Emelda Okiro: Transforming birth and death registration

I'm Professor Emelda Okiro, and my main area of research is focused on improving routine data systems, specifically the system that records births and deaths, otherwise known as the civil registration system. My work is focused on trying to understand the challenges and gaps that prevent us from getting to universal registration, so meaning every birth and death is counted and communicated to the authorities that are responsible. So, Kenya is one of many countries in sub-Saharan Africa that have incomplete or unreliable civil registration data. And what we're trying to do as part of my work is try and understand what the gaps are in terms of the system, but also ultimately to design a context specific intervention that addresses the barriers, or challenges, that we find through the research.

One recent research project that we are doing is using health and demographic surveillance sites. These are sites that are in a particular geographic area that routinely monitors population changes. So, the data from these sites is considered to be quite good. We're comparing this data with what the official statistics are, to try and identify which communities or which individuals are systematically left out of the official registries. The other thing we are trying to do is also do some interviews with the civil registration authorities, but also focus group discussions with the communities, to understand the stories or narratives behind the challenges that they're experiencing. So, from the supply side, how is the system struggling, and where are the inefficiencies in the system that could be improved to make registration faster and easier for the people, but from the users, also understanding what challenges they face in trying to either register a birth or death. So, the combination of these two pieces of information will be used to co-develop and co-design a package of interventions that is culturally appropriate, but also context specific that we hope that will be able to address some of the gaps and challenges we are identifying.

I think there are several big questions. One is to try and leverage the network of community health promoters and digital technologies, to see how we can combine those two things to improve the way registration is done. The other thing is that the majority of deaths happen outside our formal health system. So, trying to see whether there are opportunities to implement verbal autopsy, which is a lay account of the conditions before a death happened, and whether community health workers can use that information, combined with AI for example, to try and identify a cause of death. The other major issue is I think to try and understand why some people, some communities are systematically left out of the registration process, and what it is about these marginalised groups that make them systematically excluded. So, what are the systemic barriers that exist? I think the last important question is to try and remove the reliance we have on modelled estimates, and instead focus on improving real time data and real time processes, to inform the way that we rely on data systems, routine data systems to provide the information that we need to make policy, and inform evidence-based decision making.

From the patient perspective, I think the important thing is that when births occur and are not registered, it means that the user, or the mother, or the primary caregiver is excluded from services that are routinely provided by the government. One example is that to enrol in schools in Kenya, you need a birth certificate. To get access to vaccination services, you need a birth certificate. So, people who are not registered or who do not have a birth certificate are excluded from services or social protection benefits that they should have access to. The other reason why registration is important is that when a death occurs in a community, and it is not captured by the health system or the government, then they're not aware that the event has happened or what the cause of the event is. So, in terms of planning and resource allocation, they're agnostic to what's happening at the community level, because this information is not accessible or translated to them. So, the reason why this work is important is that this information is necessary for informed decision making, but also in allocating resources equitably to where the need is most. Without the data then you're essentially flying blind.

I think the reason this research matters is because fundamentally we're addressing an important gap in the public health discourse. Who is born, who dies and what they die of are critical research questions that we should know. Without this information, we have no insight into what is ailing our communities. So, focusing on trying to get a sense of why we are unable to get to universal registration of both births and deaths is critical in ensuring that we are reliant. And I think data is about accountability, it's about equity, making sure everyone is counted, and it's also critical to achieving the Sustainable Development Goals. Both birth and death registration are one of the active targets that are used in the Sustainable Development Goals, and death registration contributes to many of the other targets that are being tracked. Without death registration, for a majority of the targets that we are supposed to be tracking, we have no insight or data to inform many of those targets. So, I think those are the reasons why focusing on improving routine data systems is critical to ensuring that we get to our target goals, but also that we are able to track progress effectively and consistently.

This interview was recorded in September 2025.