Evaluation of approaches to strengthen civil registration and vital statistics systems: A systematic review and synthesis of policies in 25 countries

Background Civil registration and vital statistics (CRVS) systems play a key role in upholding human rights and generating data for health and good governance. They also can help monitor progress in achieving the United Nations Sustainable Development Goals. Although many countries have made substantial progress in strengthening their CRVS systems, most low- and middle-income countries still have underdeveloped systems. The objective of this systematic review is to identify national policies that can help countries strengthen their systems. Methods and findings The ABI/INFORM, Embase, JSTOR, PubMed, and WHO Index Medicus databases were systematically searched for policies to improve birth and/or death registration on 24 January 2017. Global stakeholders were also contacted for relevant grey literature. For the purposes of this review, policies were categorised as supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches). Quantitative results on changes in vital event registration rates were presented for individual comparative articles. Qualitative systematic review methodology, including meta-ethnography, was used for qualitative syntheses on operational considerations encompassing acceptability to recipients and staff, human resource requirements, information technology or infrastructure requirements, costs to the health system, unintended effects, facilitators, and barriers. This study is registered with PROSPERO, number CRD42018085768. Thirty-five articles documenting experience in implementing policies to improve birth and/or death registration were identified. Although 25 countries representing all global regions (Africa, the Americas, Southeast Asia, the Western Pacific, Europe, and the Eastern Mediterranean) were reflected, there were limited countries from the Eastern Mediterranean and Europe regions. Twenty-four articles reported policy effects on birth and/or death registration. Twenty-one of the 24 articles found that the change in registration rate after the policy was positive, with two supply and one penalty articles being the exceptions. The qualitative syntheses identified 15 operational considerations across all policy categories. Human and financial resource requirements were not quantified. The primary limitation of this systematic review was the threat of publication bias wherein many countries may not have documented their experience; this threat is most concerning for policies that had neutral or negative effects. Conclusions Our systematic review suggests that combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates in different geographical contexts. Operational considerations should be interpreted based on health system, governance, and sociocultural context. More evaluations and research are needed from the Eastern Mediterranean and Europe regions. Further research and evaluation are also needed to estimate the human and financial resource requirements required for different policies. Author summaryWhy was this study done? Civil registration and vital statistics (CRVS) systems generate foundational data for governance across sectors. Within public health, birth and death registrations are critical not only for empowering individuals' legal rights and for access to services but also in estimating health service needs, coverage, and impact. To our knowledge, no formal evidence review and synthesis has characterised which policies work and which do not for strengthening birth and death registration. What did the researchers do and find? We searched five literature databases and contacted global stakeholders to identify policies that improve birth and/or death registration and presented policy quantitative effects and qualitative syntheses. We identified 35 articles documenting experience in implementing policies to improve birth and/or death registration from 25 countries representing all global regions. Twenty-four articles reported supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches) effects on birth and/or death registration. Combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates across different geographical contexts. What do these findings mean? Countries interested in strengthening their CRVS systems may need to consider a combination of multiple policy approaches based on their health system, governance, and sociocultural context. Although this review and synthesis successfully identified many quantitative and qualitative data to strengthen CRVS systems, more policy evaluations and research are needed on effects from the Eastern Mediterranean and Europe regions and on human and financial resource requirements globally. Publication bias may have led investigators with neutral or negative findings to not document their findings; further research and evaluation is needed to understand which policies do not work.