Questions/Answers

Egyptian Ministry of Planning, Monitoring and Administrative Reform (MPMAR) and Ministry of Health and Population collaborated to initiate, design and roll out an automated birth and death registration system. About 4571 health office (where people legally get their births and deaths registered), 300 health departments and 27 health directorates were connected into one central database through the Egyptian Birth and Death Registration System (EBDRS). A platform had been developed to provide an efficient way for exchanging the data between the Egyptian governmental entities, through this platform the public serveries can be provided immediately to the citizens. During the implementation phase, many challenges appeared, some of them are listed as follows • Multi-stage paper registration cycle, causes inconsistency of citizens’ basic data such as names, place and date of birth. • A wide scope of work including 4571 health offices to be automated and linked which requires several technical teams for implementation and capacity building. These health offices are scattered to cover the whole country. • Lack of communication infrastructure in villages / remote areas required for data exchange. • Computer literacy and digital divide. • Non-unified registration processes for causes of death. • Defragmented multiple stakeholders. • Change resistance to the new automated system. EBDRS overcome these challenges by offering the following solutions: • Automating the Birth and Death Registration System, where 4571 health offices were automated, standardized and linked instantly through a private network to a central database. • Using 3G Mobile networks (APN secured tunnel) because it is available throughout Egypt to overcome the communication infrastructure problems. • Building capacity for more than 10,000 employees (clerks, physicians, and supervisors). • Developing a unified registration system for death causes based on the International Classification of Diseases v.10 (ICD10) accredited by WHO. • Secure and avail spontaneous data exchange between government entities and create central database through G2G (government to government) platform.

1. Facilitating the registration processes of birth and deaths which makes the live of the citizens easier when dealing with bureaucracy. 2. Availing live EBDRS to all administrative divisions throughout the whole country including governorates, urban and rural districts, cities and villages. 3. Providing the government with accurate data on birth and death to rationalize its decisions, policies and strategies. For instance, MoH has started to adapt a National Health Map since the new system provides precise data on causes of deaths. Likewise, the National Population Strategy is being built based on the system’s birth data. 4. Conduct a paradigm shift in the registration of birth and death through having fully automated system that totally paperless. 5. Cutting down the current system’s costs through saving citizens’ time and money and protecting the environment. 6. Enhance the capacity to achieve its National Sustainable Development Strategy, Egypt Vision 2030 (SDS) and SDGs. 7. Providing the government with health reports, indicators and outputs which are aligned with the WHO criteria such using the International Classification of Diseases ICD10 to register causes of death. 8. Better rank of the country in the international health reports through availability of accurate data on population and health.

EBDRS: • Enabling all citizens including vulnerable people especially in rural and remote areas to get their births and deaths registered electronically through the new system for free of charge. • An innovative practice automating and integrating of 4571 health offices and connecting them with the Ministry of Health (MoH) at the central level. • Strengthen the efficiency of the public institutions to provide better public services to all citizens through live data exchange platform that ensures the connection between EBDRS and the following databases:  National ID authority database  Census bureau  Subsidized children milk  Vaccinations  Family food subsidies  Health Insurance  Social protection database  Pension database  Voters’ registration system  ……………. • Avail registration process without discrimination, for abandoned unregistered new born, refugees so they can benefit from public services (vaccinations, education …etc.) • Indicators derived from the system, such as maternal mortality rate and the age of marriage, will help to promote efficient socio-economic planning, and better public policies and gender equity. • Availing instant birth and death records, supports the government to be citizen centric by: o Tracking epidemics o Identify and prevents causes and rates of maternal, neonatal mortality. o All children

EBDRS assists in realizing SDG number 16, Target 16.9, through: • All newborns and children up to five years are registered. • Every child has a permanent and official record, certified identity, a recognized name and a nationality. It is the first step towards safeguarding individual rights and provides every person access to all public services. • Ensure the rights of citizens to access and obtain public services immediately such as vaccination, subsidies, health insurance, and national identification card, etc. • Provide the government with a vital tool to a well-designed national annual socio-economic plan and futuristic midterm and long-term strategies based on the EBDRS data. • Protecting the citizens’ right to vote through instance updating of the voter registration database EBDRS realizes the SDG Goal 3 - Target 3.1, 3.2 and 3.8. • Provides vital statistics (records and causes of maternal and neonatal mortality). • Instant and accurate records of prevalent Epidemic. • Create a network of vaccination units and accurate vaccination database to enhance the efficiency of the vaccination system (the child can be vaccinated in any unit which was not possible according the old procedures before the EBDRS– identify the targeted groups to be vaccinated). • Better policies to face the issue of the early marriage.  

Availability of accurate records of birth and death to the government and decision makers was a major problem to identify targeted groups entitled for government public services. EBDRS solves this by: • Automating and connecting 4571 health offices, to avail and exchange spontaneously all records of death and birth. • Improving the speed and efficiency of services delivery, due to the data accuracy and the unified records in all government offices and service providers. • Updating other governmental services databases directly and automatically from the system (vaccination - health care - education – food supply - social support …. etc.) helped the government to provide more efficient and equitable services. • Establishing vaccination units network ensure the accessibility of vaccination to all children at any place anytime. • Identifying education dropouts by comparing the enrolled student’s database with targeted children database (children at the school age). • Registration of abandoned and refugee newborn, enables them to receive public services from either the government or refugee organizations such UNHCR. • Registering neonatal and maternal mortality including causes of death, enable the government to formulate policies and plans to improve health care for both women and children.

EBDRS impacted positively on the following: • Registration of the newborn, 2.496.107 cases were registered in 2017. • Availability of live data for the newborn and deaths by region, governorates, cities and villages. • Registration of the deaths, 486.494 cases in 2017. • Recording causes of Neonatal, Maternity mortality. • and other incidents of death. • Recoding the Neonatal mortality, 26.350 cases in 2017. • Recording Maternity mortality, 19.141 cases in 2017. • Recoding the causes of death due to traffic accidents (19.677 cases in 2017) helps the government to take necessary actions. • Recording the abandon newborn to help them get their rights in services like suitable living environment, foster mothers and to be enrolled in schools. • Birth database entitled all newborn to enjoy their rights and receive public services such as: name, identity, nationality, vaccination, social and health services. • Excluding death records from the subsidies lists instantly. • Obtain an automated birth and death certificate instantaneously through live connection between EBDRS and ID authority at the Ministry of Interior. • Recording of underage marriage helps the government to react positively to protect girls. • Causes of death support the government to Identify and control epidemics. • Registration of refugee newborn 6.082 in 2017.

It is very critical to provide citizens with their required services and ensure the fulfillment of their rights, this happened through developing a sustainable proactive model which is the EBDRS. EBDRS enables citizens to assure their families registration accurately in a timely manner which was a challenge in the past. EBDRS achieves the SDG targets related to attaining legal identity, by birth registration, decrease maternal and neonatal mortality and react to epidemic disease. • It is a pioneer and innovative project included developing a well-functioning birth and death registration system that provides accurate and spontaneous data and indicators of birth and causes of death that support decision makers and other stakeholders. • EBDRS, used mobile data-network based on GPRS and 3G technology to create a private secured and encrypted governmental data transmission. • EBDRS is scalable and expandable to accommodate new health offices. • EBDRS was completely designed, developed, implementing and managed in house by national IT experts and specialists who are working in the government, this reduced the cost of the system. • EBDRS is successful joint project between two ministries and all governorates. • Process and analyze data instantaneously, visualize the records and indicators in a graphically dashboard. • Live population meter centrally and locally.

EBDRS is an original innovation in the country according to different aspects: • Unifying the process of birth and death registration of 4571 health offices throughout the whole country in two years. • Providing all these offices with the required hardware such as computers, printers, servers, connectivity devices and services. • Train and enhance the computer skills of the public employees at the health offices, about 10,000 trained in two years. The training team classified the employees into several groups based on their skills and provide tailored training programs. • Fully developed software by government IT specialists with the latest friendly user interface. • Building application and database hosting center in Cairo and integration of this database with other databases through G2G platform. • Using mobile data-network based on GPRS and 3G technology to create private, secured and encrypted governmental data transmission network to connect 4571 health offices with 300 departments and 27 directorate with the Ministry of Health. • Process and analyze data instantaneously, visualize the records and indicators in a graphically dashboard with drill-down capabilities. • Establishing a technical support unit at the Ministry of Planning, Monitoring and Administrative Reform to ensure the sustainability of the new system. • Technical support by Microsoft team in Egypt.

Financial Resources: The implementation cost of the EBDRS was 80 million Egyptian pounds (USD 4.5 million with the current exchange rate) paid by the Egyptian government through the Ministry of Planning, Monitoring and Administrative Reform (MPMAR). Material Resources: The project Hardware included 10.000 computers, and 6 servers, 5.000 printers, a linking network of 4899 sites (that includes 4571 registration health offices, 300 health department, 27 Health Directorate in addition to Ministry of Health). In addition to application development, software licenses and hosting. Human Resources: 1. Building capacity of 5.000 health data entry or clerks on computer skills and EBDRS application. 2. Providing appropriate training programs for 5.000 physicians to use ICD10 codes and the EBDRS application. 3. Train 924 supervisors on monitoring and evaluation of the EBDRS and operating the system. 4. An implementation team from both the Ministry of Planning, Monitoring and Administrative Reform and the Ministry of Health consists of 74 persons ensure successful implementation of the new system in all the health offices throughout the country. 5. Assigning 27 persons to follow up the new system, one in each governorate and provide technical support 24/7.

Yes

• The platform provides multiple levels of scalability, it starts with the services level for the citizen providing a citizen centric experience, as birth registration introduces the services required from subsidy to the family, vaccinations for the child, and empowering children eligibility for education. • The second aspect is the scalability across different governorates, due to the centralization of the platform it started by dispatching the services to more than four Governorates to currently cover the 100 Million population across the different 27 governorates, 318 districts, 227 cities and 4775 village. • The model is replicable across multiple aspects, number of services. As number of services increasing everyday by connecting more government entities together to provide more public services all through multi channels either from online portals, kiosks for authorized providers (creating employability in different governorates), or even through mobile applications that are available for citizens to access and start on their services for themselves or on behalf of their families (specially for elderly or children). • Recently there has been different 13 African countries interested to replicate the model who reviewed the benefits from economic and social levels during Cairo ITC 2017. Which proves the learning and how this can impact the region.

The sustainability of the EBDRS has been considered as following: Hardware sustainability: • Train hardware support teams on troubleshooting and first line support. • Avail 10% of spare parts for equipment and operation supplies for replacement in case of major failure. • Provide spare devices in case of malfunction. • Maintenance and support of the hardware through contracts with private firms. • connectivity is provided through three different mobile data providers to ensure zero down time. • Applications and databases are hosted in two different sites (DC & DR) to ensure redundancy. System sustainability: • Monitoring and Evaluation supervisors to ensure the quality of recorded data and consistency. • Monthly meetings to clarify the problems and challenges and find solutions. Human Resources sustainability: • Beneficiaries dependency on EBDRS grants continuity. • Regular training programs and awareness sessions for EBDRS updates and training of new comers. • A clear plan to replace the retirees and those who leave job for whatever reasons such as layoff, termination, death, job rotation, and resignation. Financial sustainability: • Operating expenses on renewal of hardware according to the international lifetime cycle and applications enhancement are covered within the Ministry of Health annual budget.  

Annually: • Ensuring institutional and organizational sustainability • A replacement and renewal plan of the devices • Automate the new health offices • Renew the software licenses. • Update the application • Train the new employees • Train the new physicians • Train the new supervisors • Train the new technical support team • Evaluate the performance of the employees • Evaluate the performance of the physicians • Evaluate the performance of the supervisors • Check and upgrade the network bandwidth • Provide current expenditure needed for the operation of EBDRS. • Connecting the system with more databases especially the new ones • Annual data cleansing • Data backup • Check and test the DR • Evaluate the employees and physicians • Survey the citizens’ satisfaction • Annual report based on the monitoring and evaluation of the system • Advocacy campaign for the system • Media campaign for the system Every three years • Increasing the storage capacity of the data ware house • Review the process of registration and modify the system accordingly. • Monitoring and evaluate the system • Check the new network carrier or providers and adding them to the available networks. • Upgrade the DR • Exploring the possibility of using government private cloud. • Review the pay scale of the EBDRS employees. Every five years: • Check and upgrade the servers • Comprehensive monitoring and evaluation of the whole system • A clear plan for renewal the DR devices

Yes

Central Agency for Public Mobilization and Statistics (CAPMAS), the major beneficiary of the new system, evaluated EBDRS before connected to it. CAPMAS team conducted a random site survey in one of the governorate which was Port Said, to compare between the collected data through the census and EBDRS, also to observe the efficiency of it in all health offices. In addition, a technical team visited randomly the health offices as mystery shoppers to observe registration and issuing birth and death certificates outcome from EBDRS. Many evidences showed improvement and satisfaction by both health offices employees and citizens, which can be summarized in: 1. EBDRS process of registration takes less than 15 minutes, while paperwork takes one month. 2. EBDRS ensures that 100% accurate and live recording of all incidents of birth and death, while 28% inconsistent data in paperwork. 3. All birth registration included mothers ID number, thus facilitated identifying the underaged marriage. 4. Citizens need only one visit to one of the health offices for registration and that saves time and money. 5. Standardized process increases the efficiency of the health offices employees. 6. All employees use the new system. 7. All the health offices were automated and connected.  

• The outcomes of the evaluation ensured the positive impact of the initiative. EBDRS was tested by several agencies in the country such as CAPMAS and Ministry of Social Solidarity (MoSS). • MoSS is responsible for providing citizens with social protection assistance within a governmental program called (Takaful and Karama), the cost of this project is estimated by more than ten billion Egyptian Pounds. Now, the EBDRS is connected with the MoSS’ s database and the latter is being updated instantly through removing the assistance once the receiver died. This saved almost 80 million Egyptian Pound last year. • Another good example to prove the positive impact of the initiative is the connection of the EBDRS to the food supply database which is managed and maintained by the Ministry of Food Supply. • Additionally, the voters’ registration system is being updated automatically through connecting EBDRS to the voters’ database. It ensures instant data cleansing. • Moreover, the EBDRS is connected to the ID authority to ensure an ID number for every single case of birth in the country. • EBDRS provides an updated and live population meter to raise the awareness on risks of the increasing number of population and the need for birth control.

Several Indicators were used in the evaluation of the EBDRS such as: • Number of automated and connected health offices. • Number of trained employees • Number of trained physicians • Number of trained supervisors • Employees satisfaction of the new system • Physicians satisfaction of the new system • Number of recorded birth daily, weekly, monthly, quarterly and annually. • Number of recorded death daily, weekly, monthly, quarterly and annually. • Number of connected governmental entities. • Number of governorates implemented the system • Number of urban and rural districts implemented the system • Number of cities implemented the system • Number of villages implemented the system • Amount of saved money. • Time saved in the registration processes before and after • Accuracy and consistency of birth and death records. • average time for registration and issuing certificates. • Ability of the health office employees to use the EBDRS efficiently • Citizens’ satisfaction of the new system • The cost or the share of the Registration of birth and deaths in the public budget. • Number of IT specialists who gain experiences by working in this project. • Number of reports produced from the system • Average time of updating the live population meter of clock.  

Regarding the massive scope of the project (huge number of health offices, supporting entities, implementation of HW and SW, connectivity and training of 10.000 health office employees and physicians in 27 governorate) also the existence of multi stakeholders (Main partner and first beneficiary of the system is the Ministry of Health). A cooperation protocol was signed between the Ministry of Health and Ministry of Planning, Monitoring and Administrative Reform, which includes division of roles and responsibilities in the design, development, implementation and operation of the EBDRS. EBDRS was orchestrated by Ministry of Planning, Monitoring and Administrative Reform, by conducting stakeholder management plan as follows: • Ministry of Planning Monitoring and Administrative Reform o Design and develop the birth and death registration system o Hosting of the new system o Avail connectivity o Avail the required equipment o Training employees and physicians o Deployment and technical support o Organize awareness sessions for other governmental agencies o Provide fund for the project • Ministry of Health and Population o Review EBDRS analysis and application, testing the prototype and approve the roll out. o Enforce transition from the old registration system to EBDRS. o Enforce the usage of EBDRS outputs in the preparation of Egypt health strategy o Train physicians to identify causes of death using ICD 10 codes. • World Health Organization o Provide expertise for the formulation of a methodology for recording causes of death. o Organize workshops to present the experiences of different countries in the registration of births and deaths. • Other Government Agencies such as CAPMAS o Evaluate the system using different methods including field survey. o Connect to the EBDRS. • Private Sector: o Mobile companies (Vodafone - Orange – Etisalat) provide connectivity. • Microsoft: o Technical support in designing technical solutions for applications and implementing the required platform for data exchange.  

The key Lessons learned from the initiative: • Cooperation and coordination between public institutions are essential for success of this initiative. • Efficient utilization of the available resources especially, human resources. Trusting people capability made the difference • Training and capacity building is a key factor in the success of the initiative. • Providing the required funds for the project • Political well is an important factor • The original plan was designed to use leased lines and DSL for connectivity among the offices, but a major risk was identified (poor communication networks in 85% of the offices in the country especially in villages). An innovative idea was chosen to face this challenge by using 3G mobile data network for connectivity as it has full coverage over the country. • Good monitoring and evaluation system to ensure the sustainability of the initiative. • Digital transformation requires gradual and smooth execution during implementation phase. • Non-interruption of the old system until fully deployment of the new system. Recommendations: • It is not recommended to have two systems at the same time, paper work and electronic, it increases the time of implementation and increase the resistance level of the change. The new system should be enforced once it is up and running. • • Plan for providing intensiveness and recognition to the health office employees, this was a motivation to overcome the change resistance and computer illiteracy all employees pass the computer skills training. • The initiative pilot was in 4 governorates out of 27 there were 600 offices in these governorates. An immediate scope change was taken to start in a small governorate with only 60 offices which enabled the project team to control all resources and meet the time plan to make the pilot project success.