# Strengthening Civil Registration Through Grassroots Health Institutions in India

## TL;DR

This study shows that using primary health centers in India can significantly improve birth registration, especially for rural and disadvantaged children.

## Contribution

The study provides nationally representative evidence on how grassroots health centers can reduce birth registration gaps in India.

## Key findings

- Children born in PHCs/CHCs had 38% higher odds of registration compared to private facilities.
- Registration rates in PHCs/CHCs increased from 80.8% to 90.2% between 2015–2016 and 2019–2021.
- States like Delhi, Rajasthan, and Uttar Pradesh saw the greatest improvements when PHCs/CHCs were designated as registrars.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Civil registration is a foundational state function that ensures people’s legal identity, which is essential for children to access public health services, immunization programs, and rights protection.This study examines how the expansion of grassroots health infrastructure, specifically primary health centres (PHCs) and community health centres (CHCs), can be leveraged to achieve universal birth registration in India.

Civil registration is a foundational state function that ensures people’s legal identity, which is essential for children to access public health services, immunization programs, and rights protection.

This study examines how the expansion of grassroots health infrastructure, specifically primary health centres (PHCs) and community health centres (CHCs), can be leveraged to achieve universal birth registration in India.

Public health significance—Why is this work of significance to public health?
This study provides nationally representative evidence showing that births occurring in PHCs/CHCs have significantly higher odds of registration compared to private facilities.The findings highlight the role of decentralized public health infrastructure in reducing registration gaps among rural and socio-economically disadvantaged populations.

This study provides nationally representative evidence showing that births occurring in PHCs/CHCs have significantly higher odds of registration compared to private facilities.

The findings highlight the role of decentralized public health infrastructure in reducing registration gaps among rural and socio-economically disadvantaged populations.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
Integrating civil registration functions within primary healthcare facilities can accelerate progress toward universal legal identity and SDG.Future policy should focus on deepening the digital integration between health service touchpoints and civil registration systems to reduce the administrative burden on frontline health workers while ensuring no child remains unregistered.

Integrating civil registration functions within primary healthcare facilities can accelerate progress toward universal legal identity and SDG.

Future policy should focus on deepening the digital integration between health service touchpoints and civil registration systems to reduce the administrative burden on frontline health workers while ensuring no child remains unregistered.

Civil registration of births and deaths underpins people’s legal identity, access to essential services, and evidence-based policy. Over the last two decades, the expansion of the National Health Mission (NHM) and the dramatic increase in institutional deliveries have created new opportunities to link maternal healthcare with critical event documentation. Primary health centres (PHCs) and community health centres (CHCs), which are frequently the initial point of contact for rural households, are emerging as important places for birthing and registration. Despite their expanding importance, the particular role of these grassroots facilities in birth registration results has not been thoroughly investigated. This study addresses that gap by assessing their role in increasing registration coverage among children under the age of five. We analyzed nationally representative data from the National Family Health Survey rounds 4 (2015–2016) and 5 (2019–2021). This study focused on children under five, examining the association between place of delivery and registration status. Descriptive analysis and multivariable logistic regression estimated the odds of registration across delivery settings. Pooled data from both survey rounds captured temporal shifts, and predicted probabilities were calculated for institutional deliveries, adjusting for socio-demographic covariates. The proportion of institutional births occurring in PHCs and CHCs rose from 30.5% to 34.7% between the two survey rounds. Registration among children delivered in these facilities increased from 80.8% to 90.2%, the highest gain among all delivery settings. Regression analysis showed that births in PHCs/CHCs were associated with 38% higher odds of being registered compared to private facilities. States designating PHCs and CHCs as official registrars, such as Delhi, Rajasthan, and Uttar Pradesh, reported the greatest improvements. Lower-level government health facilities are not only advancing safe delivery but also acting as pivotal nodes for civil registration. Their dual function creates a scalable model for integrating healthcare with legal identity creation, supporting equity and accelerating progress toward Sustainable Development Goal 16.9.