Overview
According to WHO’s SCORE assessment, Kenya has limited capacity in counting births, deaths and causes of death, as a result of a weak civil registration system. This has significant consequences for the achievement of the health-related Sustainable Development Goals (SDGs) as it constrains the government’s ability to effectively plan, equitably allocate and use resources, and evaluate and monitor progress. If people are not counted, they remain invisible – increasing inequities. The challenge of weak civil registration systems is being addressed jointly by the Ministries of Health and Interior with support from signatory agencies of the Global Action Plan for Healthy Lives and Well-Being for All (SDG3 GAP) together with the Health Data Collaborative (HDC), who are working to strengthen data and digital health.
This initiative takes a two-pronged approach which focuses on improving coordination and collaboration among actors working on civil registration and vital statistics (CRVS) as well as strengthening the CRVS system and the quality, completeness and timeliness of data.
As part of efforts to improve coordination and collaboration, a UN Legal Identify Agenda (UNLIA) Taskforce which includes HDC and SDG3 GAP partners (UNDP, UNICEF, WHO, UNFPA, and UN Women), was established in August 2020.
SDG3 GAP and HDC partners are collaborating with each other to support the government to strengthen the CRVS system. These efforts to improve CVRS and health data are having an impact. In June 2021, for example, a rapid mortality surveillance (RMS) was implemented in six high Covid-19-burden and border counties by the government of Kenya with support from its partners. The RMS improved the timeliness and quality of mortality data notification from health facilities and the community and increased the coverage and completeness of death and cause-of-death registration, which led to an enhanced understanding of the epidemiology of all-cause mortalities. This in turn contributed to the identification of risk factors associated with severe outcomes of COVID-19 and improved the monitoring of longer term epidemiologic trends and the evolution of the virus. It also supported evaluation of the effectiveness of COVID-19 control measures as well as the impacts of both the pandemic and public health measures on the health system and health more generally.
A nurse holds 7-month-old Beverly Wakasa while speaking to her mother at the Malava County Hospital Child Welfare Clinic in Kakamega, Kenya. ©Gavi/White Rhino Films-Lameck Orina.
Situation in Kenya
Kenya’s SCORE assessment of its Health Information System (HIS) shows that its Civil Registration and Vital Statistics has limited capacity to count births, deaths and cause of deaths. This is despite the legal obligation to register all births and deaths that occur in the country.
According to the latest statistics from the Kenya Vital Statistics Report, 14% of births and 45% of deaths were unregistered in 2021. One key reason for this is poorly functioning civil registration and vital statistics (CRVS) systems and processes. Another cause is inadequate coordination and collaboration among the various actors working at national and subnational levels as a result of the complexity of the development ecosystem, the multiplicity of actors, and devolution which means that county governments have decision-making power and are autonomous from the national government. Every country needs real-time, accurate, reliable and disaggregated population level data on births, deaths, marriages and other key life events, as this ensures that it can effectively plan, allocate and use resources, and evaluate and monitor progress, including progress towards universal health coverage and the Sustainable Development Goals (SDGs). Not counting people when they are born for instance, means that they are likely to be invisible to key services, and they may face barriers to accessing health, education and other services. This in turn contributes to increasing inequities especially for those that are at risk of being left behind.
UNLIA taskforce for CRVS
Given the importance of CVRS, the government of Kenya has been working to strengthen it, with technical and financial support from its partners. This includes SDG3 GAP data and digital and HDC partners who are collaborating to support a joint agency CRVS HDC working group that provides technical support for countries. The initiative takes a two-pronged approach which focuses on improving coordination and collaboration among actors working on CRVS as well as strengthening the CRVS system and improving the quality, completeness and timeliness of data.
A key part of this involved the establishment in August 2020 of a UN Legal Identify Agenda (UNLIA) Taskforce by the United Nations Country Team (UNCT). The Taskforce - which includes SDG3 GAP partners UNDP, UNICEF, WHO, UNFPA, and UN Women - was created to coordinate the implementation of UN Legal Identity Agenda (UNLIA) activities in Kenya. UNLIA advocates for a global life cycle model of legal identity "from birth to death” and has prioritised CRVS improvement efforts as part of the ongoing process of establishing a National Integrated Identity Management System (NIIMS). The Taskforce has supported a number of initiatives aimed at strengthening CRVS in Kenya. This includes a mid-term review of the Civil Registration and Vital Statistics Strategy 2018-2023 which assessed the extent to which the objectives of the strategy had been met and identified gaps which could be used to inform the development of the next strategic plan. The review resulted in the development and validation of a roadmap to operationalise the Kenya Partnership and Coordination Framework 2018-2030 that is now being implemented.
Collaborative efforts to strengthen CRVS
Alongside the work by the Taskforce, SDG3 GAP and HDC partners are collaborating on other CRVS-strengthening activities. One example of this is the joint agency CRVS working group which acts as a platform for coordinating support for Government-led initiatives. The working group includes a wide range of stakeholders who play key advocacy and support roles, and its membership extends beyond SDG3 GAP multilateral and global health initiatives partners to representatives of donor agencies, academia, the private sector, civil society and communities that are left behind.
In addition to this, SDG3 GAP agencies are working closely with each other on a number of initiatives. For example, WHO recently established a Mortality Statistics Technical Working Group. This working group, which includes key stakeholders and is chaired by the department of Civil Registration Services (CRS), aims to strengthen the coordination mechanism for mortality reporting and to improve mortality statistics. The Organization has also collaborated with UNFPA on the production of the annual Kenya Vital Statistics Reports (KVSR) and is working with other partners to build the capacity of stakeholders on the analysis of mortality data. Also, WHO is undertaking capacity strengthening on Medical Certification of Causes of Deaths as well as providing technical support aimed at strengthening systems for notification and registration of death.
UNICEF is helping to coordinate UN agencies within the framework of UNLIA implementation in Kenya and is currently facilitating the development of the Scope of Work Agreement which establishes an operational framework of collaboration between the Government of Kenya and the United Nations in the implementation of National Integrated Identity Management System (NIIMS). The Scope of Work Agreement also maps UN entities’ areas of interest as well as areas of possible partnership with the government.
UNICEF has also supported business process reviews and the development of Standard Operating Procedures for the Civil Registration System (CRS), with the aim of improving the legal and policy framework and the automation of the CRVS process. In June 2018, as part of these efforts, UNICEF supported a ‘Productivity Improvement of Civil Registration Services’ workshop which aimed to review the Civil Registration ecosystem. At the workshop, the primary challenges in the user journey from both the supply and demand perspectives were identified and an action plan was proposed to address the identified challenges with new technology. The action plan covered the following four thematic areas: modernization of civil registration, digitization of records, review of the legal and policy framework, and capacity building and awareness creation. In addition, UNICEF supported a high-level multi-sectoral civil registration benchmarking mission to Estonia and Netherlands, with the aim of exploring comprehensive end-to-end CRVS systems and the operationalization of unique identifiers. The agency has also supported civil registration activities in selected counties, often by working with schools and early childhood centres to improve birth registration coverage. These activities typically include community sensitization components on topics such as birth registration.
UNDP is facilitating the coordination of ministries, departments and agencies involved in the registration of people, and supporting the implementation of UNDAF Result Area, “By 2022 people in Kenya access high quality services at devolved level that are well coordinated, integrated, transparent, equitably resourced and accountable”. The agency is providing support for awareness-raising activities and civic education and improving the inter-operability and harmonization of relevant civil registration, vital statistics and identification management systems. In addition to this, it has procured key digital registration equipment, and it is training registrars to use the equipment as well as developing legal instruments and guidelines that provide the legal framework for the integration of the registration systems and ensure data protection and privacy. In addition, UNDP is working with UNICEF to identify target counties and sub-counties where registration is below 50% and consulting extensively with the department of Civil Registration Services on how to make improvements. In terms of the functional registry, UNDP supports the Independent Electoral and Boundary Commission with registering voters for every electoral cycle, when requested.
Results and impact
These efforts to strengthen partnerships and collaboration and improve CVRS and health data are having real impact for people and their communities. In June 2021, the Kenyan Ministry of Interior and the Ministry of Health began implementing rapid mortality surveillance (RMS) in six high COVID-19-burden and border counties, with support from its partners. These partners included UNICEF which led the development of the platform for collecting the data, and WHO, US-CDC and other UNLIA partners which provided funding and technical support for the programme. The initiative aimed to generate timely, quality mortality data during the COVID-19 pandemic by streamlining, strengthening and improving the coverage and completeness of death and cause-of-death notifications from the community and health facility levels. An interactive Mobile SMS platform for real-time death notification was set up using RapidPro software. Registration agents from health facilities and communities were trained on death notification and a “Power BI” dashboard was established to aggregate and visualize the data daily.
The results have been significant. For instance, by June 2022, about 31,000 deaths had been notified using the RMS system. The data, which was disaggregated, showed important details such as the fact that about 60% of the deaths were notified from the communities, a third of the deaths were among the elderly aged >65, and a higher proportion of these were male deaths. This improved data collection and analysis led to enhanced understanding of the epidemiology of all-cause mortalities in the six counties and contributed to better decision-making around both the COVID-19 response and health more generally.
Another example is the implementation of the one-day service model for civil registration which allowed Mama Jane Chebeni to collect the birth certificates for her two school-aged children at the CRVS Office in Bungoma County in just two hours. Mama Chebeni was delighted both with the speed of the process and the fact that her children will be able to stay in school now that they have their birth certificates.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets. The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies. A “recovery strategy” (Oct 2021) serves as a strategic update on the SDG3 GAP in the context of achieving an equitable and resilient recovery from the COVID-19 pandemic to the health-related SDG targets.
The Health Data Collaborative (HDC) convenes multiple global health partners for efficient alignment of investments to empower countries for planning, implementing, evaluation of progress and standardizing processes for data collection and analysis to achieve the SDG3 targets. SDG3 GAP and HDC are interlinked through the SDG3 GAP Data and Digital Accelerator Working Group and the support provided to countries on strengthening data systems is fully aligned and integrated.
The purpose of GAP case studies is to monitor SDG3 GAP implementation at country level.