The purpose of this paper is to share lessons learned through implementing the Bloomberg Philanthropies Data for Health Initiative11. Bloomberg Philanthropies. Data for health [citado em 10 out. 2019]. Disponível em: Disponível em: https://www.bloomberg.org/program/public-health/data-health/#overview .
https://www.bloomberg.org/program/public... , a partnership of Bloomberg Philanthropies and the Australian Department of Foreign Affairs and Trade. The Initiative provides technical support to countries and cities in Latin America, Africa, Asia and the Pacific to collect and use better public health data. One component of the Initiative was aimed at strengthening civil registration and vital statistics (CRVS) systems to address the fact that many low- and middle-income countries (LMIC) do not capture all vital events occurring within their territory and do not produce information about causes of death with good quality. Without this information, governments lack a clear picture of population trends as well as the mortality profile in their countries and, therefore, cannot make evidence-based decisions on how to direct scarce resources. This paper focuses on two important topics in CRVS improvement: CRVS legal and regulatory review and reform, and notification of vital events.
LEGAL FRAMEWORKS FOR CIVIL REGISTRATION AND VITAL STATISTICS SYSTEMS
A strong legal framework is fundamental of a well-functioning CRVS system. CRVS systems are complex and often insufficiently coordinated. They are anchored across a range of ministries and agencies, all underpinned by various laws and regulations, which are sometimes conflicting or outdated. Strengthening and aligning the CRVS legal framework with international standards, including for cause of death, is a critical step to improved CRVS system functioning. Conventional wisdom has held that legal and regulatory reform is time consuming and affected by politically and socially sensitive considerations. The experience under the Initiative suggests otherwise.
A team comprised of CRVS officials and lawyers used a structured tool and process in numerous countries to compare current CRVS laws, regulations, and standard operating procedures to a set of best practices established by the United Nations Statistics Division. Discrepancies were noted, and plans made to bring legislation and official policy documents into alignment with the standards.
The Initiative implemented this review in 13 countries and cities, and prioritized legal and regulatory reforms arising from the fourth to sixth-month of review process were actioned within months. For example, in at least two countries the review resulted in drafting entirely new CRVS legislation. In a third, ministerial orders were issued mandating the use of the international form of the medical certificate of cause of death.
Undertaking this work, we learned three important lessons. First, there is high demand for legal and regulatory review and reform in countries where improving the CRVS system is a priority. The resources developed by the Data for Health Initiative have provided a solution to this repressed demand. Second, we learned that changes can occur more rapidly than was previously thought. Finally, our 13-country experience has reinforced how important a solid legal and regulatory framework is to enable functional CRVS systems. Reforms are not only central to enabling the environment for implementing CRVS practices that meet international standards, but they are also the sole means of enshrining all due rights of law and policy and protections to registered individuals, citizens or not.
NOTIFICATION OF VITAL EVENTS
The number of births and deaths in a population for a given period of time and within a specific geographic area, are of central interest to epidemiologists, as well as governments. As the Initiative engaged with countries to unpack factors related to poor completeness of CRVS data, several issues came to light. First, the transactional burdens in most LMIC and CRVS systems deter families from registering, regardless of legal obligations and fines for late registration. Based on field experience, “passive” systems, in which families carry most of the burden to register births and deaths, were strongly associated with poorer completeness. Also, the civil registrars in many countries lack a direct connection to the health sector - the largest source of birth and death information.
To address this, the Initiative adopted a two-track approach. Firstly, we facilitated dialogue between registration authorities, national statistics offices, and ministries of health to establish principles of data sharing and interoperability. This dialogue led, for example, to the establishment of functional CRVS steering committees and formal inter-ministerial agreements to enable data exchange among government departments responsible for CRVS. In an African country, major hospitals became designated registration points.
Secondly, we engaged with the civil registration authorities, ministries of health, and local government to design locally-tailored and sustainable systems of active notification of births and deaths. With the Initiative’s support, governments trained health and hospital workers, providing the civil registration with records and all information needed for the official registration of birth or deaths in facilities and communities. In the course of such system changes, it became apparent that where countries shifted to active record births and deaths, completeness increased dramatically. Promoting the adoption of active recording of vital events is a key lesson of the initiative.
In this paper we have focused on a few results and lessons learned from the Bloomberg Philanthropies Data for Health Initiative in two critical areas for CRVS improvement. There are several other CRVS domains in which the Initiative has assisted governments around the world, including:
* Improvements to facility-based cause of death. This entails strengthening medical certification of cause of death using the standard World Health Organization (WHO) form, and coding of deaths to the International Classification of Diseases.
* Establishing a system to determine community patterns of cause-specific mortality, based on the use of automated “verbal autopsy” method. In many lower-income countries, up to 80% of deaths can occur at home or outside of a health facility, giving no opportunity to medics certify the cause of death. The verbal autopsy method uses data from interviews with family members of the deceased to assign a probable cause of death.
* Ensuring the capacity to analyze, communicate and use vital statistics data, including on causes of death. The establishment of a legal identity for individual and statistics derived from records of vital events are the central products of the CRVS system. Without the actual uptake and use of vital statistics to inform policy and planning and to track international commitments like the Sustainable Development Goals, one of the main propositions of having a civil registration system cannot be delivered on.
We would like to conclude by highlighting that the strides made by governments under their national programs, cannot be sustained without the commitment of necessary capital - both human and financial. Long-term institutionalization and scale-up plans - for the improvement of CRVS business process - that are adopted, funded, and implemented offer the greatest chance for the long-term success of CRVS.
This paper is an output of the Bloomberg Philanthropies Data for Health Initiative. The views expressed are not necessarily those of Bloomberg Philanthropies.
- 1Bloomberg Philanthropies. Data for health [citado em 10 out. 2019]. Disponível em: Disponível em: https://www.bloomberg.org/program/public-health/data-health/#overview
- Financial support: Funding from Vital Strategies as part of the Bloomberg Philanthropies Data for Health Initiative (Project 23998 Fundep/UFMG).
- Publication in this collection
5 Dec 2019
- Date of issue
25 June 2019
24 July 2019