, other UN agencies and development partners intend to sustain and strengthen the partnership approach at the regional level and extend the approach to support for countries. The Regional Office is taking steps to strengthen its own capacities to respond to technical support needs from Member States. This strategy links to the broader UNESCAP-led collaboration on the Regional Action Framework for CRVS. The roles of WHO and its partners in support of this strategy can be summarized in three functions: a) advocacy to mobilize political, technical and material support; b) coordination to harmonize inputs and support from different international agencies and development partners (each according to its mandate) at regional and country levels; and c) technical support and capacity-building in line with each country’s priorities. WHO can also work with regional partners on cross-border issues such as the sharing of information on cross-border births and deaths, and the development of a repository of tools to support country implementation of CRVS strengthening, as well as a platform for countries to share the best practices and lessons learned.

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11. Conclusions and the way forward The formal registration of the important events in people’s lives is critica l for the protection of rights, a core component of good governance and sound administration, and crucial for producing reliable statistics on the demographics and health of the population. The improvement of CRVS systems is thus imperative for sustainable and inclusive development and will be central to the achievement of the health and development agenda post 2015, including universal health coverage. This Regional Strategy for strengthening the role of the health sector in improving CRVS is intended to provide unified direction and political support to prioritize CRVS. This Regional Strategy will focus on health sector initiatives at regional, national and local levels that will work towards achieving these goals. In practice, this could potentially be achieved through implementation of specific activities within the health sector, as well as through close collaboration and coordination of health sector activities with other sectors and national stakeholders in the CRVS system. The Regional Strategy is intended to guide and support the improvement of CRVS systems in the Region over the period 2015–2024. The regional strategy launches a collective intervention focusing on strengthening the role of the health sector across the Region to improve CRVS systems in ways that are efficient and evidence-based. This regional strategy is aligned with other regional initiatives, such as the Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific. The specific health goals of this regional strategy are: 1. support to the universal civil registration of births and deaths. 2. provision of relevant documentation related to notification and certification by the health sector to all individuals to facilitate the civil registration of births and deaths. 3. production of accurate, complete and timely vital statistics, with a focus on COD based on civil registration data19.    The achievement of universal civil registration of births and deaths and recording COD; ensuring that individuals are provided with legal documentation of civil registration of births and deaths as necessary to claim identity, civil status and ensuing rights; and ensuring that accurate, complete and timely vital statistics with a focus on COD are produced based on civil registration data and interim means are used to fill the gaps

Partnership between stakeholders and development partners is a quintessential prerequisite for the successful implementation of this strategy at both country and regional levels.

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Separate targets will be established for institutional and non-institutional causes of death.

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Ministries of health in the Region will need to assume stewardship, brokering and interlocutor roles in partnership with other actors within their respective governments. It is essential that a collaborative multiagency approach is adopted, emphasizing the roles of different stakeholders and the particular responsibilities of the public health sector in terms of the notification of vital events, the certification of COD and the production of vital statistics. The health sector can immediately act to address its responsibilities within the multiagency collaboration, such as while working in a whole of government approach to ensure that all elements to build a sustainable CRVS system are addressed. Overall, the proposed strategy provides a framework of action for the period of 2015–2024, illustrating the roles and responsibilities of all pertinent stakeholders nationally and regionally, including countries and WHO.

References Cable, V. (2003, May). Does evidence matter? (ODI meeting series report). London: Overseas Development Institute. Retrieved 28 July 2011, from http://www.odi.org.uk/Rapid/ Meetings/Evidence/Presentation_3/Cable.html Civil Registration and Vital Statistics 2013: challenges, best practice and design principles for modern systems, WHO,HMN, HISP India Lopez, A., AbouZahr, C., Shibuya, K., & Gollogly, L. (2007). Keeping count: births, deaths, and COD. The Lancet, 370(9601), 1744–1746. doi:10.1016/S0140-6736(07)61419-6. Mahapatra, P., Shibuya, K., Lopez, A., Coullare, F., Notzon, F. C., Rao, C., et al. (2007). Civil registration systems and vital statistics: success and missed opportunities. The Lancet, 370, 1653 –1663. doi:10.1016/S01406736(07)61308-7 Regional Committee for the Eastern Mediterranean, Sixtieth Session, Provisional agenda item 5 (b), EM/RC60/10, September 2013, Regional strategy for the improvement of civil registration and vital statistics systems Regional Action Framework for Civil Registration and Vital Statistics in Asia and the Pacific Setel, P., Macfarlane, S. B., Szreter, S., Mikkelsen, L., Jha, P., Stout, S., & AbouZahr, C. on behalf of the Monitoring of Vital Events (MoVE) writing group. (2007). A scandal of invisibility: making everyone count by counting everyone. The Lancet. Retrieved 18 July 2011, from <http://www.who.int/healthinfo/statistics/WhoCounts1.pdf>. doi:10.1016/S0140-6736(07)61307-5. Strengthening practice and systems in civil registration and vital statistics: A Resource Kit, HIS HUB, Number 19, January 2012 The Brisbane Accord Group and the Pacific Vital Statistics Action Plan (2011 –2014) - Outline June 12 United Nations Department of Economic and Social Affairs Statistics Division. (1998a). Handbook on Civil Registration and Vital Statistics Systems: computerization. Retrieved 3 August 2011 from United Nations Statistics Division website: <http://unstats.un.org/unsd/publication/SeriesF/SeriesF_73E.pdf>. United Nations Department of Economic and Social Affairs Statistics Division. (1998b). Handbook on civil registration and vital statistics systems: developing information education and communication. (Series F, No. 69). Retrieved 20 July 2011 from <http://unstats.un.org/unsd/publication/SeriesF/SeriesF_69E.pdf >. January 2012 Version 1.0 239 United Nations Economic and Social Committee for Asia and the Pacific. (2010). Development of a regional programme for the improvement of vital statistics in Asia and the Pacific. Paper presented at the second session of the Economic and Social Commission for Asia and the Pacific Committee on Statistics, Bangkok, Thailand. Retrieved 1 December 2011, from <http://www.unescap.org/stat/cst/2/CST2-3E.pdf>.

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University of Queensland School of Population Health, Health Information Systems Knowledge Hub (UQ HIS Hub), & World Health Organization (WHO). (2010a). Improving the quality and use of birth, death and cause-of-death information: guidance for a standards-based review of country practices. Retrieved 19 July 2011, from World Health Organization website: <http://whqlibdoc.who.int/publications/2010/9789241547970_eng.pdf>. University of Queensland School of Population Health and World Health Organization (2010b). Rapid assessment of national civil registration and vital statistics systems. Retrieved 24 November 2011, from <http://www.uq.edu.au/hishub/docs/WP%2002.pdf>. Using innovative approaches in the health sector to strengthen and modernize civil and vital statistics (CRVS) systems: guiding principles and good practices, Report of a technical meeting sponsored by the World Health Organization in collaboration with Canada, UNICEF, USAID and the World Bank, Geneva, 17 –18 December 2013 World Health Organization (WHO). (2007a). International statistical classification of diseases and related health problems 10th revision. Retrieved 18 July 2011, from World Health Organization website: <http://apps.who.int/classifications/apps/icd/icd10online/>. World Health Organization. (2007b). Verbal autopsy standards: ascertaining and attributing COD. World Health Organization. ISBN 978 92 4 154721 (NLM classification: WA 900) Geneva, Switzerland, 2007

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Annex: Targets for Goals20 The three goals of the Regional Action Framework address the three essential outputs of CRVS systems: the civil registration of vital events, which is a precursor to the other two goals; the provision to individuals and families of legal documentation as evidence of the occurrence and characteristics of vital events; and the production and dissemination of vital statistics based on civil registration records. The targets are designed to enable monitoring and evaluation in ways that are objective, efficient, technically sound and time-bound during the decade, 2015 to 2024. Countries set their own national target value for each target (either the percentage or the year, depending on the target) based on their current situation and national priorities, and in accordance with their comprehensive multisectoral national CRVS strategic plan for improvement, if one exists. 21

1. The targets for goal 1 are: 1.1. By 2024, at least ... % of births in the territory and jurisdiction in the given year are registered. 1.2. By 2024, at least ... % of children under five years old in the territory and jurisdiction have had their birth registered. 1.3. By 2024, at least ... % of all individuals in the territory and jurisdiction have had their birth registered. 1.4. By 2024, at least ... % of all deaths that take place in the territory and jurisdiction in the given year are registered. 1.5. By 2024, at least ... % of all deaths recorded by the health sector in the territory and jurisdiction in the given year have a medically certified COD recorded using the international form of the death certificate

2. The targets for goal 2 are: 2.1. By 2024, at least ... % of all births registered in the territory and jurisdiction are accompanied with the issuance of an official birth certificate that includes, as a minimum, the individual’s name, sex, date and place of birth, and name of parent(s) where known. 2.2. By 2024, at least ... % of all deaths registered in the territory and jurisdiction in the given year are accompanied with the issuance of an official death certificate which includes, as a minimum, the deceased’s name, sex, and age 20 21

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3. The targets for goal 3 are: 3.1. By ... (year), annual nationally representative statistics on births – disaggregated by age of mother, sex of child, geographic area and administrative subdivision – are produced from registration records or, alternatively, other valid administrative data sources. 3.2. By ... (year), annual nationally representative statistics on deaths – disaggregated by age, sex, COD defined by the ICD, latest version as appropriate, geographic area and administrative subdivision – are produced from registration records or, alternatively, other valid administrative data sources. 3.3. By 2024, at least ... % of deaths occurring in health facilities or with the attention of a medical practitioner has a COD derived from the medical certificate according to the standards defined by the ICD, latest version as appropriate. 3.4. By 2024, at least ... % of deaths taking place outside of a health facility and without the attention of a medical practitioner has their COD determined through verbal autopsy. 3.5. By ... (year), key summary tabulations of vital statistics on births and deaths using registration records as the primary source, are made available in the public domain in electronic format annually, and within one calendar year. 3.6. By ... (year), key summary tabulations of vital statistics on COD using registration records as the primary source, are made available in the public domain in electronic format annually, and within one calendar year. 3.7. By ... (year), an accurate, complete and timely vital statistics report for the previous biennium, using registration records as the primary source, is made available in the public domain.

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