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Increasing birth registration for children of marginalised groups in Pakistan

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Iffat Idris
GSDRC, University of Birmingham
16 July 2021


What type of interventions are effective for increasing the levels of birth registration for children from marginalised groups? Are there good examples from the global evidence base of ‘inclusive’ birth registration systems?

1. Summary

Birth registration is a universal right - providing access to essential services, protection and other forms of identity - but globally, significant numbers of children remain unregistered. This stems from both supply-side and demand-side barriers, with marginalised groups facing additional challenges. Promoting birth registration requires a combination of supply- and demand-side measures. Effective approaches to reach marginalised groups, which have been used in various parts of the world, include outreach efforts to target such groups, integrating birth registration with health services, and integrating birth registration with safety net (cash transfer) programmes. Pakistan is one of the countries with especially low rates of birth registration (despite recent progress) – the PDHS 2017-18 found that only 42% of children aged under five had their births registered. A promising digital initiative is being implemented in Punjab and Sindh provinces.

This review looks at approaches to promote birth registration among marginalised groups, in order to inform programming in Pakistan. It draws on a mixture of academic and grey literature, in particular reports by international development organizations. While there is extensive literature on rates of birth registration and the barriers to this, and consensus on approaches to promote registration, the review found less evidence of measures specifically aimed at marginalised groups. Gender issues are addressed to some extent, particularly in understanding barriers to registration, but the literature was largely disability-blind.

Key findings of the review are as follows:

  • Importance of birth registration: birth registration is a fundamental human right, allowing access to services such as healthcare and education; it is the basis for obtaining other identity documents, e.g. driving licenses and passports; it protects children, e.g. from child marriage; and it enables production of vital statistics to support government planning and resource allocation.

  • Barriers to birth registration mean many children are unregistered: globally, 166 million children under five are not registered (UNICEF, 2019: 16). Common problems are weak legal and policy frameworks; lack of coordination between different mandated agencies, and lack of interoperability between databases and information systems, complex and costly registration procedures, limited and under-resourced registration offices, lack of awareness and demand, and lack of prioritisation by government.

  • Additional challenges facing marginalised groups: registration rates are generally lower than average for vulnerable children, e.g. from minority groups, migrants, refugees, children with disabilities. Discriminatory policies against minorities, restrictions on movement, lack of resources, and lack of trust in government are among the ‘additional’ barriers affecting the most marginalised. Women, especially unmarried women, also face greater challenges in getting births registered.

  • General approaches to promoting birth registration: these broadly fall into supply and demand-side measures, the former to increase accessibility and affordability of registration services, the latter to increase awareness and incentivise parents. Key examples are legal and policy reform, awareness-raising activities, capacity building of registration offices, integration of birth registration with health services/education/social safety nets, and use of digital technology to increase efficiency and accessibility.

  • Outreach of registration services: Access issues are greater among marginalised (in remote rural locations, the poor, minorities facing discrimination, women, etc.) groups. Hence, one way to promote birth registration is to support outreach of registration services, specifically targeting such groups. This has been done in relation to: Roma communities in Albania using NGOs; internally displaced persons (IDPs) in Colombia using mobile registration facilities; and by building capacities of NGOs in Bangladesh to support registration of the most vulnerable and excluded children, including those of landless families, slum dwellers and minorities.

  • Integration of birth registration and health services: this can be an effective way to overcome lack of capacity (offices, staff, funds) in national civil registration systems. Common approaches are placing registrars in health institutions, engaging health staff (e.g. midwives) as outreach registrars, and including birth registration components in public health campaigns (e.g. for immunization). There are numerous benefits: health services have broader coverage than civil registration offices, there are community-based health structures, and parents interact with health facilities already.

  • Successful examples of this approach are seen in The Gambia, Uganda, Mozambique and Ghana. In the latter birth registration was tied in with annual child health promotion weeks and community health workers were trained to register births. As well as bringing about a significant rise in birth registration, the Ghanaian campaign reduced inequalities on the basis of rural-urban residence, socioeconomic status and access to health facilities. In Bangladesh birth registration of under-five children greatly increased as a result of its inclusion in the nationwide expanded programme of immunization (EPI).

  • Incentives through links with safety net programmes: Eliminating barriers to birth registration may not be enough to generate demand, but incentives can do this. Common incentives are tying birth registration to education access, and to social transfers. Birth registration has been promoted, e.g. in Brazil, by making it a requirement to access cash transfers (in Brazil’s case, the Bolsa Familia programme). In South Africa similar results were achieved by making it a condition to obtain Child Support Grants. However, in both Brazil and South Africa, efforts to incentivise demand were accompanied by reforms to the registration system to ensure the increased demand could be met. Furthermore, people should not be deprived of benefits or rights because of lack of registration. There are also examples of unconditional cash transfers (with no requirement for birth registration) helping promote this.

  • Pakistan has low levels of birth registration: despite being necessary for issuance of national identity cards and passports, levels of birth registration are low. 9% of the world’s 166 million unregistered children are in Pakistan (UNICEF, 2019:16). While progress has been made in recent years, gaps remain, and some population groups have been left behind, including the poorest households, and those speaking languages other than Urdu and Punjabi (i.e. minority ethnic groups). There are significant interprovincial and rural-urban disparities in birth registration, as well as across wealth quinitiles. The Digital Birth Registration (DBR) is a promising initiative in Punjab and Sindh provinces, which uses facilitators (e.g. lady health workers and nikah registrars) who directly access families with newborns and mobile technology to enter data for birth registration.