States have an obligation to ensure everyone in the territory is counted, regardless of nationality, ethnicity or citizenship status. The civil registration (CR) system, through issuance of official documents such as birth, marriage and death certificates, serves as the gateway for legal recognition by the State. The routine nature of these bureaucratic tasks often obscures the CR system’s fundamental importance; however, faults in the system have devastating consequences for people left without accurate documents. Ideally, civil registration and vital statistics (CRVS) systems should produce timely data necessary for policymaking and should measure the countries’ progress toward reaching key targets of the Sustainable Development Goals (SDGs). Governments should prioritize strengthening the CRVS legal and regulatory environment, given the crucial population and health statistics derived from this data, the legal implications of lack of registration, the complexity of operationalizing CRVS processes and the multiplicity of stakeholders involved in the system¹1. Lopez AD, AbouZahr C, Shibuya K, Gollogly L. Keeping count: births, deaths and causes of death. Lancet. 2007;370(9601):1744-6. http://doi.org/10.1016/S0140-6736(07)61419-6
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CR systems provide foundational data for a country’s vital statistics, including mortality data disaggregated by age, gender and causes of death across different populations. Health and social policymaking rely heavily on the completeness of death registration, the proportion of registered deaths with a medically certified cause of death, and the quality of those certifications²2. Okonjo-Iweala N, Osafo-Kwaako P. Improving health statistics in Africa. Lancet. 2007;370(9598):1527-8. http://doi.org/10.1016/S0140-6736(07)61644-4
https://doi.org/http://doi.org/10.1016/S... . Despite renewed efforts to improve CRVS systems, universal death registration remains a challenge for most low- and middle-income countries (LMICs). Many CRVS systems employ antiquated legislation that puts the burden on families and individuals to notify and register the vital events occurring in their lives. In the case of death registration, there is often a lack of incentive for family members to register the death due to informal inheritance practices and barriers to registration. These barriers include direct and indirect costs, often involving multiple trips to registration offices to meet the burden of proof required for registration. Moreover, a significant proportion of deaths in LMICs occur in the community and without medical attention, leading to unrecorded occurrence and cause of death³3. Setel PW, Macfarlane SB, Szreter S, Mikkelsen L, Jha P, Stout S, et al. A scandal of invisibility: making everyone count by counting everyone. Lancet. 2007;370(9598):1569-77. http://doi.org/10.1016/S0140-6736(07)61307-5
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Further complicating the attainment and production of high-quality mortality data are the proportion of deaths that occur outside the health sector’s purview, particularly external causes including homicides, suicides, accidents and suspicious deaths. These deaths bring other interested parties into the system including police, medical examiners and the judicial system¹. The ambiguous mandates among institutions commonly blurs the responsibility for registering deaths and determining causes of death, which leads to under-reporting of deaths. The bulk of mortality data produced and used for policymaking in LMICs is disproportionate to the deaths occurring in hospitals in urban áreas⁴4. Mahapatra P, Shibuya K, Lopez AD, Coullare F, Notzon FC, Rao C, et al. Civil registration systems and vital statistics: successes and missed opportunities. Lancet. 2007;370(9599):1653-63. http://doi.org/10.1016/S0140-6736(07)61308-7
https://doi.org/http://doi.org/10.1016/S... . These deaths may not be representative of the entire population, as urban populations may have a higher socioeconomic status and better access to health services than those residing in rural and remote areas. Meanwhile, these vulnerable communities remain vastly uncounted and invisible⁵5. Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet. 2019;393(10183):1857-910. http://doi.org/10.1016/S0140-6736(19)30233-8
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CRVS systems provide individuals with proof of identity and legal forms of identification (ID), such as birth certificates, voter ID cards or driver’s licenses. An incomplete CR system that does not fulfill this role causes real-life challenges for men, women and children excluded from it. Without a permanent and official ID, a person is denied the fundamental human right to a legal identity and, therefore, full access to social services and civic participation. Access to healthcare and education may be limited or completely inaccessible without legal ID, which may negatively impact the life course of individuals and their families¹1. Lopez AD, AbouZahr C, Shibuya K, Gollogly L. Keeping count: births, deaths and causes of death. Lancet. 2007;370(9601):1744-6. http://doi.org/10.1016/S0140-6736(07)61419-6
https://doi.org/http://doi.org/10.1016/S... . Nevertheless, many countries have outdated CRVS legal frameworks that exacerbate marginalization of vulnerable populations, including women, refugees, migrant workers and ethnic minorities, and deepen inequalities within and among countries; thus, CRVS legislation should be framed with a rights-based perspective⁵5. Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet. 2019;393(10183):1857-910. http://doi.org/10.1016/S0140-6736(19)30233-8
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The primary functions of CRVS systems, such as registration and certification of vital events, and production and dissemination of vital statistics, are usually divided amongst government ministries. For example, death registration might require collaboration between registrars, hospitals, medical examiners, police departments, ambulatory care networks and disaster management organizations¹1. Lopez AD, AbouZahr C, Shibuya K, Gollogly L. Keeping count: births, deaths and causes of death. Lancet. 2007;370(9601):1744-6. http://doi.org/10.1016/S0140-6736(07)61419-6
https://doi.org/http://doi.org/10.1016/S... . These stakeholders often do not sufficiently coordinate it due to weak governance structures and poorly defined obligations. Employing legal reform is a strategic intervention to mediate the complex network of multiple stakeholders at a national level and to delineate mandates to decentralized units of government⁵5. Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet. 2019;393(10183):1857-910. http://doi.org/10.1016/S0140-6736(19)30233-8
https://doi.org/http://doi.org/10.1016/S... .

Although CRVS systems serve the same main functions everywhere, countries adapted their approach based on their constitutional structure, history and culture. This has created many ways that CRVS systems and processes in LMICs are organized and implemented¹1. Lopez AD, AbouZahr C, Shibuya K, Gollogly L. Keeping count: births, deaths and causes of death. Lancet. 2007;370(9601):1744-6. http://doi.org/10.1016/S0140-6736(07)61419-6
https://doi.org/http://doi.org/10.1016/S... . Governments need to adopt a comprehensive systems approach and to apply methods such as business process mapping to identify gaps and inefficiencies that need to be confronted and corrected⁵5. Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet. 2019;393(10183):1857-910. http://doi.org/10.1016/S0140-6736(19)30233-8
https://doi.org/http://doi.org/10.1016/S... .

A strong legal framework is the foundation of a robust CRVS system, which is essential for achieving universal, compulsory, permanent and continuous coverage. Reforming outdated, ambiguous or discriminatory legislation catalyzes improved efficiency, security and demand for CRVS services. Benefits include strengthened governance and coordination amongst government stakeholders, resulting in more efficient use and allocation of resources and informed policymaking, in order to promote better health outcomes and life expectancies for the population¹1. Lopez AD, AbouZahr C, Shibuya K, Gollogly L. Keeping count: births, deaths and causes of death. Lancet. 2007;370(9601):1744-6. http://doi.org/10.1016/S0140-6736(07)61419-6
https://doi.org/http://doi.org/10.1016/S... . Countries seeking to strengthen their CRVS systems should review and, where necessary, reform their legislation to ensure a rights-based system that will leave no one behind.

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