Counting every birth and death could make a difference to health inequities in Africa
Many African governments were unable to monitor the millennium development goals because they lacked the vital statistics
For many African countries and especially among poorer communities, when people die there is no trace in any official legal record or statistic. It is common for a person who lives in the city and falls terminally ill to return to their rural village to await their death. When they die they are buried without any legal or official documentation of the death specifying the cause.
At the same time millions of births in Africa are not legally documented. In developed countries this would be unheard of.
In Australia and Denmark, 99% of all deaths are captured. But only four out of 54 countries in Africa – Algeria, Mauritius, Seychelles and South Africa – capture 75% or more of their births and deaths.
Africa’s situation is mainly due to problems with what is known as civil registration and vital statistics systems.
And this is detrimental for planning purposes on the continent. If we do not know how many people are dying and why they are dying we cannot do much to prevent deaths that could have been avoided.
Many African governments were unable to monitor the millennium development goals because they lacked the vital statistics, especially in the area of infant and maternal health.
A well-functioning civil registration and vital system that makes every death and birth in Africa count will be crucial to monitor the progress in achieving the newly set sustainable development goals.
The marks of a well functioning system
According to the World Health Organisation, a country has a well-functioning civil registration and vital statistics system if it registers all births and deaths, issues birth and death certificates and compiles and disseminates birth and death statistics, including cause-of-death information.
Other “vital” events that could be captured by the system are marriages, divorce and migration. These statistics are needed to inform local authorities that have to allocate public resources and monitor health progress.
A well-functioning civil registration and vital statistics system needs to be:
- universal to include all areas and the country’s entire population;
- continuous to record vital events as they happen and on a permanent basis;
- compulsory and be backed by a legal framework for its administration, operation and maintenance; and
- confidential to retain public confidence by protecting citizens from misuse of records for legal matters.
Despite the well-documented benefits of civil registration and vital statistics systems, many countries in Africa have not managed to get it right.
In Kenya for example, only about 46% of deaths and 60% of births are registered by the civil registration and vital statistics system. And even so, there are disparities within the country. In Kenya’s far-flung rural Mandera County, which borders Somalia, only 3% of deaths and 17% of births are said to be registered.
In general, poorer and more remote communities tend to be excluded from these systems. This fosters health inequities. It renders deaths and births in such communities invisible to local authorities. And if local authorities can’t determine how many people are dying, why they are dying, or how many children are born, they can’t plan for or respond to the health needs of the communities.
There are several reasons why these systems remain ineffective. First, many policymakers are largely unaware of the value and importance of these systems. As a result, civil registration and vital statistics systems are not backed by strong governance frameworks or policies. Nor are they adequately funded and resourced.
The laws and procedures guiding civil registration and vital statistics systems in some African countries date back to the colonial era. This means they are not relevant or implementable today.
But there are also infrastructural and technological challenges. Many countries still rely on paper-based records for their systems. This is in contrast to Denmark, where, for example an electronic system was established as far back as 1968.
In the past decade various global and regional initiatives have been aimed at improving these systems in the developing world. In one such initiative, the World Health Organisation partnered with the Health Metrics Networks to create the Monitoring of Vital Events through the use of information technology, also known as the MOVE-IT project.
The project successfully piloted electronic death registration systems in Kenya and Mozambique. But its greatest limitation was being project-based. It focused solely on collecting statistics rather than creating a coordinated and comprehensive approach to strengthen civil registration and vital statistics systems.
There are renewed and more co-ordinated efforts to improve systems in Africa.
The Economic Commission for Africa, with the African Union Commission, the African Development Bank and other key regional and international organisations developed a regional policy and advocacy framework to speed up civil registrations and vital systems.
Ministers across the continent responsible for civil registrations are supporting its implementation. They pledged their political commitment at a civil registrations conference in Ethiopia in 2010.
Earlier this year they met in Yamoussoukro, Côte d’Ivoire where they agreed to launch a ten-year programme supporting civil registrations and vital statistics until 2024. Their goal is to leave no child or country behind.
Developing a comprehensive approach
The meetings in 2010 and this year have brought much-needed political commitment to improve civil registrations and vital systems in Africa.
The initiative provides the policy and programmatic framework to strengthen these systems across the continent, backed by the necessary political goodwill.
This sets the stage for all countries to comprehensively assess their systems and prepare costed national action plans to improve them, irrespective of their state of development.