The unexpected benefits of an evaluation study in rural Kenya: the birth certification process

July 9, 2024

Civil registration and vital statistics are key for a country’s planning and the distribution of resources and services. Birth certificates are essential to access government services in most countries. According to the Kenya Vital Statistics Report (2021), about 92% of births in Kenya are registered.  Children who do not have birth certificates may be disadvantaged in accessing government services, including healthcare through the National Health Insurance Fund (NHIF). As outlined by the Huduma Kenya Service Delivery Programme (HKSDP), one needs a birth certificate to register for national examinations and apply for a national identification card and passport. In turn, one requires a national identity card to register a cell phone sim card, open an account, access government offices and engage in many other aspects of life.

However, there seems to be a lack of awareness of the importance of these documents, particularly in low-income households. The sometimes tedious application process and the transport cost to and from government offices, especially for those living in far-flung villages, have also been cited as reasons for failing to apply for these documents. As a result, already vulnerable and disadvantaged households are further excluded from essential government and digital financial services.


Between 2019 and 2021, the African Medical and Research Foundation (AMREF) and PharmAccess Foundation implemented the Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program in Kenya’s Kakamega County. The intervention was geared towards the training of community health volunteers (CHVs), improving quality of care at the health facility level, and providing partly subsidized, mobile phone-based access to the National Health Insurance Fund (NHIF)* for low-income households.

A team of researchers from the African Population and Health Research Center (APHRC) and the Amsterdam Institute for Global Health and Development (AIGHD) evaluated the program to provide insights into the motivations, drivers, and challenges that hinder women and their families’ access to good-quality health care. The study also evaluated the impact of the intervention on health insurance enrolment and utilization of reproductive, maternal, newborn, and child health (RMNCH) services. The evaluation study covered 240 households in 24 villages, where women between the ages of 18 and 49 were randomly assigned to the control or treatment group. The study participants were either expectant or mothers with children under four years of age. All the women were interviewed at baseline, and the treatment group was subsequently offered support in enrolling for NHIF through a subsidized package offered by i-PUSH.

The project also required the mothers in the study to have access to mobile phones, which were used to enroll them into NHIF and to save on NHIF premiums. During the COVID-19 period, the i-PUSH research team purchased low-cost phones for the participants who did not own phones. Access to mobile phones doubled as an asset for remote data collection.

The challenge

While recruiting participants for the study, the research team realized that some households did not fulfill NHIF documentation criteria. The team noted that 37% of the children did not have birth certificates, while 21% of mothers did not have identity cards.  “Some of the mothers did not have national identification cards. We also discovered that some children did not have birth certificates,” said Caroline Wainaina (APHRC), the research coordinator on the project. The reasons for lacking these important documents included misplaced birth notifications or identification cards; the impression of some parents that the children were still young and thus did not need a birth certificate; parents being unsure of the birth certification process; and financial and time constraints in accessing the civil registrar’s office and documentation required for the process. “I went to apply for a national identification card, and when I reached the stage of taking a passport photo, they referred me to a studio at Khwisero [a local town] where they were asking for 200 shillings, which I did not have. I asked my husband, and he said I should wait until he gets money,” said one of the study participants.

The lack of documentation meant fewer people were eligible for the NHIF health insurance subsidy from the i-PUSH program. This proved a challenge that the implementing partners and evaluation team had not foreseen.

The process

The research team proactively mitigated the challenges encountered through community and policy engagement. The team liaised with the civil registrar’s office, which engaged the community in raising awareness of the importance of having identification documents. “We facilitated a visit for the registration officials to sensitize the participants on the information required to acquire IDs and birth certificates,” said Bernard Kosgei, formerly of PharmAccess. Through community health workers, the research team helped households gather the documents required to facilitate the registration process. The team also helped mothers obtain documentation from health facilities and area chiefs required to obtain birth notification and birth certificates. The project facilitated the birth certificate process by paying the required fees. Through persistent follow-up, most of the women could get the birth certificates for their children and thereby ensure all their family members were covered under NHIF.

This collaborative effort resulted in a shorter turnaround time for families to obtain birth certificates. It ensured they incurred no transport costs when the registration team visited the communities. This was an essential benefit as some participants were not financially stable and thus could not afford the KES 200 – KES 300 bodaboda (motorbike) taxi fees to get to the registration offices.

Impact on the local communities

The efforts to increase registration and provide birth certificates for young children produced two longer-term benefits for the local communities. First, the certificates would be life-long assets to the children and enable their eligibility or access to a range of other essential services. Second, the challenges encountered in the community awakened local government officials to the extent of the problem after the field- team met with them and explained the challenges encountered.

These unexpected findings were unrelated to the academic and evaluation outcomes of the i-PUSH project.


Though this process was helpful in enhancing the registration of the study participants, it is neither scalable nor sustainable. There is a need for better strategies to ensure that all children have birth certificates, independent of external interventions through programs such as i-PUSH. The thrust to implement Universal Health Coverage (UHC) countrywide would strongly benefit from sensitization of the public is on the importance of obtaining identification documents.

Therefore, the team recommends the following:

  • To further strengthen linkages between local registration and health officials, health facilities should sensitize parents and caregivers on the importance of acquiring the birth certificate beyond processing the birth notification.
  • Local administration should sensitize the public on the process of obtaining identification documents.
  • It is crucial to bring civil registration services closer to communities. This can be done through mobile/portable camps and partnering with non-state actors.
  • Stakeholder mapping is critical in understanding who fits where, thus ensuring that all key actors in implementation are engaged at community and policy levels.
  • As the country prepares to roll out the Social Health Insurance Fund (SHIF), we recommend that the government consider assisting the marginalized and disenfranchised to acquire the necessary identification documents to enable them to access insurance benefits.

 *As the government works towards attaining universal health coverage, it has now transitioned from NHIF to the Social Health Insurance Fund (SHIF).

This blog was drafted by Florence Sipalla, Caroline Wainaina, Amanuel Abajobir, and Wendy Janssens
i-Push was implemented in partnership with PharmAccess with the support of the Amsterdam Institute for Global Health and Development (AIGHD).