Recent blogs by Nandini Oomman and Karen Grepin have asked whether there’s enough interest to make the necessary investments in improving health systems research and, by extension, in the data necessary for such analysis. I’ve been coming at this same question from a different direction, asking whether we can identify a measurable health outcome that could serve as the basis for a Cash on Delivery aid program. Some examples might include payments for each additional child who survives to age five, for each averted maternal death, or for each 1 percent reduction in the incidence of an infectious disease like HIV or malaria. In each case, the effort has been stymied by the poor quality of existing data – even for indicators like child mortality, maternal mortality, and the spread of infectious diseases that are widely cited, but often wildly inaccurate.
In a draft working paper, “COD Aid for Health,” Mead Over, Katherine Douglas, and I assess a range of health outcome indicators that would be easier to measure reliably if good quality vital registration were available. For example, a recipient could overstate the maternal mortality ratio by simply excluding marginal populations with higher mortality rates. A vital registration that captured most births would provide a check on such manipulation.
So in addition to considering COD Aid programs that would pay for reducing maternal mortality or the incidence of AIDS, we chose to consider vital registration as a target in its own right, even though it is not a health outcome. If foreign aid agencies are serious about knowing the impacts of their programs, creating incentives for countries to get their vital registration in order would be quite useful. What would happen, say, if an aid agency offered a country $25 for each registered birth, coupled with an independent survey to assess the accuracy of the registration system? The independent verification would not only establish credibility for the payers but also provide feedback on the quality and accuracy of the vital registration system. The existence of a vital registration system would then provide the basis for really determining whether progress is being made against maternal, infant, and child mortality.
Of course, we’re not hooked on one particular approach to vital registration. Traditionally, this means setting up administrative systems to register births at formal health facilities. But there is no reason that birth registration cannot be achieved by other approaches in countries where institutional delivery is not widespread, such as utilizing more regular household surveys or outreach programs.
My interest in promoting such a program was strengthened further when I came across articles describing the benefits of vital registration beyond the realm of research and public policy and into the realm of civil and human rights. For example, an article by Paula Gerber describes the problems faced by indigenous peoples in Australia when they lack birth certificates:
The invisibility that Indigenous people suffer was recently highlighted when participants in the Gippsland East Aboriginal Driver Education Project could not get a driver’s license – not because they could not pass the test, or safely drive a car, but rather because they could not produce the proof of identity documentation required by VicRoads as a condition precedent to obtaining a driver’s license. Sixty of the participants did not have a birth certificate, and the births of 10 of these had never been registered.
Now, focusing aid on vital registration – as with health systems and data collection – may not be terribly exciting to everyone. It certainly does not sound as compelling as contributing to save a life or eradicate a disease. Nevertheless, the growing demands for “value for money” and demonstrating results in health assistance are never going to be satisfied if we don’t make these investments. The associated benefits of vital registration in terms of giving marginalized people visibility and legal standing with regard to the public sector could be the ticket to mobilizing efforts on this critical element of public data collection.
p.s. We are busy revising the COD Aid for Health draft and would welcome any comments that would help us improve it!