- Email: [email protected]
Civil registration system (CRS) for birth and death registration in Assam – A rapid assessment
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Clinical Epidemiology and Global Health journal homepage: www.elsevier.com/locate/cegh
Civil registration system (CRS) for birth and death registration in Assam – A rapid assessment Tushar Manohar Rane, Tulika Goswami Mahanta∗, Safikul Islam, Pranjal Pratim Gogoi, Bivash Gogoi Department of Community Medicine, Tezpur Medical College, Tezpur, Assam, India
A R T I C LE I N FO
A B S T R A C T
Keywords: Civil registration system (CRS) Birth certificate Death certificate National registration system (NRC) Assam India
Problem considered: Civil registration is, only way to track all births and deaths. Globally, 2/3 of annual deaths, are not registered. Despite existence of Registration of Birth and Death Act (1969), Civil Registration System (CRS) in India registers only 68.3% births and 63.2% deaths. Aim: A rapid assessment of civil registration system for birth and death registration in Assam. Methods: Cross-sectional descriptive study using mixed method was undertaken. Predesigned, pretested questionnaires were used for quantitative study. For qualitative study key informant interview of service providers and Focus group discussion of beneficiaries was conducted in each District. Results: Only 8.5% (27) service providers, trained to operate a computer. Designated office were present in 62.5% (198) facilities, while only 15.5% (49), 7.9% (25), 25.6% (81) and 12.6% (40) of the facilities have landline telephone, cellular phone, functional computer and internet connectivity, respectively. Electricity connection present in 97.2% (308). Facilities are open for 8 h in 86.1% (273) cases. Reason for poor utilization includes difficult communication, lack of awareness, inefficient system. Conclusion: Tremendous scope of improvement in birth and death registration department with adequate investment to improve the infrastructure, manpower and IT equipment's.
1. Introduction Countries need to know how many people are born and die each year – and the main causes of their deaths – for well-functioning health systems. Civil registration not only provides basis for individual legal identity but also allows countries to identify their most pressing health issues. Almost half of the world's children go unregistered. Many barriers prevent people from registering births and deaths.1 Civil registration is the way by which countries keep a continuous and complete record of births, deaths and the marital status of their people. Definition of Civil registration is “continuous, permanent, compulsory and universal recording of occurrence and characteristics of vital events pertaining to the population as provided through decree or regulation in accordance with the legal requirements of a country”. Civil registration is carried out for establishing legal documents and also a main source of vital statistics. Complete coverage, accuracy and timeliness of civil registration are essential for quality vital statistics.2 Monitoring the status of civil registration and vital statistics for countries in the world is the first step to provide guidance and assistance to those that are in need.3
∗
National Population Policy (2000) of India emphasized the need to improve registration of vital events.4 As per the Annual Health Survey (AHS) 2012–13, the coverage of birth registration in Assam has risen in recent years to 87.1%; however, the status of issuance of birth certificate is 69.1%. There is also a significant difference between urban and rural areas and between the respective districts of different divisions in Assam. Though 86.1% births are registered in rural areas, only 67.5% have received birth certificate. Similarly, in the case of urban areas, 93.1% births are registered, but only 79.1% received birth certificate.5 For computer-based systems, a major consideration is data entry. In paper based registration system significant cost and time factor is involved. Within a computer-based system, record storage and retrieval, indexing, record searches, corrections, and the preparation of record copies for transcripts or certifications are quick and easily processed, and the security of the data is optimum. Such systems need to be developed in a networked personal computer (PC) environment or on a mainframe system depending on the volume of records and related processing. These factors bring computer systems for civil registration activities down to reasonable costs, with relatively small physical
Corresponding author. E-mail address: [email protected] (T.G. Mahanta).
https://doi.org/10.1016/j.cegh.2019.05.006 Received 20 February 2019; Received in revised form 30 April 2019; Accepted 23 May 2019 2213-3984/ © 2019 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of INDIACLEN.
Please cite this article as: Tushar Manohar Rane, et al., Clinical Epidemiology and Global Health, https://doi.org/10.1016/j.cegh.2019.05.006
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
T.M. Rane, et al.
depicted in the flow chart in Fig. 2. Responsibility of Birth and Death registration is vested upon a myriad of individuals from various deputations like MPW (multipurpose workers), Pharmacists, Ophthalmic assistants, and office assistants, DPA (Data processing assistants), BEE (block extension educator), ANM, GNM and Grade 4 etc. These persons are required to perform the duties of birth and death registration besides their own. Among these functionaries only 8.5% (27) have ever been trained to operate a computer for any government service but 68.1% (216) of them mentioned that they would be able to handle the online CRS after training [Fig. 3]. The infrastructure that houses this department needs to be looked into and upgraded from the perspective of housing an online registration system. Out of the total facilities, 62.5% (198) have designated office for birth and death registration with an information board near the outer door. Only 15.5% (49) and 7.9% (25) of the facilities had landline telephone and cellular phone connection respectively. Functional computer available in 25.6% facilities but only 12.5% (40) facilities were having internet connectivity. Electricity connection from any source was available in 97.2% (308) of facilities and 44.2% (136) facilities having secondary or back up source of electricity [Fig. 4]. The computers were generally shared among various departments for generating and sharing reports as and when required. Digital data stored in the computers is not safe as most of these computers (275, 86.8%) were shared among various departments and have open or shared passwords. Essential antivirus software or firewalls were not installed or up to date in (275, 86.8%) of the computers [Fig. 5]. Essential peripherals like printers were also found to be present in 24.9% (79) of the total facilities. The printers were primarily laser printers. Facilities are open for 8 h in 86.1% (273), while the remaining facilities were open for less than 4 h in a day. On an average 236 (ranging from 1 to 3889) birth certificates and 30 (ranging from 0 to 732) death certificates were issued in a month. Only 10.7% (34) of the facilities conducted any convergent/sensitization meeting in last 3 months. [Table 1]. Comparison of District level and block level facilities show no significant difference [Table 2].
settings required for the equipment, and highly “user-friendly" software for operations and training of staff.6 Therefore this study is undertaken to assess the status of civil registration system in Assam. 2. Methods A cross-sectional descriptive study of CRS registration units was undertaken in 2017–18 including all districts of Assam. Institutional ethical clearance was taken. Written informed consent was obtained from each participant. Necessary permission from state and district level officials was obtained before start of the study. A predesigned, pretested questionnaire was used for quantitative study which covered assessment of the computer based reporting units. The qualitative component of study was done with two main objectives: one was to understand the awareness level of the community on birth and death registration, their views, concerns and their experience with the system and second was to understand and document the shortcomings in reporting by ASHA who have now become major source of information on birth and death in village or urban area. For qualitative study in-depth interview was recorded from different level of officials, service providers, ASHAs and beneficiaries. Both facility readiness like infrastructure, manpower, and community awareness was assessed from functionaries of the reporting units along with photographic evidence of units. Focus group discussion of beneficiaries was also conducted one in each district [Fig. 1]. All district and block level centers/units that were involved in birth and death registration process were visited. Members of community were approached to gather and understand the level of knowledge about birth and death registrations as well as record points of concern. Focus group discussions of frontline ASHA workers and beneficiaries/ community were also conducted. Key informant interview was conducted amongst different stakeholders and recommendations of the respondents were also captured. Statistical analysis was done using proportion and chi-square test. 2.1. Results of quantitative study A total of 317 facilities where CRS offices are located, were visited across all the districts and development blocks of Assam. The system is
Fig. 1. Flow Chart representation of the study design. 2
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
T.M. Rane, et al.
Fig. 2. Data flow in the CRS system.
Fig. 3. Status of available Manpower in the facilities for implementing online Civil Registration System.
2.2. Key informant interview findings
birth registration. There were instances where a birth registration of a child has not been done until the age where he/she has to be sent to school and birth certificate is a mandatory document. This indicates a general lack of awareness among the masses especially of birth registration. Updating of National registrar of Citizen (NRC) initiative in Assam, which mandated the people to get the birth registration done improved birth registration. Prevalence of custom: Prevalence of various customs and rituals among the population is another aspect leading to delayed registrations; e.g. customs naming of babies after one month after consulting with the religious leaders or name being procured from a religious institution in another state or country which causes much delay in the registration process. Death registration is less in remote areas and amongst women. Monetary or property matters were the only influencing factors. Accessibility and availability: Distance was a major factor-poor roads and lack of public or private means of transport act as major deterrents due to which people do not want to go to registration centers. Supply issues like non-availability of certificates takes a long time to provide certificates. Beneficiaries and ASHA have to visit registration centers number of times to get certificates. Officials involved cited that certificates had to be procured from the state headquarters which was a tedious task as they had to travel very often with their own money. The booklets too are provided in limited numbers. Due to this reason there is always a shortage scenario in the registration centers. Education level of informers: ASHA workers were most commonly involved in the registration process. But being less educated often makes spelling mistakes which ultimately lead to erroneous certificate.
Records in centers were kept in wooden shelves/racks without any safety or indexing. As such retrieving old record is a cumbersome activity and these are also prone to damage by various means. Knowledge level of existing staff can be described as average with most officials being aware of basic rules of registration. Officials need to be updated with relevant laws/rules/amendments regarding birth and death registrations including uncommon and unusual cases in order to be more efficient. Common gaps were seen in rules involving registration of adopted children, death registration of missing persons, the process of identifying the time, date and place of a missing person and number of years as per law that mandates the missing person as presumed dead. Common issues that had been highlighted by the officials were as follows: poor building conditions, inconsistent power supply and power backup facility, irregular supply of certificate booklets causing delays in providing certificates, some facilities located in far flung areas causing less awareness and subsequently less registrations amongst beneficiaries, lack of space/facilities to store the ever growing registers and application/record forms and lack of dedicated Human resource for the department. 2.3. Focus group discussion findings Focus group discussion was done amongst beneficiaries specially mothers groups one for each District which can be explained domain wise: Casual attitude of community: people have a casual attitude towards 3
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
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Fig. 4. Status of available infrastructure for implementing online Civil Registration System.
state government does not have a dedicated person deputed solely for birth and death registration. Many Units/Registration centers lack adequate infrastructures required for up gradation of existing civil registration system into an automated system. Designated office for birth and death registration was absent in 37.5% of the registration centers. Well-functioning ICT (Information and communication technology) infrastructure, including a reliable power source, internet, and cell phone coverage, provides the enabling environment for developing modern CRS systems, which in turn provides the platform for interoperable CRS information systems and databases. While ICT is not a silver bullet, it can provide a means to collect, store and retrieve data in a fast, cost-efficient and user-friendly way.8 Existing civil registration system was largely paper-based and manual. Only 25.6% of the facilities had computers and 12.6% of those computers had internet connectivity. The workforce in charge of
During the Focus group discussions as well as personal interviews, some comments indicating incorrect practices were made by the participants. However, no document or recorded proofs of these comments were available. These are quoted as personal comments of the participants. 3. Discussion Birth registration is a fundamental right and serves as a key to ensuring the fulfilment of additional rights for children and helps recognition of any person before the law. Functioning CRS systems provide governments with reliable and up-to-date population and mortality statistics, including causes of death, which enable them to plan, deliver, and monitor effectively health and social development programs and to track progress towards international commitments such as Sustainable Development Goals.7 Department although under
Fig. 5. Status of security of digital data in the facilities. 4
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programs ASHA and other frontline health workers can be engaged with minimal training as they are already involved in the process. Materials like posters can be prepared and provided to various registrations centers and other health institutions. Performance of CRS system depends on community awareness and registration facilities, which might be inaccessible owing to physical, economic, or socio-cultural barriers. For poor and marginalized individuals, putative advantages of registration have little meaning compared with day-to-day challenges of earning a livelihood, finding shelter, and ensuring personal security. Efforts to strengthen CRS systems should be cognizant of the complex economic and socio-cultural circumstances that are deterrents to registration, and therefore take action to remove these barriers and introduce positive incentives, including access to services and benefits. CRS should be seen as a service to people rather than an imposition by authorities and should foster trust between state and society. Experiences from some successful countries show that holistic, systemic approaches involving stakeholders across several sectors—especially health, statistics, registration, justice, home affairs, and civil society organizations—are needed for effective CRS improvements. Development partners and donors should coordinate their support with country efforts and country-led priorities and plans that are most likely to be sustained over time.7 The benefits of investment in CRS will accrue across many sectors, including health, social protection, governance, and socioeconomic development, and will benefit individuals and families.9 Although a legal framework and a system of civil registration are in place since long, but India lacks systematic death registration and in Assam only 13.7% deaths were reported and the percentage of medically certified death of total registered death was only 0.9% in 2013 in Assam and ranked 29, while it was 26% in 2015.10,11 Partial completion of certificate has potential to create a lot of confusion and problems later on and may lead to legal troubles.12 Robust CRS give epidemiological data about vital statistics and can guide allocation of resources for research and national health program as health statistics, national morbidity and mortality statistics, and data on disease prevalence in population are derived from death certificates, it is essential to ensure completion and accuracy of “cause of death‟ section in death certificates. Besides, there needs to be proper filling up of death registration forms 4 and 4A. A nosologist needs to be appointed to oversee the coding of the causes of death.11 Recurring educational sessions for service providers, periodic auditing of death certificates and feedback are necessary to increase the accuracy of the system.13 There is a need to improve block level birth and death registration centers to improve accessibility and practice of birth and death registration and establish a robust system of online registration and to undertake operational research so that good demographic data can be generated and utilized for planning different development activities.
Table 1 Basic client services provided by the facilities. Basic Client Services
4 h or less
On average how many hours per day the facility open (N = 317)
Any convergent/sensitization meeting held in last 3 months (N = 317)
Birth certificate issued in a month Death certificate issued in a month
Up to 8 h
Number
Percentage
Number
Percentage
44
13.9
273
86.1
Yes Number
Percentage
No Number
Percentage
34
10.7
283
89.3
Average
Minimum
Maximum
236
1
3889
30
0
732
Table 2 Comparison of District level and block level CRS facilities. Variable
Comment
Frequency
Percentage
Chi-square
p-value
Designated office of registration Whether registration is compulsory Fee taken for registration Provision of registration of adopted child Provision of registration of death of missing person Existing staff capable of handling online CRS after training
District PHC District PHC District PHC District PHC
29 169 52 264 30 164 46 215
55.77 63.77 100 99.62 57.7 61.89 93.88 86
1.187
0.275
0.196
0.657
0.322
0.57
2.291
0.13
District PHC
41 175
87.23 72.61
4.483
0.034
District PHC
43 173
82.7 65.28
0.728
0.393
recording vital events and preparing vital statistics are neither equipped nor trained in computer applications. Only 8.5% of the personnel involved in recording and registrations of birth and death events were ever been trained to operate a computer for any Government service. There is a need and scope to train available manpower in computer applications so that their services can be utilized to upgrade the civil registration system; as 68.1% of the personnel mentioned that they can handle computerized CRS after proper training. Present study shows that security of digital data is a major concern in all types of facilities throughout Assam. Only in 13.2% of facility computers are protected by firewall/antivirus software and password protected. A desire to achieve measurable progress in a short time frame has stimulated growing interest in potential of information technologies. Good legal foundation is essential to ensure security and privacy of personal data and to set standards for database interoperability, confidentiality, data protection, and personnel clearance. Such safeguards help to bolster trust that information will be used for public good.7 Community gave opinion through FGD that awareness programs should be conducted in remote areas frequently with inclusion of target audience including both beneficiaries and various persons involved in registration process. These programs should include various benefits of birth and death registration and existing rules and regulations involved. Deviation from normal cases like registration of an adopted child and death registration of a missing person should also be included. For these
4. Conclusion Awareness programs; pertaining to process and benefits of birth and death registration; needs to be conducted in both rural and urban areas. The frontline workers should also be trained to provide better services. Infrastructure strengthening by consistent electricity supply, improved building condition, dedicated and trained human resource and establishment of online system with installation of system are essential for the success of the CRS. Conflicts of interest None. Acknowledgement UNICEF, Assam for financial support. 5
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Appendix A. Supplementary data
7. Carla Abou Zahr, Savigny Don de, Lene Mikkelsen, et al. Civil Registration and Vital Statistics: Progress in the Data Revolution for Counting and Accountability. vol 386. October 3, 2015; October 3, 2015 Counting births and deaths 1 www.thelancet.com. 8. World Bank | WHO. Global Civil Registration and Vital Statistics Scaling up Investment Plan 2015–2024. May 28, 2014; May 28, 2014. 9. Mikkelsen L. Rapid Assessment of Vital Statistics Systems: Evaluation of the Application of the WHO/HIS Hub Tool in 26 Countries in the Asia–Pacific Region. Working Paper No. 10. Brisbane, Australia: University of Queensland School of Population Health, Health Information Systems Knowledge Hub; 2010http://www.uq.edu.au/hishub/ all-publications. 10. Report on Medical Certification of Cause of Death. Office of the Registrar General, India. New Delhi: Ministry of Home affairs, Vital statistics Division, R K Puram; 2013:8–9. 11. Raut MK, Sahu AB. Addressing the rising cause of death due to diseases of the circulatory system geared towards achieving SDG 3: evidence from data on medical certification of cause of deaths in Rajasthan State, India: 1999-2015. Int J Commun Med Public Health. 2018;5:182–190. 12. Patel N, Patel S, Vidua RK, Arora A, Tamaria KC. How to evaluate the medical certification of death in a hospital: an analysis of 53 death certificates at AIIMS, Bhopal, India. Int J Commun Med Public Health. 2017;4:797–802. 13. Patel Amul B, Rathod Hitesh, Rana Himanshu, Patel Viren. Assessment of Medical certificate of medical certificate of cause of death at a new teaching hospital in Vadodara. Natl J Commun Med. 2011;2(3):349–353.
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.cegh.2019.05.006. References 1. Civil Registration: Why Counting Births and Deaths Is Important. Fact sheets. May 2014; May 2014 http://www.who.int/mediacentre/factsheets (assessed in 5/1/2018). 2. Civil Registration Systems-Introduction. http://unstats.un.org/unsd/demographic/ sources/civilreg/ (assessed in 5/1/2018). 3. Coverage of Birth and Death Registration. http://unstats.un.org/unsd/demographic/ CRVS/CR_coverage (assessed in 5/1/2018). 4. Singh Pravin Kumar, Manmeet Kaur, Nidhi Jaswal, Rajesh Kumar. Impact of policy initiatives on civil registration system in Haryana. Indian J Community Med. 2012 Apr-Jun;37(2):122–125. https://doi.org/10.4103/0970-0218.96100. 5. Annual Health Survey 2012-13 Fact Sheet; Assam. Vital Statistics Division Office of the Registrar General & Census Commissioner, India New Delhi http://www. censusindia.gov.in. 6. International Institute for Vital Registration and Statistic. Technical Papers Number 67. June 1997; June 1997 Role of Technology in the Civil Registration Process).
6
Contents lists available at ScienceDirect
Clinical Epidemiology and Global Health journal homepage: www.elsevier.com/locate/cegh
Civil registration system (CRS) for birth and death registration in Assam – A rapid assessment Tushar Manohar Rane, Tulika Goswami Mahanta∗, Safikul Islam, Pranjal Pratim Gogoi, Bivash Gogoi Department of Community Medicine, Tezpur Medical College, Tezpur, Assam, India
A R T I C LE I N FO
A B S T R A C T
Keywords: Civil registration system (CRS) Birth certificate Death certificate National registration system (NRC) Assam India
Problem considered: Civil registration is, only way to track all births and deaths. Globally, 2/3 of annual deaths, are not registered. Despite existence of Registration of Birth and Death Act (1969), Civil Registration System (CRS) in India registers only 68.3% births and 63.2% deaths. Aim: A rapid assessment of civil registration system for birth and death registration in Assam. Methods: Cross-sectional descriptive study using mixed method was undertaken. Predesigned, pretested questionnaires were used for quantitative study. For qualitative study key informant interview of service providers and Focus group discussion of beneficiaries was conducted in each District. Results: Only 8.5% (27) service providers, trained to operate a computer. Designated office were present in 62.5% (198) facilities, while only 15.5% (49), 7.9% (25), 25.6% (81) and 12.6% (40) of the facilities have landline telephone, cellular phone, functional computer and internet connectivity, respectively. Electricity connection present in 97.2% (308). Facilities are open for 8 h in 86.1% (273) cases. Reason for poor utilization includes difficult communication, lack of awareness, inefficient system. Conclusion: Tremendous scope of improvement in birth and death registration department with adequate investment to improve the infrastructure, manpower and IT equipment's.
1. Introduction Countries need to know how many people are born and die each year – and the main causes of their deaths – for well-functioning health systems. Civil registration not only provides basis for individual legal identity but also allows countries to identify their most pressing health issues. Almost half of the world's children go unregistered. Many barriers prevent people from registering births and deaths.1 Civil registration is the way by which countries keep a continuous and complete record of births, deaths and the marital status of their people. Definition of Civil registration is “continuous, permanent, compulsory and universal recording of occurrence and characteristics of vital events pertaining to the population as provided through decree or regulation in accordance with the legal requirements of a country”. Civil registration is carried out for establishing legal documents and also a main source of vital statistics. Complete coverage, accuracy and timeliness of civil registration are essential for quality vital statistics.2 Monitoring the status of civil registration and vital statistics for countries in the world is the first step to provide guidance and assistance to those that are in need.3
∗
National Population Policy (2000) of India emphasized the need to improve registration of vital events.4 As per the Annual Health Survey (AHS) 2012–13, the coverage of birth registration in Assam has risen in recent years to 87.1%; however, the status of issuance of birth certificate is 69.1%. There is also a significant difference between urban and rural areas and between the respective districts of different divisions in Assam. Though 86.1% births are registered in rural areas, only 67.5% have received birth certificate. Similarly, in the case of urban areas, 93.1% births are registered, but only 79.1% received birth certificate.5 For computer-based systems, a major consideration is data entry. In paper based registration system significant cost and time factor is involved. Within a computer-based system, record storage and retrieval, indexing, record searches, corrections, and the preparation of record copies for transcripts or certifications are quick and easily processed, and the security of the data is optimum. Such systems need to be developed in a networked personal computer (PC) environment or on a mainframe system depending on the volume of records and related processing. These factors bring computer systems for civil registration activities down to reasonable costs, with relatively small physical
Corresponding author. E-mail address: [email protected] (T.G. Mahanta).
https://doi.org/10.1016/j.cegh.2019.05.006 Received 20 February 2019; Received in revised form 30 April 2019; Accepted 23 May 2019 2213-3984/ © 2019 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of INDIACLEN.
Please cite this article as: Tushar Manohar Rane, et al., Clinical Epidemiology and Global Health, https://doi.org/10.1016/j.cegh.2019.05.006
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
T.M. Rane, et al.
depicted in the flow chart in Fig. 2. Responsibility of Birth and Death registration is vested upon a myriad of individuals from various deputations like MPW (multipurpose workers), Pharmacists, Ophthalmic assistants, and office assistants, DPA (Data processing assistants), BEE (block extension educator), ANM, GNM and Grade 4 etc. These persons are required to perform the duties of birth and death registration besides their own. Among these functionaries only 8.5% (27) have ever been trained to operate a computer for any government service but 68.1% (216) of them mentioned that they would be able to handle the online CRS after training [Fig. 3]. The infrastructure that houses this department needs to be looked into and upgraded from the perspective of housing an online registration system. Out of the total facilities, 62.5% (198) have designated office for birth and death registration with an information board near the outer door. Only 15.5% (49) and 7.9% (25) of the facilities had landline telephone and cellular phone connection respectively. Functional computer available in 25.6% facilities but only 12.5% (40) facilities were having internet connectivity. Electricity connection from any source was available in 97.2% (308) of facilities and 44.2% (136) facilities having secondary or back up source of electricity [Fig. 4]. The computers were generally shared among various departments for generating and sharing reports as and when required. Digital data stored in the computers is not safe as most of these computers (275, 86.8%) were shared among various departments and have open or shared passwords. Essential antivirus software or firewalls were not installed or up to date in (275, 86.8%) of the computers [Fig. 5]. Essential peripherals like printers were also found to be present in 24.9% (79) of the total facilities. The printers were primarily laser printers. Facilities are open for 8 h in 86.1% (273), while the remaining facilities were open for less than 4 h in a day. On an average 236 (ranging from 1 to 3889) birth certificates and 30 (ranging from 0 to 732) death certificates were issued in a month. Only 10.7% (34) of the facilities conducted any convergent/sensitization meeting in last 3 months. [Table 1]. Comparison of District level and block level facilities show no significant difference [Table 2].
settings required for the equipment, and highly “user-friendly" software for operations and training of staff.6 Therefore this study is undertaken to assess the status of civil registration system in Assam. 2. Methods A cross-sectional descriptive study of CRS registration units was undertaken in 2017–18 including all districts of Assam. Institutional ethical clearance was taken. Written informed consent was obtained from each participant. Necessary permission from state and district level officials was obtained before start of the study. A predesigned, pretested questionnaire was used for quantitative study which covered assessment of the computer based reporting units. The qualitative component of study was done with two main objectives: one was to understand the awareness level of the community on birth and death registration, their views, concerns and their experience with the system and second was to understand and document the shortcomings in reporting by ASHA who have now become major source of information on birth and death in village or urban area. For qualitative study in-depth interview was recorded from different level of officials, service providers, ASHAs and beneficiaries. Both facility readiness like infrastructure, manpower, and community awareness was assessed from functionaries of the reporting units along with photographic evidence of units. Focus group discussion of beneficiaries was also conducted one in each district [Fig. 1]. All district and block level centers/units that were involved in birth and death registration process were visited. Members of community were approached to gather and understand the level of knowledge about birth and death registrations as well as record points of concern. Focus group discussions of frontline ASHA workers and beneficiaries/ community were also conducted. Key informant interview was conducted amongst different stakeholders and recommendations of the respondents were also captured. Statistical analysis was done using proportion and chi-square test. 2.1. Results of quantitative study A total of 317 facilities where CRS offices are located, were visited across all the districts and development blocks of Assam. The system is
Fig. 1. Flow Chart representation of the study design. 2
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
T.M. Rane, et al.
Fig. 2. Data flow in the CRS system.
Fig. 3. Status of available Manpower in the facilities for implementing online Civil Registration System.
2.2. Key informant interview findings
birth registration. There were instances where a birth registration of a child has not been done until the age where he/she has to be sent to school and birth certificate is a mandatory document. This indicates a general lack of awareness among the masses especially of birth registration. Updating of National registrar of Citizen (NRC) initiative in Assam, which mandated the people to get the birth registration done improved birth registration. Prevalence of custom: Prevalence of various customs and rituals among the population is another aspect leading to delayed registrations; e.g. customs naming of babies after one month after consulting with the religious leaders or name being procured from a religious institution in another state or country which causes much delay in the registration process. Death registration is less in remote areas and amongst women. Monetary or property matters were the only influencing factors. Accessibility and availability: Distance was a major factor-poor roads and lack of public or private means of transport act as major deterrents due to which people do not want to go to registration centers. Supply issues like non-availability of certificates takes a long time to provide certificates. Beneficiaries and ASHA have to visit registration centers number of times to get certificates. Officials involved cited that certificates had to be procured from the state headquarters which was a tedious task as they had to travel very often with their own money. The booklets too are provided in limited numbers. Due to this reason there is always a shortage scenario in the registration centers. Education level of informers: ASHA workers were most commonly involved in the registration process. But being less educated often makes spelling mistakes which ultimately lead to erroneous certificate.
Records in centers were kept in wooden shelves/racks without any safety or indexing. As such retrieving old record is a cumbersome activity and these are also prone to damage by various means. Knowledge level of existing staff can be described as average with most officials being aware of basic rules of registration. Officials need to be updated with relevant laws/rules/amendments regarding birth and death registrations including uncommon and unusual cases in order to be more efficient. Common gaps were seen in rules involving registration of adopted children, death registration of missing persons, the process of identifying the time, date and place of a missing person and number of years as per law that mandates the missing person as presumed dead. Common issues that had been highlighted by the officials were as follows: poor building conditions, inconsistent power supply and power backup facility, irregular supply of certificate booklets causing delays in providing certificates, some facilities located in far flung areas causing less awareness and subsequently less registrations amongst beneficiaries, lack of space/facilities to store the ever growing registers and application/record forms and lack of dedicated Human resource for the department. 2.3. Focus group discussion findings Focus group discussion was done amongst beneficiaries specially mothers groups one for each District which can be explained domain wise: Casual attitude of community: people have a casual attitude towards 3
Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx
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Fig. 4. Status of available infrastructure for implementing online Civil Registration System.
state government does not have a dedicated person deputed solely for birth and death registration. Many Units/Registration centers lack adequate infrastructures required for up gradation of existing civil registration system into an automated system. Designated office for birth and death registration was absent in 37.5% of the registration centers. Well-functioning ICT (Information and communication technology) infrastructure, including a reliable power source, internet, and cell phone coverage, provides the enabling environment for developing modern CRS systems, which in turn provides the platform for interoperable CRS information systems and databases. While ICT is not a silver bullet, it can provide a means to collect, store and retrieve data in a fast, cost-efficient and user-friendly way.8 Existing civil registration system was largely paper-based and manual. Only 25.6% of the facilities had computers and 12.6% of those computers had internet connectivity. The workforce in charge of
During the Focus group discussions as well as personal interviews, some comments indicating incorrect practices were made by the participants. However, no document or recorded proofs of these comments were available. These are quoted as personal comments of the participants. 3. Discussion Birth registration is a fundamental right and serves as a key to ensuring the fulfilment of additional rights for children and helps recognition of any person before the law. Functioning CRS systems provide governments with reliable and up-to-date population and mortality statistics, including causes of death, which enable them to plan, deliver, and monitor effectively health and social development programs and to track progress towards international commitments such as Sustainable Development Goals.7 Department although under
Fig. 5. Status of security of digital data in the facilities. 4
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programs ASHA and other frontline health workers can be engaged with minimal training as they are already involved in the process. Materials like posters can be prepared and provided to various registrations centers and other health institutions. Performance of CRS system depends on community awareness and registration facilities, which might be inaccessible owing to physical, economic, or socio-cultural barriers. For poor and marginalized individuals, putative advantages of registration have little meaning compared with day-to-day challenges of earning a livelihood, finding shelter, and ensuring personal security. Efforts to strengthen CRS systems should be cognizant of the complex economic and socio-cultural circumstances that are deterrents to registration, and therefore take action to remove these barriers and introduce positive incentives, including access to services and benefits. CRS should be seen as a service to people rather than an imposition by authorities and should foster trust between state and society. Experiences from some successful countries show that holistic, systemic approaches involving stakeholders across several sectors—especially health, statistics, registration, justice, home affairs, and civil society organizations—are needed for effective CRS improvements. Development partners and donors should coordinate their support with country efforts and country-led priorities and plans that are most likely to be sustained over time.7 The benefits of investment in CRS will accrue across many sectors, including health, social protection, governance, and socioeconomic development, and will benefit individuals and families.9 Although a legal framework and a system of civil registration are in place since long, but India lacks systematic death registration and in Assam only 13.7% deaths were reported and the percentage of medically certified death of total registered death was only 0.9% in 2013 in Assam and ranked 29, while it was 26% in 2015.10,11 Partial completion of certificate has potential to create a lot of confusion and problems later on and may lead to legal troubles.12 Robust CRS give epidemiological data about vital statistics and can guide allocation of resources for research and national health program as health statistics, national morbidity and mortality statistics, and data on disease prevalence in population are derived from death certificates, it is essential to ensure completion and accuracy of “cause of death‟ section in death certificates. Besides, there needs to be proper filling up of death registration forms 4 and 4A. A nosologist needs to be appointed to oversee the coding of the causes of death.11 Recurring educational sessions for service providers, periodic auditing of death certificates and feedback are necessary to increase the accuracy of the system.13 There is a need to improve block level birth and death registration centers to improve accessibility and practice of birth and death registration and establish a robust system of online registration and to undertake operational research so that good demographic data can be generated and utilized for planning different development activities.
Table 1 Basic client services provided by the facilities. Basic Client Services
4 h or less
On average how many hours per day the facility open (N = 317)
Any convergent/sensitization meeting held in last 3 months (N = 317)
Birth certificate issued in a month Death certificate issued in a month
Up to 8 h
Number
Percentage
Number
Percentage
44
13.9
273
86.1
Yes Number
Percentage
No Number
Percentage
34
10.7
283
89.3
Average
Minimum
Maximum
236
1
3889
30
0
732
Table 2 Comparison of District level and block level CRS facilities. Variable
Comment
Frequency
Percentage
Chi-square
p-value
Designated office of registration Whether registration is compulsory Fee taken for registration Provision of registration of adopted child Provision of registration of death of missing person Existing staff capable of handling online CRS after training
District PHC District PHC District PHC District PHC
29 169 52 264 30 164 46 215
55.77 63.77 100 99.62 57.7 61.89 93.88 86
1.187
0.275
0.196
0.657
0.322
0.57
2.291
0.13
District PHC
41 175
87.23 72.61
4.483
0.034
District PHC
43 173
82.7 65.28
0.728
0.393
recording vital events and preparing vital statistics are neither equipped nor trained in computer applications. Only 8.5% of the personnel involved in recording and registrations of birth and death events were ever been trained to operate a computer for any Government service. There is a need and scope to train available manpower in computer applications so that their services can be utilized to upgrade the civil registration system; as 68.1% of the personnel mentioned that they can handle computerized CRS after proper training. Present study shows that security of digital data is a major concern in all types of facilities throughout Assam. Only in 13.2% of facility computers are protected by firewall/antivirus software and password protected. A desire to achieve measurable progress in a short time frame has stimulated growing interest in potential of information technologies. Good legal foundation is essential to ensure security and privacy of personal data and to set standards for database interoperability, confidentiality, data protection, and personnel clearance. Such safeguards help to bolster trust that information will be used for public good.7 Community gave opinion through FGD that awareness programs should be conducted in remote areas frequently with inclusion of target audience including both beneficiaries and various persons involved in registration process. These programs should include various benefits of birth and death registration and existing rules and regulations involved. Deviation from normal cases like registration of an adopted child and death registration of a missing person should also be included. For these
4. Conclusion Awareness programs; pertaining to process and benefits of birth and death registration; needs to be conducted in both rural and urban areas. The frontline workers should also be trained to provide better services. Infrastructure strengthening by consistent electricity supply, improved building condition, dedicated and trained human resource and establishment of online system with installation of system are essential for the success of the CRS. Conflicts of interest None. Acknowledgement UNICEF, Assam for financial support. 5
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Appendix A. Supplementary data
7. Carla Abou Zahr, Savigny Don de, Lene Mikkelsen, et al. Civil Registration and Vital Statistics: Progress in the Data Revolution for Counting and Accountability. vol 386. October 3, 2015; October 3, 2015 Counting births and deaths 1 www.thelancet.com. 8. World Bank | WHO. Global Civil Registration and Vital Statistics Scaling up Investment Plan 2015–2024. May 28, 2014; May 28, 2014. 9. Mikkelsen L. Rapid Assessment of Vital Statistics Systems: Evaluation of the Application of the WHO/HIS Hub Tool in 26 Countries in the Asia–Pacific Region. Working Paper No. 10. Brisbane, Australia: University of Queensland School of Population Health, Health Information Systems Knowledge Hub; 2010http://www.uq.edu.au/hishub/ all-publications. 10. Report on Medical Certification of Cause of Death. Office of the Registrar General, India. New Delhi: Ministry of Home affairs, Vital statistics Division, R K Puram; 2013:8–9. 11. Raut MK, Sahu AB. Addressing the rising cause of death due to diseases of the circulatory system geared towards achieving SDG 3: evidence from data on medical certification of cause of deaths in Rajasthan State, India: 1999-2015. Int J Commun Med Public Health. 2018;5:182–190. 12. Patel N, Patel S, Vidua RK, Arora A, Tamaria KC. How to evaluate the medical certification of death in a hospital: an analysis of 53 death certificates at AIIMS, Bhopal, India. Int J Commun Med Public Health. 2017;4:797–802. 13. Patel Amul B, Rathod Hitesh, Rana Himanshu, Patel Viren. Assessment of Medical certificate of medical certificate of cause of death at a new teaching hospital in Vadodara. Natl J Commun Med. 2011;2(3):349–353.
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.cegh.2019.05.006. References 1. Civil Registration: Why Counting Births and Deaths Is Important. Fact sheets. May 2014; May 2014 http://www.who.int/mediacentre/factsheets (assessed in 5/1/2018). 2. Civil Registration Systems-Introduction. http://unstats.un.org/unsd/demographic/ sources/civilreg/ (assessed in 5/1/2018). 3. Coverage of Birth and Death Registration. http://unstats.un.org/unsd/demographic/ CRVS/CR_coverage (assessed in 5/1/2018). 4. Singh Pravin Kumar, Manmeet Kaur, Nidhi Jaswal, Rajesh Kumar. Impact of policy initiatives on civil registration system in Haryana. Indian J Community Med. 2012 Apr-Jun;37(2):122–125. https://doi.org/10.4103/0970-0218.96100. 5. Annual Health Survey 2012-13 Fact Sheet; Assam. Vital Statistics Division Office of the Registrar General & Census Commissioner, India New Delhi http://www. censusindia.gov.in. 6. International Institute for Vital Registration and Statistic. Technical Papers Number 67. June 1997; June 1997 Role of Technology in the Civil Registration Process).
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