Evaluation of approaches to strengthen civil registration and vital statistics systems: A systematic review and synthesis of policies in 25 countries

Background Civil registration and vital statistics (CRVS) systems play a key role in upholding human rights and generating data for health and good governance. They also can help monitor progress in achieving the United Nations Sustainable Development Goals. Although many countries have made substantial progress in strengthening their CRVS systems, most low- and middle-income countries still have underdeveloped systems. The objective of this systematic review is to identify national policies that can help countries strengthen their systems. Methods and findings The ABI/INFORM, Embase, JSTOR, PubMed, and WHO Index Medicus databases were systematically searched for policies to improve birth and/or death registration on 24 January 2017. Global stakeholders were also contacted for relevant grey literature. For the purposes of this review, policies were categorised as supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches). Quantitative results on changes in vital event registration rates were presented for individual comparative articles. Qualitative systematic review methodology, including meta-ethnography, was used for qualitative syntheses on operational considerations encompassing acceptability to recipients and staff, human resource requirements, information technology or infrastructure requirements, costs to the health system, unintended effects, facilitators, and barriers. This study is registered with PROSPERO, number CRD42018085768. Thirty-five articles documenting experience in implementing policies to improve birth and/or death registration were identified. Although 25 countries representing all global regions (Africa, the Americas, Southeast Asia, the Western Pacific, Europe, and the Eastern Mediterranean) were reflected, there were limited countries from the Eastern Mediterranean and Europe regions. Twenty-four articles reported policy effects on birth and/or death registration. Twenty-one of the 24 articles found that the change in registration rate after the policy was positive, with two supply and one penalty articles being the exceptions. The qualitative syntheses identified 15 operational considerations across all policy categories. Human and financial resource requirements were not quantified. The primary limitation of this systematic review was the threat of publication bias wherein many countries may not have documented their experience; this threat is most concerning for policies that had neutral or negative effects. Conclusions Our systematic review suggests that combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates in different geographical contexts. Operational considerations should be interpreted based on health system, governance, and sociocultural context. More evaluations and research are needed from the Eastern Mediterranean and Europe regions. Further research and evaluation are also needed to estimate the human and financial resource requirements required for different policies.


Methods and findings
The ABI/INFORM, Embase, JSTOR, PubMed, and WHO Index Medicus databases were systematically searched for policies to improve birth and/or death registration on 24 January 2017. Global stakeholders were also contacted for relevant grey literature. For the purposes of this review, policies were categorised as supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches). Quantitative results on changes in vital event registration rates were presented for individual comparative articles. Qualitative systematic review methodology, including meta-ethnography, was used for qualitative syntheses on operational considerations encompassing acceptability to recipients and staff, human resource requirements, information technology or infrastructure requirements, costs to the health system, unintended effects, facilitators, and barriers. This study is registered with PROSPERO, number CRD42018085768. Thirty-five articles documenting experience in implementing policies to improve birth and/or death registration were identified. Although PLOS  25 countries representing all global regions (Africa, the Americas, Southeast Asia, the Western Pacific, Europe, and the Eastern Mediterranean) were reflected, there were limited countries from the Eastern Mediterranean and Europe regions. Twenty-four articles reported policy effects on birth and/or death registration. Twenty-one of the 24 articles found that the change in registration rate after the policy was positive, with two supply and one penalty articles being the exceptions. The qualitative syntheses identified 15 operational considerations across all policy categories. Human and financial resource requirements were not quantified. The primary limitation of this systematic review was the threat of publication bias wherein many countries may not have documented their experience; this threat is most concerning for policies that had neutral or negative effects.

Conclusions
Our systematic review suggests that combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates in different geographical contexts. Operational considerations should be interpreted based on health system, governance, and sociocultural context. More evaluations and research are needed from the Eastern Mediterranean and Europe regions. Further research and evaluation are also needed to estimate the human and financial resource requirements required for different policies.

Author summary
Why was this study done?
• Civil registration and vital statistics (CRVS) systems generate foundational data for governance across sectors. Within public health, birth and death registrations are critical not only for empowering individuals' legal rights and for access to services but also in estimating health service needs, coverage, and impact.
• To our knowledge, no formal evidence review and synthesis has characterised which policies work and which do not for strengthening birth and death registration.

What did the researchers do and find?
• We searched five literature databases and contacted global stakeholders to identify policies that improve birth and/or death registration and presented policy quantitative effects and qualitative syntheses.
• We identified 35 articles documenting experience in implementing policies to improve birth and/or death registration from 25 countries representing all global regions.
• Twenty-four articles reported supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches) effects on birth and/or death registration.
• Combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates across different geographical contexts.

Introduction
Civil registration is defined as the continuous, permanent, compulsory, and universal recording of the occurrence and characteristics of vital events in accordance with the legal requirements in each nation [1]. Vital events captured in civil registration and vital statistics (CRVS) systems include the registration of births, deaths (including cause of death), marriages, adoptions, and divorces [1]. Civil registration and supporting legal documentation provide individuals with proof of legal identity, help establish their right to acquire nationality, allow individuals to exercise a broad range of rights, and facilitate access to essential services including social welfare, education, health, and legal protection [2]. Systematic compilation of civil registration data into vital statistics also provides the demographic information necessary for good governance [3]. For example, birth and death data can help monitor population growth and movement and inform fiscal policy. Within the health sector, functioning CRVS systems with a medically certified cause of death both provide an individual with the legal documents they need to access health, inheritance, and legal protection and the country with the data needed to estimate national and subnational burden of disease, the impact of different disease programmes, and the cost-effectiveness of disease interventions [4]. Birth and death registration data are also essential to inform health service needs and coverage. These functions are critical to monitoring progress in achieving the United Nations Sustainable Development Goals (SDGs) [5]. The systematic recording of vital events in many countries remains a serious challenge [5]. In the absence of reliable CRVS data, household surveys have become a key source of data to monitor levels and trends in births, deaths, and other core population indicators [6][7][8][9]. In most low-and middle-income countries, such surveys represent the sole source of this information. Unfortunately, many of these data sources are time limited, costly, externally supported, and not always current when published. Surveys also lack the local area CRVS data most effective for local public health planning. Locally developed and sustainable CRVS systems can provide a legal identity from birth, the fundamental documentation to claim a nationality, and generate granular strategic information both to successfully deliver services and improve planning, budgeting, and programming for health and other sectors.
Public health authorities primarily focus on notifying births, deaths, and causes of deaths to the civil authority to enter into the registration system used for decision-making [10]. Global guidelines are useful in establishing CRVS norms and standards for countries. The United Nations Statistics Division provides comprehensive guidance on how CRVS systems can achieve universal coverage, continuity, confidentiality, data quality, and regular dissemination in order to be a dependable and primary source of vital statistics [11]. This guidance also suggests alternative sources and interim methods to generate vital statistics when CRVS systems are underdeveloped [11]. Technical guidance from the United Nations Children's Fund, World Health Organization (WHO), the World Bank Group, and various UN regional offices covers CRVS system strategic planning, legal frameworks, registration practices, birth certification, death certification and cause of death, quality of data according to the International Classification of Diseases (ICD), interim methods for vital statistics, and how to build political and community support for CRVS systems [10,12,13].
All countries agreed to achieve the SDGs that specify targets related to CRVS, including (1) by 2030, provide legal identity for all, including birth registration, (2) by 2020, enhance capacity-building support to developing countries to increase significantly the availability of highquality, timely, and reliable disaggregated data, and (3) by 2030, build on existing initiatives to develop measurements of progress on sustainable development that complement gross domestic product, and support statistical capacity-building in developing countries [14]. CRVS systems also contribute to public health SDG targets, such as measuring progress towards ending the epidemics of HIV, tuberculosis, malaria, and neglected tropical diseases, reducing maternal and child deaths, and reducing deaths due to noncommunicable diseases and road traffic accidents [14,15]. Although there has been some progress in CRVS system development over the past two decades, birth and death registration rates continue to increase at a slow rate [16][17][18]. Worldwide, the proportion of children under five with a registered birth increased from 58% in 2000 to 65% in 2015 whilst the proportion of deaths registered increased from 36% to 38% during the same period [19]. In addition to informing national mortality and life expectancy trends, death registration is also critical because it is the first step before determining causes of death. Unfortunately, independent assessments indicate that the majority of registered deaths have issues surrounding the quality of cause-of-death ascertainment [20]. For example, the latest data available from WHO indicate that while an average of 48% of registered deaths included cause of death, 18% of ICD cause-of-death reports used ill-defined ICD codes [21]. Although significant progress was made in evaluating the role of information technology (IT) interventions in CRVS systems, non-technological interventions lack formal reviews and evaluations [22,23]. We systematically reviewed the evidence on national policy interventions to improve birth and death registration.

Study conduct
This systematic review was conducted in accordance with the PRISMA guidelines using a predefined protocol (International Prospective Register of Systematic Reviews identification number, CRD42018085768) [24,25] (S1 and S2 Texts). The ABI/INFORM, Embase, JSTOR, PubMed, and WHO Index Medicus databases were systematically searched without language, publication, or any other limits on 24 January 2017. Given that the Statistical Commission of the United Nations adopted the International Programme for Accelerating the Improvement of Vital Statistics and Civil Registration Systems to assist countries with incomplete registration or entirely lacking a CRVS system in 1991, we included articles implemented and published from 1991 onward [26]. All sources cited in the 2007 and 2015 CRVS Lancet series were reviewed for inclusion [3,19,[27][28][29][30][31][32]. Global stakeholders, including the Centers for Disease Control and Prevention's International Statistics Program, United Nations Children's Fund, UN Statistics Division, World Bank Group, and WHO, were also contacted to provide relevant publications on CRVS systems and policies.

Eligibility criteria and search strategy
Per recommendations from the PRISMA group, eligibility criteria were based on key article characteristics: population, intervention, comparator, outcome, and design [24]. Specifically, sources were included when (1) they comprised a population eligible for birth and/or death registration, (2) the intervention was a new national policy (i.e., novel legislation or change in programme implementation designed to improve birth and/or death registration), (3) the comparator includes the lack of the new policy, (4) the outcome was birth registration rate, death registration rate, timeliness of birth registration, timeliness of death registration, and/or operational considerations (i.e., acceptability to persons registering births or deaths, acceptability to staff managing and implementing birth or death registration, human resource requirements, costs to the health system, adverse events, and/or facilitators or barriers learnt during implementation), and (5) the article design was a cross-sectional, cohort, case-control, or randomised controlled trial. Articles did not require a minimum time period of follow-up to be eligible. Articles describing operational considerations did not require a comparator arm to be included. The search strategies were designed by a librarian to identify articles that met these eligibility criteria (S3 Text).

Study screening and extraction
Two investigators independently screened titles of all identified articles, followed by screening abstracts from relevant titles. The investigators then matched the full texts of all articles selected during abstract screening against the inclusion criteria. Disagreements were resolved through discussion with a third investigator. References for included articles were reviewed for additional reports. Articles failing to meet inclusion criteria were excluded from this review. Two investigators completed the data extraction using a standardised extraction form comprising four tables summarising setting, design, quantitative outcomes and results, and operational considerations.

Quantitative and qualitative syntheses
For the purpose of establishing a policy framework for this systematic review, we used the following mechanisms and definitions to guide our categorisation of individual articles: (1) supply (policies focussed on increasing accessibility, acceptability, and/or affordability of registration services), (2) demand (policies focussed on increasing awareness for registration through information, education, communication, and/or advocacy), (3) penalty (policies that penalise citizens for failing to register a birth or death), (4) incentive (policies that encourage citizens to register a birth or death), and (5) combination (a combination of at least two of the preceding policy mechanisms). Given that numerators and denominators were not provided for most quantitative results, data stabilisation, meta-analyses, and heterogeneity assessment could not be performed [33][34][35]. Instead, we presented individual article results on changes in vital event registration rates during policy implementation. In cases in which multiple articles reported quantitative results on an intervention from the same country, we reported results from the article with the longest period of follow-up.
We used Cochrane qualitative systematic review methodology, including meta-ethnography, to synthesise qualitative data [36][37][38][39][40]. Meta-ethnography involved reciprocal translational analysis (comparison), refutational synthesis (contrast), and line of argument synthesis (highlevel synthesis) [41,42]. We developed themes based on quotations from each article. These themes were then categorised into one of our operational considerations: (1) acceptability to staff, (2) human resource requirements, (3) IT or infrastructure requirements, (4) costs to the health system, (5) unintended effects, (6) facilitators, and (7) barriers [43]. For reciprocal translation analysis, we compared similar themes from individual articles and synthesised operational considerations reflective of themes from multiple articles. For refutational synthesis, we contrasted themes and noted disagreements. Line of argument synthesis was used to synthesise operational considerations drawn from combination policy approaches [42].

Association with birth and death registration rates
Six combination policy articles reported results for birth registration, with all having a positive change in registration rates (Fig 2; S1 Table) [45,55,62,71,73]. One article from Tanzania reported that a supply policy had a negative change on the birth registration rate (Fig 2; S1 Table) [76]. One article reported that Canada's penalty policy had a negative change in birth registration [65] (Fig 2; S1 Table). One article from Zimbabwe reported that an incentive policy had a positive change in birth registration (Fig 2; S1 Table) [54]. Two combination policy articles reported results for death registration, with both positively affecting registration rates (Fig 3; S1 Table) [53,59]. Three supply policy articles reported results for death registration, with two positively affecting rates and one negatively affecting the rate (Fig 3; S1 Table) [48,50,76].

Operational considerations
Across all policy categories, 15 operational considerations were meta-synthesised (Table 2) from eligible articles (S2 Table). This included nine considerations for supply-side policies, one for incentive policies, two for supply-side and demand-side policies, and three for supply, demand, and incentive combination policies. who also provide preventive/curative healthcare and promotion. These workers were incentivised with quarterly airtime for phone calls, data review meetings, and given a participation allowance of USD 11 per data review meeting (every 3 months). These workers were given a village health register, cell phone, and backpack.

Discussion
This systematic review indicates that new policies have the potential to have positive long-term effects on improving birth and death registration rates. However, there are a variety of considerations needed to interpret these data correctly. For example, an intervention implemented at a subnational scale may face different operational issues and a different direction of effect when implemented nationally. One example of this is use of community-based registration services [47,58,64]. This type of policy would be useful to fill a geographic void in rural settings but may prove redundant in many urban settings. Furthermore, in areas with poor telecommunication platforms and connectivity, mobile registration fills a void; however, in facilities that have computers with connectivity, it may prove redundant [44].
Although most articles reported effects on registration rates, registration rates should be contextualised as part of CRVS business processes [78]. The business process for death typically encompasses five steps: (1) the death itself, (2) notification of the death to a designated site, (3) registration of the death by the registration authority, (4) assigning the death a cause of death, and (5) including the causes of death in the national vital statistics system. The order of the steps is different for health facility deaths, for which the notification typically includes the cause of death. The business process for birth registration encompasses the first three steps and includes the issuance of the birth certificate. Future policy evaluations should report effects by steps in the business process. This may help countries understand policies' effects more comprehensively, identify bottlenecks in the registration process, and work towards improving birth and death registration for their context. For example, Kabadi and colleagues reported that both birth and death registration rates declined after implementing a supply policy in Tanzania [76]. However, closer inspection of the data reveals that birth notifications improved 2-fold, while death notifications improved 5-fold with their intervention. The challenge in Tanzania appeared to be translating these increased notifications to registered events.
Universal access to birth and death registration services is important for clients to register vital events. Supply policy interventions consistently increased birth and death registration rates. The one article that showed a negative direction in the registration of births and deaths from Tanzania, discussed above, found increased birth and death notifications that did not Policies for improving birth and death registration translate into increased registration rates [76]. The policy quantitative and operational considerations synthesised should be considered based on the health system, governance, and sociocultural context of contributing articles. For example, fragile and conflict settings may need to consider a supply policy with community-based registration services, whilst settings with a

Supply
Telecommunication and/or electricity connectivity requirements can hinder information flow in some parts of the country.
Ghana [64], Republic of South Africa [45] Supply Decentralisation to community health workers may be insufficient for large geographic areas that are sparsely populated.
Ethiopia [58], Tanzania [76] Supply Community-based registration fills a void in settings where births and/or deaths occur outside of a facility, but can be costly.
India [62], Malawi [52] Supply Integration of birth and/or death registration in existing services (e.g., health facilities or burial sites) was low cost, required minimal additional human or IT infrastructure, and reduced indirect costs for clients.
Republic of South Africa [12,60] Supply Despite the development of strong national legislation, there were challenges due to differences in implementation and enforcement of legislation at the subnational level (e.g., some regions still charged registration fees when they were not required by law).
Brazil [73], The Gambia [73], India [12], Indonesia [46] Supply Legislation requiring registration, or requiring registration for government services, is insufficient without increasing accessibility and decreasing direct and indirect costs associated with registration.
The Gambia [73], Republic of South Africa [45] Supply and Demand Identifying the appropriate government cadre to take on new responsibilities, and ensuring appropriate remuneration, helps ensure long-term sustainability of policy implementation.
Botswana [72], Republic of South Africa [45], Thailand [77] Supply, Demand, and Incentive Collaboration between government, nongovernmental organisations, bilateral partners, and multilateral partners increased resources and approaches to improve registration.
Examples included registration campaigns to improve geographic gaps in coverage with multilateral partners and educational campaigns with community and grassroots organisations.
Botswana [72], Brazil [71], India [62], Republic of South Africa [12] Supply, Demand, and Incentive While central government coordination was helpful because it allowed multiple ministries to guide implementation and enforcement in Southern Africa, autonomy from government allowed technical issues surrounding birth and death registration to remain independent of changes in political priorities in Peru.
high proportion of births and deaths occurring in health facilities would likely benefit from integration of registration services into health facilities. Moreover, the role of good governance should not be discounted [79]. Despite enabling legislation in several countries, enforcement challenges at the subnational levels led to obstacles for clients [12,46,73]. Across operational considerations, caution should be exercised in interpreting the findings due to the small sample size of articles with qualitative data. Information, education, communication, and effective advocacy through demand-side policies can help strengthen implementation of functional CRVS systems by social and behavioural change. However, this approach may have limited utility without functional CRVS systems in place. Most articles that reported results of demand policies did so for policies that coupled demand along with other approaches. For example, 15 articles reported on a demand policy coupled with at least supply [12,45,55,58,60,62,64,69,70,72,73]. The single article that reported on a demand-only policy did so in a context, Mongolia, where birth and death registration rates already exceeded 90% [57]. Therefore, the challenge in Mongolia was reaching the remaining few rather than increasing wide-scale access. This underscores the need to interpret the findings based on the health system, governance, and sociocultural context of contributing articles.
Countries took different approaches to utilising incentives for vital event registration, most of which included provision of a national identification card (ID) or certificate that was required for public service(s). Thailand and Botswana integrated national ID provision, which is required for a wide range of government services, with birth registration [72,77]. Ensuring a life cycle of identity, starting with ensuring that every child is registered and issued a birth certificate and ending with recording the cause of death and providing the family with a death certificate, will maximise the full spectrum of rights and data generated by CRVS systems. For example, infants and young children are able to access life-saving medical interventions, including vaccines and access to early childhood education and nutrition services [80,81]. For children and adolescents, a birth certificate is the first line of defense to be protected against child marriage, labour, and recruitment into armed forces. A birth certificate can also provide the legal identity needed for educational exams and to access higher education and the formal job market. For adults, they enable financial inclusion, social assistance, insurance, inheritance, and land rights. In Brazil, a birth certificate was required to enroll into the Bolsa Familia programme, in which a cash transfer was conditioned upon school enrollment [63]. In South Africa, birth certificates were required for child support grants and school enrollment [12,45,60]. Botswana and Bangladesh also require birth certificates for school enrollment [72,73]. Death certificates provide the evidence needed to access inheritance and land rights, often combined with marriage certificates to prove the legal family ties that establish rights to inheritance [10]. This is especially important for women whose access to financial services and property are often through their husband. Death certificate use was more rare; Botswana reported requiring a death certificate for body burial, while Bangladesh reported requiring a death certificate to pass on inheritance [72,73]. There were no articles evaluating direct financial incentives for registering births or deaths.
Due to limited data, it was not possible to conduct subanalyses. If data permitted, analysing effects by the country CRVS functional level would help inform policy categories that are most relevant based on their current CRVS system functional level. For example, any emerging policy to record births or deaths is unlikely to boost the registration rate if the key elements such as legal framework and national ID are not supported by a current policy. Further research is needed to validate these hypotheses. Nonetheless, combination approaches tailored to country context uniformly and consistently improved birth and death registration rates. Fifteen of the sixteen articles reporting on combination approaches included at least a supply and demand element, while six included a supply, demand, and incentive element. South Africa reported positive experiences collaborating with local universities in order to research how best to design supply policy interventions [12,60].
The exclusion of individuals from registering a birth (establishing their legal identity) or obtaining a birth certificate (proof of legal identity) is often an unintended consequence of policy, rather than a deliberate effort by the state to exclude them. For example, laws (1) requiring documentary prerequisites (e.g. ID, birth/marriage certificates), (2) with paternity requirements (i.e. name or presence of the father), and/or (3) that impose fines/fees to discourage late registration may be designed with the intention of legitimising registration documents but can deter or legally even prevent women and the most vulnerable members of society from being included in civil registration systems. This systematic review did not identify evaluations of these types of policy changes.
There may be limitations with this systematic review. First, there is possibility of publication bias because many countries, or regions such as Europe and the Eastern Mediterranean, may not have documented policy interventions. Other countries may have documented changes in registration rates without explaining contributing policy shifts [82]. Finally, policies that did not lead to positive effects may not have been documented at all by their investigators. Knowledge of what does not work is also critical for effective CRVS strengthening in countries. Moreover, given that there was no systematic way to search the grey literature, our grey literature search may have been limited in its sensitivity in the global stakeholders contacted. Including additional global stakeholders, such as the European Union, Plan International, United Nations Population Fund, and the United Nations High Commissioner for Refugees, as well as regional stakeholders such as regional development banks, regional economic commissions of the United Nations, and regional technical assistance institutions, may further expand reach. We may have also missed relevant literature that predated our inclusion criteria [83]. Because numerators and denominators for registration were not reported, meta-analysis was not possible. There were several methodological limitations of the studies included. First, given the limited amount of methodological detail provided by eligible articles, it was not possible to ascertain the quality of studies as was planned in the protocol. Second, most eligible studies were included on the basis of their qualitative data and did not have a comparator group to quantify policy effects. Finally, both the design and analytical approach of included quantitative articles limited inferences on causality. This underscores the need to carefully design, monitor, evaluate, and document future CRVS policies.
We identified several gaps in this systematic review. First, more information is needed on financial and human resource requirements for different policies. This information was rarely reported and is critical information required for decision-makers considering national or subnational implementation. Second, many of the articles had a short duration; continued monitoring is needed to understand effects of policies over time. Third, the articles did not provide detail on how migratory populations were registered for births and deaths and whether the findings presented were generalisable to them. Fourth, this systematic review focused on birth and death registration data directly collected from CRVS systems; including whether the policies had effects on additional health outcomes merits further research.
In conclusion, to our knowledge this systematic review provides the first comprehensive compilation of national policies to strengthen birth and death registration. Effective and enforced policies will play a critical role in improving birth and death registration globally. Countries will need to understand their barriers to identify which policy approaches are most appropriate to their context. Further research using a more systematic approach to intervention design and evaluation is needed to improve the knowledge of effects, resource requirements, and acceptability of policies for strengthening CRVS systems.