On the 24–28 November, Ministers of Interior, Health and Home Affairs, Heads of National Statistical Offices and regional development partners from across Asia and the Pacific will be gathering in Bangkok to discuss a key emerging issue in the developing world; that of civil registration and vital statistics (CRVS). The concept of comprehensive civil registration may seem second nature to us – almost 180 years of registration of births and deaths has helped us internalise both our place in the state and the associated lifelong rights that this registration entitles us to. But where do our registration systems stand in a global sense and what are we doing to export the lessons of 180 years of CRVS in practice?
The efforts of UN ESCAP and others to advocate more comprehensive and functional registration systems in developing countries may act as a useful prompt for reflection upon our own systems. While they may be relatively advanced, they are by no means perfect, and potential areas of improvement may help maximise domestic benefits whilst also providing a model for the developing countries of the world.
For the sake of this blog post, CRVS is broken down into two of its core components – registration of births and deaths – although this is by no means a comprehensive summary of CRVS issues.
It is estimated that around the world, the births of some 230 million children under the age of five are currently unregistered. The aim of the Bangkok meeting is to counter the threat to the rights of these children who, as things stand, are “invisible” to policymakers.
There are a number of obvious and not so obvious implications of under-registration that would pertain, not only to the early years of life, but also to potentially pervasive, lifelong impacts on the unregistered.
The case of Myanmar (also known as Burma) is a valuable example of the consequences of poor CRVS. A recent census – the country’s first in over 30 years – revealed that Myanmar has around 9 million fewer people than official estimates thought. This overestimation would be the equivalent of overstating the number of UK inhabitants by the entire population of Northern Ireland, Scotland and Wales combined.
The estimates by the Myanmar Department of Labour were based on fertility and mortality rates that were themselves based on the 1983 Census. Despite the difficulties with conducting a census in 1983 (at a time of significant civil conflict), the scale of the inaccuracy is unlikely to be solely due to an incomplete census or even the substantial number of Burmese workers abroad. Inadequate CRVS systems, both around the time of the 1983 Census and ever since, are likely to have exacerbated errors in the underlying fertility and mortality assumptions and thus the inaccuracies of population estimates.
The importance of comprehensive registration in the UK
To put the consequences of poor registration systems into a domestic perspective, if we imagine applying the registration rate of children under five in Pakistan to the UK, it reveals that the UK would have over a million unregistered under fives.
This “invisible” million might be affected in a number of ways throughout their lives.
- Healthcare and education – Being unregistered and without medical records might compromise uptake of post-natal NHS care and immunisation programmes in a child’s early years. Even though, unlike in some countries, the provision of NHS services does not exclude those without birth certificates, certain services requiring proof of age (e.g. free prescriptions) may also be unattainable.
- Social security – Limited access to benefits may impact entire families – child benefits and tax credits require official documentation of children to be provided by claimants.
- Certain rights – The right to obtain a passport and to inherit property would equally be compromised, not to mention the ability to register to vote which could further compound the “invisibility” of the unregistered.
- Supply of public services – Long-term plans for service provision depend significantly on population projections, which in turn depend on fertility rates and these themselves depend on statistics on registered births. The graph below shows the differences between births in hospitals and registered births, showing how the absence of a functional registration system might allow many births that occur outside of hospitals to slip through the cracks (a total of 123,000 between 2008/09 and 2012/13).
- Targeted social policy – It is also important to note that the “invisible” are unlikely to be a broad cross-section of society. In Pakistan, registration rates among the poorest quintile are less than half that of the richest quintile, therefore making it difficult to target effective health and education policies to those who most need them – the poor.
While the UK’s relatively effective registration systems may help limit these risks, certain organisations have still highlighted room for improvement, particularly through joint parental registration. While part of the Welfare Reform Act of 2009 made steps in that direction by increasing the number of ways that a birth could be jointly registered, it stopped short of making it a requirement. The benefits of increasing the rate of joint registrations have been posited by a number of government publications, including this one by the DWP which argues for the positive impact on child welfare such a change will have.
Just as poor registration of births leads to people being “invisible” in life, deficiencies in the registration of deaths may lead to poor understanding of causes of death, weakening the ability of policymakers to design effective public health policies or measure their impact. This applies as much here in the UK as it does to low-income countries.
One particular weakness of CRVS here at home was underlined in a letter from the Royal Statistical Society (RSS) and a number of other organisations to the Prime Minister in June of this year. The letter highlighted concerns regarding delays in the registration of deaths in England and Wales, particularly from premature deaths including suicides, sudden infant deaths, drug-related deaths and deaths in prison.
When a death occurs in England or Wales it is only added to the national register if a cause can be established. As a result, one in five of all deaths of those aged 5–44 goes unregistered for at least 6 months and in certain cases, researchers and statisticians may be unaware of the death for up to two and a half years.
Take the example of a team of researchers investigating whether changes to the criminalisation of drugs has an impact on the number of deaths by overdose. This kind of analysis requires detailed statistics by death-year, not by the delayed year of registration. As a result of the staggered delays encountered in the death register, the undertaking of time-sensitive research and the delivery of up to date research findings can be hindered, with serious implications for evidence-based policymaking surrounding constantly evolving health and social issues. 23 other European countries operate systems that allow them to promptly count the dead for this reason, and in Scotland, a “holding diagnosis” can be used to allow authorities to record the death immediately and amend the register later.
As the letter unequivocally points out, the registration system in England and Wales “is embarrassed by its unacceptable failure to properly count the dead.”
A point for ourselves and the developing countries of the world to take note of.
Author: Steven Ayres