PONE-D-21-33029Performance barriers of Civil Registration System in Bihar: An exploratory studyPLOS ONE

Dear Dr. Saikia,

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Additional Editor Comments:

This is an important area of work; however, there are areas that can be strengthened further. I suggest the authors to take a careful look at the very useful suggestions from the reviewers and revise the paper accordingly.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a good piece of scientific work addressing a very important yet neglected issue. Good efforts have been put together to develop this manuscript though it needs some major revisions.

Major points:

1. Line Nos 121-129: Please make study rationale more clear

2. Figure 1:

a. How are the deaths at 'home' in 'urban' areas registered? Missing in the diagram.

b. How are the deaths in 'hospitals' in rural areas registered? missing in the diagram.

c. Is ASHA/ANM playing any role in death registration as being currently used in Punjab and Haryana? if yes, then mention please. Who are the designated key informants to whom family members can report FIR of an event in both urban and rural areas?

d. At district and state level, which department is responsible for births and deaths registration? Is it Health department like in Haryana and Punjab? These points are not coming out explicitly from the diagram itself!!

3. Please mention three things in each box of Figure 3: Designation of the person under CRS, name of the department the person holds and his/her designation in that department. Example: Like you have mentioned Chief Registrar is the Director of Statistics and Evaluation but of which department???? Please elaborate

4. Did you consider the levels of birth and death registration of district and block as selection criteria for sampling units because that might give a better picture of reasons.

5. The methodology is indicating that the study was conducted among rural aspect of CRS as none of the study participants represented the urban population or municipal corporation. This has undermined the study findings to rural area only. I feel you need to explain this as a study limitation and provide a valid reason for not including the urban representation.

6. In the methodology section, it's important to mention about the levels of birth and death registrations of two districts you have selected. and compare it with other districts.

Minor revisions:

1. Please use one terminology throughout either CRS or CRVS in introduction section

2. Expand ORGI in caption of Figure 1

3. Please correct the spelling of 'anganwadi sevika' throughout the manuscript

4. Mention inthe data collection part of methodology section about the total number of FGDs done

5. Mention inthe data collection part of methodology section about the total number of KII done

6. Line nos 290-93 not clear

7. Please provide supporting data for statement no. 528-529

8. Please provide supporting data for statement no. 338-39

9. Please add references for lines 182-186

10. In line no. 556-57, you have mentioned that birth and death registration is not being done at sub-center or village levle? Is it not community based as of now? Revoew the lines

11. You have mentioned in line 567 that all PHCs are not linked to CRS. Is this statement true? Please review.

Reviewer #2: Review: Performance barriers of Civil Registration System in Bihar: An exploratory study

This is an interesting exploratory study, relying on interviews with government officials and rural residents, which documents the functioning of the civil registration system in Bihar before the pandemic. Given the importance of understanding and improving the civil registration system, such studies are urgently needed. I felt that the study should have been more in-depth. Interviews with CRS officials and with community members could have been more detailed, and the description of the overall state of the CRS in Bihar, despite the authors’ attempts, is still quite incomplete. However, given the paucity of scholarship on the civil registration system in India, specially of a qualitative nature, this paper is welcome. I have some minor suggestions, which I hope would be helpful for the authors in revising their work.

1. The authors motivate their paper saying that it is important to study the civil registration system in Bihar because of its poor development indicators in general, and the fact that its CRS is estimated to record the lowest proportion of deaths and births. However, although the authors provide some hints at why Bihar’s CRS performs so poorly, we do not get an explicit discussion of why precisely Bihar lacks even other northern Indian states, such as Madhya Pradesh or Rajasthan, which have higher registration coverage than Bihar. In this, the state of Bihar and Uttar Pradesh are way behind all the other states in India, and it is not clear why this is the case. To truly understand this, a comparative design is needed. Perhaps the case is that the lack of linkages between health systems and the CRS which the authors document, or the lack of computerization in Bihar explains why it lags behind other Indian states (even similarly poor ones). My suggestion to the authors is to consider this line of thinking carefully. They can see what the extant literature says about other poor Indian states (they may find looking at the annual CRS reports at the state level and the national level useful here) about CRS being so poor in Bihar. They should also note some lines of thinking for future researchers in the discussion section, as well as perhaps a limitation that they have not adequately addressed these questions.

2. Related to this point, we also don’t get a sense of the changes in the Civil Registration System before the pandemic in Bihar. Existing patterns, both from the data that has been accessed by journalists during the pandemic period (for instance see https://www.indiacovidmapping.org/reports/mortality/BiharFactsheet.pdf), as well as annual estimates before the pandemic suggest improvements in the Civil Registration System in Bihar. How did these improvements came about? If the authors have information on this, it would be extremely valuable. Similarly, what happened to Bihar’s civil registration system during the pandemic? Answering this likely requires fresh data collection. If that is not feasible, then that should be noted in the discussion. If it is possible to call CRS staff on phones and ask some of these questions, then that would be quite valuable. If this is not possible, then perhaps the authors can consider this as a future research endeavor.

3. At a large number of places, I felt that the authors have policy recommendations that were not supported by the information they present. In some cases, their recommendations can actually be harmful. For instance, the authors recommend “mandatory burial or cremation permits.” Instead of improving registration, I can see how this kind of procedure would cause even more problems in a place like Bihar. For instance, people will have to wait to get a death registered and could then only approach burial or cremation grounds? Instead of this, what would work well is a “notification” and “proof” system: burial grounds can notify CRS authorities about a death, and the family could have a slip which would help as a proof of death. These linkages exist in other states, especially with healthcare facilities. Public hospitals can in fact issue death certificates in many states, and private hospitals issue a hospital death certificate (or birth certificate) which can be taken to a registrar to get a death registered.

I was also uncomfortable with the recommendation of fines (lines 533-534). First, the authors already say that there is a fine of Rs. 10 to register a death after 21 days. Worse, the procedure described here to register a death after 21 days looks like a nightmare, with visits to far off offices. More fines when clearly it is the government system that is lacking is a bit counterproductive. The authors should remove this recommendation. In any case, this does not follow from the data presented by the authors.

4. I found the sentence “there was no strict implementation of the birth and death registration law” vague. Which aspects of the law were not strictly implemented, and how was this ascertained?

5. I was not convinced by the literature cited that “lack of birth registration is associated with school dropout …” and so on. It is quite likely that this is just selection, for instance poor children are more likely to drop out and poor children are less likely to have had their births registered. I would suggest dropping this citation.

6. The authors cite the CRS report to report that 7 percent of births and 8 percent of deaths were not registered in 2019. Although this is an official estimate, it is likely an over-estimate. There are multiple reasons for this, among them the fact that the 2019 CRS deaths in this report are compared to 2018 SRS. Other reasons include the fact that the SRS may under-estimate the crude death rate. This line of thinking is explored in detail here (appendix 1: https://www.medrxiv.org/content/10.1101/2021.09.30.21264376v1). I leave it to the authors to decide how best to convey the uncertainty in the true rate of registration completion. Perhaps the authors can say “according to official estimates …”.

7. In figure 1, which provides the organization of the CRS, I was surprised that the Panchayat was not mentioned anywhere in the hierarchy. In figure 3, the panchayat sevak is mentioned as a registrar. In some other northern states, such as Madhya Pradesh, the bulk of rural death and birth registration happens at the Panchayat level. Is it the case that this does not happen in Bihar? In Madhya Pradesh, I have seen functioning computers in Panchayat offices which can register deaths. In which case, this may be the reason why death registration is so poor in Bihar – the lack of panchayat registration. The authors could perhaps explore this more, and correct figure 1 if necessary. If the panchayat is not a functional place to register deaths, then this is actually an important policy suggestion, to improve registration and computerization at the Panchayat level.

8. Figure 1 claims that an annual report at the “state level is published by the chief registrar” and also that “Annual report at India and state level is published by ORGI”. This is confusing, and likely the latter sentence needs modification.

9. I thought that the bit about people not reporting infant deaths because it is considered a sin of parents in previous birth was quite revealing. The state government should consider potentially challenging this belief, and this also is a policy recommendation that flows from the findings from the paper. In addition, given the levels of awareness that the authors document, perhaps more information campaigns are also worth recommending.

10. Similarly, I was surprised by the sentence that “Public facilities record all birth and death but don't update on the CTS portal until birth and death certificates are requested by family members.” The authors do not present evidence for it. This is quite important, and also deserves to have highlighting from the perspective of policy recommendation that the paper generates.

11. In line 536: the authors say the CRS form is complex. Perhaps they should elaborate more? I do not agree with all the things the CRS form asks (for instance, whether the person smoked or drank alcohol is not collected by most other countries) but I didn’t have the impression that it was very complex. If the authors think it is complex, I would like to see an explanation why. Otherwise, I would like this sentence to be reformulated.

Reviewer #3: I am reviewing this paper from a non-expert perspective - I have limited knowledge of the civil registration system itself, and the specific issues faced in Bihar.

The paper clearly explores an important issue, namely barriers to civil registration in Bihar. The importance of strengthening civil registration has been highlighted by the pandemic, making this study timely. The methodology - interviews with key informants and members of the public - seems appropriate, and the paper includes a number of interesting insights about these barriers at both administrative and cultural levels.

I have a few comments for the authors to consider:

1. Quantitative data. Although this is a qualitative study, it would still be helpful to have some summary quantitative data. At least: amongst the focus group participants in Patna how many births and how many deaths were reported; and how many of these were registered. Plus the same for Vaishali. This is not to draw any quantitative conclusions, but merely to understand the overall sample.

In fact, some quantitative data is presented, but too unclearly. "A few participants (n=15) reported death at the registration centres situated at cemeteries or burial places" - this sentence needs a denominator: 15 out of how many? In sentences such as "Besides, two-fifth of the study participants reported the death of their household members at the block or municipality offices." it would be better to present the actual numbers of how many deaths were reported, and out of these how many at block or municipality offices.

The same comments apply at several other places in the text, for example: "Nearly one-sixth of the total participants were unaware of the death registration procedures and benefits associated with death registration. A higher number of participants from Patna applied for birth and death registration of their household members than participants from Vaishali. Rural and urban differentials in birth and death registration were found." In every case numbers, with denominators, would be better.

"However, a subset of participants (n=10) did not receive a birth certificate for their child at all." Again, a denominator is needed. Also, not clear: were these people who applied for, but never received, the birth certicificate; or who never applied for the certificate?

2. Context and history of death registration in the state. The authors mention inconsistency in death registration in Bihar - the lack of a clear trend (up to 2019 at least). Do they have any insights as to why there is so much year-to-year variation in the estimated levels of death registration? Are the SRS-based estimates of coverage reliable in their view? What are the factors which could cause a significant drop in registration from one year to the next? If there were changes in the systems in place which affected trends in registration, then this would be interesting to know. Did the interviews provide any hints?

3. Poverty and marginalisation. I find these sentences problematic: "Lack of birth registration is associated with increased school dropout, child trafficking, and child labor [1,12]. The child mortality rate is higher among unregistered children [13]." It is very likely that the common factor behind these associations is poverty and marginalisation - the sentences are not formally wrong, but suggest the lack of birth registration could be a causal factor behind, say, child trafficking or infant mortality. It seems important to be more clear here.

This raises an important point: the authors really should discuss how factors such as caste and poverty are associated with levels of registration. Are there studies on this topic, relevant to Bihar? If there is a relevant literature, then it should be referenced and discussed at least briefly. It would be interesting to know whether there are examples of other states where poverty and marginalisation are comparable to Bihar, but civil registration is higher and more stable, and if the authors have some insight about why. If many people in Bihar perceive little benefit in reporting deaths, then why is this different in other comparable states? Are the practical barriers - loss of time and income, difficulty, etc., different in other states?

Although the sample may be too small to understand how attitudes to registration vary by caste/class there still seem to be some hints in the data (e.g. not registering infant deaths - "sin of previous birth"). It seems that the authors did not collect demographic data on caste/ occupation/ socioeconomic status, etc? Perhaps the authors should mention this as a limitation of the study. It would still be interesting if they have any insights from this work or the work of others on how these factors might affect access to registration or attitudes to registration.

4. Recommendations. A number of the recommendations for how to improve vital registration are made by the authors, and many of these could be useful. But it is not really clear where responsibility lies for the failings. After statements like "the officers did not take any steps for improving the registration level in recent times, particularly death registration." could the authors indicate what the officers could have done? Also perhaps there could be more discussion of resources. A "lack of adequate investment" is mentioned in the abstract, and later the key informants "...suggested that adequate funds should be provided for the smooth functioning of the system." What is the resourcing of the CRS in Bihar? Did the interviews provide insight into where such funds should go (more staff? better pay? better training? more registration offices?) Here, again, some comparison with other states would be interesting.

5. Minor points

"Epidemiological purposes" are mentioned in the introduction - the authors could say more about how, in the context of the current pandemic, there has been an urgent need for all cause mortality data on account of weak official surveillance of COVID mortality. Any comments on uncertainties around pandemic mortality in Bihar and in comparable states would help to highlight the current importance of this study.

In Table S1, the fertility rates for Bihar and India appear to be exchanged.

Table S1 should perhaps include the estimated death registration level based on SRS and/or NFHS?

I would suggest the authors carefully reread the manuscript for typographical errors.

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Reviewer #1: Yes: Mamta Gupta

Reviewer #2: Yes: Aashish Gupta

Reviewer #3: No

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PONE-D-21-33029R1Performance barriers of Civil Registration System in Bihar: An exploratory studyPLOS ONE

Dear Dr. Saikia,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 09 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Bidhubhusan Mahapatra, Ph.D.

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Line no. 170-72- Here you are mentioning that 05 persons of given designations were considered for KII. And you had selected four blocks from each district that means 08 blocks in total. so there should have been 40 KIIs instead of 15? Clarify please.

Please mention the department and ministry in Figure 3 for all registrars as highlighted in the attached file

Line 209: If the questionnaire was semi-structured, then it will have both open and closed ended questions. It cannot be both semi-structured and open ended simultaneously!!

Line 242-43: Do you think awareness and knowledge of registration procedures is a barrier to well-functioning CRS? Please reframe the sentence correctly.

Line 246-47: Please write the theme which is acting as a critical barrier from these paragraphs.

Line 250 : How many delivered in public hospital?

Line 254: Requiremnt of I-card should be mentioned as "PERCEIVED BARRIER"

Line 297: Did you conducted any analysis for this? Please mention the data

Line 386-96: I think this is a perceived administrative barrier. May think to shift in theme 2 paragraph

Line 459-61: Please mention the birth and death registration level of bihar from the latest CRS report

Reviewer #2: Thank you for paying attention to my comments. I still have minor comments, that I believe will strengthen the paper.

- In the objectives (line 33-34), the authors say that "Among all India's states, Bihar showed a lower recording of birth and death in 2019." I think this is not clear, because it can be interpreted as Bihar's death rate being actually lower than other states. Perhaps its better to write: "Bihar had one of the lowest levels of mortality registration among India's states".

- I don't get the point in the results of "death registration was not mandatory for burial or cremation permits." This is as it should be. Waiting for death registration before burial or cremation would be a nightmarish scenario. I really would like this sentence to be removed (I made similar remarks about this appearing elsewhere in the manuscript in the first revision).

- "a dedicated staff shortage" - you mean shortage of dedicated staff, I am guessing.

- Fig 1: I am surprised that the aanganawadi sevika can register deaths in rural Bihar. this could actually be a nice system, but its not clear from the paper about the extent to which this functions.

- Fig 1: similarly, its surprising that for births and deaths in health institutions in Bihar, the health system doesn't generate a birth certificate, and one still has to go to the panchayat secretary. In Fig 3, the authors mention the health system at local area level, but not in fig 1. again, this is quite confusing.

- It is revealing that the researchers visited the households with assistance from panchayat secretary. this could lead to biases in reporting, given the power a panchayat secretary has. I feel this should be mentioned as a limitation.

Reviewer #3: I think the paper is satisfactory and the revisions are adequate.

As a comment for the auhors, I still do feel that the authors could have attempted a summary of the data - e.g., a simple table of how many events (birth or death) occurred amongst the focus group participants, how many were registered (with/without delay), how many of the total births were registered through anganwadi sevikas/block officers, and so forth... this would have been helpful to set the scene. Sentences like "However, two-fifth of the total participants (n=90) applied for their child's birth registration after one year" remain ambiguous unless we know that births occurred in every family.

But perhaps it is not possible for the authors to be more precise if the data gathered does not allow this. And this comment is not critical to the qualitative conclusions of the manuscript.

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Reviewer #1: Yes: Mamta Gupta

Reviewer #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: PONE-D-21-33029_R1.pdf

Performance barriers of Civil Registration System in Bihar: An exploratory study

PONE-D-21-33029R2

Dear Dr. Saikia,

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Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #2: No

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Reviewer #2: Yes

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Reviewer #2: Thanks for addressing these comments. I look forward to seeing this paper in print. It would also be interesting to see follow up work on these topics. Thanks for your work!

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Reviewer #2: No