Elsevier

The Lancet

Volume 370, Issue 9598, 3–9 November 2007, Pages 1569-1577
The Lancet

Series
A scandal of invisibility: making everyone count by counting everyone

https://doi.org/10.1016/S0140-6736(07)61307-5Get rights and content

Summary

Most people in Africa and Asia are born and die without leaving a trace in any legal record or official statistic. Absence of reliable data for births, deaths, and causes of death are at the root of this scandal of invisibility, which renders most of the world's poor as unseen, uncountable, and hence uncounted. This situation has arisen because, in some countries, civil registration systems that log crucial statistics have stagnated over the past 30 years. Net of debt relief, official development assistance reached US$80 billion in 2004. Yet because of the weakness in recording vital statistics, we have little authoritative evidence that these funds have their desired effects on either mortality or poverty reduction. Sound recording of vital statistics and cause of death data are public goods that enable progress towards Millennium Development Goals and other development objectives that need to be measured, not only modelled. Vital statistics are most effectively generated by comprehensive civil registration. Civil registration has a dual function, both statistical and legal; it also helps with economic development. 30 years of stagnation will not be overcome quickly, although new efforts to develop national statistical capacities offer a unique opportunity to refocus attention on civil registration. Now is the time to make the long-term goal of comprehensive civil registration in developing countries the expectation rather than the exception. The international health community can assist by sharing information and methods to ensure both the quality of vital statistics and cause of death data, and the appropriate use of complementary and interim registration systems and sources of such data. The continued cost of ignorance borne by countries without civil registration far outweighs the affordable necessity of action.

Section snippets

Who counts?

By posing this question, our goal is to focus worldwide attention on the need to recommit resources to the registration of births and deaths, and to certify the causes of death in the world's poorest countries. Published fertility, mortality, and cause-specific mortality figures for rich countries are based on data from functioning civil registration systems and can sensitively monitor long-term and short-term demographic changes, and give up-to-date population counts. Fertility and mortality

Sources of vital statistics

The administrative and technical functions of civil registration and vital statistics systems can be configured in many ways, and responsibilities for maintaining the system and obtaining the vital statistics vary from country to country.10, 11, 12, 13 Figure 1 shows levels and functions in civil registration and the production of vital statistics. Locally, individuals report births and deaths to civil authorities and receive legal documentation—birth and death certificates or burial permits.

Health sector demands for data

Several UN and WHO reports and publications have summarised the poor state of birth and death registration in poor countries.9, 10, 15, 16, 17 The table shows the estimated proportion and number of births in each WHO region that go unregistered every year. The inequalities in registration rates are large; developing countries account for 99% of the estimated 48 million unregistered births, with South Asia and sub-Saharan Africa together accounting for 79% of all unregistered births. According

The beneficiaries, benefits, and risks of registration

Civil registration and death certification with high and representative coverage is essential for individuals, national and sub-national authorities, and the international community. Other methods of registration and collection of data (eg, sample registration systems or research demographic surveillance sites) for cause of death address some statistical needs, but are clearly less useful than civil registration in the long term, and cannot provide the benefits that civil registration provides

Conclusions

The worldwide AIDS pandemic clearly shows that visibility demands accountability, which in turn generates the ability to count. In the 1990s the realities of people living with AIDS in heavily affected countries became visible, and the imperative of action became irresistible. In 2001, the international community put a price-tag on action, and decided that provision of pharmaceutical care at the same standard as developed countries to as many people as could be reached in developing countries

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