A Transformative Journey of Mass Birth Registration and Health Insurance in The Gambia

Key Highlights

• During a short seven-month period (from August 1, 2022, to February 28, 2023), more than half of the population of The Gambia nearly 1.17 million people of all ages) was registered and issued birth certificates and national health insurance cards with a unique national identification number.
• The World Bank-financed Gambia Essential Health Services Project transformed a paper-based, manual birth registration process into a functional electronic Civil Registration and Vital Statistics (eCRVS) system.
• The eCRVS system has become the foundational system for interoperability with the information systems of ministries and authorities, using the unique national identification numbers as the common key.

Challenge

Prior to 2020, when the World Bank started supporting the Ministry of Health, the completeness of paper-based birth registrations was only about 59 percent in The Gambia. That meant that a large proportion of the population did not possess a birth certificate. This important identity document is often required to apply for identification (ID) cards, passports, and driver's licenses, as well as to open bank accounts, take school or certification exams, and apply for a job. The lack of this document could hinder people from the full exercise of their rights, as well as their participation in various activities in society. Even when births had been registered, if people lost their birth certificates, they were not able to obtain a replacement or retrieve their records anywhere. This was because the original paper registration records were difficult to retrieve at the original registration center. The manual, paper-based civil registration process itself presented numerous challenges, including the cumbersome collection of data, inefficient archiving, and difficulties in retrieving certificates. Paper records are difficult to store, prone to damage, and hard to locate without an effective organization system. This problem also undermined the government's ability to identify an accurate number of people at the national and sub-national levels, which in turn made it difficult to plan and provide adequate and targeted social services, including essential health services-especially in the absence of a national health insurance program in the country. This problem was pervasive because the majority of government information systems relied on traditional paper-based methods.

Approach

Taking a multi-sectoral approach was vital to achieving the project's success and maximizing its impact. In 2022, implementation focused on: (i) integrating the national ID system of the Ministry of Interior with the civil registration system of the Ministry of Health; (ii) working with the private sector to establish an eCRVS system tailored to the Gambian context; and (iii) partnering with the National Health Insurance Authority to conduct a combined national campaign capable of registering both births and insurance membership.

The World Bank provided technical advice from project inception to execution. In the area of citizen identification, obtaining support from the Ministry of Interior, which issues national ID cards for people aged 18 years and older, was critical. Collaboration between the Ministry of Health and the Ministry of Interior also fostered a productive working relationship between the two ministries, which are at the forefront of implementing the eCRVS system.

The government negotiated with a software company to secure an electronic civil registration system software at a discounted rate. This new system can generate unique national identification numbers in real-time during registration. Departing from the conventional practice of solely conducting birth registration, the project undertook an innovative approach of collaborating with the National Health Insurance Authority to register people for the national health insurance program at the same time. Consequently, people received both documents concurrently, each featuring a unique national identification number and a Quick Response (QR) code.

The project faced unexpected difficulties during the mass registration process and adapted to address these challenges:

• Some remote areas lacked internet connectivity to issue a unique national identification number, so the project implemented satellite internet, which has been scaled up to all health facilities.
• Errors in some birth certificates were corrected by establishing a dedicated portal for the public to report errors using their mobile phones, tablets, and laptops.
• Registration slowed during the initial days when registration teams moved to a new location. This was monitored by a daily electronic registration dashboard. Thus, the project minimized team movements within regions.
• Managing paper timesheets for over 1,500 registration officers posed a difficulty. Therefore, an online attendance register was created to streamline the payment process.

The project also financed the procurement of large quantities of information technology (IT) equipment and accessories (such as laptops, tablets, and ID card printers) for registration centers across the country to conduct the mass registration.

Results

Between August 2022 and February 2023, mass registration of births and national health insurance memberships resulted in the registration of 1,167,460 people of all ages. The Gambia Bureau of Statistics conducted a household survey in March 2023, which revealed that about 54 percent of the population reported having been registered (with 43 percent of electronic birth certificates seen by the interviewer and 10 percent not seen). This was also corroborated with the total number reported in the eCRVS system.

The assignment of national identification numbers is enabling further advances for services. The government of The Gambia has established a multi-sectoral task force to enable information systems of various ministries to be able to exchange reliable, real-time data using the unique national identification numbers as the common key. This stands in stark contrast to how ministries had been operating their own information systems in silos, which made it hard to share, merge, and update data in a timely manner through secure methods. The health sector is bringing about a digital transformation, digitizing most of the information systems, including the electronic human resource management information system, the electronic national health insurance system, and the electronic health records systems.

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Partnerships

Within the government of The Gambia, the project was carried out principally by the Ministry of Health in collaboration with the Ministry of the Interior. Moreover, to ensure interoperability of the eCRVS and the national ID system and also with information systems of other sectors, an elaborate interoperability document has been developed, and a memorandum of understanding (MOU) between Ministry of Health, Ministry of Interior and the Ministry of Communications & Digital Economy was signed on March 22, 2024. Additionally, Ministry of Health will also sign similar MOU with other ministries such as Ministry of Basic and Secondary Education.

Looking Ahead

The Ministry of Health has transitioned from mass registration to providing routine registration services in all public health facilities with an eye toward universal registration. The goal is timely birth registration of newborns at health facilities, as well as the registration of the rest of the population of all ages. As the National Health Insurance Scheme is rolled out across the country in 2024 with initial focus on delivery and newborn care, it will contribute toward achieving universal health coverage in The Gambia.

The Gambia's experience with mass registration is providing inspiration and a useful policy example for other countries in the region. For example, a delegation from the Ministries of Education and Justice of Cameroon visited The Gambia on a study tour in January 23-26, 2024, to learn about the mass birth registration.

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