Dr. Surya B. ParajuliMBBS(KU), MD(BPKIHS), MARD(TU)

Principles and practice of Epidemiology course (Christian medical college, Vellore)

Health Advocate, Dengue researcher, Snake bite Instructor

11/24/2016

Teaching Learning Method: Lecture

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ContentBackground/objective of study

What is Health

Indicator

Characteristics of Indicator

Quality & quantitative indicator Vs Development of Country

Spectrum of Health

Tools of measurements

Types of indicators

Sullivan’s index

DALY

HFA

UN/ILO

MDG

SDG

Recent trends of indicators

References

Topic: Health Indicator

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Background/Objectives of study

Understand the variety of health indicators,

their data sources, their key attributes, context

and use

Describe health indicators

Common health indicators and data sources

How are health indicators used and compiled?Examples of reports and on-line tools

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What is Health?

By far, the most accepted definition is that of the World Health Organization:

“[Health is] the state of complete physical, mental and socialwell-being and not merely the absence of disease or infirmity”(WHO, 1948) and the “extent to which an individual or groupis able to realize aspirations and satisfy needs, and to changeor cope with the environment. Health is a resource foreveryday life, not the objective of living; it is a positiveconcept, emphasizing social and personal resources as well as

physical capabilities” (WHO, 1984).

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What are Health Indicators? (1)

With the goal of good health in mind, think of

an indicator as

“…a measure that helps quantify the

achievement of a goal.”

-Mark Friedman

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What are Health Indicators? (2)

Power of indicators is comparisons

- over time (trends)

- geographic areas

- groups of people

and the focus on the most essential domains of

health.

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Terminology concept

Indicator also known as Variable

Amalgamation of health indicators= Health

Index

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Characteristics of Indicators

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1.Valid

2.Reliable

3.Sensitive

4.Specific

5.Feasible

6.Relevant

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Comprehensive Indicator Systems

• Focus on overall Quality of Life with

health being one of many components

(e.g., economy, health, education)

• ExampleSullivan's Index

DALY

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Spectrum of Health

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Positive Health

Better Health

Freedom from sickness

Unrecognized sickness

Mild sickness

Severe sickness

Death

Rate: a/a+b… time specification…. multiplier

CDR=death/pop X1000 Population…in 1 year

Ratio: a/b…male/female

Proportion: a/a+b X 100 …..percentage

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Tools of Measurements

Framework for Health Indicators

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What makes a good indicator?

• Data Power – high quality, available data

• Proxy Power – central importance to health

• Communication Power – that the meaning is

transparent.

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What are the bases for health indicators?

Health indicators are based upon conceptual models for whatinfluences health status, based upon scientific research.

Models have evolved over time, as have definitions of health, but

trace historical improvements in health, e.g., increases in lifeexpectancy, declines in mortality due to infectious diseases.

Context is important: For example, in 1900 the leading causes of

death were Pneumonia, Tuberculosis, and Diarrhea and Enteritis ascompared to Heart Disease, Cancer, and Stroke in 2006.

Source: MMWR. July 30, 1999 / 48(29);621-629

http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

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Current Conceptual Frameworks

Today’s context:•Rate of healthcare spending is unsustainable, and, levels of

spending not consistent with level of health. Ripe opportunities forincreasing the return on investments in health through prevention.

•Burden of chronic diseases (e.g., premature mortality, costs) and

•Complex public health problems (e.g., violence, obesity, HIV), andhealth-related behaviors (e.g., smoking, diet, substance use)

•The influence of social and environmental conditions ondetermining health outcomes, either directly or indirectly

•Deep, persistent disparities in health

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Common Frameworks for Health Indicators

1. Broad “Determinants of Health” - emphasizes thephysical environment, social environment, healthbehaviors, medical care.

2. “Life Course” - emphasizes conditions/experiencesearly in life (e.g., 0-5) and interactions at developmentalstages throughout life in optimizing our health"trajectory".

3. “Social Determinants” emphasizes educational,economic, and social conditions and interactions inshaping health.

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How are health indicators used?

Indicators are powerful tools for monitoring and communicating

critical information about population health.

Indicators are used to support planning (identify priorities, develop

and target resources, identify benchmarks) and track progress toward

broad community objectives.

Engagement of partners into civic and collaborative action (build

awareness of problems and trends, generate interventions).

Inform policy and policy makers, and can be used to promote

accountability among governmental and non-governmental agencies.

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Who compiles health indicators?

•Reports are compiled at local level

•Regional level - Health departments, businesses,

educational, law enforcement, human services

providers, and other civic leaders, faith

organizations, universities, media.

• National– Government/private partnerships.

• International – WHO, UNICEF

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Gaps in Data Sources or Measures

Examples of indicators that lack of systematically

collected and standardized data:

• Early life - developmental outcomes at the time of

primary school and conditions throughout childhood

and youth, e.g., obesity.

• Later life – community care and support, long term

care, quality and availability of services.

• Social environments, e.g., neighborhood

characteristics, quality of social interactions.

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Types

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1. Mortality indicators

2. Morbidity indicators

3. Disability rates

4. Nutritional status indicators

5. Health Care delivery indicators

6. Utilization rates

7. Indicators of social and mental health

8. Environmental indicators

9. Socio-economic indicators

10.Health policy indicators

11.Indicators of quality of life

12.Other indicators

HFA, MDG, SDG

1. Mortality indicators

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A.Crude Death Rate

B.Expectation of life

C.Infant mortality rate

D.Child mortality rate

E.Under-5 mortality rate

F. Maternal(puerperal) mortality rate

G.Disease specific mortality rate

H.Proportional mortality rate

2. Morbidity indicators

A. Incidence & Prevalence

B. Notification rates

C. Attendance rates at OPD, health centers

D. Admission, readmission and discharge rates

E. Duration of stay in hospital

F. Spells of sickness or absence from work or

school

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3. Disability Rate

I. Event-type indicators

i. Number of days of restricted activity

ii. Bed disability days

iii. Work loss days (or school loss days) within a specified period

II. Person-type indicators

i. Limitation of mobility

ii. Limitation of activity

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Sullivan’s index

• Expectation of life free of disability

• Considered one of the most advanced indicators

• E.g. the expectation of life at birth for all persons

in the USA in 1965 was 70.2 years, and the

approximate expectation of life free of disability

worked out to be 64.9 years.

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HALE

• Health-Adjusted Life Expectancy

• DALE to HALE

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DALY: Disability-adjusted life year

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4. Nutritional status indicators

A. Anthropometric measurements of preschool

children, eg weight and Height, MUAC

B. Heights of children at school entry

C. Prevalence of low birth weight

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5. Health care delivery indicators

A. Doctor-population ratio

B. Doctor –nurse ratio

C. Population-bed ratio

D. Population per health/subcentre

E. Population per traditional birth attendant

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6. Utilization rates

• Proportion of infants who are fully immunized against EPI disease

• Proportion of pregnant women who receive ANC, or have their deliveries supervised by a Trained birth attendance

• Percentage of the population using the various methods of family planning

• Bed-occupancy rate

• Average length of stay

• Bed turn over ratio

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7. Indicators of social and mental

health

• Suicide rate

• Homicide rate

• RTA

• Alcohol and drug abuse

• Smoking

• Consumption of tranquilizers

• Obesity

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8. Environmental indicators

• Pollution of air and water

• Radiation

• Solid waste

• Noise exposure

• Exposure to toxic substance in food or drink

• Proportion of population having access to safe water

• Sanitation facility

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9. Socio-economic indicators

• Rate of population increase

• Per capita GNP

• Level of unemployment

• Dependency ratio

• Literacy rates

• Family size

• Housing

• Per capita calorie availability

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10. Health policy indicators

• Proportion of GNP spent on health services

• Proportion of GNP spent on health related

activities (including water supply and

sanitation, housing and nutrition, community

development)

• Proportion of total health

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Health System Performance Indicators

• Access (additional)– Trends in health insurance enrollment, range of benefits, exclusions, premiums

– Rural health provider supply, linguistic or cultural barriers to getting care

• Cost– Total health expenditures

– Health as share of Gross Domestic Product (GDP)

– Prescription drug costs

– Payments to hospitals, facilities

– Comparisons of resources used per patient between hospitals/areas

• Quality of care– Effective care – receipt of recommended screenings, treatment, readmission

rates.

– Patient Safety – medical error

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11. Indicators of quality of Life

• PQLI (Physical quality of Life Index) Infant mortality rate + life expectancy at age 1+

literacy

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12. Others

A. Social indicators:– Given by United nation statistical office 12in number

B. Basic needs indicators: – ILO

– Calorie consumption, access to water, life expectancy, deaths

due to diseases, literacy, doctors and nurses per population,

rooms per person, GNP per capita

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C. Health for All indicators

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D. MDGs

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17 goals and 169 targets

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SDG

Some trends of Indicators

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• K. Park “Park’s textbook of preventive and social medicine,” 23rd Edition 2016

• Annual report of DoHS, MoHP, Nepal

• NDHS 2011

• NPHS 2011

• WHO report

References/Acknowledgement

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Student Questions

Sir,…………………………..………….

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