Civil Registration and Vital Statistics in Bangladesh

CRVS country report Bangladesh: A successful journey towards CRVS system improvement

March 2018 Resources available from the University of CRVS technical guides Melbourne, Bloomberg Philanthropies Data Specific, technical and instructive resources in the form of for Health Initiative quick reference guides, user guides and action guides. These guides provide a succinct overview and/or instructions for CRVS course prospectuses the implementation or operation of a specific CRVS-related These resources outline the context, training approach, intervention or tool. course content and course objectives for the suite of CRVS trainings delivered through the Bloomberg Philanthropies CRVS tools Data for Health Initiative. Each course focuses on a specific Interactive and practical resources designed to influence CRVS intervention or concept, and is designed to support and align CRVS processes with established international or countries to strengthen their CRVS systems and data. best-practice standards. These resources, which are used extensively in the Initiative’s training courses, aim to change CRVS Fellowship reports and profiles practice and ensure countries benefit from such changes by The CRVS Fellowship Program aims to build technical developing critical CRVS capacity among technical officers capacity in both individuals and institutions to enhance and ministries. the quality, sustainability and health policy utility of CRVS systems in Fellows’ home countries. Fellowship reports Published by the University of Melbourne, Civil Registration are written by Fellows as a component of the program, and Vital Statistics Improvement, Bloomberg Philanthropies and document, in detail, the research outcomes of their Data for Health Initiative. Fellowship. Fellowship profiles provide a summary of Melbourne School of Population and Global Health Fellows’ country context in relation to CRVS, an overview Building 379 of the Fellowship experiences, the research topic and the 207 Bouverie Street projected impact of findings. Carlton, VIC 3053 CRVS analyses and evaluations Australia These analytical and evaluative resources, generated through [email protected] the Initiative, form a concise and accessible knowledge-base www.mspgh.unimelb.edu.au/dataforhealth of outcomes and lessons learnt from CRVS initiatives and interventions. They report on works in progress, particularly for large or complex technical initiatives, and on specific Made possible through funding from components of projects that may be of more immediate Bloomberg Philanthropies relevance to stakeholders. These resources have a strong www.bloomberg.org empirical focus, and are intended to provide evidence to assist planning and monitoring of in-country CRVS technical initiatives and other projects Suggested citation CRVS best-practice and advocacy Generated through the Initiative, CRVS best-practice and Bangladesh Implementation Working Group. Bangladesh: advocacy resources are based on a combination of technical A successful journey towards CRVS system improvement. knowledge, country experiences and scientific literature. CRVS country country reports. Melbourne, Australia: These resources are intended to stimulate debate and ideas Bloomberg Philanthropies Data for Health Initiative, Civil for in-country CRVS policy, planning, and capacity building, Registration and Vital Statistics Improvement, The University and promote the adoption of best-practice to strengthen of Melbourne; 2018. CRVS systems worldwide.

CRVS country reports CRVS country reports describe the capacity-building experiences and successes of strengthening CRVS systems in partner countries. These resources describe the state of CRVS systems-improvement and lessons learnt, and provide a baseline for comparison over time and between countries. CRVS country reports 1 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Figure 1: Participants at the Bloomberg Data for Health Initiative’s midterm evaluation meeting, Dhaka, midterm evaluation Health Initiative’s Data for at the Bloomberg 1: Participants Figure Bangladesh, July 2017 We would especially like to acknowledge Dr Philip Setel, vice-president, Dr Martin W Bratschi, deputy director and Mr Andres Dr Philip Setel, vice-president, Dr Martin to acknowledge especially like would We Carla Douglas Riley, AC, Professor Ian Professor Alan Lopez Vital Strategies; Laureate of Montes, senior program officer, and Dr J Moore, Dr Hafiz R Chowdhury, Timothy Associate Professor Deirdre McLaughlin, Dr Alison Morgan, Dr AbouZahr, and Dr Nicolas Maire, Swiss Tropical of Melbourne; and Dr Daniel Cobos Muñoz and Gulshan Ara Khanom of the University contributions. Public Health Institute for their invaluable We would like to acknowledge the valuable contributions of Mr Mohammad Shafiul Alam, cabinet secretary; Mr N M Zeaul the valuable contributions of Mr acknowledge to like would We of the Cabinet Division; Mr A K Mohiuddin, additional secretary (Coordination) Alam, secretary (Coordination and Reforms) Azad, director general, Directorate General of Health Services; Mr Anir and project director; Professor Dr Abul Kalam Md Ashfaqul Amin Mukut, deputy Office; and Mr Access to Information program, Prime Minister’s policy adviser, Chowdhury, project. CRVS secretary and deputy project director of this The Cabinet Division, Local Government Division, Economic Relations Division, Finance Division, Directorate General of Health Division, Directorate General Finance Division, Economic Relations Division, Government Cabinet Division, Local The Office, Access to Information program under the Prime Minister’s Welfare, Family Services under the Ministry of Health and vital roles in the journey. all played and HiSP Bangladesh have mPower icddr,b, UNICEF, The remarkable journey towards achievement of the Bloomberg Philanthropies Data for Health (BD4H) Civil Registration and Data for Health (BD4H) Civil Registration of the Bloomberg Philanthropies achievement towards remarkable journey The through the Technical of Bangladesh by the Cabinet Division of the Government begun was Initiative Statistics (CRVS) Vital under Article 55(6) of the Rules of Business, promulgated Government System Improvement. Support Project for CRVS business among different ministries government authorised the Cabinet Division to coordinate Bangladesh Constitution, of Department Government Australian by BD4H and the project is being financially supported significant and divisions. This (DFAT). Trade Affairs and Foreign Acknowledgements 2 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 Related resources andproducts...... Next steps:Moving forward...... Intervention: Introduction ofmedicalcertificationcausedeathin four hospitals ...... Intervention: Introducing VA atthecommunitylevel todeterminecauseofdeath...... Intervention: Improving birthanddeathregistration...... The project: How Bangladeshadvancing itsCRVSsystem-strengthening agenda...... Civil registration andvitalstatisticsinBangladesh...... Key terms...... Abbreviations...... Acknowledgements...... Contents Further reading...... University ofMelbourne, BD4HInitiative, CRVS Knowledge Gateway: Courses...... University ofMelbourne, BD4HInitiative, CRVS Knowledge Gateway: LearningCentre...... University ofMelbourne, BD4HInitiative, CRVS Knowledge Gateway: Library...... Key factorsto success...... The VA intervention pilotedinKaliganjUpazila...... Key factorsto success...... The ‘KaliganjModel’ forbirthanddeathnotification andregistration...... Current focus CRVS history...... 21 20 19 15 22 21 21 21 17 16 13 10 9 8 4 3 3 1 6 5 CRVS country reports 3 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Bloomberg Philanthropies Data for Health Initiative Bloomberg Philanthropies cause of death vital statistics civil registration and Services Director General of Health (Australian Affairs and Trade Department of Foreign Government) Immunization Expanded Program on assistant family welfare health assistant identification information technology medical certification of cause of death open-source data kit autopsy verbal Verbal autopsy is a method for collecting information about an individual’s signs and symptoms before their death from their about an individual’s autopsy is a method for collecting information Verbal or most probable cause of death. the likely of kin and interpreting these to diagnose family or next An upazila or subdistrict, pronounced: upojela) functions as an administrative sub-unit within a larger district. Bangladesh sub-unit within functions as an administrative An upazila or subdistrict, pronounced: upojela) presently has 491 upazilas. Union Parishad is the local birth and death registry office in Bangladesh. is the local birth and death registry Union Parishad Key terms Key Process and requirements of a system. end-to-end activities, stakeholders A process map is a visual snapshot of the system. assessment of any CRVS in the comprehensive mapping is becoming an essential early step COD CRVS DGHS DFAT EPI FWA HA ID IT MCCOD ODK VA BD4H Abbreviations 4 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 other regions. helping thecommunitytounderstandimportanceofthesedata.The pilotinterventions arenow beingexpanded into The interventions have beenhighlysuccessful,significantlyincreasingthedatabeingcollectedonbirthsanddeaths Bloomberg PhilanthropiesDataforHealth(BD4H)Initiative, andfocusedon: The threepilotinterventions were rolledoutbetween 2016and2017 withthesupportofCRVS specialisttechniciansfromthe Technical SupportforCRVS SystemImprovement inBangladesh. Implementation CommitteeundertheCabinetDivision,interventions formpartoftheCommittee’s larger project on registration andvitalstatistics(CRVS) stakeholders tostrengthenthecountry’s CRVS system.LedbytheNationalCRVS This paperhighlightsthreesuccessfultechnicalinterventions implementedbytheGovernment ofBangladeshanditscivil towards CRVSsystemimprovement Bangladesh: Asuccessfuljourney Medical certificationofcausedeathinhospitals Implementing VA for communitydeaths The KaliganjModel:improving birthanddeathregistration Advancing theCRVSsystems-strengthening agenda The statusofCRVSinBangladesh prioritised strengthening counted andincludedin 3. 2. 1. its CRVS system to Introducing medicalcertificationofcausedeathinfourhospitals,basedoninternationalbest-practice standards. Introducing verbal autopsiestocollectinformationoncauseofdeathforcommunitydeaths the vitalevent occurswithinthe45 day periodrequiredunderBangladesh’s BirthsandDeathRegistration Act2004 Improving thetimelinessandcompletenessofbirthdeathregistration,particularlyensuringthatregistration ensure everyone is policy decisions. Bangladesh has planning and With justunder163millionpeople, in Bangladesh Civil registration andvitalstatistics 3 2 1 with thelaw. Registration shouldbecontinuous,permanent,compulsoryand universal, inaccordance – includingbirths,deaths,marriages,divorces andadoptions–areofficiallyrecorded. Civil registrationistheprocessthroughwhichmajorvitalevents thatoccurinapopulation Bangladesh isprioritisingstrengtheningitscivilregistrationand vitalstatistics(CRVS) system. asset –itshugepopulationintoahumanresourceforbuilding abetterfuture.To dothis, income countrybyits50thbirthday in2021, countries intheworld (Figure 2).To achieve thecountry’s aspirationtobecomeamiddle- systems generatevitalstatistics.Suchstatisticsinclude: revision 3.New York, USA: UNSD;2014. UN DepartmentofEconomicandSocialAffairs (StatisticalDivision).Principlesandrecommendations foravital statistics system, World Bank. Bangladesh:Overview. Available at: worldbank.org/en/country/bangladesh/overview (accessed5September 2017). World Bank. Bangladesh:Data.Available at: https://data.worldbank.org/country/bangladesh (accessed 5September2017).

3 Usingtheinformationcontainedinindividualcivilregistration records,CRVS

1 Bangladeshisoneofthemostdenselypopulated 2 Bangladeshaimstotransformitsrichest CRVS country reports 5 The new Act, new The 4 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey (updated April 2010). Available at: https://www.unicef.org/bangladesh/Birth_ at: in Bangladesh (updated April 2010). Available Birth registration deaths by key characteristics such as age, sex, location and cause of death (COD). location and characteristics such as age, sex, deaths by key numbers and rates of deaths, and numbers and rates of key characteristics of births, such as births by sex, location and maternal age location as births by sex, characteristics of births, such key numbers and rates of births numbers and rates of

Registration(1).pdf (accessed 5 September 2017). ■ ■ ■ ■ which came into force in 2006, made birth and death registration compulsory within 45 days 45 days which came into force in 2006, made birth and death registration compulsory within Bangladeshi citizen a and made the birth and death registration of every of the vital event, and an individual legal right. matter of law identification (ID) number Act 2004 also ushered in a new Births and Deaths Registration The issued by the Bangladeshi system. Each Bangladeshi citizen has a unique ID number, from birth until death. Use of a single, unique ID number streamlines and government, duplicate or multiple IDs being attributed to an standardises ID collection and avoids vital statistics data, which increases the accuracy and quality of Bangladesh’s individual. This population health policy and planning. can then be used to support reliable evidenced-based 4 UNICEF. Source: Adapted from World Atlas, available at worldatlas.com/webimage/countrys/asia/lgcolor/ Atlas, available Source: Adapted from World at http://www.maphill.com/bangladesh/location-maps/satellite- and Maphil, available bdcolor.htm map/ CRVS history began almost a century journey Bangladesh officially came into being in 1971, but its CRVS enacted under British rule of the earlier when the Birth and Death Registration Act was and policy reform, the country legislative positive 3). Following subcontinent in 1873 (Figure practice by repealing the long-standing Act of 1873 and enacting the CRVS its renewed Act brought a major shift in increasing Births and Deaths Registration Act 2004. This nation’s of death registration. as better enforcement birth registration rates, as well Figure 2: Map of Bangladesh Figure Registering births and deaths within 45 days of the event of the event 45 days became law in 2006. became law 6 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 Registrar GeneralofBirth was established in 2016: strengthening activities a criticalevent inCRVS and DeathRegistration The Officeofthe in Bangladesh. smooth implementationofCRVS inBangladeshthefuture. 2006. The updatedrules detailedtheresponsibilitiesofconcernedauthoritiestoensure This was followed in2017bythecountry’s updateoftheBirthandDeathRegistration Rules counted andincludedthroughCRVS improvement. momentum forpositive development thatcanderive fromitspopulationunlesseveryone is Bangladesh acknowledges thatitwillbeunabletofullyandeffectively managethe Current focus establishment oftheOfficeRegistrarGeneralBirthandDeathRegistrationin2016. Amendments totheBirthsandDeathsRegistration Act2004in2013resultedthe cause ofdeath;NPR=nationalpopulationregister COD =causeofdeath;CRVS =civilregistrationandvitalstatistics;MCCODmedicalcertificateof Figure 3Key events instrengthening theCRVSsystemofBangladesh 6 5 Division sitsdirectlyunderthePrimeMinisterofBangladesh. headed bythesecretaryforCoordinationandReformsin Cabinet Division.The Cabinet Steering Committeeisfurthersupportedbya14-memberCRVS Implementation Committee, consists of22members,including17secretariesministries forpolicysupport.The CRVS the cabinetsecretary, toimprove theBangladesh CRVS system. This high-level committee In 2014,theBangladeshigovernment establishedaCRVS SteeringCommittee,headedby high-level politicalsupportforthisimprovement. Lo S&HortonR(2015).Everyone counts–socounteveryone. The386:1313–1315. Lancet br.lgd.gov.bd/english.html (accessed 5September2017). Government ofBangladesh.OfficetheRegistrar General, BirthandDeathRegistration, LocalGovernmentDivision.Available at: 6 Bangladeshhasthereforeestablished 5

CRVS country reports 7 ebruary 2018). The Declaration to ‘get everyone in the picture’ Declaration to ‘get everyone The 7 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Ministerial Declaration to ‘Get everyone in the picture’ in Asia and the Pacific; adopted by the Ministerial Conference on Civil in the picture’ in Asia and the Pacific; Ministerial Declaration to ‘Get everyone getinthepicture.org/ Available at: Thailand. 2014 in Bangkok, on 28 November Statistics in Asia and Pacific Registration and Vital sites/default/files/resources/Ministerial.Declaration.English.final_.pdf (accessed 8 F proclaimed the ‘Asian and Pacific CRVS Decade’ for 2015–2024. Bangladesh’s CRVS vision CRVS Decade’ for 2015–2024. Bangladesh’s CRVS and Pacific proclaimed the ‘Asian in the picture’ goal. everyone and mission marries with this visionary ‘get UID = universal identification UID = universal Available at Statistics in Asia and the Pacific. Source: Adapted from Civil Registration and Vital 2018). (getinthepicture.org/country/bangladesh (accessed 8 February 7 Figure 5 Bangladesh CRVS vision and mission 5 Bangladesh Figure Figure 4: CRVS project steering committee meeting and CRVS project imple- CRVS project steering committee meeting and 4: CRVS project Figure meeting, 2017 mentation committee Also, in 2014, the ministers and representatives of members and associate members of the of members and associate members of Also, in 2014, the ministers and representatives assembled at the for Asia and the Pacific United Nations Economic and Social Commission They Statistics in Asia and the Pacific. and Vital Ministerial Conference on Civil Registration recognized to be ‘the human right of everyone made a Ministerial Declaration that reaffirmed as a person before the law’. everywhere improving its improving CRVS system. CRVS Bangladesh has commitment for high-level political high-level 8 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 Bangladesh focussedon five majorinterventions. System Improvement in The Technical Support Program forCRVS Figure 6:Pre-training workshop onSmartVA, Dhaka,Bangladesh,2016 Registrar GeneralforBirthandDeathRegistration,including: There were five majorinterventions facilitatedbytheproject: StrengtheningtheOfficeof in April2016bytheCRVS ImplementationCommittee,locatedintheCabinetDivision. The Technical SupportProjectforCRVS SystemImprovement inBangladeshwas established CRVS system-strengthening agenda The project: How Bangladeshadvancing its 8 below, includingkey factorsthatledtotheirsuccess. registration, introductionofVA, andintroductionoftheMCCOD)arediscussedindetail completed byJune2017.Three interventions (theKaliganjModelforbirthanddeath With technicalsupportfromBD4H,mostoftheproject’s firstphaseofactivities was ■ including: 1. 5. 4. ■ 3. ■ 2. ■ of Melbourne;2018. Australia: BloombergPhilanthropiesDataforHealthInitiative, CivilRegistrationandVital StatisticsImprovement, The University University ofMelbourne.Strengthening CRVSsystemsthrough effectivelegislation.CRVS development series.Melbourne,

tions tobestlegallyembedCRVS systemsimprovement practices helping theOfficeofRegistrarGeneraltoreview existing CRVS laws andregula- Strengthening theOfficeofRegistrarGeneralforBirthandDeathRegistration, for qualityanalysisofBangladesh’s vitalstatisticsdata. (MCCOD), VA, informationtechnology(IT)anddatamanagementtobuildcapacity Training appropriatestaffonthetopicsofmedical certificationofcausedeath major Bangladeshihospitals. Introducing theInternationalForm ofMedicalCertificateCauseDeathinfour ty-based Has. a pilotroll-outofVA datacollectionprogramintheGazipurDistrict,ledbycommuni- (ie forthedeathsthatoccuroutsideofhospitalsandotherhealthfacilities).This entailed: Introducing verbal autopsy(VA) fordeterminingCODcommunity-level deaths welfare assistants (FWAs). in theGazipurDistrict,ledbycommunity-based healthassistants(HAs)andfamily a pilotroll-outofthe‘KaliganjModel’ forbirthanddeathregistrationnotification the 45-day specified period. This included: Improving thecompletenessofnotificationandregistrationbirthsdeathswithin stakeholder integrationanddataflow. process mappingexisting CRVS systems forbirthanddeathregistrationimproved 8 CRVS country reports 9 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Figure 7: Location of Gazipur, Dhaka Division, Bangladesh Dhaka Division, of Gazipur, 7: Location Figure Intervention: Improving birth and death birth Improving Intervention: registration and registration birth and death notification for improving pilot model A comprehensive and local government intense community discussion, planning rolled out in 2017 after was staff training. notification and an optimal model to ensure develop to purpose of the pilot was The by Bangladesh civil of occurrence as required and deaths within 45 days registration of births within this and 1% of deaths are currently registered than 3% of births Fewer registration law. and supporting families, awareness based on raising community model was time frame. The were strengthened to cope with increased demand. and ensuring the local registry offices at Kaliganj Upazila in the Gazipur District of the Dhaka Division undertaken was pilot The of 7). Kaliganj Upazila spans an area of 218 square kilometres and has a population (Figure in some 7000 births and 1800 deaths occur year 288 670 people. It is estimated that each the area. the event. within 45 days of within 45 days At the start of the intervention, less than intervention, deaths were registered deaths were 3% of births and 1% of 3% of births and 1% 10 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 the Kaliganjmodelwere Two key componentsof workers andlinkswith the useoflocalhealth As partofthemodel, linked withchildren’s immunisation cards. the successfulEPI. birth registrationis complex. Upazila healthandfamilyplanningofficer, whoisalsothechief executive healthofficerofthe HAs andFWAs fromtheKaliganjUpazilaHealthComplex, undertheleadershipof The initiative was delivered byateamofcommunity-based workers, comprisinglocal-level registration The ‘KaliganjModel’for birthanddeathnotification 9 application withlocalCRVS authoritiesintheirtwice-monthlyreports. forms atthelocalregistryoffice.Pilotteammemberscould n verify thebirthregistration helped parentstocompletetheapplicationforms,andreturn andlodgethecompleted parents collectthesefromtheUnionParishad (thelocalbirthanddeathregistryoffice). They HAs andFWAs provided parentswithprintedbirthregistrationapplicationforms,orhelped in life(Box 1). having auniqueIDnumbergives childrenaccesstopubliceducationandotherserviceslater birth registrationisespeciallyimportanttoenabletheirchild accesstheEPI,andthat the importanceofbirthregistrationchildren.HAsandFWAs highlightedtoparentsthat They explained topregnantwomen, mothersofnewborns, familyandcommunity members with completingandsubmittingthedocumentsforbirthregistration. interaction withtheCRVS systemintheirlocalcommunities.Healthworkers helpedparents As partofthepilotscheme,HAsandFWAs supportedfamilies’engagementandsmooth early childhoodvaccinations. birth registrationnumbermustalsobeincludedonthebaby’s EPIcardtofacilitate accessto 45 days ofthedate ofbirth.Newborn registrationisimperative becausethebaby’s unique The HAsandFWAs alsoensuredthatfamiliesregisteredthebirthofnewborn babieswithin the mosteffective andsuccessfulcommunity-level health programinBangladesh. supervisors. They integratedtheseactivitiesintotheirroutinedutiesrelatedtoEPI,whichis local birthanddeathnotificationsregistrations,twiceamonthinwrittenreporttotheir number ofdeathsintheircommunities.They provided thisinformation,alongwithdataon expected datesof delivery, thewomen accessingantenatalorpostnatalhealthcare,andthe As partofthepilotinitiative, theHAsandFWAs kept trackofthenumberpregnanciesand including: positioned toidentifybirthsanddeathsinthecommunity. HAsandFWAs have manyduties, ■ ■ ■ ■ ■ ■ The Upazila Health Complex isa50-bedsubdistrictlevel hospital.There are421suchtypesofhospitalsinBangladesh.

Collecting healthandpopulationdatafromthefieldwhenrequiredbygovernment. their mothers. Supporting healthcarereferrals,especiallyforpregnantwomen, andnewborns and Providing health promotion andpreventive healtheducationandfamilyplanning. Coordinating satellitehealthclinics. Keeping recordsofvitalevents (birthsanddeaths). within therecommendedperiodafterbirth. munization (EPI),includingensuringtheimmunisationofnewborns intheircommunity Conducting routineimmunisationsaspartofBangladesh’s ExpandedProgramonIm- 9 Team memberslive andwork withintheircommunitiesandarethereforewell- CRVS country reports 11 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Figure 8: A health assistant in Kaliganj Upazila briefing a mother about Kaliganj Upazila briefing a mother 8: A health assistant in Figure occurring of the birth within 45 days birth registration the importance of (used with permission) Under the pilot, HAs and FWAs also ensured that all currently unregistered children were were that all currently unregistered children also ensured and FWAs Under the pilot, HAs their issued an EPI card on receipt of were when they Parishad registered with the Union childhood vaccinations. 12 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 ‘Now Icanunderstand thebenefitsas well asimportanceofthebirthregistrationababy’. birth registrationnumber.” necessary. Most important[ly]…ababyachieves thefirst-time staterecognitionwithhis and manyotherserviceslike theseinthebaby’s life,it[thebirthcertificate] would be what hesaid.Heexplained, “To gethimadmittedintoschool,prove hisage,getapassport is avaluabledocument; itwillbeusefulforthe[entire]lifeofchild.” Iwas surprisedat chairman handedover thebirthcertificateandsaid,“Preserve thiscertificatecarefully. It ‘After aweek, whenIwent tocollectmychild’s birthcertificate,theUnion Parishad of mychildandIshouldbringthatwithmetotheEPIcentrefornext vaccination. ‘She thentoldme,afteroneweek, eithermyhusbandorIwould collectthebirthcertificate that, shebroughtitwithhertosubmittheUnionParishad. application form supplied by the Union Parishad and helped me to fill out the form. Not only ‘I thoughtthatitwas troublesome.Butsheimmediatelygave meaprintedbirthregistration because thebirthregistrationnumberofbabymustbeincludedinEPIcard. the babywould have togetbirthregistrationattheOfficeofBirthandDeathRegistrar, for thevaccinationofmybaby. The babywould getvaccinatedattheEPIcentre.For that, she informedmethatIwould have tocollectEPI[ExpandedProgramonImmunization]card who works atmyvillagemademeconsciousaboutthematter. Afterthebirthofmychild ‘I didnotthinkabouttheimportanceofbirthregistrationchildren.The healthworker Box 1:Amotherbenefitingfrom the registration ofherbaby’s birth CRVS country reports 13

Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey implementing the new birth and death notification and registration system, and raising birth and death notification and registration system, and raising implementing the new birth and death notification and registration to ensure accurate, timely and complete then optimally integrated into were 2). These (Box practices at the local registry level system. the national CRVS Motivating and training the community health workers (ie the HAs and FWAs) on (ie the HAs and FWAs) workers Motivating and training the community health processes and procedures within the local birth and death registry Streamlining work community awareness of the importance of birth and death registration of the importance of birth and community awareness

1. 2.

Before commencing the pilot, the HAs and FWAs were trained in a series of motivational were FWAs Before commencing the pilot, the HAs and why birth and death of the Kaliganj Model, aims and objectives on the overall workshops timely and complete birth and death registration and registration is important and how would bring both short and long-term benefits for the local people and the notification on engaging with the HAs and FWAs also involved motivational workshops The country. could the HAs and FWAs with concerned family members, and how to work the best way to register a birth or death within the 45-day optimally motivate local community members to correctly fill in the on how upskilling HAs and FWAs sessions involved time frame. Training birth or death registration application forms. trained and motivated around the birth and death the HAs and FWAs Not only were of Kaliganj Upazila. Motivational workshops the local leaders registration process, so too were registration with local leaders, including held on the importance of birth and death were officials local councillors and community members. High-level mayor, with the municipality’s Planning for Deputy Director of Family also present, such as the Civil Surgeon and were the Gazipur District. Such officials added much value and legitimacy by addressing the registration. attendees on the importance of birth and death workshop’s The Kaliganj Model resulted in a much-improved rate of total birth and death registration rate of total birth and death in a much-improved Kaliganj Model resulted The in timely by the significant increase This is shown period. the 45-day and notifications within and 2016–17. After 2015–16 at the local registry office between birth and death registration of births registered the rate 2016, the Kaliganj Model in August of introduction year. with the previous 33% compared by improved within 45 days community many stakeholders: involving initiative a collaborative Kaliganj Model was The registrar and Union the local birth and death HAs and FWAs, members, local leaders, respects, the health and family planning officials. In many as other key as well staff, Parishad pre-planning. and intensive successful because of community ownership pilot model was that to successfully introduce the new agreed among stakeholders the outset, it was From important: be very factors would model, two Key factors to success factors Key to cope with\ were strengthened were increased demand. the model’s success. the model’s The model was based model was The on raising community on raising community local leaders was key to key local leaders was the local registry offices the local registry offices Active engagement with Active awareness, and ensuring awareness, 14 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 family member(usedwithpermission) Figure 9:Family members from Kaliganjwithadeathcertificateofdeceased the provisions oftheBirthsandDeathsRegistration Act2004. granted toeachchildatbirth)isrecordedpermanentlyinthe national birthregistrationper birth registrationnumberforthenewborn Bangladeshichild(whichisindeed a uniqueID signed bythechairpersonofUnionParishad. Inaddition,thebirthcertificatewithits death. The birth(ordeath)certificatethatcontainstheuniqueregistrationnumber isthen is automaticallygeneratedforevery birth(ordeath)andprintedonthecertificateofor Once thedataareentered,aregistrationnumber(auniqueindividualidentificationnumber) General forBirthsandDeaths. Registration andInformation-ITsystemofthecentralBangladeshiOfficeRegistrar the birthanddeathnotificationformsintocomputerslinked withtheBirthandDeath staff isadataentryoperatorresponsibleforenteringthevitalstatisticshandwrittenon support torecordbirthanddeathnotificationinthecivilregisters.The second memberof Union Parishad office.Onestaffmemberisanofficesecretarywhoprovides administrative The UNOhastwo membersofstaffdedicatedtobirthanddeathregistrationactivitiesinthe chairperson oftheUnionParishad, thelocalbirthanddeathregistrar. government inGazipurcoordinatethebirthanddeathregistrationactivitiesonbehalfof In KaliganjUpazila,theUpazilaNirbahiofficer(UNO)anddeputydirectoroflocal Box 2:ActivitiesoftheUnionParishad (localregistry office) CRVS country reports 15

11 10 12 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Interpreting the interview data to diagnose the most probable COD. Interpreting the interview illnesses/events that the deceased suffered before death. illnesses/events Conducting a structured interview to collect information on signs and symptoms of Conducting a structured interview appropriate place). Setting up an interview by a trained VA staff member at the household (or another by a trained VA Setting up an interview Population Health Metrics 2011; 9:19. autopsy: who needs it? Population AbouZahr C. Verbal Health challenges. Bulletin of the World current practices and Autopsy: K. Verbal Solemon N, Chandramohan D, Shibuya Organization 2006; 84:239-245. autopsy into civil registration and vital community based verbal I, Chandramohan D, et al. Integrating D, Riley de Savigny considerations. Global Health Action 2017; 10: 1272882. system-level statistics (CRVS): 3.

1. The VA process consists of three basic steps: process VA The 10 11 12 In Bangladesh, where most deaths occur in the community and are not medically certified by In Bangladesh, where most deaths occur statistics on the for producing policy-relevant becomes an important method a physician, VA introduced at Kaliganj was pilot intervention 3). A VA distribution of COD in a population (Box of part was pilot initiative in January 2017. This Upazila in the Gazipur District in Bangladesh that began in in Bangladesh System Improvement Support Project for CRVS the Technical is a method Implementation Committee.VA by the National CRVS mid-2016 and is overseen prior to death from their signs and symptoms for collecting information about an individual’s or most probable COD. of kin, and interpreting these to diagnose the likely family or next Intervention: Introducing VA at the VA Introducing Intervention: cause of death to determine level community these as hospitals, and even 15% of deaths occur in health facilities, such In Bangladesh, only and in the community, means that 85% of deaths occur This are not necessarily registered. on of the Registrar General are not officially registered by the Office most of these deaths was not certified COD deaths are officially registered, if the when Births and Deaths. Even to ICD-10 standards), the to international standards (ie MCCOD by a physician according from a statistical and to be of limited or no value on COD is likely quality of the information COD data are crucial is highly problematic: high-quality reliable This public health perspective. policy and practice. COD information is critical for countries and their for evidence-based allocation. Gaps in mortality data planning and resource health policy, partners for effective and addressing public health concerns. create major obstacles to understanding 16 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 sensitivity, how thedata was allocatedaunique questionnaire content, Each registereddeath death registrationID VA trainingincluded VA interview could and managingIT. number beforea can beused, take place. successfully encouragingthenext ofkintoengage intheVA interview process, theHA or caretakers ofthedeceased.Afterexplaining thepurposeof VA interview, andon 2017 were reviewed byVA interview. To achieve this,theHAcontactedfamilymembers a VA interview. AllcommunitydeathsinKaliganjUpazilaregisteredfromJuly2016toJune decedent’s uniquedeathregistrationIDnumberandaddressfortheinterviewer toconduct Under thepilot,registraroflocalUnionParishad provided thedesignatedHAwith Union Parishad. subsequently beofficiallyregistered,andthecertificateissuedbychairpersonof the formtocivilregistrarwithin45days ofoccurrencethevitalevent. The deathwould registration applicationform,helpingfamiliesfillthisin,andsupportingthesubmissionof helped familiestoapplyforregistrationofthedeathdeceased byobtainingthedeath to theHAsinvolvement intheKaliganjModelforbirthanddeathregistration,HAs The VA pilotwas rolledoutinKaliganjUpazilabetween January andJune2017.Similar tablets toidentifychallengeswithuseofthetabletand/orVA questionnaire. to theopen-sourcedatakit(ODK)server. how totransmitthe datatotheManagementInformationSystem(locatedinDGHS)and component; HAslearnthow tousetabletscollectresponsestheVA questionnaireand with potentiallygrieving communitymembers.Training sessionsalsoinvolved adigital VA questionnairecontent,andhow tosensitively administerandmanageaVA interview defining VA and explaining why VA dataare importantinhealthcarepolicyandplanning, with HAtraining,technicalsupportprovided byBD4H.Training sessionsfocusedon jurisdiction oftheDirectorGeneralHealthServices(DGHS).The projectthereforebegan the UpazilaHealthandFamily PlanningOfficeoftheKaliganjUpazila,whichfallsunder The VA pilotwas tobedelivered byHAs,thedomiciliarycommunity-level healthworkers in The VA intervention pilotedinKaliganjUpazila 14 13 mortality data. system failuresrelatedtothesecauses.VA isacost-effective toolforfillingthegapsin Countries canuseVA tocategorisecausesofdeath,andidentifysocialhealth viable methodsofdoingsowhenMCCODisnotanoption. relevant informationoncause-specificmortalityfractionsinapopulationandistheonly in theperiodbeforethey died.VA isanimportantmeanstosupportgenerationofpolicy- caregivers orfamilymembersaboutthesignsandsymptomsexperienced bythedeceased VA isamethod fordeterminingthemostlikely CODbasedoninformationcollectedfrom help overcome thisinformationgap, verbal autopsy(VA) canbeimplemented. When peopledieoutsideofhospitals,itcanbedifficulttoknow whatthey diedfrom. To unregistered andunreported. capacity. Itisimportantthatcountriesensurethesedeathsarecapturedanddonotgo in thehomeorareaswithoutphysicians–healthfacilitieswithlimiteddiagnostic In manycountries,includingBangladesh,mostdeathsoccuroutsidehospitals–thatis, data, whichhealthdepartmentsneedforevidence-based policyandplanningefforts. Accurate medicalcertificationofcausedeath(MCCOD)is key forproducingreliablemortality Box 3:The importanceofverbal autopsies For moreinformationonODKtechnologies,pleasesee:https://opendatakit.org/about/. gold standarddiagnosisandunderlyingcause ofdeathinselectedMexican hospitals. Population HealthMetrics2011;9:38. Hernández B,Ramírez-Villalobos D,RomeroM,etal.Assessingqualityofmedical death certification:concordancebetween 13

14 HAswere alsoinvolved infieldtestingoftheir CRVS country reports 17

15 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Gouda HN, Flaxman AD, Brolan CE, et al . New challenges for verbal autopsy: Considering the ethical and social implications of challenges for verbal Gouda HN, Flaxman AD, Brolan CE, et al . New autopsy methods in routine health information systems. Social Science and Medicine 2017; 184:65–74. verbal would attend the decedent’s home at the scheduled interview time and sensitively conduct conduct time and sensitively the scheduled interview home at attend the decedent’s would had been uploaded. questionnaire to which the VA using the tablet interview, the VA 15 The VA pilot resulted in 1728 VA interviews being completed during the six-month roll- being completed interviews resulted in 1728 VA pilot VA The for the first time, the main causes of death in the pilot revealed, from the VA out. Findings VA COD data generated from the age groups. The Kaliganj Upazila community for different among all age groups, are found the main causes of death in the community, interviews instance, in the adult population, the highest For noncommunicable diseases and injury. heart disease, whereas for and ischaemic due to stroke proportion of total deaths was meningitis or sepsis. neonates was and the dominant COD among drowning, children it was to is crucial for helping local and regional health managers and planners information This healthcare services to the and preventive healthcare targeted and cost-effective better, deliver community. process, led by HAs, will be VA interview that the were so impressive in the pilot findings The Technical CRVS The District in coming years. introduced and replicated in the whole Gazipur effectiveness its process in scaled up in Gazipur, VA Support Project will ensure that while the examination of plausibility of COD of ongoing way and efficiency is closely monitored by and costing analyses. evaluation distribution, phase-by-phase HAs, who could of the training and involvement success in the pilot was factor for key The In addition, the use of families in the community. the engagement and involvement then drive data to be easily collected and uploaded to technology in the form of tablets allowed of new system. the CRVS Key factors to success factors Key Afterwards, the HA would transmit the VA questionnaire data to the ODK server. Trained Trained questionnaire data to the ODK server. the VA transmit the HA would Afterwards, department subsequently in the Management Information System data management teams software. the information using SmartVA data and analysed the VA downloaded accompanied into the field randomly were purposes, HA interviewers quality assurance For In addition, periodically a health inspector or assistant health inspector. by their supervisors, and verified be randomly checked digitally collected by the HAs would the COD information Kaliganj Health Complex. by physicians from the for the first time. Findings from the VA from the VA Findings COD in the community pilot revealed patterns of pilot revealed 18 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 members ofthedeceased(usedwithpermission) Figure 10:Ahealthassistantconductingaverbal autopsyinterview withfamily CRVS country reports 19 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey Figure 11: Physicians attending the ‘master trainers’ session on medical certifi- session attending the ‘master trainers’ 11: Physicians Figure permission) cation of cause of death (used with Intervention: Introduction of medical Introduction Intervention: hospitals four in of cause of death certification the introduction Support Project was part of the Technical that formed Another intervention Health Organization (WHO) World the first time in Bangladesh – of the in major hospitals – for in conjunction with was This Medical Certification of Cause of Death. of International Form for WHO Form policy decision to implement the Welfare’s and Family the Ministry of Health MCCOD into Bangladesh has throughout Bangladesh. Introducing MCCOD in health facilities (based on the ICD-10) for internationally recognised system institutionalised an important, where physicians are available. determining causes of deaths in health facilities occurred in January 2017. MCCOD was Introduction and pilot roll-out of the certificates Dhaka area, with the strong support of hospital subsequently piloted in four hospitals in the supported by BD4H, upskilled 1350 administrators and physicians. MCCOD training, 20 physicians trained as MCCOD ‘master Bangladeshi physicians in MCCOD, including as part of an initiative provided coding was trainers’. In addition, training in ICD-10 mortality close to cadre of statistical coders for cause of death analysis. So far, a new to develop in all four pilot hospitals, and the been completed 2000 medical certificates of COD have Information System department in the DGHS certificates are currently with the Management and data analysis. undergoing quality review 20 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 and expertise to meet thegrowing IT-related challengesforsecure,digitisedCRVS systems. In moving forward, Bangladeshacknowledges itwill needadditionalITtechnicalknowledge systems improvement willinvolve: Support Project,withongoingsupportfromtheBD4HandDFAT. The secondphaseofCRVS A secondphaseofCRVS systemsimprovement isalreadybeingundertaken bytheTechnical system improvement canalready beseen. Bangladesh, particularlyinsuchashortamountoftime,arehighlyencouraging:CRVS The achievements oftheTechnical SupportProjectforCRVS SystemImprovement in Next steps:Moving forward ■ ■ ■

health institutions. Embedding thepracticeofMCCODintomoreBangladeshihealthservicesandtertiary District Expanding theintroductionofVA forcommunitydeathsintootherareasintheGazipur parts ofthecountry and timelinessofbirthdeathnotificationregistrationwithin45days intoother Expanding thesuccessfulblueprintofKaliganjModeltoimprove completeness CRVS country reports 21 Bangladesh: A successful journey towards CRVS system improvement | Version 0318-04 | Version system improvement CRVS towards Bangladesh: A successful journey CRVS development series. development mapping. CRVS process importance of CRVS systems: The Understanding SmartVA. CRVS summaries. CRVS completeness. registration measuring birth and death importance of routinely The Medical certification of cause of death. CRVS development series. development CRVS effective legislation. CRVS systems through Strengthening 4: Cause of death in CRVS. Topic Courses Gateway: CRVS Knowledge of Melbourne, D4H Initiative, University crvsgateway.info/courses CRVS development series. development the quality of cause of death data in hospitals. CRVS for improving Strategies processes. 3: CRVS Topic CRVS resources and tools. user guide (V1.0). CRVS Technical SmartVA: crvsgateway.info/learningcentre CRVS resources and tools. Interviewer’s manual. CRVS SmartVA: Gateway: CRVS Knowledge of Melbourne, D4H Initiative, University Learning Centre CRVS summaries. of death. CRVS Intervention: Medical certification of cause CRVS summaries. CRVS practices. registration Intervention: Improving CRVS summaries. CRVS verbal autopsy. Intervention: Automated CRVS summaries. offices. CRVS CRVS systems need well-functioning civil-registry CRVS summaries. Bangladesh. CRVS CRVS country overview: CRVS summaries. CRVS the quality of cause of death data in hospitals. Action guide on improving crvsgateway.info/library University of Melbourne, D4H Initiative, CRVS Knowledge Gateway: Library Gateway: CRVS Knowledge Initiative, of Melbourne, D4H University Related resources and products and Related resources 22 CRVS country reports Bangladesh: Asuccessful journey towards CRVS systemimprovement |Version 0318-04 Organization 2006;84:239-245. Soleman N,Chandramohan,Shibuya K.Verbal autopsy:currentpracticesandchallenges.BulletinoftheWorld Health implications ofverbal autopsymethodsinroutinehealthinformationsystems.SocialScienceandMedicine2017;184:65-74. Gouda HN,FlaxmanAD,BrolanCE,JoshiR,etal.New challengesforverbal autopsy:Consideringtheethicalandsocial and vitalstatistics(CRVS): system-level considerations.GlobalHealthAction2017;10(1):1272882. de Savigny D,Riley I,Chandramohan D,OdhiamboF, etal.Integratingcommunitybasedverbal autopsyintocivilregistration AbouZahr C.Verbal autopsy:whoneedsit?Population HealthMetrics2011;9:19. Further reading The program partners on this initiative include: The University of Melbourne, Australia; CDC Foundation, USA; Vital Strategies, USA; Johns Hopkins Bloomberg School of Public Health, USA; World Health Organization, Switzerland.

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