Digital ID for Healthcare Equity in Bangladesh

Eighty percent of Bangladeshi children do not have a birth certificate. These children are functionally invisible, systemically excluded. Unable to prove who they are, they will struggle to access essential services, including healthcare and education, to participate as citizens and voters, and to join the modern economy. 

In addition to current seasonal migration, Bangladesh anticipates significant climate-related displacement in coming decades, necessitating a means by which these individuals can prove their identity when far from home.

Despite low birth registration coverage, 95% of Bangladeshi children receive basic immunizations, providing an opportunity -- without overhauling existing ineffective systems -- to ensure all 45M Bangladeshi children have a verifiable, recognized ID.

ID2020, working with the Bangladeshi government and Gavi, the Vaccine Alliance, will digitize the immunization process and provide every Bangladeshi child with a “good” digital ID, one that protects privacy, is widely recognized, and provides access to services from early childhood.

The ability to prove who you are is a basic human right and a prerequisite for accessing vital services. But more than 1B people have no form of identification and nearly one-quarter of all children live without any official record of their existence, hindered at nearly every turn.

Furthermore, across the globe, it's becoming obvious that existing digital identity systems don’t protect privacy, aren't portable, and turn data into a commodity. And increased interest in closing the ID gap has, unfortunately, accelerated programs that pay little heed to privacy or user-management.   

These converging challenges are perhaps most acutely visible in Bangladesh, where eighty percent of Bangladeshi children do not have a birth certificate. These children are functionally invisible and systemically excluded. Much of this is the product of a high dropout rate due in part to a lack of record portability and siloed, non-interoperable systems. An integrated, holistic digital ID system could go a long way to rectifying the challenges faced by these currently excluded children. 

In the near term, we are serving eighty percent of Bangladeshi children without a birth certificate. The success of our program depends on beneficiary uptake. Core to our design process are the recipients of the ID. This is true of all our programs, which have to meet a long list of technical requirements, including online/offline functionality, and ease-of use. But it is especially true of our work in Bangladesh. Though the program will ultimately benefit all of the country’s citizens, it seeks to benefit first and foremost economically disadvantaged households. These children are functionally invisible and excluded from access to rights and services. The program will work on behalf of these children and their families. 

The program will also work on behalf of the community health workers who work everyday to ensure that these children have access to basic services. Currently, community health workers use cumbersome, slow tools. A digital ID system could alleviate much of the burden on these community health workers while improving continuity of care for the children they serve. 

Longer-term, we believe this program advances a global public good, and that Bangladesh could be a trailblazer for a program with global scale and impact. 

The program would scale a user-centric, portable digital health ID in order to improve health services in Bangladesh, improve birth registration coverage and, ultimately, support access to rights and services throughout a citizen’s life-course. 

As referenced above, we believe that digital ID must prioritize privacy, user-centricity and portability to meaningfully improve lives. The program will develop a child health ID system which is consistent with the ID2020 Technical Requirements for ‘good’ digital ID and which will be capable of interoperating with existing and future systems.

The program is also designed to research/co-create, test and accelerate the roll-out of novel infant biometric solutions, which would allow records to be linked to a child directly. Recently, infant biometric solutions have been proven to be sensitive enough to allow for authentication of newborn infants (starting at 6 hours after birth), but these technologies are new and there is insufficient longitudinal data to establish the necessary frequency for re-enrollment. By advancing this research, this program will accelerate the availability of persistent child biometrics, yielding impact well beyond Bangladesh.

Health workers will be able to register children, manage authentication (based on biometric matching and an individual’s stated NID), input health data, and issue verifiable claims using a handheld device, a custom-built application (usable both off- and on-line) and any necessary biometric hardware. The system will integrate via API with the existing database systems including BDRIS, DHIS2, and SHR, enabling access to a variety of services throughout the health care sector.

The system will be built in accordance with the ID2020 principles of applicability, identification and verification, authentication, privacy and control, attestations and trust, interoperability, and recovery and redress as specified in the Technical Requirements. Compliance with the requirements will ensure that the health ID will be able to interoperate with other existing and future systems, enabling access to rights and services throughout the citizen’s life course.

The program proposes two significant innovations: 1) using immunization as an entry point to drive increases in coverage, and 2) a standards-based approach to digital ID that negates the need for costly and inefficient point-to-point integrations.

In many developing countries, immunization coverage greatly exceeds birth registration rates: an estimated 95% of children receive at least one dose of one vaccine, while only 73% have a birth certificate. This is especially true in Bangladesh, where though only 20% of children receive a birth certificate during the first five years of life, yet 90% of its population receives the DTP3 vaccine. This gap creates an opportunity to use point of immunization to generate portable, user-centric digital identities in Bangladesh and globally. 

A standards-based approach to decentralized, portable digital ID  intentionally goes beyond the “easy” solution: point-to-point integration of the national civil registry, health systems and electronic immunization registries. While that approach could yield improvements in birth registration coverage, it raises concerns about privacy and does not provide any basis by which individuals could use their data - their digital health records or digital birth certificate - to access subsequent services. Our approach would allow a Bangladeshi child, as she grows, to use her digital ID to access to rights and services beyond the health sector. 

Our approach also seeks to provide a global public good: biometry capable of performing authentication under 1 year of age. Currently only a hypothetical, this work will provide critical longitudinal data towards unlocking effective biometrics for the very young. 

In Bangladesh, the digital identity improves the lives of participants through three avenues: enhancing access to healthcare; improving vaccination delivery; and expanding birth registration coverage.

The program provides newborns with a unique digital health identity through leveraging the existing healthcare network. During routine visits, specially trained health workers enroll newborns using advanced but tested biometric. The identity is interoperable with existing state, nonprofit and private health information systems. 

When accessing healthcare, the guardian uses the platform to accurately authenticate herself, and share her comprehensive medical record with professionals. The platform’s portability enables patients to move between providers and locations. Providers use the more accurate data to afford patients better quality of care – including faster treatment and targeted therapies - before updating their records. This personalized care is proven to lead to better health outcomes. By reducing time and duplicative procedures, the program increases the efficiency and economy of delivering healthcare services. 

Similarly, newborns build complete digital vaccination records across providers, organizations and locations - without the need for easily lost or damaged paper immunization cards. With the more accurate immunization information, providers can increase course completions and reduce duplicative doses. The better data drives, through more precise targeting, improvements in coverage, course completion and the efficiency of vaccination delivery.

The ID program integrates with national identity system – providing unique registrations for unreached individuals. By satisfying identity requirements, this program allows participants to access future social services – including education, employment. 

We are currently supporting two analogous programs in Thailand and Indonesia, collectively reaching 10,000 individuals, which demonstrate the viability of user-managed, portable and privacy-protecting digital ID as a solution for improved service delivery. Our program in Thailand, which similarly focuses on using digital ID to improve healthcare outcomes and continuity of care, is on-track towards targets of 80% reduction in the number of treatment defaulters in IRC’s chronic care programs and 100% record portability across multiple IRC databases. 

In Bangladesh, the program will proceed in three overlapping phases. In Phase 1, beginning in mid-2020, the program will be piloted in two areas: Kapasia (Gazipur District) and Ward 5 of DNCC (collectively approximately 10,000 digital IDs to newborns). During this phase, the program will reach newborns, which is the entire annual birth cohort of the two areas. Simultaneously, the program will collect valuable data on the viability on multiple infant biometric vendors in order to determine which solution is best fit-for-purpose for scale-up.

Phase 2 will expand the program’s reach to the five districts over a two-year period beginning in 2021, beginning in Sunamganj, chosen to test the program’s viability in a remote, hard-to-reach area. The remaining districts for expansion are TBD, but will be chosen strategically to offer a representative sampling of the national population. 

During Phase 3, the program will scale up to the national level between 2022 and 2024, and aim to cover the full 3M annual birth cohort of Bangladesh. 

Digital ID may the most leveraged investment one could make in global development. 

Whatever issue you care about -- refugees, homelessness, digital rights, universal education — secure digital ID is step one. Take, for example, the challenge of providing financial services to the world’s 2B unbanked individuals. Given rigorous (and necessary) Know Your Customer and Anti-Money Laundering regulations, banks cannot offer financial services to individuals without a verifiable identity.  Similarly, organizations working to address poverty (SDG Goal 1), hunger (SDG Goal 2), global health (SDG Goal 3) or education (SDG Goal 4), are often stymied because they don’t know how many people they’re actually trying to serve, nor can they accurately measure progress. While digital identity alone cannot solve these issues, it provides a path to individual empowerment while providing accurate population-level data that amplifies ongoing work.  

This program offers the first viable avenue to close the identity gap. Nearly 60% of the 1.1B people without an identity are children under 18, most of whom are too young to quality for a national ID. While these children may be poorly served by current approaches, 89% of children and adolescents without identity live in Gavi-eligible countries and 50% -- over 235M -- live in countries where a similar piggy-backing approach seems viable. Gavi has committed, pending early positive results from this program, to raising additional funds at Gavi’s June 2020 Replenishment conference to scale this program across Gavi-eligible countries, creating a route to truly closing the ID gap. 

Barrier 1: Loss of political support. This program’s success hinges on the continued support of multiple ministries in the Government of Bangladesh including the Ministry of Health and Family Welfare, the CRVS Secretariat, the ICT Ministry, and the Ministry of Local Government. We have mitigated this risk by seeking approval for the program at the Cabinet-level and already have the strong support of the Director General of Health. We’ve also seen an unexpected viral interest in the program, with non-government actors (NGOs, Bangladeshi and international companies) asking to participate as both issuers and relying parties for digital credentials, building a wider base of support. 

Barrier 2: Lack of infrastructure. When working on a technically complex program, there is always risk related to reliance on (or lack of) existing infrastructure. This risk is mitigated by Bangladesh’s high cell phone coverage rate, as well as a technical architecture that connects with, but is not dependent on, government servers. 

Barrier 3: Speed. Our privacy-oriented approach is explicitly meant to displace other approaches to digital ID that provide fewer individual protections. But increased interest in closing the ID gap has, unfortunately, accelerated programs that pay little heed to privacy or user-management. It’s vital that this program move forward quickly, giving Bangladesh the proof of concept required to commit to “good” digital ID -- and proving to other Gavi-eligible countries that such an option exists.

The loss of political support, lack of infrastructure, and speed all threaten to undermine the program. We have taken steps to mitigate each risk. This program’s success depends on continued support of multiple ministries in the Government of Bangladesh including the Ministry of Health and Family Welfare, the CRVS Secretariat, the ICT Ministry, and the Ministry of Local Government. We are in the process of securing full approval at the Cabinet-level in order to ensure that we will have continued support from each of these agencies. Likewise, we have partnered with organizations (like Gavi) and are in the process of partnering with others (like UNICEF and WHO) that have significant stake in the success of the program and should be able to help push it forward. Though infrastructure can be a challenge to implementing program in Bangladesh, we have organized the program around the country’s high cell phone penetration rate and we plan to use a distributed architecture that would enable us to store critical information across several servers, ensuring that we avoid long-term vendor-lock-in and potential risks of shutdown. Our privacy-oriented approach is explicitly meant to displace other approaches to digital ID that provide fewer individual protections. Lastly, it is essential that we carry the program forward at speed, but in a responsible manner. We are mitigating this risk by ensuring that the program continues to pass the review of our independent third party evaluators, and we remain duty-bound to our principles. 

We are currently supporting two analogous programs in Thailand and Indonesia, collectively reaching 10,000 individuals, which demonstrate the viability of user-managed, portable and privacy-protecting digital ID as a solution for improved service delivery. Our program in Thailand, which similarly focuses on using digital ID to improve healthcare outcomes and continuity of care, is on-track towards targets of 80% reduction in the number of treatment defaulters in IRC’s chronic care programs and 100% record portability across multiple IRC databases. 

In Bangladesh, the program will proceed in three overlapping phases. In Phase 1, beginning in mid-2020, the program will be piloted in two areas: Kapasia (Gazipur District) and Ward 5 of DNCC (collectively approximately 10,000 digital IDs to newborns). During this phase, the program will reach newborns, which is the entire annual birth cohort of the two areas. Simultaneously, the program will collect valuable data on the viability on multiple infant biometric vendors in order to determine which solution is best fit-for-purpose for scale-up.

Phase 2 will expand the program’s reach to the five districts over a two-year period beginning in 2021, beginning in Sunamganj, chosen to test the program’s viability in a remote, hard-to-reach area. The remaining districts for expansion are TBD, but will be chosen strategically to offer a representative sampling of the national population. 

During Phase 3, the program will scale up to the national level between 2022 and 2024, and aim to cover the full 3M annual birth cohort of Bangladesh. 

6 FTE, 2 PTE, 1 Contractor

Launched in 2017, the ID2020 Alliance is a global public-private partnership whose mission is to ensure  that digital ID is widely accessible and responsibly implemented. Alliance partners share a commitment to user-centric, privacy-protecting and portable digital identity. (https://id2020.org/manifesto/)

We believe that this type of platform approach is necessary for individuals’ identities to be widely recognized, for ethical standards to be  broadly adopted and safeguarded, and for technological innovation to be carefully embraced. The Alliance partners collaborate to produce a blueprint for identity systems that truly improve lives. As the Alliance (already our partners touch well over two billion people) reaches critical mass, there’s both a strong network effect and a built-in route to scale. This is an approach that is holistic, market-based, and scalable. 

The ID2020 secretariat has a wide range of expertise that encompasses Monitoring, Evaluation, and Learning to managing digital identity programs in five countries across three continents, and beyond. The Secretariat also benefits from support (in both an advisory and a financial capacity) from innovators across the public and private sectors, including from organizations like Accenture, Microsoft, Gavi, the University of California, Berkeley, and others. 

The Access to Information (a2i) Program, ICT Division of Ministry of Post, Telecommunication & Information Technology of the Government of Bangladesh, the Directorate General of Health Services, Health Services, Division of Ministry of Health and Family Welfare of the Government of Bangladesh, Gavi, and ID2020 are all active partners in the program.

This is a true multi stakeholder collaboration with each team organization performing the following functions: ID2020 will serve as program development, run monitoring and evaluation, facilitate the development of an RFP to source the necessary technology, and serve as ongoing advisor. Gavi will serve as high-level policy negotiation lead, key stakeholder convener, liaison with MOHFW, and will ensure programmatic alignment with immunisation goals. Cabinet Division, a2i EPI Hq, DGHS, will provide ongoing intergovernmental coordination, and lead outreach to bring additional ministries into Phase 2. Office of the Registrar General, Birth and Death Registration, Local Government Division will perform implementation through existing programs, which will include training of local stakeholders. We will also be joined by third party technical providers and third party monitoring and evaluation teams. 

Through its partners, ID2020 is driving multi-stakeholder collaboration to set the future course of digital ID. As an Alliance, we work to ensure that safety, security, interoperability, and individual control are built into digital ID systems by-design. From it’s launch in 2017, the ID2020 Alliance has grown to 15 partners from across the digital ID ecosystem. Our partners include Accenture, Gavi, Rockefeller Foundation, Microsoft, IDEO, Mercy Corps, Kiva, Hyperledger, iRespond, Care, Simprints, ICC, FHI360 and University of California Berkeley. Each come to the table with a firm commitment to user-centric, portable digital ID and it’s clear that, in working together, we go further.

ID2020 is funded by a combination of founding and general partnership level donations from private sector partners and grants from philanthropies. ID2020 is generously supported by Rockefeller Foundation and Open Society Foundations. The commitments of philanthropic organizations and private sector organizations will ensure that ID2020 sustains. 

ID2020 not only provides value to organizations, but also to individuals. In the near term, our Alliance seeks to benefit the eighty percent of children in Bangladesh without a birth certificate, but it eventually seeks to benefit the estimated 1.1 billion globally without any form of officially recognized ID. 

At the outset, the program will depend on in-kind funding from the Government of Bangladesh and catalytic funding from philanthropists funding work in the technology for social impact space will be core to our resource mobilization effort. Though critical, financial commitments from these stakeholders are not the core of our plan for long term sustainability. In order for this program to thrive for decades, it will need to sustain government support. And this means a full long term commitment from the Government of Bangladesh to user-centric, portable digital ID. From the outset, we have recognized that this program needs to be a government-lead effort. Which is why we have built a transition to government funding into our timeline, to ensure that a full handoff of all key responsibilities are handed over to the government. 

It is also why during phases one and two, a PMO will be established in Dhaka in order to oversee the activities of all program partners, under the leadership of DGHS. A funding manager will also be selected in-country in order to serve as fiduciary representative on behalf of all program partners. The PMO will manage the efforts of an independent research team which will be hired to gather data and generate key insights that will enable program partners to determine the suitability of program scaling into phases 2 and 3. At the outset, the program will launch simultaneously in the districts. 

We are applying for the Tiger Challenge because we feel closely value-aligned and because we are in the formative stage of a project with world-changing potential that needs catalytic funding in order to get off the ground and begin improving lives. The Tiger Challenge is built around supporting innovators to integrate proven old approaches with novel new approaches. By advancing portable, privacy-protecting, user-managed digital ID that is supported by as yet unproven infant biometrics technologies, we are working to use our proven implementations strategy to make huge strides in improving lives on the ground. Though we have assembled all the necessary partners and political will, we are coming up on a major roadblock: funding. With the money from the Tiger Challenge we can launch in the field and begin improving lives on day 1, while beginning to build the evidence base for how we can apply this same process laterally to the global community. 

We would like to partner with everyone from cutting edge technologists innovating at the edges of the known to innovative financiers who have worked to push the envelope of what is possible in development programs. We have worked hard over the past 4 years to build the network of the ID2020 Alliance (and the Alliance itself) which already gives us access to industry-leading talent on digital ID, but we also know what we do not know: the technology landscape in Bangladesh. We are eager to add more local partners (beyond government agencies) that can enable this project to reach critical mass and scale.