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Correspondence
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234
2013 legal amendment to eliminate
fees for all CRVS documents, the
implementation of these laws has been
inconsistent across regions, and many
parents continue to pay hidden fees.
Acquisition of the prerequisite
documents, including parents’
marriage certifi cates (found to increase
a child’s odds of birth certificate
ownership by 90%), contributes to
the fi
nancial burden of applying for a
birth certifi cate. A marriage certifi cate
from birth parents is among the six
documents required, and is costly and
complicated to obtain. Many religious
marriages remain unregistered by the
state. In regions such as NTT, these
costs are compounded by cultural
expectations for expensive religious
weddings, which often prevent
couples from entering into both
religious and civil marriage. Without
a marriage certifi cate, a child is issued
a birth certifi cate specifi c to children
born out of wedlock; this document
is stigmatising, further deterring
unmarried couples from registering
their children.4
Navigating Indonesia’s complex
CRVS system was an impediment
for 130 (12%) respondents, and
potentially required them to
interact with several governmental
agencies, including the courts, to
obtain marriage legalisation, the civil
Barriers to birth
registration in Indonesia
Birth registration is the first
legal recognition of a child and a
fundamental human right.1 Worldwide,
nearly 230 million children younger
than 5 years do not have a birth
certificate, rendering them invisible
to the state.2 Indonesia is one of
the countries plagued by this so-
called scandal of invisibility,3 with
more than 24 million Indonesian
children remaining undocumented.4
This number is concerning, given
existing evidence linking a lack of
birth registration to increased school
drop-out, child traffi cking and labour,
and reduced access to health, social
services, and education.2,4 Furthermore,
effective civil registration and vital
statistics (CRVS) systems are vital to
inform and monitor health policy
and programming and will be central
to tracking progress towards the
Sustainable Development Goals.5
Empirical research on birth
registration is lacking in many
countries, including Indonesia. This
study examines the correlates of birth
registration in three of Indonesia’s
most impoverished and under-served
jurisdictions: East Nusa Tenggara
(NTT), West Nusa Tenggara (NTB), and
West Java (JB).
Our analysis drew on baseline data
(collected between May, 2013, and
August, 2013) from the Legal Identity
Program, a serial cross-sectional
study described in detail elsewhere.4
Heads of household (aged >16 years,
preferentially female) were identifi ed
using systematic random sampling.
Participants completed a household
survey and provided information
about three randomly selected
children (aged <18 years) from their
household. As published elsewhere,4,6
the survey elicited a wide range of
information including data on birth
certifi cate ownership and barriers to
birth registration.
We used descriptive statistics,
bivariate, and multivariable logistic
regression using generalised estimating
equations with a working correlation
matrix (to account for clustering within
households) to identify the associations
between potential covariates identifi ed
a priori from the scientifi c literature and
children’s birth certifi cate ownership.
We used principal component
analysis on various asset ownership
indicators to create a socioeconomic
status variable.7 As in our previous
research,6 we used a backwards
selection approach to arrive at the fi nal
multivariable model.
1024 heads of households were
interviewed, providing data for
1978 children: 853 from NTB,
805 from NTT, and 320 from JB. Fewer
than half (911 [46%]) of children
reportedly had a birth certifi cate, and
only 665 (73%) of these participants
were able to show the document.
Sample characteristics are presented
in the appendix and reasons for not
having a birth certifi cate, by province,
are given in the table.
The following factors were
associated with a child’s birth
certificate ownership: marriage
certifi cate ownership of the parents,
higher household socioeconomic
status, and older age. Prohibitive costs
prevented 547 (51%) participants from
obtaining their child’s or children’s
birth certificates (table).4 Despite a
Total (n=1067) JB (n=145) NTT (n=556) NTB (n=366)
Cost 547 (51%) 88 (61%) 242 (44%) 217 (59%)
Distance 201 (19%) 5 (3%) 137 (25%) 59 (16%)
Process is complicated 130 (12%) 9 (6%) 44 (8%) 77 (21%)
Do not know how to arrange for one 160 (15%) 15 (10%) 90 (16%) 55 (15%)
Too busy/have not had time to arrange for one 105 (10%) 15 (10%) 60 (11%) 30 (8%)
Do not have required documents (eg, marriage
certifi cate, baptism certifi cate, family card)
69 (6%) 5 (3%) 62 (11%) 2 (1%)
Not responsible for the child 7 (1%) 0 5 (1%) 2 (1%)
Birth certifi cate is being processed 63 (6%) 14 (10%) 24 (4%) 25 (7%)
Do not need a birth certifi cate 35 (3%) 1 (1%) 27 (5%) 7 (2%)
Do not think birth certifi cates are important 33 (3%) 5 (3%) 20 (4%) 8 (2%)
Waiting until child is school-aged 11 (1%) 0 10 (2%) 1 (<1%)
Other 19 (2%) 4 (3%) 14 (3%) 1 (<1%)
Data are n (%). Participants were able to give more than one reason if applicable. *As reported by heads of households.
Table: Reasons why birth certifi cates were not obtained for 1067 children across East Nusa Tenggara (NTT), West Nusa Tenggara
(NTB), and West Java (JB), Indonesia*
See Online for appendix
Correspondence
e235
www.thelancet.com/lancetgh Vol 4 April 2016
6 Jackson M, Duff P, Kusumaningrum S, Stark L.
Thriving beyond survival: understanding
utilization of perinatal health services as
predictors of birth registration: a cross-
sectional study. BMC Int Health Hum Rights
2014; 14: 306–15.
7 Vyas S, Kumaranayake L. Constructing socio-
economic status indices: how to use principal
components analysis. Health Policy Plan 2006;
21: 459–68.
8 UNICEF Indonesia. Issue briefs: maternal and
child health. October, 2012. http://www.
unicef.org/indonesia/A5-_E_Issue_Brief_
Maternal_REV.pdf (accessed Feb 4, 2016).
9 Trisnantoro L, Soemantri S, Singgih B, et al.
Reducing child mortality in Indonesia.
Bull World Health Organ 2010; 88: 641–716.
10 Education and Policy Data Center. Indonesia:
National education profi le, 2014 update.
http://www.epdc.org/sites/default/fi les/
documents/EPDC NEP_Indonesia.pdf
(accessed Oct 20, 2015).
Scaling up of birth registration is
crucial to Indonesia’s development
and promotion of the wellbeing of the
nation’s most vulnerable people. On a
global scale, a CRVS research agenda
is needed that includes the rigorous
assessment of innovative CRVS
models. With continued investment
in its CRVS system, political
commitment, and strong leadership,
the Government of Indonesia has an
opportunity to ensure that millions of
children offi cially count in its system.
We declare no competing interests. The Legal
Identity Program is implemented by the Center on
Child Protection (PUSKAPA) at the University of
Indonesia together with PEKKA (an NGO working on
empowerment of female heads of households) and
made possible through funding from the Australian
Government’s Australia Indonesia Partnership for
Justice. We thank our research associates
(Rahmadi Oesman, Wenny Wandasari, Harriz Jati,
Rama Adi Putra, and Prisilia Riski) and local
enumerators, who collected the data for the study.
We also thank Craig Spencer and Matt MacFarlane
for their contribution to the study design and
implementation, and Nick Fishbane for his advice
and assistance with the statistical analyses.
Copyright © Duff et al. Open Access article
distributed under the terms of CC BY-NC-ND.
Putu Duff , Santi Kusumaningrum,
*Lindsay Stark
ls2302@columbia.edu
Department of Medicine, University of British
Columbia, St Paul’s Hospital, Vancouver, BC, Canada
PD; Center on Child Protection at the University of
Indonesia, Gedung Nusantara II (Ex PAU Ekonomi)
FISIP, Kampus UI, Depok, Indonesia (SK); and
Department of Population and Family Health,
Columbia University Mailman School of Public
Health, New York, NY 10032, USA (LS)
1 UN Human Rights Offi ce of the High
Commissioner. Convention on the rights of
the child, 1990. http://www.ohchr.org/EN/
ProfessionalInterest/Pages/CRC.aspx (accessed
Feb 4, 2016).
2 UNICEF. Every child’s birth right: inequities and
trends in birth registration. New York: United
Nations Children’s Fund, 2013.
3 Setel PW, Macfarlane SB, Szreter S, et al, on
behalf of the Monitoring of Vital Events
(MoVE) writing group. A scandal of invisibility:
making everyone count by counting everyone.
Lancet 2007; 370: 1569–77.
4 Australia Indonesia Partnership for Justice,
Center on Child Protection. Indonesia’s
missing millions: AIPJ baseline study on legal
identity. 2014. http://www.cpcnetwork.org/
wp-content/uploads/2015/02/AIPJ-PUSKAPA-
BASELINE-STUDY-ON-LEGAL-IDENTITY-
Indonesia-2013.pdf (accessed Feb 4, 2016).
5 Handley K, Boerma T, Victora C, Evans TG.
An infl ection point for country health data.
Lancet Glob Health 2015; 3: e437–38.
registration office or department
of religious aff airs (for Muslims) for
a marriage certificate, and the civil
registration offi ce for birth certifi cate
issuance. Processing times can take
up to several days at each office.
Many citizens pay middlemen (eg,
village officials) to navigate the
system for them, increasing overall
cost and further reducing birth
certifi cate access. Interventions that
off er free, low-cost support to assist
impoverished families with navigation
of the complex system could improve
birth certifi cate access.
Distance was a barrier for 201 (19%)
participants, particularly those in
remote or rural regions (such as NTT)
who faced increased financial and
opportunity costs (eg, transportation
costs, lack of infrastructure).
Programmes that integrate civil
registration into regularly frequented
services, such as community health
centres (Puskesmas) or schools,6
could help mitigate distance-related
barriers.2 Indonesia’s 8000 Puskesmas
are highly accessed (82% of births
were delivered in such facilities in
2010),8,9 and run successful outreach
programmes that deploy mobile
immunisation services to remote
communities.9 Schools also hold
promise as sites for integrating birth
registration, with 92% of Indonesian
children enrolled in primary
education.10 Overall, the burden of
birth registration needs to be shifted
from individuals to policy makers to
address the underlying systemic and
legal issues that give rise to current
barriers. A priority should be to
eliminate the requirement for proof
of parents’ legal marriage. Finally,
information and communication
technology solutions might be useful
to explore, such as mobile phone
systems that can send birth registry
data to a central database; however,
such systems would require thorough
assessments of the capacity of existing
infrastructure, human resources,
and operational procedures ahead of
roll-out.
- CitationsCitations1
- ReferencesReferences4
- "These results demonstrate the relevance of Thaddeus and Maine's model to civil registration in rural SUMUT and NTB. The focus group discussions confirmed findings from previous studies of civil registration in Indonesia, where cost, distance, application information, and a complex application process obstructed access to birth certificates for children in poor and rural settings [5]. Unsurprisingly, financial barriers were the most frequently mentioned and often the highest ranked factor in the PRM exercise. "
[Show abstract] [Hide abstract] ABSTRACT: The Three Delays Model has proven a useful framework for examining barriers to seeking obstetric care and preventing maternal and child mortality. This article demonstrates the applicability of the Three Delays Model to the case of civil registration in rural Indonesia and examines ways that efforts to strengthen civil registration services can draw on lessons from maternal and child health programming. Twenty focus group discussions were conducted using a participatory ranking exercise in four Indonesian districts. Focus groups were stratified into four groups: (1) government officials involved in civil registration, (2) civil society organization members that assist communities in civil registration, and (3) female and (4) male community members. Transcripts were analyzed using constant comparative method and thematic analysis, revealing barriers that communities commonly faced in accessing civil registration services. In examining the categories and themes related to these barriers, the research team found a significant overlap with the factors and phases of the Three Delays Model. Participants were delayed from seeking registration services by a range of sociocultural factors and by the perceived inaccessibility and poor quality of services. Once they decided to seek care, long distances to services and poor transportation options delayed their access to registration offices. Finally, a series of bottlenecks in service provision created extended delays once applicants reached registration offices. Ownership of civil registration documents in Indonesia remains exceptionally low, with just over half of children and youth possessing a birth certificate. To strengthen civil registration and health systems more generally, it is important to understand the factors that enable and constrain civil registration, how these factors relate to one another, and how they change over a child's life.
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