1. Overcoming low birth registration coverage and improving death registration in Nigeria by Sharon Oladiji

2. Outline 1. Description of the Challenge –The Country –Background information and problem description 2.Critical Evaluation –Underlying Causes –The methodological and conceptual framework 3. Changes in Practices –Role of legal Moral and social norms –What did not work –Plan of action to promote institutional shift 4. Conclusion

3. The country Land area of 923,768 square kilometres. Population of about 162 Million (2006 Census). Operates a 3-tier federal system of government comprising the Federal, State and Local Governments. There are 36 states, 774 local government areas and a Federal Capital Territory, Abuja. Six geo-political zones. Children (0-17 years)constitute about 50. Children < five populations constitute 17%.

5. Background information and problem description -1 Efficient civil registration systems. Importance of birth and death registration. Birth registration is a frontline tool in combatting of early marriage. Parents and care-givers cannot inflate age to disguise child marriage if evidenced by birth registration. Real protection is elusive in the absence of certainty about age, be it 12, 16, 18 or anywhere in between. Death registration helps monitoring the impact of public health programs and child hood deaths. All these can be linked to other harmful practices discussed during the UPenn course

6. Background information and problem description -2 Major disparity exists between the South and the Northern part of Nigeria. 58% of about five million children born annually in Nigeria are not registered at birth: –They have no birth certificates, –In legal terms they do not exist, Northern zones have 2 times lower registration levels compared to southern zones. All health indicators are poorer and worse off in the North compared with the South.

7. Southern and Northern States Disparity IndicatorsSouthNorth Birth registration31.4%16.2% Adolescent birth rate89 births for 1,000 women 170 births for 1000 women Fertility rate5.7 births per woman 7.2 births per woman Infant mortality rates55 and 83 per 1000 live births 123 and 208 per 1000 live births Women literacy rate81%37%

8. Underlying causes of low birth registration in the North The cultural values of the people of Northern Nigeria are practically shaped by religion/Islam. Practice of a serious gender bias/norm that excludes most women from the entire decision making process in the home. There is a continuous disadvantage in educational access for girls and high rates of female illiteracy. Huge ignorance and lack of awareness of the importance of births and deaths registration. Limited knowledge base. Most women give birth at home and do not register the births of their children and do not access health services or attend health centres.

9. Scripts and Schemata The ‘script’ for a lot of very rural women in Northern Nigeria whether in Purdah or not features: “limited knowledge base” “delivering of babies in their homes”, “not knowing the importance of accessing health care services” “disadvantaged educationally and with poor socio economic status” “exposed to cultural/religious practice based on deep rooted religious beliefs” impacting negatively on the registering of births and deaths of their children and other health indicators.

10. Conceptual Framework Normative Expectation Empirical Expectation I believe other women believe I must be subjected to my husband I should be subjected to my husband Social Expectation Deep rooted core beliefs Pattern of behavior with sanctions Schemata / stereotypes Scripts

11. Critical Evaluation of the work Strategies that worked: Core group formed: NPOPC and NPHCDA and INGOs. Changed the script through - Coordinated Actions: Opportunities such as MNCHW, IPDs and RI targeting newborns and under-five population. Social Network Analysis by Health Social Mobilization teams: Communication strategies developed and implemented. Worked within high degree and nodes: Religious and traditional leaders persuaded to shift grounds. Incentives introduced: Level of ignorance and practices fueling the problems dealt with. Organized diffusion took place: Over a million births registered during 2 rounds of MNCHW- 8 days

12. What worked Engaged second core group to implement the MNCHW. Value deliberation: Preparatory and participatory consultation and deliberations between the NPHCDA and NPopC held in Kano state- Northern part of Nigeria; to Trigger: integration activities Clarified key issues Mapped out the diffusion strategy, logistics, roles and responsibilities of different teams involving: – birth registrars, –health social mobilization teams, –sub-registrars and health facility personnel

13. D iffusion of the innovation Diffusions enabled out- reach to thousands of women/mothers/care givers of millions of <5 under-five in communities including remote, excluded and hard to reach areas. House‐to‐House (H‐H) engagements, established Fixed Posts (FP) and use of Special Teams Source: Everett M. Rogers, 2004.

14. Change in practices Positive sanctions/Incentives introduced: ”obtain birth certificate free to obtain passport for your child, to be able to go to Mecca” Change in social expectations: Women were made/allowed by their husbands to access health care services and register the births of their children. –Women changed their factual beliefs and registered the birth of their children, because other women in their reference networks (within the same communities) conformed to registering (empirical expectations). –Women did register their children because most women in their relevant networks believe that they ought to conform/ought to leave their homes and enclaves and come out to register their children (normative expectations).

15. Key results 334,027 births from 33 states and FCT registered in May/June rounds. 694, 922 children in 34 states and the FCT registered during the November/December rounds. Within the two rounds (4 days each) of MNCHW, about 1,028,549 births were registered.

16. MNCHW State Results, 2010 May-June 2010 Nov-Dec 2010 20,000-39,000 5,000-19000 missing 40,000 and above

17. Mockus theory of Legal, moral and social norms Despite the ‘Births and Deaths (Compulsory Registration)’ Act No.39 of 1979’ and Act 69 of 1992 in place - but low coverage persists (Legal norm). Social mobilization of men and women, raising awareness on the importance of birth registration, changing of social expectations, (Social norm) use of incentives and high degree nodes (Moral norm) all contribute to achieving higher birth registration coverage.

18. What did not work Issue of death registration was not raised/affected. Core beliefs of keeping women in the background- to be seen and not heard, to have poor education status and deep rooted belief of Purdah was not affected.

19. Plan of action for institutional shift Post triggering actions: Diagnostic study: by Ulamas and muslim clerics to create messages for diffusion. Public declaration. Working with women groups and town criers Strengthening fathers/male dominated core groups/value deliberations. Social marketing. Sustainability strategies.

20. M&E Indicators QUANTitative: Help to answer questions about things inherently expressed in # How many? How often? How much? QUALitative: Help to demonstrate, describe, or measure that something has happened How? When? Who? Where? Which? What? Why? Qualitative! Quantitative!

21. Conclusion The approach: – to raise awareness on the importance of birth registration; –to dealing with socio cultural barriers; –unequal power relations; – patriarchal beliefs – that persistently limits mothers and care givers to register their children will be further accelerated by successful models learnt at Upenn.

22. Thank you