Comment
Civil registration as a means to promote human security
www.thelancet.com Vol 386 October 3, 2015
and impact of which have been questioned.10 The
Ebola outbreak in west Africa has challenged systems
of global health governance,11 and required the
international community to adapt and find new ways
to deal with epidemics as threats to human security. As
part of this strategic re-evaluation, the global health
community needs to strengthen its commitment to
the fundamental platforms of global health, such as
CRVS systems, that have been neglected.
As Carla AbouZahr and colleagues4 argue, this
Lancet Series is a wake-up call for the global health
community to reconsider the way we tackle health
and development challenges in the coming decades.
Global health conversations are often about phrases:
disease initiatives, health-system strengthening, or
vertical versus horizontal approaches. But eventually
the global health community is talking about the
same thing: how to provide health for each individual
in an equitable way—ie, how to provide and support
human security. Universal health coverage (UHC)
is an essential requirement of this goal,9 and more
countries are turning to UHC to provide their citizens
access to necessary health services without the threat
of financial catastrophe.12 However, UHC cannot
be established or made sustainable in places that
do not have CRVS systems, because these systems
are essential both for providing health services and
for supporting tax or social insurance systems that
sustain UHC. Here, development efforts in health and
Published Online
May 11, 2015
http://dx.doi.org/10.1016/
S0140-6736(15)60765-6
See Comment page 1313
See Series pages 1373, 1386,
1395, and 1407
Giacomo Pirozzi/Panos
Every day we see media coverage of the casualties of
wars, disasters, and epidemics somewhere in the world.
But nothing is more tragic than the deaths of those
who have never been registered when they were born
and died. Such deaths are neither reported nor recorded
anywhere, as if these people had never existed. In the
Lancet Counting Births and Deaths Series1–4 on civil
registration and vital statistics (CRVS), Lene Mikkelsen
and colleagues3 report a shocking figure: only about
40% of deaths are registered globally through CRVS
systems, and there has been virtually no progress in this
coverage since 2000. During this period the world has
improved in terms of economic growth and population
health,5,6 but the lack of major progress in CRVS is
probably the most critical development failure during
the era of the Millennium Development Goals (MDGs).7
CRVS is a primary data source for global
epidemiological analyses, such as the Global Burden of
Disease study,5 but it is not only a dry bureaucratic or
statistical instrument. CRVS also grants individuals an
identity within their state and access to basic welfare
services and civil rights, and protects children and
women from exploitation and hardship.1 Through
safeguarding individual rights to survival, livelihood,
and dignity, CRVS contributes to human security, which
aims “to protect the vital core of all human lives in ways
that enhance human freedoms and human fulfillment”.8
In this Series, David Phillips and colleagues2 underline
this fundamental benefit of CRVS, and present evidence
that well functioning CRVS systems are associated with
better population health outcomes after adjustment
for potential confounders. Although multiple causal
pathways make it difficult to link CRVS and individual
health, Phillips and colleagues2 show that CRVS systems
contribute both directly and indirectly to health, which
is a core element of human security.8,9
Global health is at a crossroads. For the global health
community, 2015 should be a time for reflection
about the 15-year efforts on the MDGs that not only
put health high on the development agenda, but also
focused on outcomes rather than inputs and spurred
the collection, synthesis, and analysis of metrics to
monitor progress.4 However, debate has shifted from
what works and what does not work to the lengthy
list of Sustainable Development Goals, the value
e14
Comment
human security converge around the critical need
for better information, and the movements towards
UHC and universal registration should go together.
But the move to sustainable UHC requires domestic
political commitment and recognition by national
governments of their individual responsibility—
and, often, their shortcomings—in establishing and
maintaining the core CRVS systems that support
human security and ultimately UHC.
The Lancet Commission on Investing in Health
linked UHC goals to global inequity in mortality and
morbidity.13 The Counting Births and Deaths Series now
provides an important lesson in support of this idea:
countries do not have to wait to be rich to improve
CRVS systems rapidly, and to reap the health rewards
such improvements provide. In countries where
there has been sustained and informed government
commitment, substantial progress in CRVS systems can
be achieved in a fairly short time, potentially through
new ICT technologies.2
The most exciting aspect of the post-2015
development agenda is not just the chance to renew
our efforts in health, but the opportunity to connect
sectors and start looking at individuals, families, and
communities, based on a human security approach.
However, this cannot be done without development of
basic systems to count births and deaths—one of the
foundations for health. CRVS systems have an essential
part to play at a time when the world needs strong ideas
that can build cohesiveness, enhance human security,
and unite rather than divide.
e15
*Kenji Shibuya, Stuart Gilmour
Department of Global Health Policy, Graduate School of Medicine,
The University of Tokyo, Tokyo 113-0033, Japan
shibuyak@m.u-tokyo.ac.jp
We declare no competing interests.
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statistics: progress in the data revolution for counting and accountability.
Lancet 2015; published online May 11. http://dx.doi.org/10.1016/S01406736(15)60173-8.
Phillips DE, AbouZahr C, Lopez AD, et al. Are well functioning civil
registration and vital statistics systems associated with better health
outcomes? Lancet 2015; published online May 11. http://dx.doi.
org/10.1016/S0140-6736(15)60172-6.
Mikkelsen L, Phillips DE, AbouZahr C, et al. A global assessment of civil
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progress. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/
S0140-6736(15)60171-4.
AbouZahr C, de Savigny D, Mikkelsen L, Setel PW, Lozano R, Lopez AD.
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everyone count by counting everyone. Lancet 2007; 370: 1569–77.
Commission on Human Security. Human security now: protecting and
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www.thelancet.com Vol 386 October 3, 2015