Civil Registration and Vital Statistics 2013: challenges, best practice and design principles for modern systems

Transcription

1 Civil Registratio ad Vital Statistics 2013: challeges, best practice ad desig priciples for moder systems

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3 CONTENTS Abbreviatios... v Executive summary...1 Sectio 1. Civil registratio ad vital statistics iformatio systems What is CRVS? The importace of CRVS IS ad their curret eglected state Treds emphasizig the importace of CRVS IS...7 Sectio 2. Curret status ad challeges relatig to CRVS IS Status of iformatio systems for recordig ad otificatio Status of iformatio systems for registratio Status of iformatio systems for vital statistics Key uderlyig characteristics of the existig systems...17 Sectio 3. Best practices of CRVS iformatio systems Examples from developed coutries Examples from low ad middle icome coutries...24 Sectio 4. Challeges ad opportuities for CRVS systems Scalig up Iovatio Itegratio of systems Busiess process streamliig Automatio of CRVS processes...36 Sectio 5. Reflectios o desig priciples for moderizig CRVS IS Five desig priciples A case-study from Tajikista...41 Sectio 6. Coclusios...45 Refereces...49

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5 challeges, best practice ad desig priciples for moder systems ABBREVIATIONS AIDS BCRS BRIS COD CoIA CPR CSB CR CRVS HIS HIV HMN HRS ICT INDEPTH IS MOVE IT MCD NSO PIN SMS UNICEF VA VS WHO WOMB acquired immuodeficiecy sydrome Baragay Civil Registratio System Birth Registratio Iformatio System cause of death Uited Natios Commissio o Iformatio Accoutability Cetral Populatio Register Citize Service Bureau civil registratio civil registratio ad vital statistics health iformatio system(s) huma immuodeficiecy virus Health Metrics Network Household Registratio System iformatio ad commuicatio techology Iteratioal Network for the Demographic Evaluatio of Populatios ad Their Health iformatio system(s) moitorig of vital evets usig iformatio techology Muicipal Corporatio of Delhi Natioal Statistics Office persoal idetificatio umber short message system Uited Natios Childre s Fud verbal autopsy vital statistics World Health Orgaizatio Watchig over Mothers ad Babies v

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7 challeges, best practice ad desig priciples for moder systems Executive summary Withi the domai of public health, iformatio obtaied from civil registratio ad vital statistics (CRVS) is critical, allowig trackig of idividual births ad buildig profiles of mortality ad causes of death. These data play a fudametal role i plaig ad moitorig public health outcomes, as well as a broad rage of outcomes i other policy domais. CRVS iformatio systems (IS) may be paper based or icreasigly techology-drive, ad icorporate multiple busiess processes icludig: recordig of all details related to the vital evet, for example a birth or a death; otificatio of the evet to the authorities; registratio of the evet; ad geeratio of VS. A variety of actors are ivolved i the recordig, otificatio ad registerig of these vital evets, as well as i the use of the system s outputs. The ivolvemet of multiple istitutios ad actors i CRVS makes coordiatio ad goverace a key challege i buildig effective CRVS IS. I recet times, there have bee various efforts i coutries to haress the potetial of techologies, computer ad mobile based, to stregthe CRVS IS ad the CRVS as a whole. This report seeks to study experieces ad best practices of such systems from differet coutries. This aalysis helps to idetify best practices associated with well-fuctioig systems, ad also the various desig ad implemetatio challeges that exist ad potetial approaches. A key effort is made to idetify how existig best practices from well-fuctioig systems i both developed coutries ad low ad middle icome coutries ca be adapted ad applied to others egaged i curretly stregtheig their CRVS IS. Cosiderig the experieces of coutries across the developmet spectrum, the challeges ad opportuities for CRVS IS are idetified as scalig up, iovatio, itegratio of systems, busiess process streamliig ad automatio of CRVS processes. Five desig priciples are proposed i this report to support improvemet of CRVS IS: (a) establish CRVS as a public good; (b) establish istitutioal icetives to keep the CRVS updated ad of good quality; (c) establish a holistic approach to CRVS desig; (d) establish the busiess relatioships of idetified iformatio flows; ad (e) develop the techical approach for operatioalizatio of these relatioships. 1

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9 challeges, best practice ad desig priciples for moder systems SECTION 1. CIVIL REGISTRATION AND VITAL STATISTICS INFORMATION SYSTEMS 1.1 What is CRVS? Civil registratio ad vital statistics (CRVS) systems are cocered with the legal registratio ad aalysis of vital evets i the populatio. Vital evets iclude births, deaths, marriages, divorces, foetal deaths, aulmets, judicial separatios ad adoptios, ad through the registratio process these evets are made legal ad legitimate. Civil registratio (CR) is defied by the Uited Natios as the uiversal, cotiuous, permaet ad compulsory recordig of vital evets provided through decree or regulatio i accordace with the legal requiremets of each coutry (1). Vital Statistics (VS) represets the statistical output of a well-fuctioig CR system (2). CR ad VS systems are itrisically itercoected, ad their combied iformatio systems (IS) are termed Civil Registratio Vital Statistics Iformatio Systems (CRVS IS). A well-fuctioig CRVS IS has i recet times bee recogized as a key igrediet i stregtheig CRVS systems i geeral, ad the Uited Natios Commissio o Iformatio Accoutability (CoIA) for Wome s ad Childre s Health has especially madated that coutries would eed to stregthe their CRVS IS. Specifically, Recommedatio 1 of CoIA poits to the key issue of systematic registratio of vital evets, statig: By 2015, all coutries have take sigificat steps to establish a system for registratio of births, deaths ad causes of death, ad have well-fuctioig health iformatio systems that combie data from facilities, admiistrative sources ad surveys. (3). Withi the domai of public health, data from the CRVS IS are critical, allowig trackig of idividual births ad buildig profiles of mortality ad causes of death. These data play a fudametal role i plaig ad moitorig of public health outcomes, for example relatig to immuizatio plaig, ad moitorig of broader developmetal process idicators such as for materal ad ifat deaths, sex ratios ad fertility rates. A effective CRVS ca help esure erolmet of every child ito immuizatio programmes, ad VS idicators ca be tracked to better support the prevetio of avoidable diseases. If draw from a well-fuctioig CRVS system, these data also provide rigorous mortality data which are of sigificat public health cocer, icludig those cocerig the huma immuodeficiecy virus ad acquired immuodeficiecy sydrome (HIV/AIDS), tuberculosis ad malaria. CR is crucial for idividuals to establish legal idetity ad to access public health services, while VS provides essetial iformatio about the demographics ad health of the populatio, makig policies more effective ad resposive to the eeds of society. CRVS systems are also fudametal to various developmet processes other tha health, such as relatig to social security, literacy ad educatio, law ad order, idetity ad differet forms 3

10 Civil Registratio ad Vital Statistics 2013: of citize services. Sice CRVS by defiitio is multisectoral, a variety of actors are ivolved i the recordig, otificatio ad registerig of vital evets (citizes, health-care workers, doctors, police officers, clerics, ad miistries of health, justice ad home affairs, for example) ad the use of its outputs (such as health authorities, tax authorities ad policy-makers). The ivolvemet of multiple istitutios ad actors i CRVS makes coordiatio ad goverace a key challege i buildig effective CRVS IS. I practice, CRVS systems ted to be fragmeted ad compartmetalized: differet sectors, for example health, populatio statistics ad social security, are typically ot able to access the same database ad to geerate VS directly from the CR system. Arguably, providig such access requires CRVS IS to be treated as a public good, beig able to support decisio-makig for a multiplicity of sectors (4). VS o births ad deaths is crucial iformatio for policy-makig ad plaig ad for the guidace of health programmes at the global level as well as across atioal health systems. Where CRVS systems are weak ad differet sectors are ot liked, plaig icludig for health must rely o cesus data, which are typically iadequate as they are of decadal frequecy ad lack the right level of graularity. Cotributig to this situatio of poor itegratio of systems ad iter-istitutioal data sharig is the fact that CRVS i low ad middle icome coutries have bee largely paper based ad maual. I recet times, there have bee various efforts i coutries to haress the potetial of techologies, computer ad mobile based, to stregthe CRVS IS ad the CRVS as a whole. For example, i Sri Laka, there has bee use of scaig ad digitizig techologies to automate their paper records. These efforts are reflected i a sigificat icrease i the volume of global ad regioal activities to stregthe systems, icludig of the Uited Natios i Africa, the Arab states, Asia ad the Pacific, ad the global attetio of iteratioal parters as a result of the Bagkok Call to Actio i There thus ow exists a large base of experieces from both developed coutries ad low ad middle icome coutries from which we ca lear what works ad what does ot, ad draw guidelies to support future efforts. This report cotributes to that aim. Coutries such as Australia, Demark ad Norway have strog ad itegrated CRVS IS supported by istitutioalized goverace structures, ad various low ad middle icome coutries such as Albaia ad Egypt have made impressive progress i stregtheig their respective CRVS systems, icludig the supportig IS. However, despite these exceptios, by ad large the situatio i may low ad middle icome coutries suggests that CRVS IS are ot up to satisfactory levels i terms of coverage ad quality of registratio data, ad i the maer i which this data is aggregated, used ad shared across the istitutios ivolved. Weak IS have adverse iflueces o multiple coected systems of idetificatio, health services, issuig of passports, ad various others. Buildig a well-fuctioig CRVS IS remais a o-trivial challege, give its multisectoral ature. The CRVS IS eeds thus to spa systems of systems, ivolvig desig approaches that are differet from what is used for idividual systems (5). These are by defiitio techically ad istitutioally complex to build ad use. 4

11 challeges, best practice ad desig priciples for moder systems A key challege i makig CRVS IS multisectoral i practice (icludig sectors such as health, populatio registries, justice ad others) is to develop strategies for the differet systems to commuicate ad share data (5). But eablig commuicatio ad sharig data is ot eough the differet compoets must be iterdepedet i a ecological framework that mutually icetivizes the productio, sharig ad cosumptio of quality data. However, such thikig, ufortuately we may add, has escaped the CRVS ad Health Iformatio Systems (HIS) reform efforts, leadig to piecemeal ad fragmeted systems. For example, the Health Metrics Network (HMN) report (6) has described as a lost opportuity the way that data o births ad deaths beig captured i the routie HIS of a coutry do ot ecessarily itegrate with CRVS registratio records. Creatig such multisectoral likages would be mutually beeficial for the participatig sectors, but practical ad research-related kowledge is limited o how this ca be effectively doe i practice. I order to stregthe our kowledge of the ature of this multisectoral CRVIS IS, with its iheret techical ad istitutioal challeges (6), ad how they ca be desiged, developed ad implemeted, this report studies experieces of such systems from differet coutries. This aalysis helps to idetify best practices associated with well-fuctioig systems, ad also the various desig ad implemetatio challeges that exist ad approaches to meet them. A key effort here is to see how existig best practices, from both developed ad low ad middle icome coutries, ca be adapted ad applied to other coutries, especially the latter group that is curretly egaged i stregtheig their CRVS IS. A key objective of this report is to provide a overview of the status of some coutry CRVS IS, with a view to aswerig the followig specific questios. 1. What are relevat desig guidelies for the buildig of itegrated CRVS IS? 2. What guidace ca be provided to global developmet parters, doors ad atioal policy-makers o how to ivest i iformatio ad commuicatio techology (ICT) iitiatives to stregthe CRVS systems? The report aalyses five key themes ad the associated opportuities, challeges ad approaches. These are scalig up, iovatio, itegratio of systems, busiess process streamliig, ad opportuities for automatio. Scalig up relates to the process of takig itervetios from pilot projects ito workig solutios across admiistrative levels, iteragecy ad expasio i terms of geographical areas, fuctioality ad time; iovatio is the capacity to carry out ew tasks with techological itervetios, or usig ew techology to address hard-tohadle problems; itegratio of systems relates to the techical ad istitutioal issues of makig differet systems commuicate ad share data; busiess process streamliig is the capacity to desig itervetios that support a sustaiable flow of high quality iformatio betwee differet etities; ad opportuities for automatio relates to the potetial of usig digitized ad computerized iformatio systems i terms of triggerig actios ad drivig processes, ad buildig itercoectios betwee sub-processes. 5

12 Civil Registratio ad Vital Statistics 2013: 1.2 The importace of CRVS IS ad their curret eglected state CRVS represets key istitutios of a coutry as well as providig a basis for assessig a coutry s status ad developmet i geeral. Most low ad middle icome coutries have iadequate CRVS IS, cotributig to the ufortuate situatio where may births ad deaths are ot beig registered, described as the scadal of ivisibility (1). A well-fuctioig CRVS IS has i recet times bee recogized as a key igrediet i stregtheig CRVS activity i geeral, exemplified by the CoIA recommedatios. There is emergig evidece that techology ca play a critical role i esurig that births, deaths ad causes of deaths are registered ad that quality iformatio is available to iform coutry ad global developmet priorities. Both the Uited Natios Childre s Fud (UNICEF) ad HMN have sposored activities i coutries to stregthe CRVS systems through iovative use of ICT iitiatives. However, there is yet o guidace for coutries, iteratioal developmet parters or doors regardig appropriate techologies ad architecture desigs ad priciples to be promoted or ivested i a CRVS system. So, despite icreasig emphasis o CRVS IS, ad growig ivestmets i techology, it ca broadly be iferred that the state of these systems i most low ad middle icome coutries teds to be below desired satisfactio levels, ad that ICT itervetios have ot yielded desired beefits as yet. Most low ad middle icome coutries have CRVS IS that are primarily paper based, ad may of them are i the process of applyig ICTs for their moderizatio. The Health Metrics Network, a secretariat of the World Health Orgaizatio (WHO), iitiated i 2007 a set of projects called Moitorig of Vital Evets usig Iformatio Techology (MOVE IT) which explicitly sought to uderstad how ICTs ca be iovatively applied to stregthe CRVS systems. Various coutries, such as Albaia, Bagladesh ad Liberia, have also udertake ICT-based CRVS reform iitiatives either o their ow or with support from door agecies. But the success of these iitiatives does ot mirror the ivested efforts. A recet survey of ecrvs ad mcrvs iitiatives i low ad middle icome coutries (6) has idicated that may of these iitiatives remai o a small scale ad at a pilot level; as such, they have ot delivered to their promised potetial ad the impact o actually reformig the CRVS systems has remaied margial. I the public health domai, while HIS have gaied i importace over the years as a object of research (7), CRVS IS, arguably due to their multisectoral ature, have slipped betwee the cracks ad ot bee systematically studied withi oe domai be it public health, demography or (health) iformatio systems. As a result, there has util recetly ot bee the urgecy ow beig expressed by the research commuity to stregthe CRVS IS. For example, the IFIP 9.4 Workig Group o Social Implicatios of Computers i Developig Coutries, i its last three decades of cofereces, does ot show eve oe paper o CRVS despite its cetrality to developmet processes. As a result of this research eglect, fidigs 6

13 challeges, best practice ad desig priciples for moder systems i the IS domai pertaiig to multisectoral, large-scale ad complex systems such as those emphasizig the architecture approach (5), sociotechical etworks (8) ad flexible stadards (9), despite their direct relevace to CRVS, have ot bee applied to the uderstadig of the domai of CRVS systems. This report thus seeks to eable learig also betwee research commuities ivolvig desig ad implemetatio studies of iformatio systems more broadly ad CRVS IS i particular. 1.3 Treds emphasizig the importace of CRVS IS While computerizatio of CRVS IS has bee aroud for several years, eve i the cotext of low ad middle icome coutries, what is ew today is how systems are becomig icreasigly iterliked with databases that are able to exchage iformatio. Such iterlikig was ot techically possible i the earlier time of stad-aloe, ad ofte paper-based, systems. Iterlikig of databases together with server-based solutios opes up a rage of ew opportuities. For example, it allows atioal databases to coect with registratio offices i districts ad sub-districts, creatig the techical ability for the sub-atioal offices to register ad issue certificates. Furthermore, health istitutios recordig births ca ow potetially trasmit the ame-based records pertaiig to a evet of a birth or a death electroically to the civil registry offices to register the evet. Mobile phoe techology further exteds the geographical ad temporal access to databases, eablig reporters of evets takig place i remote areas to commuicate directly with databases located elsewhere. The possibilities that are beig created through these techologies ad their iterlikig represets ot merely a simple automatio of a paper-based birth or death registratio system, but potetially ushers i a radical trasformatio of how the busiess processes aroud births ad deaths registratio takes place. Haressig the potetial of these techologies will also require the legal processes to be redefied, for example to eable the acceptace of mobile phoe-based otificatios of a birth or a death related evet, for example by usig the short message system (SMS). 7

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15 challeges, best practice ad desig priciples for moder systems Sectio 2. Curret status ad challeges RELATING to CRVS IS The CRVS IS comprises multiple facets icludig: recordig of data where all details related to the vital evet, for example a birth or a death, are oted dow typically at the poit of evet (for example, the health facility or the home) o paper; otificatio of the evet iformig the details of the recorded evet, which i case of death would also ivolve details of the cause of death (COD), to the authorities resposible for the issue of legal documets, for example the Registrar Geeral s Office; registratio of the evet which ivolves the issue of the certificate of registratio; ad geeratio of VS which ivolves the geeratio of aggregate idicators o key health ad developmet idicators by the atioal authorities. A itegrated ad holistic CRVS system should etail data likages across these various facets i a seamless maer, eve if they have their ow respective systems. The differet compoets that comprise the overall CRVS system represet a multiplicity of iformatio flows from differet sources ad agecies, each of which has uique relatios (uilateral or multilateral) with the CRVS system. For example, birth records from health registers may provide the source of registratio i CRVS, while surveys of births ad deaths ca provide a framework for triagulatio ad stregtheig of data quality ad coverage. These relatios will be shaped very much by the legal ad political framework i the coutry. To deal with multiplicity withi this ad other areas ecessarily requires takig a itegrated architectural approach oe that ivolves the relatioship of the differet compoets with each other ad the whole. Surroudig these multiple flows are several stakeholders with their ow IS ad istitutioal arragemets. Gettig istitutioal agreemets for sharig data has ofte bee foud to be more complex tha buildig the techical bridges (5). Doors ofte cofoud this problem by providig support to buildig idividual systems, such as for stregtheig COD reportig, without lookig ito the issue of how these data will iterface with processes of registratio ad geeratio of VS. Such idividual support leads to typically fragmeted systems because the differet compoets are desiged as silos, withi a short-term project framework with strog door depedecies that ecourage a limited focus. As such, these systems are ot istitutioalized as a part of a larger ecology of systems: they remai oe-dimesioal, are either scalable geographically or fuctioally, ad cosequetly are ot sustaiable. Aother key challege i this regard is how to deal with legacy data that historically represet CR data. Most low ad middle icome coutries would have primarily paper-based records of idividual birth ad death records, ad these are ot easily ameable to computerizatio ad thus retrieval ad sharig. Some coutries, such as Sri Laka, have iitiated projects ivolvig the digitizatio of all such records, but progress has bee slow ad also there is still ot a clear 9

16 Civil Registratio ad Vital Statistics 2013: strategy o how they become part of a itegrated CRVS. May others, for example Albaia ad Egypt, have recogized the potetial value of ICT ad have usefully leveraged HMN support to develop iovative prototypes of such itegrated systems. These efforts still eed to cosider the larger challege of movig from prototypes ad pilots to systems of provicial ad atioal scale with sustaiable models to cotiue their evolutio. Little is kow about IS (based o computers ad mobiles) supportig CRVS systems from a systemic ad architecture perspective, which spas the etire CRVS process from recordig the evet, its otificatio ad registerig, ad the issuig of the legal documet surroudig the evet, to its cosolidatio ito VS. The literature presets various examples of descriptios of particular ICT itervetios relatig to limited parts of the overall whole, such as o birth otificatio (10), death registratio (11), COD recordig (12) ad the compilatio of VS (13). While these specific examples provide stories of both successes ad failures for the particular itervetio they practise, they do ot ad caot by desig help to illumiate issues relatig to the trasformatio ad scalability of the overall CRVS system, as they do ot take accout of issues of relatios with other flows ad with the broader cotext. For example, Toivae et al. (14) describe a mobile birth registratio system usig GPRS techology ad smartphoes i Liberia which, while appearig techologically sleek ad cost effective for birth registratio, does ot deal with scalig issues ad egagig with the additioal complexities that scale iheretly ivolves. For the govermet to make every citize cout, or every mother ad child cout, as CoIA madates, the eed is for the techology to help the CRVS systems to achieve full coverage based o good quality data. This requires systems to be scalable both geographically ad fuctioally. Geographical scalig implies full coverage of the whole populatio i which every vital evet be it a birth, death, marriage or other is registered. Fuctioal scalig should eable the capacity to be able to register ad process every type of vital evet ad its compoets i its completeess, ad will also ivolve the ability of the CRVS system to exchage iformatio with associated systems. For example, verbal autopsy (VA) systems collectig COD iformatio should be able to speak to the CR system dealig with death registratio. Similar is the case with surveillace systems ad populatio registries, as they eed to be liked to systems of births ad deaths registratio. I a majority of the cases studied, techology-based itervetios i the CRVS domai have bee applied i pilot or small scale settigs, ad focused towards oe aspect of the system, such as birth otificatio or COD studies, without cosiderig how that speaks to other compoets like the registratio system ad further to the geeratio of the VS. Typically, itervetios ted to be focused o oe or more of these three areas: (a) at the poit of occurrece of the evet (of birth or death); (b) at the poit of creatio of the legal documet (birth or death certificate); ad (c) at the poit of cosolidatio of the VS. Two broad kids of challeges ca be see to characterize these itervetios. First, these itervetios focus 10

17 challeges, best practice ad desig priciples for moder systems o a limited compoet of the overall CRVS system, ad are thus arguably limited to brig i systemic improvemets. Secod, these itervetios by desig are focused towards pilot efforts ad ot to the larger scale of atioal systems. The scalig challege gets further magified, because the pilot iitiatives are door fuded ad ot state owed, ad ted to wither away oce exteral door attetio ad fuds are withdraw. These desig ad implemetatio limitatios are reflective of challeges faced i IS ad HIS more broadly, leadig to a crisis of sustaiability ad scalability of systems (8). Aother key challege relates to the goverace of CRVS IS. Goverace of itegrated systems, or architecture, is based o a focus of how idividual systems both techical ad istitutioal are iterdepedet, how they commuicate ad distribute differet tasks, who makes decisios, ad what icetives exist to participate i the architecture. The origial metaphor of architecture comes from city plaig, where it is importat that systems of utility, water, power, saitatio, sewage ad others are sychroized with each other for the city to work effectively. Despite city plaig efforts, cities, especially megacities i low ad middle icome coutries, are ofte i a state of chaos because they have ot bee able to aticipate migratios, purchase of cars, terrorism attacks, atural shocks such as earthquakes, ad various other evetualities. However, most people will agree that without city plaig efforts, the coditios of cities would be worse tha they curretly are. Effective goverace mechaisms ca help to better uderstad, pla ad implemet ew architectures or to chage existig systems. I doig so, the goverig authorities eed to ackowledge that the future is ot determiate ad ca ever be fully aticipated, so decisios made today should ot block or make irreversible certai paths i the future. This requires a approach to buildig CRVS IS as oe of architectig, as a verb, sigifyig the architecture is ot a fiished product but is somethig that is always i the makig. Goverace should ivolve a holistic perspective to maage curret ad expected future sociotechical heterogeeous compoets that eed to costitute, together, purposeful work systems. For example, there is little poit i itroducig mobile phoes to otify births ad deaths evets if the legal system that oly accepts figerprited or siged otificatios does ot also chage. A effective goverace system should esure these heterogeeous compoets act together with each other, cotributig to the overall stregtheig of the system. I the busiess world, goverace has bee addressed through cocepts of eterprise or busiess architecture to maage sociotechical arragemets of software, hardware, orgaizatioal structures, huma competeces ad icetive schemes (15, 16). I such eviromets, goverace seeks to deal with efficiecy ad effectiveess cocers based o levels of stadardizatio ad itegratio withi large-scale work systems, supportig the overall operatios of the orgaizatio. This eterprise architecture approach is ow also beig adopted i other domais such as the developmet of health iformatio architectures (5). While may of the meta-priciples of eterprise architecture, for example that a architecture 11

18 Civil Registratio ad Vital Statistics 2013: is comprised of three layers of the users, busiess logic ad data exchage, will remai the same i the case of the CRVS, the details of the differet systems ad the stakeholders ivolved ad the specific flows of iformatio will eed to be worked out. These particularities will have implicatios o the goverace of the architecture. Some of the learigs from IS research relevat for CRVS IS goverace iclude: the adoptio of a social systems approach, which emphasizes the historical ad istitutioal cotext, icludig people, data ad istitutioal practices; a emphasis o a holistic approach, which takes ito accout the wide rage of systems ivolved, the relatios betwee them ad the strategies for data exchage; the idetificatio of best practice stadards, as the glue to eable data exchage across the various sub-systems ivolves the adoptio of a modular structure, eablig compoets to be plugged i or out, based o evolvig eeds of stakeholders. Systems i coutries such as Australia ad Norway provide models o how these metapriciples have bee put ito practice, ad ca serve to guide efforts i low ad middle icome coutries with appropriate ad cosidered customizatio. I describig the state of art of the existig CRVS IS, we do it with respect to three broad fuctioal areas o which the systems broadly focus. The first cocers systems for the recordig ad otificatio of a vital evet; the secod cocers the legal act of registratio; ad the third system cocers those related to the geeratio of VS. The very fact that these systems are described separately for these three fuctioal areas reflects the fragmeted ature of the systems that exist. This poit is revisited at the ed of the followig sectios describig the three sets of systems. 2.1 Status of iformatio systems for recordig ad otificatio A sigificat proportio of techology-based iitiatives related to CRVS takes place at the poit of the evet of the birth or death, especially related to births. We ca see the techological itervetios to support three differet kids of activities aroud the vital evet relatig to recordig, otificatio ad registerig of the evet. Recordig refers to the otig dow of all details relatig to the evet, for example with respect to a birth it would iclude details relatig to the ame of the mother, place, type of birth ad address. Notificatio would take place after recordig ad represets the act of official commuicatio of the details of the evet to the authorities resposible for the issuace of the legal documet relatig to the evet. Registratio the represets the higher-level fuctio i which the evet is legally registered withi the CRVS IS. This ca be i the provicial or atioal-level database, 12

19 challeges, best practice ad desig priciples for moder systems electroic or paper-based, ad made ready for the compilatio of the VS. The registratio the also icludes the importat act of issuig the certificate of birth, death, marriage, etc. Commoly these three fuctios are ofte ot clearly demarcated, ad everythig is said to ivolve a registratio. Despite it beig difficult to separate the itervetios described i these three categories, we believe it is importat to do so as a certai techology may have features that led it better to certai fuctioalities tha others. For example, mobile phoes ituitively seem more suited to fuctios of otificatio tha for registratio, which could be better carried out i a electroic data warehouse. Also, techical chages will ecessarily eed to happe i cojuctio with other systems, such as legal ad goverace. For example, eve though the otificatio of the birth may take place through the mobile phoe, the issuig of the registratio certificate legally requires the physical presece of the idividual who is the subject of the vital evet. As legal systems chage much more slowly tha techical oes, the use value of techological itervetios eeds to be assessed accordigly. Table 1 briefly summarizes some examples of systems related to each of these activities, ad some correspodig examples. 13

20 Civil Registratio ad Vital Statistics 2013: Table 1. Summary of activities ad systems relatig to civil registratio systems Nature of CR activities Status of the iformatio system Examples Recordig There exist examples of real-time recordig of births, but death recordig systems are far more limited There exist systems for VA, but they are rarely liked to death registratio Agicourt Health ad Demographic Surveillace System i South Africa (13) Birth recordig i Ghaa based o a OpeMRS based system called MGV-et is used to record real-time birth iformatio i a pilot project (11) It is ofte uclear if systems are oly recordig the evet or also carryig out otificatio ad actual registratio Typically, systems are stad-aloe Various efforts are made by coutries to use ICD-10-based classificatio systems for mortality iformatio, but they suffer from weak likages with CR systems Burkia Faso, Ethiopia, the Gambia, Mozambique, Seegal ad the Uited Republic of Tazaia are all reported to have itroduced stad-aloe CR systems, ofte based o the Household Registratio System (HRS) to register births, deaths ad migratios (17) Notificatio Mobile phoes may be especially suited for low ad middle icome coutries, where a sigificat proportio of the birth ad death evets typically takes place outside the jurisdictio of the health facility Sice otificatio would ivolve legal mechaisms to be created, i their absece SMS ca be used to trigger the process of otificatio rather tha carry out registratio Likages of SMS with CR are relatively uclear, other tha possibly triggerig iformatio about the evet I Ghaa, the CR database ca be accessed, or i our terms otified ad updated by mobile phoe, which ca the allow the geeratio of the birth certificate at the commuity level Moitorig of vital evets usig iformatio techology (MOVE IT) projects i Keya ad Rwada, based o low ed phoes ad Rapid- SMS, support that the details of the evet are appropriately coded ad etered i a paper form, take the ito a form o the mobile phoe ad set by SMS to the district level which is expected to register the evet. Legal processes eed to be established whereby a SMS ca be treated as a formal otificatio, somethig typically ot curretly i place Registratio There are few examples of fully automated registratio systems Computerized registratio iitiatives are typically ot itegrated with other systems Typically, registratio iitiatives are based o a electroic data warehouse approach where iformatio is stored i oe place I Albaia, for each citize a idividual record was created i the CRVS database, also treated as a populatio registry, ad issued a Uique ID (18) The Govermet of Fiji has itroduced a webbased system that itegrates iformatio from Health, Registrar Geeral ad Statistical departmets, elimiatig duplicatio of data etry ad codig Bagladesh has itroduced the Birth Registratio Iformatio System (BRIS) o a pilot basis with the aim to record idividual birth iformatio, automatically issue birth certificates, ad t retrieve ad report birth data whe required by storig them cetrally i a electroic database (19) 14

21 challeges, best practice ad desig priciples for moder systems 2.2 Status of iformatio systems for registratio Registratio of a vital evet by defiitio is a legal act, ad ivolves typically the issuace of a certificatio of registratio of the evet. Mostly, coutries have maual systems that are historical ad may have bee ruig for more tha a hudred years. As a part of reform efforts, may of these coutries are i the process of automatig their maual systems, ad differet techologies such as spaig ad computerizatio have bee ivolved i the process of digitizatio ad archivig. Amog low ad middle icome coutries, there are arguably oly a few that have fully automated systems with capabilities of geeratig also the legal documetatio required for the completio of the act of CR. Some examples are offered i Table 2. Table 2. Examples of automated civil registratio systems Coutry Albaia Mauritius Ghaa Examples Every citize has a separate record i the populatio database cotaiig his or her birth iformatio, residetial ad civil status iformatio (18). This is based o a web-based system facilitatig the geeratio of documets. This system uses as the primary key a uique persoal ID umber. CR iformatio is shared with other govermet departmets, ad citizes may obtai birth, death ad marriage certificates ad register marriages olie Uder the e-busiess pla, the coutry has put i place a system that, i additio to registerig vital evets ad geeratig VS iformatio, produces legal documets locally by accessig the cetral database CR systems do ot appear to be equipped with the facility for geeratio of the legal documets (11). Possibly, because these are mostly pilot systems, they may ot be etrusted with this resposibility Namibia A birth certificate is provided to all babies before they leave the health facility (20), which the eables itegratio with other govermet iformatio systems. The same situatio is reported i Ugada Philippies The Natioal Statistics Office (NSO) provides the facility to obtai birth certificates olie, sice all CR documets are digitized ad available i a database. It ca be see that there are may differet models beig used by coutries to carry out the registratio of the evet, ad the techologies are varied. Further, a large majority of the evets beig registered relate to births rather tha deaths, ad COD details are most ofte difficult to fid. 15

22 Civil Registratio ad Vital Statistics 2013: 2.3 Status of iformatio systems for vital statistics While some coutries are reported to have itegrated CR ad VS systems, for example Albaia, Egypt, Mauritius, Moldova, Mogolia, South Africa ad Thailad, most coutries by ad large seem to have separate systems. Itegratio of systems ehaces the capability of geeratig vital iformatio statistics reports ad also permits the aalysis of data, such as profilig of deaths by causes ad geography. Some of these systems store idividual records for life evets, from which statistical reports ca techically be geerated to help formulate demographic ad other idicators. I Fiji, the CR system is itegrated with the Health ad Statistics departmet, makig full use of birth iformatio which is etered at the time of birth at the health facility. This robust itegratio facilitates the extractio of VS data ad each citize is idetified by the birth registratio umber issued by the Registrar Geeral s departmet at the time of birth. From the Sample Registratio System (SRS) i Idia, statistical reports ca be also geerated. Also, basic demographic idicators are beig geerated from some of the demographic surveillace systems (17). The Chiese disease surveillace poit system collects COD data based o ICD-10 codes ad geerates statistics from these records (21). I the Muicipal Corporatio of Delhi, there is a itegrated system capable of producig statistical reports related to births as well as deaths. The BRIS from Bagladesh is oly reported to have the capacity to aggregate birth iformatio. Some surveillace systems, for example the Agicourt Health ad Demographic Surveillace System (HDSS) i rural South Africa, are updated aually with residet ad vital evets, from which they are capable of geeratig statistical reports. The Ghaa system is described to be capable of geeratig VS reports for the cluster of villages where the system is operatioal (11). Various systems have bee described as beig capable of geeratig statistics from idividual data such as those i Iraq (22), Malawi ad the Uited Republic of Tazaia (10), but it is uclear whether these represet the formal VS systems of the area. Similarly, the Electroic Idoor Morbidity ad Mortality Reportig system (eimmr) of Sri Laka reports COD iformatio for deaths occurrig i hospitals. Though it does ot cotribute to the formal death registratio statistics, this system is capable of geeratig statistical reports at facility, regioal ad atioal levels regardig hospital deaths, COD ad age-specific mortality rates (12), which do ot ecessarily relate to the formal VS systems of the coutry. As ca be see from this brief overview, there are various kids of systems i coutries that deal with VS. Some of the uderlyig characteristics of these systems are that ofte such statistics are ot geerated automatically from the idividual records of births ad deaths but represet a parallel system. The systems are sometimes techically ot capable of carryig out automatic aggregatio from the idividual records to geerate VS. Furthermore there are efficiet systems, such as the oe i Sri Laka, which are capable of geeratig aggregate 16

23 challeges, best practice ad desig priciples for moder systems statistics from idividual death records but, because they are ot liked to the CR system, are ot treated as the official VS ad thus face challeges i beig scaled atioally. 2.4 Key uderlyig characteristics of existig systems The above review of the status of CRVS IS based o their three fuctioal areas, which leads to a broader discussio of some of their uderlyig characteristics. While some of these characteristics have bee discussed earlier, they are further elaborated o ad combied below. CRVS IS are historically maual records Most low ad middle icome coutries still cotiue to have primarily paper-based systems, ad it ideed is a challegig task to make the existig systems digital ad redefie practices to support the ew digital eviromet. Icorporatig ad itegratig legacy data that ru ito may years eve over a hudred with ew systems, represets both a techical ad a istitutioal challege. There are of course associated problems i ot dealig with a digital database, such as the challeges this creates i sharig data electroically across systems, or i beig able to create cosolidated statistics by drawig upo data over time ad place. Small-scale systems, typically pilots CRVS systems represet the classical scalig problem i the health-care sector of allor-othig. This implies that if all the vital evets from a catchmet populatio are ot registered, oe caot say the VS are complete ad usable by the authorities. To achieve the beefits of a fully fledged CRVS system, all births ad deaths must be properly registered, ad these data must be shared widely a eed that caot be resolved through pilots, ad thus the merits of the CRVS IS become difficult to show. However, full-scale CRVS systems coverig the whole geographical area or all the vital evets are differet to costruct, give that most projects are fuded by doors ad are pilot ad short term i ature. A door project is usually desiged to cover a small pilot area, or a small part of the overall CRVS system, say birth or death registratio or a study o COD. This the does ot led itself favourably to fullscale deploymet. Focus o recordig A majority of techical itervetios seem to be takig place at the level of where the evet occurs, mostly cocered with recordig details of the evet, ad trasmittig iformatio either through paper i the traditioal model or by SMS where there are experimetal efforts usig mobile phoes. I may cases, this trasmissio does ot serve as a formal otificatio of the evet, because that calls for additioal legal requiremets to be i place, for example the thumb impressio or the sigature of the citize beig accepted. If this optio is ot available, the details trasmitted ca at least serve as a trigger for actios leadig to otificatio ad 17

24 Civil Registratio ad Vital Statistics 2013: registratio. The other importat characteristic with the recordig systems are that they focus primarily o the birth evet. Death recordig evets are more difficult to fid, a fact which ca be attributed to the challege i determiig COD, ad the fact that staff are typically reluctat to report a death, especially of mothers ad ifats. O the other had, systems that focus o COD, such as VA, are usually ot coected with the CR systems. Use of stad-aloe systems ot a holistic approach The differet systems beig used i CRVS ted to be largely fragmeted i ature, breakig the CRVS process ito smaller bits ad ot beig able to recostitute it as a whole due to their lack of techical capability to exchage ad share iformatio. I may cases, the use of a stad-aloe system, rather tha a web-based applicatio deployed through server cliet architecture, impedes the local settig to lik up with cetral databases; the local level is thus restricted i carryig out all the CRVS fuctios icludig the issuig of legal documets. Systems that cocetrate o oe or two aspects of the overall process, as do may i Africa, make the results of computerizatio ad moderizatio rather limited ad ot so promisig. May Africa coutries are experimetig with CRVS systems that ca collect relevat details at the poit of evet ad be capable of geeratig VS reports i their catchmet areas, but they most ofte lack the capacity to geerate documets that are legally acceptable. Furthermore, sice efforts are cofied to a small geographical area ad carried out i a research mode with limited capacity ad itetio to scale up, they are ot equipped with the legal authorizatios required. This leads to a vicious cycle: because of their pilot status they caot fully impact o the CRVS system, ad without its legal capacity, they are ot able to scale up. Agai, this impedes beig able to develop a overall picture of the CRVS status. Focus o births, ot deaths As metioed earlier, processes of death registratio ad the associated VS geeratio are see to be geerally poor i low ad middle icome coutries, where much greater emphasis seems to be give to moderizig birth-related systems. This is probably because birth registratios are relatively trouble free, while death records are ofte ot completed ad COD iformatio is otoriously difficult to fill. The problem is further magified whe deaths take place outside the health facility, i the commuity or at home. There are limited examples of atioal systems that are itegrated with death-related data comig from various sources such as hospitals, fueral homes or burial grouds. I additio to the challege of coverage of data, death data also suffer i terms of quality because of the challeges i accurately determiig COD, which is ofte left blak or completed as other. Proprietary techical platforms Most of the examples of CRVS systems reported i the literature are built o proprietary or o-ope source platforms, for example i Albaia. A cosequece of this is that data sharig across such platforms is a o-trivial challege because of costraits i accessig the code or the database structure by the agecies ivolved. The use of proprietary platforms 18

25 challeges, best practice ad desig priciples for moder systems teds to create vedor lock-is, where it becomes difficult to create ay chages to the code without cotract-based itervetios from the vedor. The problem of data sharig is further magified i the absece of the use of ope stadards i the CRVS domais. Or eve worse, i the absece of stadards themselves, sharig of data is problematic. Give the multisectoral ature of CRVS systems, the absece of easy ad free mechaisms of data sharig across systems makes it extremely difficult to have effective ad well-fuctioig systems. Lack of architecture focus Overall, there is a absece of a architecture approach i which, by desig, the various systems that costitute parts of the overall CRVS are see to exchage iformatio. These limitatios arise from both techical ad istitutioal coditios. Techical challeges arise from reasos of the use of proprietary platforms or systems ot desiged for iteroperability, ad the use of stad-aloe rather tha web-based platforms, which makes it complex for multiple systems to speak to each other. The lack of data-sharig stadards also provides other techical costraits. Istitutioally, there are various challeges for the systems to commuicate, the biggest oes beig that systems are owed by differet miistries ad are thus guided by differet orms ad sets of practices. For example, while the HIS come uder the purview of the Miistry of Health, the CRVS IS is the resposibility of the Miistry of Justice. As a cosequece of differet istitutioal owerships, problems arise because of the absece of shared vocabularies by which the respective systems are able to recogize each other s data, ad eve more challegig is the absece of a political will to share. I summary, the challeges to CRVS ca coceptually be uderstood at three itercoected layers. The first is at the political or istitutioal level reflectig the weak uderstadig ad agreemets betwee the differet stakeholders (for example, the Miistry of Health ad the Miistry of Justice) to share data ad to have commo stadards. Furthermore, these differet etities act oly o their respective fuctios, ad ofte do ot value itegrated iformatio comig from differet fuctios. The secod is at the level of the busiess logic or the sematic level cocerig the aligmet of the purposes of why the systems should share data. For example, if both the health ad justice departmets are collectig data o evets of deaths, they should share also the commo busiess goal that the recordig of these evets should lead to the evets beig registered with the CRVS system accordig to the legal requiremets of the coutry, resultig i the issuace of a death certificate from a commo database of vital evets. For this to take place, at the third, techical level, there must exist iteroperability or to have sytactic iteroperability by which data could be shared with each other. A importat poit to ote is that these three levels are itercoected, ad without agreemets o ay of the three levels the system caot operate i totality. This three level itercoected model is represeted i Figure 1, which the becomes also a ormative ideal to strive for i the process of reformig CRVS systems. 19

26 Civil Registratio ad Vital Statistics 2013: Figure 1. Three level iter-coected model of CRVS Level 1 Iformatio eeds, users, usage across orgaizatios Social system level Istitutioal use of iformatio Level 2 Software applicatios ad iformatio systems Applicatio level Other systems HMIS Applicatios supportig use of iformatio CRVS applicatios Level 3 Techical level Iteroperability ad stadards, techical ifrastructure Health records Verbal autopsy Populatio Cause of registries Death reportig Facility list Data stadards ad ifrastructure supportig the applicatios Source: adapted from (5). There are some best practices, see i both developed ad low ad middle icome coutries, which iscribe the priciples of this three level model ad which arguably has cotributed to their beig described as best practices. It thus becomes importat to try ad uderstad how i these examples they have operatioalized desig represetig this three level model. The ext sectio examies examples of five best practices comig from diverse cotexts of Australia, Demark ad Norway represetig developed coutries, ad two low ad middle icome coutries Albaia ad Idia. After havig itroduced these examples, i the followig sectio we iductively draw learigs from them to try ad ifer desig priciples that ca ormatively guide system buildig efforts to achieve this three levelled itercoected model. Followig this, we discuss some of the perceived techical ad istitutioal challeges, from the perspective of a low or middle icome coutry, i achievig this ormative framework. Workig to meet these challeges ca provide a road map for future CRVS IS buildig efforts. 20

27 challeges, best practice ad desig priciples for moder systems Sectio 3. Best practices of CRVS INFORmatio systems 3.1 Examples from developed coutries There are experieces i developed coutries from which low ad middle icome coutries may usefully gai. This sectio thus presets CRVS-related experieces from Australia, Demark ad Norway which are see to be relevat for all coutries i how they approach the desig ad implemetatio of their respective CRVS systems. Australia I Australia, there is strog coordiatio betwee the differet actors ivolved i CRVS, based o iteragecy cooperatio betwee people ad agecies to achieve good quality data o births, deaths ad COD. These iclude health facilities (for births, death certificates), the Registries of Births, Deaths ad Marriages, Justice Agecies ad courts (for coroer deaths), ad various private agecies (such as hospitals ad fueral directors). The Australia Bureau of Statistics serves as the poit of cosolidatio of data from these differet sources, ad to esure completeess ad coverage. I Australia, health iformatio is treated as a essetial compoet of the CR process, ad birth otificatios ad medical certificatio of death must be received before a birth or death ca be registered. I particular, this creates a very strog icetive for deaths to be properly certified. The registratio of deaths is the resposibility of the eight states ad territory Registrars of Births, Deaths ad Marriages, who receive the cofirmatio of a birth or death from the health system. Iformatio o COD is supplied by the medical practitioer or by a coroer to the registrar, who the forwards it to the Bureau of Statistics for codig, compilatio ad supplemetatio with iformatio from the Natioal Coroers Iformatio System. Data quality assurace is provided at every poit i the productio of statistics, icludig receipt from registries, editig, codig ad publicatio. The key experieces from Australia ca be summarized as follows: Health data are treated as a essetial compoet of CR. The Bureau of Statistics plays a key role to coordiate iformatio collectio, codig ad publicatio ad esure coverage ad quality. There exists a widespread ivolvemet of various actors of the CRVS systems, ad their systems of coordiatio. There are strog processes i place at differet stages of the iformatio flow to stregthe data quality. The system is especially strog i brigig i COD iformatio, which remais historically weak i most atioal CRVS systems. 21

28 Civil Registratio ad Vital Statistics 2013: Demark The electroic CPR system i Demark was established i 1968 (25). Registratio is based o the otificatio of birth to the atioal birth registry, ad covers 99% of births i the coutry. Each birth record is liked to the mother s PIN i the CPR. The CPR system records cotai PIN, ame, geder, date of birth, place of birth, place of residece, citizeship, vital status, CPR umber of parets ad spouses, alog with a additioal 150 variables. The records are updated o a daily basis. The PIN assiged to each idividual is uique ad used i all atioal registers. The PIN has te digits, where the first six idicate the date of birth (two digits each for day, moth ad year), the ext three idicate a serial umber to distiguish betwee persos bor o the same day, ad the last oe is a cotrol digit itroduced to miimize recordig errors ad it lso idicates the sex of the perso registered. Oce a perso has bee assiged a PIN, the same will ot be assiged to aother, ad stays with the perso forever. The CPR umber does ot cotai ay persoally attributable data other tha the date of birth ad the sex (25). The Daish system reflects a good architecture, where there is a cetral PIN liked to various other systems such as health ad admiistrative services. While privacy is esured, it still has a cetral system of likage. Security ad privacy cocers are importat whe dealig with CRVS, ad computerizatio icreases the vulerability of the iformatio as sesitive ad vital iformatio is available i electroic format (26). The challege is to secure iformatio from uauthorized access, while maitaiig itegrity ad esurig authorized access. It has bee reported by Pederse et al. (27) that the iformatio i the CPR is of very high quality, ad various factors could cotribute to this. Iformatio is cotiuously used by public admiistratio employees, who correct erroeous iformatio as they ecouter it. Whe the CPR was established, all citizes received a certificate with their ow iformatio, ivitig them to correct it. The PIN is well desiged ad serves the eeds of the populatio. The system architecture is well desiged supportig privacy, itegrity ad accessibility of the ame-based records. Like the Norwegia system described earlier, the Daish system also shows well-desiged techical ad istitutioal measures cotributig to a robust ad well-fuctioig CRVS system. Norway From as log ago as 1685, Norwegia churches reported aggregated births, deaths ad marriages (23, 24). I 1876, a ew law required all births, deaths ad marriage iformatio o a idividual basis to be set to the Norwegia Cetral Bureau of Statistics aually. I 22

29 challeges, best practice ad desig priciples for moder systems 1964, a computerized Cetral Populatio Register (CPR) was itroduced i Norway based o the 1960 cesus. I the same year, a Persoal Idetificatio Number (PIN) was established. I 1994, all local registratio offices were fully computerized ad had a o-lie coectio with the CPR database. VS i Norway date back to 1735 with figures o births ad deaths, ad marriages were icluded from From 1968, aual VS have bee produced based o the data hosted i the CPR. Statistics Norway was formally established as a etity i 1876, ad produces today approximately 90% of all official statistics i Norway. Sice 1991, the Norwegia Tax Admiistratio uder the Miistry of Fiace has had the resposibility to esure that the CPR is accurate ad up to date. A statistical copy-register rests with Statistics Norway ad similarly with a distributor (a private compay). While the CPR is updated i real time, the copy-registers are kept up to date with batches every ight. The CPR is used for populatio statistics, but also acts as the foudatio for tax admiistratio, electios ad public admiistratio i geeral, as well as beig available to the private sector (baks, isurace compaies ad credit iformatio agecies i particular). At the same time, access to the CPR is strictly regulated. Public etities are grated access if ecessary for admiistrative purposes, while private compaies oly have access to o-cofidetial iformatio if it is ecessary to esure their respective legal rights. Access ca be grated as direct logi to the registry based o a cliet, or batch trasfers of the registry to local databases. Keepig the atioal registry up to date is based partly o otificatios from the authorities, such as birth ad death otificatios, but also otificatio from citizes. For example, Norwegias are obliged by law to register if they are chagig address, ad doctors ad midwives are obliged by law to otify the local tax office o later tha a week after a child is bor. If the child was bor without a doctor or midwife preset, the mother shall withi oe moth after the birth sed a otificatio to the local tax office. The local tax office forwards this paper-based birth otificatio to the CPR, which subsequetly requests the issuig of a PIN from the Office of the Natioal Registrar ad registers the baby i the cetral database. Fially, the tax authorities are issuig birth certificates. I the case of a death, it is the resposibility of the ext of ki to sed a otificatio to the probate court ad the local police i the muicipality where the perso was livig. The probate court will forward the otificatio to the CPR. At the same time, a doctor will issue a death certificate, whether the death occurs i a hospital, a istitutio or at home. CR is for Norwegia citizes a obligatory passage poit to access a rich ad varied set of social services. For example, registerig a birth will trigger the paymet of family allowaces ad registerig a chage of address will grat citizes the right to receive public services i the viciity of where they are livig. Further, may public registries (tax offices, real estate, vehicles, passports, police, etc.) ad private corporatios are usig the CPR for address iformatio. Whe chagig address or ame, chages i the CPR will propagate, as ame ad address is fetched from the atioal registry by a rage of public ad private istitutios whe eeded. Thus, citizes will save the efforts of iformig all these istitutios idepedetly 23

30 Civil Registratio ad Vital Statistics 2013: by iformig the CPR, ad the differet public etities ca keep track of the citizes to assure correct collectio of taxes ad paymet of pesios. The CPR is further used as the foudatio for rights ad duties, issuig of passport, birth certificates ad other idetificatio documets. Based o these strog icetives, the CPR has achieved the status of beig the cetral register, havig high quality data ad operatig i a idepedet fashio ad thus beig trustworthy. Accordig to a assessmet i 2006, the quality of data i the Norwegia CPR is very good, both i the sese that the data are accordig to the otificatio received as well as legally correct. The success of the Norwegia system ca be attributed to the followig factors. Both CR ad VS are historically well-developed istitutios datig back more tha two ceturies. The close likage betwee CR ad VS was established more tha a cetury ago, ad has bee deeply stregtheed through istitutioal use over time. All fuctioal areas of CRVS are supported by regulatio ad legal acts (recordig ad otificatio, registratio ad VS). CPR is used as a master registry for a rage of public ad private purposes strog icetives for citizes ad private ad public istitutios to keep it up to date. Well-desiged techical systems based o a architecture approach support the istitutioal madates of data sharig. I summary, it ca be see that the Norwegia CRVS has achieved success through a series of techical ad istitutioal measures, icludig a strog goverace model. 3.2 Examples from low ad middle icome coutries I Sectio 2, while describig the status of CRVS systems geerally, the various examples primarily described some of the weakesses of systems i low ad middle icome coutries. While the geeral picture of CRVS IS i such coutries is a challegig oe there are also some exceptios, which ca be see as best practices ad serve as ispiratio for other coutries to emulate. I this sectio, two such positive examples are draw from very differet cotexts i Albaia ad Idia. Albaia Based o the Moderizatio of the Civil Registratio System i Albaia project, Albaia has improved o periodicity, quality, reliability ad comparability of data ad idicators, especially o demographics ad VS. The aim of the project was to develop a cetralized CPR, with a dual focus o stregtheig the ability ad capacity of the CR system by establishig a cetral admiistrative uit, a cetral atioal register ad the ecessary legislatio ad moderizig the CR offices, icludig the trasitio from paper to digital records. 24

31 challeges, best practice ad desig priciples for moder systems Durig the iitial stages of the project, the focus was o scaig ad archivig of paperbased register books ad sharig of iformatio with third parties. Statistics Albaia utilized this shared iformatio to geerate register-based statistics. I 2008 all the registratio offices were coected through the Iteret with a web-based system ad all citizes were registered i the CPR. The CPR was also used for creatig the voters list ad to issue biometric passports ad ID cards. A limitatio here is the proprietary ature of software used to develop the web-based system, which firstly made it expesive to develop ad secodly i eablig data sharig processes with other systems. This also restricted the likages betwee the CRVS ad other govermet data. For each citize, a idividual record is created i the CRVS database, also treated as a populatio registry, ad issued a uique ID (18). This system is reported to have achieved atioal scale ad is capable of geeratig atioal-level VS. The web-based system also facilitates geeratio of legal documets at the local settig, accessig the iformatio stored i a cetral locatio where idividuals are idetified by their uique ID umber. This registered iformatio is shared with other govermet departmets, for example facilitatig the issuace of passports ad other documets based o the registered birth certificate. The legitimacy of the idividual is cofirmed through the system whe the perso accesses other govermet welfare services. A commo govermet web portal is used for may egovermet services icludig vital registratio. I this system, each citize is registered with a birth registratio umber issued by the Registrar Geeral s departmet. A citize ca obtai birth, death ad marriage certificates ad register marriages olie. The Norwegia statistical office has bee actively supportig the moderizatio iitiative i Albaia. Key experieces from Albaia ca be summarized as follows: Moderizatio requires a dual focus o the cetral database ad the registratio offices that are distributed. Overall, a holistic approach has bee adopted by examiig the likages betwee the CRVS system ad other supportig systems. Usig the CR system as the basis for the list of voters helps to stregthe the istitutioal role of the system. Despite the extra costs ad barriers for itegratio iduced by the proprietary ature of the software used, the system has facilitated sharig of iformatio betwee public etities ad has esured accessibility for the citizes. Muicipal Corporatio of Delhi, Idia The Muicipal Corporatio of Delhi (MCD) is a big orgaizatio coverig 14 millio citizes livig i Delhi. The MCD Health Departmet has computerized birth ad death registratios sice 2003 with the aims of reducig errors, improvig speed ad efficiecy, developig better maagemet of huma resources, allowig more complete access to iformatio ad 25

32 Civil Registratio ad Vital Statistics 2013: permittig real time trasparecy. The other iterestig aspect of the system is the itegratio betwee the health ad registratio fuctios, ad details of births ad deaths takig place i the hospitals are electroically trasferred to the registrar office. The MCD has a Citize Service Bureau (CSB), which serves as a sigle-widow port for the citizes to access differet services, icludig the issuace of birth certificates. Ay citize who eeds a certificate ca i perso request a prited copy, or use the olie orderig facility, payig by credit card ad receivig the certificate at the doorstep upo paymet of courier charges. Computerizatio has also facilitated the process of geeratig a uique PIN for each child. It has helped to improve data maagemet, speed up the geeratio of reports ad provide ehaced olie moitorig. It has also helped i the moitorig of births by sex ad zoe i the city. CSB has further lauched a olie istitutioal registratio system supportig all govermet ad private hospitals/istitutios to register births ad deaths. Because the scheme primarily covers istitutioal births, the head of the family or the relative livig earest to the registratio cetre registers births or deaths that have take place at home. The olie system maages early 1200 etries ad geerates some 3000 birth ad death certificates every day. Furthermore, a pilot project was lauched i 2006 to lik immuizatio to birth registratio. This has covered 32 materity homes with the aim of itegratig basic services for childre. This was implemeted withi the framework of a tripartite partership ivolvig the MCD, the Office of Registrar Geeral ad UNICEF. Immuizatio ad birth registratio are two services provided for childre by the MCD ad hadled by two separate sectios withi its Health Departmet. At the time the pilot was iitiated the birth registratio system was already computerized, while the immuizatio programme ivolved a maual process, with a fair degree of overlap i data collectio ad ext to o sychroizatio. There were obvious advatages to be had through itegratio, as it would help to track a child from birth to the cycle of completig full immuizatio (or ot) i additio to reducig duplicatio of work ad iformatio flows. Data etered oce while registerig births would also be used for immuizatio, for the compilatio of a database o childre by area, ad for plaig ad supervisio at the facility level, icludig the geeratio of electroic registers. It was evisaged that the system would help to stregthe reportig of evets (births/deaths) occurrig i the commuity covered by outreach staff of the immuizatio programme, icludig uregistered childre bor outside the MCD area. This iformatio would be set to the Office of the Registrar Geeral of Idia for forwardig to respective states (provices). UNICEF supported two compoets of this pilot project, amely staff traiig ad software developmet, ad the project was scaled to cover the etire MCD area from April This has helped to have a very efficiet system for geeratio ad dissemiatio of birth certificates. Key experieces from MCD ca be summarized as follows: Computerizatio is facilitatig data maagemet, reportig ad aalysis such as the profilig of births. 26

33 challeges, best practice ad desig priciples for moder systems Through itegratio, data etered while registerig births are also used for immuizatio, to compile a database o childre by area, ad for plaig ad supervisio at the facility level. A likage betwee the birth recordigs i materity cliics with birth registratio i the registrar office has bee established, so data do ot eed to be etered twice. The CSB eables citize-friedly services i the dissemiatio of the birth ad death certificates to citizes. This case demostrates that olie systems for recordig ad registratio are feasible also i low ad middle icome coutries. 27

34

35 challeges, best practice ad desig priciples for moder systems Sectio 4. Challeges ad opportuities FOR CRVS systems This sectio describes five key themes emergig from the assessmet related to challeges ad opportuities for CRVS systems: scalig up, iovatio, itegratio of systems, busiess process streamliig ad automatio of CRVS processes. Drawig o experieces from the MOVE IT projects i Bagladesh, Cambodia, Idoesia, Keya, Mozambique, the Philippies ad Thailad (6), the focus is o idetifyig opportuities ad how they were leveraged, challeges experieced ad promisig approaches that have show results. 4.1 Scalig up CRVS iformatio itervetios must provide scale-up opportuities to move beyod pilots. More particular, CRVS IS must work across admiistrative levels (facility to district up to cetre ad also back), iteragecy (e.g. automatically from commuity workers registry or health ad ito a cetral database used by registries or health) ad expadig i terms of geographical ad temporal coverage. Fuctioal scalig also ivolves expadig the techical capabilities of the system, so that it ca cater to more fuctios, ad provides for likages with other systems. Opportuities ad how they are exploited The MOVE IT project i Thailad built upo existig learig, icludig a prior Global Fud project, thus leveragig existig capabilities. While the project focused o a research project cotaiig limited data o HIV/AIDS-related causes of death, it ca potetially be scaled to the atioal level coverig the etire HIV/AIDS programme, ad also to other health programmes such as those for malaria ad tuberculosis. Similarly i Bagladesh, by positioig the project withi the framework of govermet s use of medical record system (OpeMRS) ad health iformatio system (DHIS2), the potetial for scalig was established, eablig developmet of existig capabilities ad ifrastructure. I the Philippies, the project was tried out i six baragays withi a particular Local Govermet Uit. Sice it built upo two govermet systems related to CR Baragay Civil Registratio System (BCRS) ad Watchig over Mothers ad Babies (WOMB) it created the potetial to scale easily withi the framework of existig govermet mechaisms. I Keya, there were strategies tried out to develop a itegrated architecture at the couty level that would lik through iteroperability a suite of facility-level tools icludig medical record systems, HIS, logistics, huma resources ad others. The pla is to make the MOVE IT iitiative a cetral compoet of this architecture, thus beig scaled with the architecture. I Mozambique through a real-time implemetatio, the scalig challeges of CRVS IS could be uderstood, leadig to the developmet of improved itervetios. 29

36 Civil Registratio ad Vital Statistics 2013: Challeges experieced I Thailad, a key challege to scalig came from movig from a research eviromet to the practical field of the Miistry of Health. The persoel ad expertise to carry out the ecessary aalysis (statistical ad epidemiological) of CRVS data was housed i the uiversity departmet, ad was typically ot available i the miistry. I Bagladesh, the developmet of the CRVS software was outsourced to a private compay. Also, the scalability of the applicatio depeds o agreemets o owership of the code ad liceces. While licesig fees may be small for a pilot implemetatio, a atioal roll-out would prove very expesive; if the govermet were to experiece costraits i assumig full owership of the fiished product, scalig would be adversely affected. I Keya, the key challege to scalig was that the server was cetralized ad hosted i Geeva for the mobile solutios made. As this will restrict local owership of the data ad ifrastructure, it would adversely ifluece scalability ad sustaiability. Approaches Dealig with these issues must be based o a uderstadig that scalig will ot happe o its ow, but eeds to be desiged, plaed ad implemeted. These processes must focus o the followig cosideratios. Build i the perspective of a total cost of owership i the desig of such systems, so that the efforts required for operatig, maagig ad supportig the systems over time, ad at full scale, are firmly budgeted i the process. Door projects should explicitly build i mechaisms of fudig ad resources to support these scalig processes. Geographical ad fuctioal scalig must be made a explicit aspect of cosideratio i the system desig ad i particular its architecture. Where coutries are developig itegrated atioal architectures i the health area (HIS, logistics, patiet records, etc.) the CRVS systems must be made a key part. To support scalig itervetios, the CRVS system should be positioed withi existig frameworks ad stadards ad should develop based o existig techological ad huma capabilities. 4.2 Iovatio Broadly, iovatio is uderstood as the capacity to carry out ew tasks usig techological itervetios, or usig iovative methods to deal with ogoig problems that have previously bee difficult to solve usig existig meas ad techologies. Aother importat aspect of iovatio comes from the istitutioal factor, reflectig the degree to which the state or coutry was ivolved i the desig, developmet ad implemetatio of the project. This potetially stregthes the level at which the host coutry or istitutio would have leart about the local iovatio, ad their capacity to ow ad take it forward. 30

37 challeges, best practice ad desig priciples for moder systems Opportuities ad how they are exploited The Thailad MOVE IT project focused o a existig problem of weak coverage ad quality of COD data by combiig data sets relatig to CR ad HIV prevalece, especially for year-olds. This helped to gai iovative isights o prevetio ad treatmet effects aroud HIV/AIDS, ad how to deal with icomplete data sets. The iovative techique that was developed through the project could potetially be scaled to the atioal level HIV/AIDS programme i Thailad, or to other disease programmes ad also to other coutries. The Mozambique project demostrated the iovatio of beig able to discer mortality treds based o routie data. This was ot possible earlier because the tools ad registers were ot i place, ad also routie data had ot bee used for this purpose. By buildig upo ogoig efforts of the miistry to stregthe the CR systems, the SIS-ROH software provided the required tools to allow iovative isights. These were further eabled by traiig ad support efforts of local staff i each of the sites, ad also the steady expasio i the software fuctioalities, such as icludig facilities for processig iter-hospital deaths. Scalig was, however, limited by the fact that the software was ot web based, which meat improvemets i a ew versio of the software eeded to be reflected i every istallatio. The project staff ackowledged this limitatio ad were proceedig to make the software web-eabled i the secod versio, ad also likig the system with the DHIS2, a ope source web-based applicatio curretly i the process of beig implemeted atioally for the Miistry s Health Maagemet Iformatio System. The Bagladesh project ca also be applauded for its emphasis o supportig the atioal miistry s use of ope source software for aggregate ad patiet-based systems, which potetially allowed more possibilities for creatig iovative uses. Further, by cosciously tryig to desig for the likages betwee these differet systems, other potetially more iovative uses ca be eabled. The Keya project showed iovatio i applyig a commuity-based approach to stregthe CR systems. Withi the existig framework of how CR is carried out, mobile phoe applicatios were used to stregthe systems of otificatio of a vital evet. O receivig the otificatio, the authorities were supposed to iitiate processes to carry out the act of CR. I the past, they would say they had ot received the iformatio of the vital evet from the commuity; today, with the ew system of otificatio, there is less chace of sayig that ad thus a higher probability that the evet is registered. Challeges experieced The project i Cambodia was focused o the HIS stregtheig processes, ad the potetial iovatios with respect to CRVS stregtheig were limited to primarily buildig awareess. Whe a project is part of a larger iitiative, i this case HIS stregtheig, there is the challege that oly limited attetio is give to CRVS IS stregtheig because the overall focus is o somethig else. Aother key challege experieced i Keya was that oly 57% of all births ad 49% of all deaths were beig registered. This low coverage could be attributed to the fact that evets outside health facilities were ot beig registered. The Mozambique project poits to the techical limitatios of workig with o-web-based software, while the Keya 31

38 Civil Registratio ad Vital Statistics 2013: case shows the istitutioal challeges of likig the otificatio process with others such as registratio ad the geeratio of VS. Approaches A iterestig observatio across these differet examples of iovatio was that the drivig impetus came ot oly from the techology but from the fact that the effort was grouded i strog programme-based logic. For example, i Thailad the guidig logic was a strog public health uderstadig of how CR data could be combied ad modelled with HIV data to develop ew isights. Similarly, the example from Philippies was the logic of tryig to uderstad from the programme perspective why people do ot register vital evets of births, deaths ad marriages. Based o this uderstadig, clear recommedatios could be made how the systems (such as the BCRS form) must be modified to gather more relevat data to help ehace the quality ad coverage of data. Also, i the Keya case, the startig poit was the programme-based uderstadig of how to stregthe the commuity compoet of the vital registratio system. Based o this, a appropriate mobile applicatio was developed that complemeted the existig commuity registratio systems. The key learig is the eed to situate the system withi strog programme logic, ad ot to itroduce techology for its ow sake. 4.3 Itegratio of systems CRVS systems i low ad middle icome coutries are disparate, typically ot desiged to be itegrated, ad focusig o oe aspect of the overall CRVS process. This is a key challege udermiig both the coverage ad quality of CRVS data. Itegratig the differet compoets is a techical challege related to stadards, protocols ad ifrastructure data iterexchage. At the same time, the multisectoral ature of CRVS implies that itegratio is also a equally sigificat istitutioal challege requirig istitutioal agreemets achieved at the level of departmets ad miistries, ad the establishmet of goverace ad coordiatio mechaisms. Opportuities ad how they are exploited The cases of Australia, Demark ad Norway demostrate a broader ad systemic itegratio rather tha a piecemeal itegratio ivolvig oly certai subsystems. I all these cases, a key igrediet seems to have bee twofold: (a) makig oe cetral repository of data to esure quality ad itegrity, while eablig access to differet istitutioal data owers to esure data are updated; ad (b) establishig strog goverace mechaisms to esure that there is appropriate techical ad istitutioal coordiatio ad the developmet of shared uderstadig. I the cotext of low ad middle icome coutries such as Albaia ad Idia, we ca see similar priciples beig adopted. Techical solutios i Delhi provided for birth ad death data as they were recorded i the hospital facility to be made available automatically to the Registrar offices for the evet to be registered. Itegratio i Albaia was eabled through 32

39 challeges, best practice ad desig priciples for moder systems fosterig iterdepedecies, where for example the issuig of a passport depeded o the use of the registratio data. Delhi also showed how registratio was itegrated with citize services, makig it easier for citizes to receive their registratio certificates: for example, they could visit kiosks to collect certificates or eve have these couriered to their home address o payig a ormal fee. Use of techologies such as mobile phoes i Keya ad Rwada have fudametally helped to itegrate differet sub-processes such as the recordig of a evet to its otificatio. A key learig here is how to eable itegratio through both techical ad istitutioal mechaisms, which are best take i cojuctio. Challeges experieced I low ad middle icome coutries, itegratio teds to fail at two levels. First, CR ad VS systems are typically separate, hamperig the ability to geerate VS reports or to carry out data aalysis such as profilig of deaths by causes ad geography. Secod, CRVS systems (separate or ot) are typically ot itegrated with other systems geeratig relevat data, for example iformatio related to death emaatig from hospitals, fueral homes ad burial grouds. This is typically a combied result of a prevalece of paper-based registries; lack of stadards, protocols ad ifrastructure for data iter-exchage; ad lack of willigess to share ad policies supportig iformatio sharig. The use of proprietary systems i may such coutries acts as a severe impedimet to itegratio, although as Albaia demostrates they ca be overcome with strog istitutioal efforts to itegrate, albeit at higher cost. Aother challege ofte see is that the istitutios do ot have clearly defied cases for deployig itegrated data, ad by desig the systems are ot made to share data. Approaches There are several treds that may cotribute to chagig the situatio i meetig itegratio challeges. First, are ew techological opportuities such as the Iteret ad mobile phoe etworks. Iteret backboes ad coectivity are cotiuously improvig i low ad middle icome coutries, eablig the use of web-based ad cliet-server architecture which, by desig, allows for itegratio i sigle repositories. There is rapidly icreasig coverage i the extet ad quality of coverage of mobile phoe etworks as a data carrier bears with it the potetial to coect remote sites. Secod, there is a growig awareess of the eed for coordiated sharig at both global ad atioal levels, ad with it the elaboratio of iitiatives to develop frameworks ad stadards related to, for example, HIS architectures, supportig the use of ope source tools ad stadards to stregthe itegratio. The HMN promoted the use of a data warehouse approach to eable the itegratio of data ad the creatio of a shared repository to support a multiplicity of user eeds. Coutries such as Idia have a atioally declared policy to support ope stadards, which provides a eablig eviromet to support itegratio. Third, there are iitiatives ogoig i various coutries to promote ope iformatio by removig data-sharig ad kowledge-sharig barriers. Thus a broader eviromet is beig created to stregthe itegratio efforts, ad tools are comig forth to help materialize these opportuities ito practical realities to stregthe itegrated 33

40 Civil Registratio ad Vital Statistics 2013: systems. A key igrediet is for istitutioal actors to actively pursue itegratio efforts right from the desig phase. 4.4 Busiess process streamliig CRVS systems are composed of various busiess processes such as recordig, otificatio, registratio ad the geeratio of VS. These busiess processes each have their particular iformatio flows, artefacts i use ad applicatios. CRVS IS itervetios must be carefully desiged to support flows of iformatio both withi the process ad also betwee differet etities ad iformatio systems that comprise the CRVS IS architecture. Takig a busiess process view of CRVS ca help to establish the flows ecessary to geerate high quality data i a sustaiable way ad esure active use of the data by differet stakeholders. I low ad middle icome coutries, there teds to be a lack of busiess process thikig i relatio to CRVS systems, also reflected i the itegratio discussio above. Takig such a perspective ca be vital for stregtheig the overall system. Opportuities ad how they are exploited While origially the otio of busiess process reegieerig came from the domai of maagemet cosultacy, i recet times this methodology has also bee applied to the social sector, such as i the public health reform effort i Ethiopia. As a part of this reform process, each fuctioal uit of the health uit was defied as a busiess process, with clearly documeted process owers, processes of iformatio ad workflows, iputs ad outputs, ad criteria to evaluate the effectiveess of a process. I this way, the systems are able to idetify clearly ay bottleecks i the processes ad suggest how they ca be removed. I CRVS, there are clear opportuities for such a busiess process approach to be adopted to help alig, streamlie ad recofigure processes so as to attai stroger syergies. By treatig, for example, otificatio as a busiess process, the practice of otificatio ca be applied just as easily to birth otificatio as it ca to death otificatio, ad is a opportuity to have both effectiveess ad efficiecy i implemetig the process. A medical otificatio of a death ca be used both to geerate COD iformatio ad to serve as the basis for death registratio. A busiess process perspective ca help to idetify how the outputs of a sigle process ca feed ito multiple processes, thus improvig itegrity of data ad reducig redudacies. Mappig out ad aligig the busiess relatioships betwee differet stakeholders ad etities require defiig the orms of the iterlikages betwee these etities, process owers, what are source(s) ad destiatio(s) of differet processes, thus emphasizig iterlikages right at the desig stage. Such thikig provides guidelies o how should data be shared, what are mutual beefits, how to resolve coflicts ad other such processes. 34

41 challeges, best practice ad desig priciples for moder systems Challeges experieced A key challege i applyig such a approach to the domai of CRVS is to develop a shift i mid set, ad be able to coceptualize the etire system as a set of itercoected processes. The existig systems of fragmetatio ad compartmetalizatio serve as sigificat impedimets to the applicatio of such a approach. Aother challege comes i the maer i which such a approach has bee applied i busiess settigs. The approach take has ofte bee to eglect history, by elimiatig existig processes, ad rebuild them by startig from a clea slate. However, history ca ever be elimiated, ad there always will be a istalled base both techical ad istitutioal which will shape the trajectories of all ew itervetios. A challege i desig is thus to foster a deep uderstadig of these existig processes, ad how they ca be leveraged to shape future trajectories. Aother key challege experieced is largely istitutioal i gettig the differet stakeholders to adopt a radically differet way of workig ad coceptualizig the CRVS domai. There may be resistace comig from the stakeholders because of fear of visibility, a sese of loss of cotrol ad other such reasos. These will have to be gradually dealt with through strog ad clear goverace mechaisms. Aother challege would cocer aligig the differet processes so that they ca meaigfully commuicate with each other. As poited out earlier, redefiig busiess processes i CRVS ecessarily ivolves also chages i the legal framework, for example of acceptig computer-geerated documets for the geeratio of a birth or death certificate. Legal chages are much more difficult to make, so high-level political will eed to be cultivated. Aother challege is techically likig systems which are aturally distributed, such as a VA carried out i a commuity withi the death certificatio processes. While there are potetially techologies that ca eable these likages, ot all areas ad groups of people have effective access to them. Esurig ifrastructural ehacemets equally will thus be aother key challege. Approaches Sice the busiess process reegieerig techique came ito vogue i the 1980s, much experiece has bee gathered o what works ad what does ot. Similar experieces exist from the social sector i low ad middle icome coutries. A uderlyig desig guidelie is to lear from these experieces, ad to uderstad how they must be customized to the particular coditios of the CRVS cotext. A key aspect to the approach take is to udertake a visioig exercise, where the differet busiess process owers are brought to a table to uderstad the approach ad its costituet igrediets, the beefits to be achieved by adoptig such a approach, ad how techologies ca eable the process. Oce a commo visio is adopted, the challege is to preset the etire CRVS system through this busiess process approach ad to idetify the various sub-processes ad how they iteract, both historically ad as evisaged for the future. 35

42 Civil Registratio ad Vital Statistics 2013: 4.5 Automatio of CRVS processes Digitizig ad computerizatio of CRVS systems bears with it the potetial for ehaced effectiveess ad efficiecy by automatig processes. First, automated systems ca have the capability to geerate ad issue legal documetatio such as birth certificates for the completio of the act of CR. Secod, aother area of opportuities is automatio to eable the triggerig of ext steps such as otificatio ad registratio based o certai evets ad actios. For example a death otificatio, beyod triggerig a otificatio process, ca also help to iitiate a VA process. Third, ad related to itegratio as discussed above, a otificatio i oe system ca also trigger actios i other, itercoected systems, beefitig registries as well as HIS. The biggest advatage of automatio is the developmet of cetralized ad shared databases, which ca eable multiple actios to be triggered from the same source. Opportuities ad how they are exploited The MOVE IT projects provide a rage of examples o how various CRVS IS-related processes ca be effectively automated: recordig, otificatio, registratio, geeratio of VS, ad aalysis ad use of data. Further, a rage of techological optios computers, mobile phoes ad digitizig ad scaig techologies are available ad have bee tested to help support the automatig fuctios. For example, several of the MOVE IT projects used SMS o mobile techologies, such as i Keya ad Rwada, to help automate the process of recordig ad otifyig a birth or death evet. Coutries such as Albaia ad Idia have demostrated how large databases ca be used to create cetral repositories of data ad their sharig across istitutioal actors. Projects i Thailad ad the INDEPTH etwork demostrate the power of computers to carry out aalysis of data, ofte itegratig hitherto fragmeted data sets to geerate more itegrated aalysis. Sri Laka has show the value of usig digitizig ad scaig techologies to deal with the challege of legacy data. Similarly, Mozambique demostrated how the process of death ad COD (based o ICD codes) ca be automated, to develop very useful COD profiles. Challeges experieced Challeges experieced i the above examples are ofte similar to those see i other computerizatio projects carried out i the public sector of low ad middle icome coutries. These relate to weak ifrastructure, poor huma resources capacity, scalig ad sustaiability challeges, ad issues of chage maagemet. However, these challeges are ot isurmoutable, ad efforts i sectors such as health have demostrated approaches o how they ca be overcome. Agai, as has bee emphasized earlier i this report, while the techical optios are becomig more widespread, costs are fallig, ad there are more itegratio optios techically possible, the istitutioal ad political challeges remai a thory challege. There are ofte iappropriate techical choices made, for example the use of proprietary systems, which the go o to impede further computerizatio efforts i the future whe scalig of systems is required. Automatio leads to iformatig, where 36

43 challeges, best practice ad desig priciples for moder systems through automatio, iformatio becomes visible which was ot possible before. For example, automatig ad likig of VA ad death registratio data may highlight how may death certificates are ot carryig the COD iformatio. Such visibility of iformatio may have istitutioal ad political implicatios, as people may resist such visibility of their work processes. Approaches Examples of approaches to rise to these challeges are may, ad ca be foud especially i the literature cocerig iformatio techology for developmet studies. For example, Braa et al. (8) describe the etworks of actio approach i the cotext of HIS developmet ad implemetatio i low ad middle icome coutries, to eable the sharig of learig ad experieces i the etwork, so that the same mistakes ca be avoided ad it is ot ecessary to replicate the work i developig solutios. This etworked approach, Braa et al. have argued, ca help to overcome the challeges of sustaiability ad scalability iheret i HIS automatio ad implemetatio efforts. Desigig withi a architectural perspective, keepig i mid future computerizatio requiremets ad how existig efforts eed to relate to them, is aother key approach to deal with iheret challeges. Desigig for flexible ad hybrid systems that cater to ueve ifrastructure eviromets ad capacities is aother valuable approach towards computerizatio ad automatio. Adoptig multilevel ad ogoig capacity-buildig approaches that cater to mid set ad attitudial chages i additio to buildig skills to use systems is aother key igrediet for a effective approach. 37

44 Civil Registratio ad Vital Statistics 2013: Table 4. Summary of opportuities, challeges ad approaches Opportuities Various techological opportuities ow exist, icludig the use of mobile techologies ad social media Advaces i database techologies eable opportuities for hostig large cetralized databases that ca speak to each other Various itegratio opportuities exist, especially based o the widespread use of the Iteret, mobile etworks, ad systems based o cliet server architecture The growth of the cloud architecture provides opportuities for hostig large databases Wider acceptace by global ad atioal authorities for the use of ope source techologies ad ope stadards May positive examples, such as from the MOVE IT projects, o how techologies (ecrvs ad mcrvs) ca be effectively deployed to stregthe the CRVS process. Effective learig ca be attaied through the study of these experieces Challeges The challege of brigig chages to the legal systems to eable the deploymet of ew techical solutios to existig processes The absece of a architectural thikig to support the desig process A istitutioal iertia to proactively maage chage processes, especially those that are radical i ature as ofte iscribed i ew techological itervetios Lack of appropriate techical ad istitutioal strategies to deal with vast amouts of paper-based legacy records that exist i coutries Poor data quality, both i terms of coverage ad quality of data, especially relatig to COD. As there may be good orgaizatioal reasos for poor data, the challege here lies i focusig o istitutioal reasos, which may ot ecessarily ivolve techological solutios Weak culture i the aalysis ad use of data, especially that ivolvig data from cross-cuttig busiess processes Approaches Build more multisectoral approaches that emphasize the iheret ature of a CRVS IS to ivolve multiple stakeholders ad sectors Cosciously adopt architectural approaches to desig that emphasize the role of history, future eeds, ad the itercoectio betwee systems Lear from best practice experieces from withi the CRVS domai ad also related domais such as health o how to desig, build ad implat systems. Adoptig a etworks of actio approach to eable sharig experieces i a collective Give primacy to brigig i required legal chages; this requires much stroger advocacy efforts through global ad atioal players Promote the use of ope source techologies, tools ad stadards as a platform for the architecture developmet Lik research ad practice i CRVS IS, as we are chartig ew ad relatively uexplored domais 38

45 challeges, best practice ad desig priciples for moder systems Sectio 5. Reflectios o desig priciples FOR moderizig CRVS IS The first part of this sectio develops a set of desig priciples at the strategic ad operatioal levels, which have bee iductively derived from the best practices described i the previous sectio. The secod part of the sectio cotais a discussio of how these priciples may or may ot be adapted i the cotext of a low or middle icome coutry, illustrated by the ogoig reform effort i Tajikista. 5.1 Five desig priciples Give the multisectoral ature of the CRVS IS, a fudametal priciple of a well-fuctioig ad effective system is to foster strog mutual iterests (by citizes ad private ad public etities) i maitaiig a cetral registry of the populatio with updated ad high quality data. Data should be based o iputs from the public sector, the private sector as well as citizes, ad made easily available for the productio of high quality VS. With these poits i mid, some key properties of the system iclude the followig. Oe cetralized database (CPR) uder the cotrol of oe agecy providig quality assurace ad beig accoutable for the quality ad access of data. Accessibility ad ready at had ifrastructure for eablig electroic flows of iformatio to ad from the CPR ad the other agecies sharig the CRVS ifrastructure. The CRVS is based o a PIN that is ideally stadardized ad legally madated at a atioal level. There are well-defied istitutioalized practices i the public ad private sectors that use the PIN as the uique idetifier/key for differet operatios such as issuig a passport, opeig a bak accout ad other similar operatios. The CPR is the master for persoal iformatio ad for the updatig of specific iformatio systems, such as births, deaths ad chage of address. Free ad ope access to data provides strog icetives to use ad report data, ad to maitai the high quality of data. These properties poit to moderizatio of the CRVS IS system as ivolvig more tha just techological fixes. Rather, CRVS systems must be coceptualized ad desiged as parts of larger architectures, which is crucial for their good fuctioig ad for the quality of the data they hold based o maitaiig ad stregtheig mutual iterests. While cetral authorities ca itroduce major chages as they may cotrol larger parts of the architecture, they still have to egage with the wider etwork of private etities ad citizes to guaratee the ecessary iformatio sharig ad reportig practices. Further, coflicts of iterest betwee 39

46 Civil Registratio ad Vital Statistics 2013: differet public etities must be elimiated ad replaced by a mutual iterest i iformatio sharig ad ope iformatio. This will require chages i laws ad regulatios. CRVS moderizatio requires chagig existig istitutios ad supportig the establishmet of ew oes, especially relatig to legal structures such as data owership, ad assurig their sustaiability. It is a log-term process that eeds a strog political madate over time. Thus, it has to be a process that is based o top-dow iitiatives from the govermet that trigger bottom-up participatio by public ad private etities as well as citizes. I short, it ivolves a large-scale cultural chage i how CRVS data are see ad used, as compared to what systems curretly exist i most low ad middle icome coutries. These iitiatives thus have to be urtured over time, ad will ot take place i the short term. Based o these guidig assumptios, five key desig priciples across the strategic ad operatioal levels to support the moderizatio of CRVS iformatio systems are summarized i Table 3. Table 3. Desig priciples for the moderizatio of CRVS iformatio systems Strategic level 1. Establish CRVS as a public good Public or collective goods are goods that all members of society will beefit from, regardless of whether they cotribute to creatig or sustaiig them. Of particular relevace to CRVS is how public goods support ad stregthe the depedecies betwee the citizes, the private ad the public sectors, ad public sector etities. A commo situatio is that the public sector etity owig the CPR ad producig statistics also cotrols ad restricts the usage of its cotet. This may severely impede the value of CRVS for the more geeral public ad thus udermie the sustaiability of the CPR. 2. Establish istitutioal icetives to keep the CRVS IS updated ad of good quality Citizes, public ad private sector eed icetives (ad ot disicetives) to take part i securig the fuctioig of the CRVS IS. For example, makig it a obligatory passage poit to access social services or propagatig chages to may public registries will icetivize citizes to have their iformatio up to date. At the same time, usage of the CPR as the master register by public etities will ecourage their reportig as well as those admiisterig the CPR to make certai the data are accurate. Operatioal level 3. Establish a holistic approach to CRVS desig Desigig CRVS IS requires the establishmet of a holistic approach, which icludes all existig CR ad VS evets, their supportig iformatio systems both iput ad output ad surroudig legislatio. Legal acts must madate the CPR to secure the privacy of the citizes while, at the same time, must offer wide access to the registry ad support the sharig of data betwee authorities as well as with private eterprises to the beefits of the citizes. A CRVS system must ot oly be based o a uderstadig of existig istitutios of public etities ad iformatio systems, laws, practices ad the iterrelatioships betwee these, but must also carefully build o these foudatios. 4. Establish the busiess relatioships of idetified iformatio flows with the CPR The way i which the iformatio i the CPR is updated by citizes ad public etities ad used by other public ad private etities must be established ad supported by the CRVS. Chagig a CRVS iformatio system must be desiged carefully to support these flows of iformatio as well as to establish the flows ecessary to geerate high quality data i a sustaiable way. 5. Develop the techical approach for operatioalizatio of these relatioships, usig tactics of itegratio ad iteroperability A CRVS IS must be based o the itegratio of idepedet systems with the CPR for readig ad updatig iformatio. The key to support iformatio exchage is a uique PIN, eablig the likage of ot oly the CRVS but also the CPR with a rage of public ad private etities. Other factors such as legal ad policy frameworks must also be aliged to support iteractio. 40

47 challeges, best practice ad desig priciples for moder systems The strategic priciples relatig to public good ad istitutioal icetives provide the broad template withi which the CRVS IS should evolve. A example of a public good ca be maps that are part of a spatial data ifrastructure, which are developed through public moey but eed to be made available to citizes, govermet departmets ad the private sector for differet purposes. For example, the health departmet ca use them for mappig health facilities, the trasport departmet for creatig bus routes, ad citizes for markig hikig trails. These differet users should ot have to create these maps separately, but should be able to use the publicly available map database. However, i retur for free access, the differet users have the obligatio to cotribute to keepig the database updated ad of good quality by providig iputs where possible, which would be subjected to the scrutiy of a cetral quality assurace agecy before beig committed to the database. A similar kid of public goods framework is beig proposed for the CRVS ivolvig multiple users ad mutual iterests. Istitutioal icetives, the secod strategic priciple, the play a importat role i defiig the rules of behaviour of the differet actors with respect to the CRVS system. The three operatioal priciples eed to be desiged ad implemeted withi the strategic framework. The priciples of holistic desig ad defiig ad operatioalizig the busiess relatioships would eed to be created to stregthe the use of CRVS as a public good, ad follow the istitutioal relatioships ad icetives that are evisaged. 5.2 A case-study from Tajikista To illustrate the applicability of the desig priciples suggested above, this sectio itroduces a mii case-study from Tajikista. Tajikista has a well-established ad robust system for CRVS, though almost totally without support of ICT (28). Here, the CR is hadled by Civil Registry Offices, which are located i all 68 districts of the coutry uder the resposibility of the Miistry of Justice. Tajikista provides a example of strog routies ad a istitutioalized system, still relyig o paper, which was also reported to be adequate durig a earlier HMNsupported assessmet. Later assessmets, however, have reported serious shortcomigs. A sigificat umber of eoatal deaths are ot beig recorded; these typically happe withi Miistry of Health facilities, so the data ed up i a differet system. Sice the CRVS system relies maily o paper records, there is o easy way of accessig ad sharig this iformatio. There are also other challeges ot related to the techology, such as disicetives to report early deaths ad paymet requiremets for patiets. There are plas to computerize the system: startig from 2013, support for CRVS will be icluded i the ew Miistry HMIS supported by the Europea Commissio, which will use DHIS2 as a web-based database. The data warehousig approach eabled through DHIS2 should support the itegratio of the health ad judiciary systems ad their data, as both systems will be usig the same software. This example also emphasizes that, while ew techologies are adopted i differet ways to tackle each coutry s particular challeges, they are part of the larger systems ad ifrastructures i the coutry that make scalig of projects a complex task. 41

48 Civil Registratio ad Vital Statistics 2013: I Table 4, the relevace of the five key desig priciples detailed i Table 3 is examied i the cotext of the o-goig moderizatio of the CRVS system i Tajikista. This aalysis helps to idetify the challeges that exist i makig the desig priciples ad guidelies work o the groud. While the Tajikista case-study is a example of a effort to build a itegrated system, similar challeges will also be experieced i other low ad middle icome coutries. Table 4. Desig priciples of CRVS IS i relatio to Tajikista Strategic level 1. Establish CRVS as a public good I Tajikista, iformatio collected ad stored by the authorities is ot commoly hadled as a public good. A move towards ope iformatio requires makig istitutioal chages. Further, the supportig techology ad ifrastructure must eable the establishmet ad maiteace of relatios amogst the differet stakeholders of the CRVS IS. A key area of cocer i this respect is to establish a cetral database, esure quality assurace mechaisms, practise a ope access policy, put i place access routies ad legislatios, apply the techology ecessary to serve multiple purposes ad users, ad be able to deal with the chages required over time. I Tajikista, i commo with most ex-soviet republics, there teds to be a strog cetralized bureaucracy ad slow chagig systems, which make iformatio access a iefficiet task. While ope iformatio is ot the rule, the establishmet of a sigle widow cetre uder the customs service for export/import ad trasit of goods to ad from Tajikista shows that istitutioal chages are ideed possible. This requires a strog political will ad a multiplicity of coordiated iitiatives towards customs cotrol, stadardizatio, certificatio ad quality ispectio. Learig from such experieces, ad based o a strog political madate, gradually istitutioal orms ca be created to treat CRVS as a public good. 2. Establish istitutioal icetives to keep the CRVS IS updated ad of good quality Tajikista lacks istitutioal icetives, impedig the smooth flow of iformatio at differet levels of the IS ad i the recordig of evets. From the perspective of the citize, there are few direct icetives for registratio of vital evets as they occur. For example, oly low icome families receive a fueral allowace i case of registerig deaths. Moreover, paymet of sigificat fees for issuig certificates ad other paperwork acts as a disicetive ad a deterret to timely registratio. While at the idividual level, icetives have to be created for citizes to register the vital evets i a timely maer, simultaeously the existig disicetives of their havig to make paymets would eed to be elimiated. Alog with this, at the istitutioal level, the differet orgaizatios cotributig to the CRVS system ad database would eed to have icetives to share their respective data, esure good quality ad compliace, ad participate i processes ivolvig the collective. For example, a passport office would oly use the idetificatio details icluded i the cetral database to issue a passport. While some additioal iformatio may be stored locally at the passport office, idetificatio details should ot be duplicated. I such a structure, the passport office has a istitutioal icetive to keep the cetral database efficiet. While techology, effectively desiged, ca eable the techical part of the cetral database ad its flows, a equally importat challege is developig the legal ad istitutioal frameworks aroud these mechaisms, such as makig it law that the CRVS idetificatio umber will be the sole oe to be used for various istitutioal trasactios. This requires uderstadig ad political will at the highest level. Operatioal level 3.Establish a holistic approach to CRVS desig To make a CRVS iformatio system work i Tajikista, there are a few key areas to be atteded to at multiple levels. At the first level is the legal basis regulatig the registratio of vital evets, which is of equal importace for the govermet ad the populatio. Tajikista has a well-established legislative framework regulatig CRVS activities. This will eed to be modified to reflect the ew demads comig from a coordiated CRVS IS. At the secod level are the orgaizatioal ad istitutioal arragemets that are directed towards uificatio of the CRVS with the other public ad private stakeholders. At the third level is the techology, which will eable ad support the uificatio of CRVS ad the other related public ad private systems. These three levels will eed to be desiged for eablig iterlikages ad mutual support. For istace, a etworked ad olie system ca potetially allow may istitutioal actors to joi ad, i the same way, create icetives for the populatio. If the Tajik address bureau gets coected to CRVS system, it creates icetives for the populatio to register i the CRVS i order to use the address bureau s services. So techology ca eable the data exchage, which i tur geerates a larger user base, fouded o the priciples of a public good. 42

49 challeges, best practice ad desig priciples for moder systems 4. Establish the busiess relatioships of idetified iformatio flows with the CPR I Tajikista, differet CR-related activities are uder the resposibility of differet public etities. For example, addresses are registered by the address bureau at the Miistry of Iterior ad its passport desks at the districts. Upo reachig the age of 18, each citize is obliged to obtai a atioal passport. Oce the passport is issued, the citize is registered ito the Miistry of Iterior system. The situatio gets more complicated because there is o PIN ad each documet type (certificate, passport) has its serial ID makig it difficult to referece. Mappig the busiess relatioship would the require defiig the orms of the iterlikages betwee these etities, icludig how should data be shared, what are mutual beefits, how to resolve coflicts ad other such processes. Similarly, busiess relatioships will eed to be defied to support the ogoig attempts to itroduce a uique PIN. For example, the tax committee of Tajikista has its ow taxpayer idetificatio umber (INN), ad the labour ad social welfare admiistratio has itroduced social security umbers (SIN). INN is madatory for all citizes above 18 years, ad there are icetives both related to INN as requiremet for employmet ad for doig private busiess. INN is stamped i the atioal passport ad the passport serves as a proof of INN. Uifyig these ad the related data flow through itroductio of a PIN would be advatageous for all. 5. Develop the techical approach for operatioalizatio of these relatioships, usig tactics of itegratio ad iteroperability Iitially, a full featured computerized CR system likig all CR office divisios with a CPR should be established. The CPR should be based o a uique PIN desig, accordig to the Daish system for example. Oce the system is fully implemeted ad operatioal, other public actors could be attracted by the meas of providig (limited) access to the database ad ivolvig them i CRVS. This uificatio will be a log political, legal ad istitutioal procedure, though ICTs could be used to catalyze the processes. With the establishmet of a CPR, icetives will be geerated for other public actors to joi ad beefit from it, at the same time cotributig to the sustaiability of the system by improvig data quality ad availability. 43

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51 challeges, best practice ad desig priciples for moder systems Sectio 6. Coclusios This report has aalysed the curret state of play i CRVS IS existig techological ad istitutioal treds, ad has also sketched some future directios o the stregtheig of these systems. A poit of departure i this aalysis is the argumet that CRVS IS is curretly by ad large usatisfactory ad eeds to be stregtheed urgetly. There are various developmetal priorities such as reiforcig the health of citizes, icreasig itervetios towards uiversal health coverage, improvig huma rights of citizes, ad supportig iteratioal declaratios such as the CoIA, which brig ito focus the urget eed to stregthe CRVS IS particularly i low ad middle icome coutries. The report is a step i this directio, i tryig to idetify some of the existig limitatios ad also the best practices from both developed ad other coutry cotexts to extract lessos from them ad help defie a ageda for stregtheig CRVS IS. CRVS IS itervetios udoubtedly carry the potetial to eable iovatios i the CRVS domai ad thus break the iertia ad stagatio that has characterized these systems for more tha three decades (1). While tryig to uderstad the potetial of techology computers ad mobile phoes to stregthe the CRVS domai, it is at the same time importat to place the techology withi the broader sociopolitical legal multisectoral cotext withi which the CRVS applicatio ufolds. History shows that we ofte ted to adopt a techologically determiistic approach, assumig that techology ca be posited as the silver bullet that ca solve particular developmetal challeges (29). While ackowledgig the tremedous potetial that ew techologies such as the mobile phoe provide to the domai of CRVS (30), puttig it withi the framework of the busiesses processes, other techological systems i operatio, ad the broader cotext is essetial. IS research, for example Walsham (31), has historically ad emphatically argued for the fudametal eed for sesitivity to cotext ad a sociotechical form of thikig to desig ad implemetatio, as cotrasted to a techological determiistic approach which teds to place techology as the ed rather tha the meas of developmet. IS to support CRVS represet just oe amog a multiplicity of other flows that itersect the CRVS domai. For example, the HMN techical framework (32) described CRVS as oe of the five data sources, which also icludes surveys, cesus, health ad disease records ad health service records, as well as iput sources related to resources ad fiaces. The various data systems have their ow usages, ad are typically supported by a rage of IS icludig also paper based, ad ivolvig the applicatio of techologies i diverse ways. For example, VA systems are grouded i medicie to geerate COD iformatio; VS systems are orieted towards geeratig cosolidated idicators based o statistics; while cesus systems come with a decadal frequecy ad a household focus. There is a eed to emphasize such likages across systems, while the likages are composed of much more tha just the techology 45

52 Civil Registratio ad Vital Statistics 2013: ad the uts, bolts ad wires that coect them. There is importatly the historical ad political istitutioal legal cotext withi which these systems eed to be uderstood ad implemeted. Oly based o such a perspective ca we uderstad the challeges i gettig these techologies to work o the groud, ad the uiteded cosequeces that typically occur, as people ad istitutios always provide surprises with uexpected ways i which they respod to techology. The strategic ad operatioal priciples towards adoptig a architecture approach to CRVS, preseted earlier, ca help to deal with some of the challeges ad cautios that have bee idetified with respect to CRVS IS. To summarize, this project preseted five desig priciples to guide the buildig of itegrated CRVS IS. 1. Establish CRVS as a public good. 2. Establish istitutioal icetives to keep the CRVS updated ad of good quality. 3. Establish a holistic approach to CRVS desig. 4. Establish the busiess relatioships of idetified iformatio flows with the CPR. 5. Develop the techical approach for operatioalizatio of these relatioships, usig tactics of itegratio ad iteroperability. A secod objective of this report is to provide guidace to global developmet parters, doors ad atioal policy-makers o how to ivest i ICT-based iitiatives to stregthe CRVS systems. While the desig guidelies should prove useful as iput o this level, this report also offers the followig guidace. 1. CRVS IS should be made a itegral part of atioal HIS ad the health ifrastructure stregtheig plas. 2. Natioal, as well as regioal ad iteratioal agreemets must be made o stadards ad mechaisms for their compliace to esure iteroperability of CRVS IS with other systems. 3. CRVS IS ca oly be operatioalized withi a framework of atioal policies o healthdata sharig that esure data protectio, privacy ad coset. 4. Scalig of CRVS IS, geographically ad fuctioally, must be a explicit aspect of cosideratios i the desig of ay ew system or itervetio. 5. Itervetios should follow a icremetal approach to implemetatio ad scalig, where the system is itroduced i a gradual maer particularly to be able to gai quick iitial successes, ad the slowly be able to move to more complex domais. 6. CRVS IS itervetios must cosider ad take ito accout the existig systems ad istitutioal ways of doig thigs, ad ot focus too much of their project effort o buildig software ad databases from scratch. 46

53 challeges, best practice ad desig priciples for moder systems 7. The itervetios must be desiged to support all types of existig systems: paper-based, usig computers, eterig data through mobile phoes or ay other method. 8. A CRVS IS should be see as part of a larger iformatio ifrastructure with o fiite start ad ed date or a cofied set of users, but desiged with evolutio i mid. 9. A CRVS IS should follow a architecture approach with a focus o (a) the boudaries betwee differet systems ad compoets ad how they commuicate; ad (b) loose couplig betwee compoets ad favour ope stadards ad ope source to support flexibility ad eablig a future we caot aticipate. 10. Strog programme logic should drive the system stregtheig efforts, rather tha the fact that a ew techology is ow available. 47

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55 challeges, best practice ad desig priciples for moder systems Refereces 1. Setel PW, Macfarlae SB, Szreter S, Mikkelse L, Jha P, Stout S, AbouZahr C. A scadal of ivisibility. Makig everyoe cout by coutig everyoe. Lacet. 2007;370: Family of Iteratioal Classificatios Network. Civil registratio ad vital statistics. Geeva: World Health Orgaizatio; 2010 (FIC iformatio sheet, April 2010). 3. Commissio o Iformatio ad Accoutability for Wome s ad Childre s Health. Keepig promises, measurig results. Geeva: World Health Orgaizatio; Mahapatra P, Shibuya K, Lopez A, Coullare F, Notzo F, Rao C et al. Civil registratio systems ad vital statistics: successes ad missed opportuities. Lacet. 2007;370: Braa J, Sahay S. Itegrated health iformatio architecture: power to the users. Delhi: Matrix Publishers; Health Metrics Network. Systematic review of ecrvs ad mcrvs itervetios i LMICs. Geeva: World Health Orgaizatio; 2013 (Draft report). 7. Haux R. Health iformatio systems? Past, preset, future. It J Med Iform. 2006;75: Haseth O, Lyytie K. Desig theory for dyamic complexity i iformatio ifrastructures: the case of buildig iteret. J Iform Techol. 2010;25(1): Braa J, Moteiro E, Sahay S. Networks of actio: sustaiable health iformatio systems across developig coutries. MIS Quarterly. 2004;28(3): Ngoma C, Marle SC, Herstad J. Adaptatio of mobile applicatio to improve flow of birth iformatio from the commuity to the district level. E-Ifrastructures ad E-Services for Developig Coutries. Lecture Notes of the Istitute for Computer Scieces, Social Iformatics ad Telecommuicatios Egieerig. 2011;64: Ohemeg-Dapaah S, Proyk P, Akosa E, Nemser B, Kater A. Combiig vital evets registratio, verbal autopsy ad electroic medical records i rural Ghaa for improved health services delivery. Stud Health Techol Iform. 2010;160(1): Kariyawasam N, Weerasekera V, Dayarate M, Hewapathiraa R, Karuapema R, Badara I. eimmr: the future of health statistics i Sri Laka. Sri Laka J Bio-Med Iform. 2011;1(Suppl 14): Kah K, Tollma S, Colliso M, Clark S, Twie R, Clark B et al. Research ito health, populatio ad social trasitios i rural South Africa: Data ad methods of the Agicourt health ad demographic surveillace system. Scad J Public Health. 2007;35(69): Toivae H, Hyvöe J, Wevelsiep M. Mobile birth registratio i Liberia. Report from VTT Techical Research Cetre, Filad; Gharajedaghi J. Systems thikig: maagig chaos ad complexity. A platform for desigig busiess architecture. Burligto, MA: Elsevier Sciece; Nevo S, Wade MR. The formatio ad value of IT-eabled resources: atecedets ad cosequeces of syergistic relatioships. MIS Quarterly. 2010;34(1):

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