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Session 2: Different Perspectives of CRVS -- CRVS and Health
Professor Dr Abul Kalam Azad
Additional Director General & Director, Management Information System
Directorate General of Health Services, MOHFW, Bangladesh
Chair and distinguished participants,
I am sure that all of you understand importance of
CRVS System very well.
I shall tell you from personal experience -- why CRVS
System matters for health.
Then I shall tell you -- why health matters for CRVS.
However, I mean a CRVS System -- that is
electronically maintained.
Let me tell first -- how CRVS can benefit health
Here I shall make 6 points from experience:
1. Communicable Disease Surveillance-- why we will
collect same demographic data every time?
2. Routine immunization -- poor estimation of number
of children causes wastage of resource or poor
protection of children.
3. Two MMR Surveys in Bangladesh -- we missed
UN-MDG5 Award.
4. Want to know MDG 4 & 5 status real time.
5. Routine facility MCH data 2011 -- what is
happening in the community?
6. Causes of death data -- we do not know for what
causes most people are dying.
To resolve problem -- MOHFWstarted population EHR
program in its own way -- to create statistical evidence.

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CRVS systematic assessment -- new lessons
Recently we understood very hard facts from
systematic CRVS assessment.
Thanks to the UN ESCAP and WHO-SEARO for
assistance.
We observed -- fragmented efforts -- inefficient --
unproductive -- non-standard system -- wastage of
resource.
The gaps:
1. The births & death registration project -- only
interested to register and issue birth and death
certificates;
2. The Election Commission -- interested only about
voters;
3. The NSO -- collects 10 CRVS data elements -- but
only in sentinel sites -- and cause of death data not
according to ICD-10;
4. The MOHFW -- started EHR project -- but not for
issuing legal birth or death registration certificate;
5. None of the system is designed in standard way --
and is not inter-operable.
Now let me tell you -- why without health -- effective
CRVS may not be possible -- this observation came from
our CRVS assessment
1. The birth & death registration project -- will wait say 100
years after registering birth for the death to occur -- not
interested to know cause of death;
2. The election commission will only search a voter every
4 or 5 years to update voter list;
3. The NSO does not have enough staff for universal civil
registration -- the NSO is non-professional to determine
cause of death;

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4. Only MOHFW has responsibility and universal contact
with citizens through life course -- in fact -- it does
require more CRVS data than others -- it does collect
also more CRVS data than other.
New strategy from lessons of CRVS Assessment
1. We agreed to establish a common -- full coverage --
standard --interoperable -- and -- sharable CRVS
system -- together by all stakeholders - public, private
and DPs.
We have a good start -- The COIA intervention
Conclusion

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IEDCR experience of Communicable Disease
Surveillance
Year 2004 -- I took the responsibility of Director of
IEDCR.
We were confronted with risk of rapid global spread of
emerging and re-emerging communicable diseases --
like SARS, Bird flu, Nipah virus infection, etc.
My institute was under pressure to build a functional
and responsive surveillance system to help forecasting,
rapidly investigating and interveningsudden outbreak of
any communicable disease.
You can imagine, in a country of 150 million population,
mostly rural with not so advanced society, this was
really a difficult task.
When surveillance means -- collecting data on
respondents at intervals, the most obvious question
came.
Why should we write the name, age and sex of the
respondents, every time?
These are static data.As alternate, we can make a
citizens’ registry with unique ID, name, date of birth and
sex information, etc.
An electronically maintained CRVS System can help
avoid this repetitive task, and save valuable staff time
for other priority and productive work.
Wastage of resource in child immunization
The second problem our ministry of health usually faces.
Bangladesh is a successful country in universal routine
child immunization.
However, in no year, we can accurately estimate how
many doses of vaccines we would need.

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Because we exactly do not know how many children
population we may have in any -- Because we don’t
have mechanism to know population denominator other
than census year.
In non-census years, we estimate target population size
by adjusting year-wise population growth rate by
adjusting with census year’s population -- and in doing
so, we use same population growth rate for all regions
of the country.
It means, either weover-estimate or underestimate
children’s number.
And so we buy vaccine doses either in excess or less
than needed.
Excess means we waste money -- Less means, we
keep some children unprotected.
A good CRVS System could help better manage the
situation.
MMR Survey -- Bangladesh missed UN-MDG5 Award
The immediately past two maternal mortality surveys of
Bangladesh were done in 2001 and 2010 respectively
with a 10 years’ interval in between.
In 2001, the MMR was 320 per 100,000 live births.
Even immediately before release of 2010 survey report
there was a widespread assumption that the current
figure should be above 290 per 100,000 live births --
because we had no idea that our maternal health
interventions were working.
Surprisingly enough, the 2010 survey showed it to be
194 per 100,000 live births.
Just prior to release of the 2010 report, Bangladesh
received MDG 4 award from the UN; but missed the
MDG 5 award, which was given to Nepal.

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But, after release of our 2010 MMR report, we
understood that our maternal health situation was much
better than in Nepal.
We missed the MDG 5 award because we did not have
an effective CRVS System.
Bangladesh wants to MDG 4 & 5 status real time
Bangladesh seriously wants to achieve MDGs 4 & 5.
The country also believes that it would be possible.
But, we want to know on real time -- how the
interventions are working.
An electronic CRVS System integrated with HIS is the
best answer.
And experts have identified that 42 MDG indicators out
of 60 can be derived from CRVS data.
Routine facility data on child deliveries & IMCI
In 2011, my department collected routine data on about
0.6 million institutional deliveries.
But, we do not know from these data how many
deliveries were taken place in the whole country that
year -- or what was the institutional or home delivery
rates or national skilled birth attendance rate.
Similarly, in 2011, we collected routine data on 25
millionU5 children treated for IMCI diseases in health
facilities.
But, these huge data could not tell us was the
prevalence of those diseases among U5 children.
We do not know for what causes most people die
Recently, we started collecting causes of death data as
well as morbidity data from health facilities according to
ICD-10.
But, more than 90% of deaths in Bangladesh occurs
homes.

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Unless unnatural, these deaths do not require any
medical certification or need for finding cause of death
for burial or for any other purpose.
If we don’t know why most people die, or what are most
common disease burdens -- then how can we plan for
preventing unwanted or premature deaths -- or making
hospitals -- or creating human resource?
MOHFW’s population EHRs to create statistical
evidence
MOHFW wanted to have a better solution to all these
problems.
So, the ministry started making a population health
registry.
The work began in 2009 and we collected data on 120
million citizens out of 150 million.
The data are now being fed into electronic database to
develop into EHRs and to be accessible across the
country through electronic devices like computers,
laptops, tablets in health facilities and community health
workers.
The preparation for this gigantic vision is also moving
satisfactorily.
The whole idea is to have reliable and representative
statistics available real time to generate evidence and
make plans and decisions based on actual situation and
thereby also minimize need of costly and time
consuming common population surveys.
CRVS systematic assessment -- new lessons
Recently we understood very hard facts.
Thanks to the UN ESCAP and WHO-SEARO that these
two organizations assisted us in conducting rapid and
the comprehensive systematic assessment of our
CRVS System.

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These assessments provided us clear lessons that no
silo effort by any individual stakeholder ministry or
agency will, in itself, be complete and fulfilling.
We have explored -- how injudiciously, scarce
resources are about to be inefficiently used.
We identified number of gaps:
6. The MOLGRDC has a National Birth & Death
Registration Project supported by UNICEF, which
registers only live births -- no still births -- and deaths
without causes of death; the project has been
designed only to issue legal birth and death
registration certificate -- and not for generate
statistical evidence;
7. The National Election Commission, registers only
citizens eligible for voting, i.e., citizens 18 years and
above;
8. The National Statistics Office collects data on 10
variables of CRVS, viz., birth, death, cause of death
not according to ICD-10, marriage, divorce,
immigration, emigration, etc.; but only from 1,000
primary sampling sentinel sites -- unable to represent
country; and
9. The MOHFW is interested for preparing electronic
health record -- not for other issues like issuing legal
birth or death registration certificate.
The CRVS assessmentidentified that none of the
system, either individually or collectively is designed in
proper way.
All the systems have been designed as stand-alone
without intention to mutually benefit each other.
And will not serve whole range of purpose of CRVS
system.
Many pertinent observations from CRVS assessment

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5. The birth & death registration project is interested to
know about a citizen only after birth and then may be
after 100 year when the person will die; and is not
interested to know with what causes the person has
died;
6. The election commission is interested to know about a
citizen only during election --to know whether or not
s/he is eligible for voting or if registered, whether or not
surviving during the next election;
7. The national statistics office has no ability to fulfill
universal coverage of civil registration -- does not
record death according to ICD -- and also have no
authority to issue legal birth or death registration
certificate;
8. The MOHFW, does not have mandate for issuing legal
birth and death certificate;
But, due to having wider health service network and
opportunity to access citizens throughout the life
cycle; and
Due to relevance of all data parameters of CRVS
System with health for understanding an individual’s
or overall community or national health status;
The MOHFW in its own right deserve engagement in
the national CRVS System as a core stakeholder --
but not excluding others.
Consensus for building national CRVS System as
common sharable resource
Bangladesh has great learning from the assessment of
CRVS System
From this lesson, we built the consensus that all the
stakeholders in Bangladesh will work together for an
integrated, shared, standard and inter-operable
electronic system.
A good start -- COIA intervention

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We have started an intervention for COIA Country
Framework to institutionalize a community based Monitor-
Review-Act cycle for improving maternal and child health
situation in each small community of the country.
Conclusion
I believe that these example will help us how to build an
effective CRVS System and as a result will produce more
health for money.
Thank you.