HEALTH INDICATORSHEALTH INDICATORS

ByBy

Col Naseer Alam Tariq (Retd)Col Naseer Alam Tariq (Retd)

HealthHealth• Health is defined as “Health is defined as “a a statestate of complete of complete

physical, mental & social wellbeing, and not physical, mental & social wellbeing, and not merely an absence of disease or infirmitymerely an absence of disease or infirmity””

• This statement has been amplified to This statement has been amplified to include the ability to lead a “include the ability to lead a “socially and socially and economically productive life” economically productive life”

• Health cannot be measured in exact Health cannot be measured in exact measurable formsmeasurable forms

• Measurement have been framed in terms of Measurement have been framed in terms of illness (or lack of health), consequences of illness (or lack of health), consequences of ill-health (morbidity, mortality) & economic, ill-health (morbidity, mortality) & economic, occupation & domestic factors that promote occupation & domestic factors that promote ill healthill health

Indicators of HealthIndicators of Health

• Indicator also termed as Index or Variable Indicator also termed as Index or Variable is only an indication of a given situation or is only an indication of a given situation or a reflection of that situationa reflection of that situation

• Health Indicator is a variable, susceptible Health Indicator is a variable, susceptible to direct measurement, that reflects the to direct measurement, that reflects the state of health of persons in a community.state of health of persons in a community.

• Indicators help to measure the extent to Indicators help to measure the extent to which the objectives and targets of a which the objectives and targets of a programme are being attained.programme are being attained.

• Health Index is a numerical indication of Health Index is a numerical indication of the health of a given population derived the health of a given population derived from a specified composite formula.from a specified composite formula.

IndicatorsIndicators

WHOWHO defines Indicators as defines Indicators as

““variables which measure variables which measure changechange””

Uses of Indicators of Uses of Indicators of HealthHealth

• Measurement of the health of the Measurement of the health of the community.community.

• Description of the health of the community.Description of the health of the community.

• Comparison of the health of different Comparison of the health of different communities.communities.

• Identification of health needs and Identification of health needs and prioritizing them.prioritizing them.

• Concurrent evaluation and terminal Concurrent evaluation and terminal evaluation of health services.evaluation of health services.

• Planning and allocation of health resources.Planning and allocation of health resources.

• Measurement of health successes.Measurement of health successes.

Characteristics of IndicatorsCharacteristics of Indicators

• ValidValid - - They should actually measure They should actually measure what they are supposed to what they are supposed to

measuremeasure

• ReliableReliable – The answers should be the – The answers should be the same if measured same if measured by by

different people in similar different people in similar circumstances circumstances

• SensitiveSensitive - - They should be sensitive to They should be sensitive to changes in the situation changes in the situation

concerned concerned

Characteristics of IndicatorsCharacteristics of Indicators

• Specific Specific - They should reflect - They should reflect changes changes only in the situation only in the situation concernedconcerned

• FeasibleFeasible - - They should have the They should have the ability to obtain dataability to obtain data neededneeded

• RelevantRelevant - - They should contribute to They should contribute to the understanding of the understanding of the phenomenon of interestthe phenomenon of interest

Factors influencing health Factors influencing health IndicatorsIndicators

• Health is multidimensionalHealth is multidimensional

• Each dimension is influenced by Each dimension is influenced by numerous factorsnumerous factors

• Economic, occupational, cultural, Economic, occupational, cultural, educational, socialeducational, social

Health IndicatorsHealth Indicators

Health IndicatorsHealth Indicators• Mortality indicatorsMortality indicators• Morbidity indicatorsMorbidity indicators• Disability ratesDisability rates• Nutritional status indicatorsNutritional status indicators• Health care delivery indicatorsHealth care delivery indicators• Utilization ratesUtilization rates• Indicators of social and mental healthIndicators of social and mental health• Environmental indicatorsEnvironmental indicators• Socio-economic indicatorsSocio-economic indicators• Health policy indicatorsHealth policy indicators• Indicators of quality of lifeIndicators of quality of life• Other indicatorsOther indicators

Mortality Indicators Mortality Indicators

Crude Death RateCrude Death Rate • Is considered a fair indicator of the Is considered a fair indicator of the

comparative health of the people.comparative health of the people.

• It is defined as the number of deaths per 1000 It is defined as the number of deaths per 1000 population per year in a given community, population per year in a given community, usually the mid-year populationusually the mid-year population

• The usefulness is restricted because it is The usefulness is restricted because it is influenced by the age-sex composition of the influenced by the age-sex composition of the population, socioeconomic and socio-cultural population, socioeconomic and socio-cultural environment of the communities.environment of the communities.

• Current CDR is Current CDR is 7.27.2 deaths/1,000 population deaths/1,000 population

• CBR 27.2CBR 27.2

Mortality Indicators Mortality Indicators

Expectation of lifeExpectation of life is the average number is the average number of years that will be lived by those born alive of years that will be lived by those born alive into a population if the current age specific into a population if the current age specific mortality rates persist.mortality rates persist.

• It is a statistical abstraction based on It is a statistical abstraction based on existing age-specific death rates.existing age-specific death rates.

• Estimated for both sexes separately.Estimated for both sexes separately.• Good indicator of socioeconomic developmentGood indicator of socioeconomic development• Positive health indicator of long time survivalPositive health indicator of long time survival• Life expectancy at birth: Life expectancy at birth:  Total population: Total population:  65.2 years  65.2 years 

Male:  64.3 years  Male:  64.3 years  Female:  66.1 years Female:  66.1 years

Infant mortality rateInfant mortality rate

The ratio of deaths under 1yr of age in a The ratio of deaths under 1yr of age in a given year to the total number of live given year to the total number of live births in the same year, usually expressed births in the same year, usually expressed as a rate per 1000 live birthsas a rate per 1000 live births

Indicator of Indicator of health statushealth status of not only of not only infants but also whole population & infants but also whole population & socioeconomic conditionssocioeconomic conditions

SensitiveSensitive indicator of availability, indicator of availability, utilization &effectiveness of health care, utilization &effectiveness of health care, particularly perinatal care.particularly perinatal care.

Current IMR – Current IMR – 67/100067/1000live birth (69)live birth (69)

Child Mortality RateChild Mortality Rate

• The number of deaths under 5yrs in a The number of deaths under 5yrs in a given year, per 1000 children in that age given year, per 1000 children in that age group at the mid-point of the year.group at the mid-point of the year.

• Correlates with Correlates with inadequate MCH servicesinadequate MCH services, , malnutrition, low immunization coverage malnutrition, low immunization coverage and environmental factorsand environmental factors

• Current rate – Current rate – 8686/1000/1000 Other indicators are Perinatal mortality Other indicators are Perinatal mortality

rate, Neonatal mortality rate, Stillbirth rate, Neonatal mortality rate, Stillbirth rate, etc.rate, etc.

• Correlates with inadequate antenatal care Correlates with inadequate antenatal care and perinatal careand perinatal care

Mortality Indicators Mortality Indicators

Maternal Mortality RateMaternal Mortality Rate• Ratio of number of deaths arising during Ratio of number of deaths arising during

pregnancy or puerperal period per 1000 pregnancy or puerperal period per 1000 live birthslive births

• Accounts for the greatest number of Accounts for the greatest number of deaths among women of reproductive age deaths among women of reproductive age in developing countriesin developing countries

• Current MMR – Current MMR – 276276/100000 live births/100000 live births

Bal Bal 762762 Islamabad/Karachi Islamabad/Karachi 230-240230-240

Mortality IndicatorsMortality Indicators

Disease Specific Death RateDisease Specific Death Rate

Mortality rate which is computed for Mortality rate which is computed for specific diseases. E.g. TB mortality is 23 specific diseases. E.g. TB mortality is 23 per 100000 population per year .per 100000 population per year .

Proportional Mortality RateProportional Mortality Rate

Proportion of all deaths attributed to the Proportion of all deaths attributed to the specific diseasespecific disease

E.g. Coronary heart disease causes 25 E.g. Coronary heart disease causes 25 to 30 % of all deaths in developed world.to 30 % of all deaths in developed world.

Morbidity IndicatorsMorbidity Indicators Morbidity IndicatorsMorbidity Indicators reveal the burden of ill reveal the burden of ill

health in a community, but do not measure health in a community, but do not measure the subclinical or inapparent disease the subclinical or inapparent disease states.states.

IncidenceIncidence• The number of new events or new cases of The number of new events or new cases of

a disease in a defined population, within a a disease in a defined population, within a specified period of time. E.g. Incidence of specified period of time. E.g. Incidence of TB is 168 per100000 population per year.TB is 168 per100000 population per year.

PrevalencePrevalence• TThe total number of all individuals who he total number of all individuals who

have disease at a particular time divided have disease at a particular time divided by population at risk of having disease at by population at risk of having disease at this point of timethis point of time

• Reflects the chronicity of the diseaseReflects the chronicity of the disease• E.g. Prevalence of TB (sputum+ve in E.g. Prevalence of TB (sputum+ve in

population) is 249 per 100000 population population) is 249 per 100000 population

Morbidity IndicatorsMorbidity Indicators 2.2. Notification ratesNotification rates is calculated from the reporting is calculated from the reporting

to public authorities of certain diseases . to public authorities of certain diseases . yellow yellow fever , poliomyelitis, cholera, plaguefever , poliomyelitis, cholera, plague

They provide information regarding geographic They provide information regarding geographic clustering of infections, quality of reporting system clustering of infections, quality of reporting system

3.3. Attendance ratesAttendance rates at OPDs and at health centers. at OPDs and at health centers.

4.4. AdmissionAdmission, Readmission and discharge rates., Readmission and discharge rates.

5.5. Duration of stay in hospitalDuration of stay in hospital – reflects the – reflects the virulence and resistance developed by the etiological virulence and resistance developed by the etiological factorfactor

6.6. Spells of sickness or absence from work or schoolSpells of sickness or absence from work or school.. - reflects economical loss to the community - reflects economical loss to the community

7.7. Hospital data constitute a basic and primary source of Hospital data constitute a basic and primary source of information about diseases prevalent in the community.information about diseases prevalent in the community.

Disability RatesDisability RatesSullivan’s IndexSullivan’s Index refers to “expectation of refers to “expectation of

life free of disability”.life free of disability”.• Sullivan’s Index = life expectancy of the Sullivan’s Index = life expectancy of the

country -probable duration of bed disability country -probable duration of bed disability and inability to perform major activities and inability to perform major activities

• It is considered as one of the most It is considered as one of the most advanced indicators currently available.advanced indicators currently available.

HALE - Health Adjusted Life ExpectancyHALE - Health Adjusted Life Expectancy..• It is based on the framework of WHOIt is based on the framework of WHO• It is based on life expectancy at birth but It is based on life expectancy at birth but

includes an adjustment for time spent in includes an adjustment for time spent in poor health.poor health.

• It is the equivalent number of years in full It is the equivalent number of years in full health that a newborn can expect to live health that a newborn can expect to live based on current rates of ill-health and based on current rates of ill-health and mortality.mortality.

Disability RatesDisability Rates

DALYs: Disability Adjusted Life Years.DALYs: Disability Adjusted Life Years.• It is defined as the number of years of healthy It is defined as the number of years of healthy

life lost due to all causes whether from life lost due to all causes whether from premature mortality or disability.premature mortality or disability.

• It is the simplest and the most commonly It is the simplest and the most commonly used measure to find the burden of illness in used measure to find the burden of illness in a defined population and the effectiveness of a defined population and the effectiveness of the interventionsthe interventions

• Two things needed to measure DALYs areTwo things needed to measure DALYs are - Life table of that country, to measure the - Life table of that country, to measure the

losses from premature deathslosses from premature deaths - Loss of healthy life years resulting from - Loss of healthy life years resulting from

disability; the disability may be permanent disability; the disability may be permanent (polio) or temp(TB, leprosy), physical / (polio) or temp(TB, leprosy), physical / mental. mental.

Disability RatesDisability Rates

Uses of DALYsUses of DALYs

• To assist in selecting health service prioritiesTo assist in selecting health service priorities

• To identify the disadvantaged groupsTo identify the disadvantaged groups

• Targeting health interventions Targeting health interventions

• Measuring the results of health interventionsMeasuring the results of health interventions

• Providing comparable measures for planning Providing comparable measures for planning & evaluating programmes& evaluating programmes

• To compare the health status of different To compare the health status of different countriescountries

DALY express years of life lost to premature DALY express years of life lost to premature death and years lived with disability for the death and years lived with disability for the severity of the disabilityseverity of the disability

One DALY is one lost year of healthy lifeOne DALY is one lost year of healthy life

Disability RatesDisability RatesPremature deathPremature death – defined as one that occurs – defined as one that occurs

before the age to which a dying person could before the age to which a dying person could have expected to survive if he or she was a have expected to survive if he or she was a member of a standardized mode population member of a standardized mode population with a life expectancy at birth equal to that with a life expectancy at birth equal to that of world longest surviving population e.g. of world longest surviving population e.g. JapanJapan

QALY- Quality Adjusted Life YearQALY- Quality Adjusted Life Year. . • It is the most commonly used to measure the It is the most commonly used to measure the

cost effectiveness of health interventions .cost effectiveness of health interventions .• It estimates the number of years of life It estimates the number of years of life

added by a successful treatment or added by a successful treatment or adjustment for quality of life.adjustment for quality of life.

2424

Nutritional Status IndicatorsNutritional Status Indicators Nutritional Status is a positive health indicator.Nutritional Status is a positive health indicator.NewbornsNewborns are measured for their are measured for their i. Birth–weight ii. Length iii. Head i. Birth–weight ii. Length iii. Head

circumferencecircumference They reflect the maternal nutrition statusThey reflect the maternal nutrition status Pre-school children Pre-school children

AnthropometricmeasurementsAnthropometricmeasurements i.i. WeightWeight – measures acute malnutrition – measures acute malnutrition ii.ii.HeightHeight – measures chronic malnutrition – measures chronic malnutritioniii.iii.Mid-arm circumferenceMid-arm circumference - measures chronic - measures chronic

malnutritionmalnutrition Growth Monitoring of childrenGrowth Monitoring of children Measuring weight-for-age, height-for-age, weight-Measuring weight-for-age, height-for-age, weight-

for- height, head & chest circumference and mid-for- height, head & chest circumference and mid-arm circumference.arm circumference.

AdultsAdults Underweight, Obesity and Anemia are Underweight, Obesity and Anemia are generally considered reliable nutritional indicators.generally considered reliable nutritional indicators.

Nutritional status Nutritional status indicatorsindicators

Prevalence of low birth weightPrevalence of low birth weight

>2.5 Kg >2.5 Kg

24%24%

Poverty LevelPoverty Level1$ 32.9% (44%)1$ 32.9% (44%)

2$ 2$ 60% 60%

Health Care Delivery Health Care Delivery IndicatorsIndicators These indicators reflect the equity of These indicators reflect the equity of distribution distribution

of health resourcesof health resources in different parts of the country in different parts of the country and of the and of the provisionprovision of health care of health care

• Doctor – population ratio Doctor – population ratio 1 : 1222 1 : 1222

• Doctor – Nurse ratioDoctor – Nurse ratio 2.2 : 1 2.2 : 1

• Population – bed ratioPopulation – bed ratio 1:1701 1:1701

Population per dentist 16,854 Population per dentist 16,854

Population per nurse 2,501Population per nurse 2,501

• Population per health centre 5000-10000Population per health centre 5000-10000

• Population per TBA 0.47/1000Population per TBA 0.47/1000

HEALTH MANPOWER IN PAKISTANHEALTH MANPOWER IN PAKISTAN

Registered Doctors Registered Doctors 153567 153567 (149,201)(149,201)

Registered Dentists 11740 Registered Dentists 11740 (10,958)(10,958)

Registered Nurses 76244Registered Nurses 76244

Population per doctor 1,222 Population per doctor 1,222

Population per dentist 16,854 Population per dentist 16,854

Population per nurse 2,501Population per nurse 2,501

Population per bedPopulation per bed 1,701 1,701

Utilisation RatesUtilisation RatesUtilisation Rates is expressed as the Utilisation Rates is expressed as the

proportion of people in need of a service who proportion of people in need of a service who actually actually receivereceive it in a given period, usually a it in a given period, usually a yearyear

• It depends on It depends on availability & accessibilityavailability & accessibility of of health services and the attitude of an health services and the attitude of an individual towards health care systemindividual towards health care system

1.1.Proportion of infants who are fully Proportion of infants who are fully immunizedimmunized

2.2.Proportion of Proportion of pregnant womenpregnant women who receive who receive ANC care or have institutional deliveriesANC care or have institutional deliveries

3.3.Percentage of population who adopt Percentage of population who adopt family family planningplanning

4.4.Bed occupancy ratio, bed-turn over ratio, etc. Bed occupancy ratio, bed-turn over ratio, etc.

Indicators of Social and Mental Indicators of Social and Mental HealthHealth

• Rates of suicide, homicide, other crime, Rates of suicide, homicide, other crime, road traffic accident, juvenile delinquency, road traffic accident, juvenile delinquency, alcohol and substance abuse, domestic alcohol and substance abuse, domestic violence etc.violence etc.

• These indicators provide a These indicators provide a guide to social guide to social actionaction for improving the health of people. for improving the health of people.

• Social and mental health of the children Social and mental health of the children depend on their parents. E.g. Substance depend on their parents. E.g. Substance abuse in orphan children, smokingabuse in orphan children, smoking

Environmental IndicatorsEnvironmental Indicators

• These reflect the These reflect the qualityquality of physical and of physical and biological environment in which diseases biological environment in which diseases occur and people live.occur and people live.

• The most important are those measuring The most important are those measuring the proportion of population having the proportion of population having access to safe drinking access to safe drinking water and water and sanitationsanitation facilities. facilities.

• These indicators explains the prevalence These indicators explains the prevalence of of communicable diseasescommunicable diseases in a community in a community

• The other indicators are those measuring The other indicators are those measuring the pollution of air and water, radiation, the pollution of air and water, radiation, noise pollution, exposure to toxic noise pollution, exposure to toxic substances in food and water substances in food and water

Socio-economic Socio-economic indicatorsindicators

These do not directly measure health but are These do not directly measure health but are important in interpreting health indicators.important in interpreting health indicators.

• Per capita incomePer capita income $ 1372 (1258) $ 1372 (1258)

• Level of unemploymentLevel of unemployment 8% 8%

• Literacy rateLiteracy rate 58% (57.7%) 58% (57.7%)

• Per capita caloricPer capita caloric 2450 2450

availabilityavailability

• Population Population 180.71 M 180.71 M (178)(178)

• Total Fertility Rate (TFR)Total Fertility Rate (TFR) 3.4 (3.5) 3.4 (3.5)

• Family sizeFamily size 5.9 5.9

• Population increase ratePopulation increase rate 2.03% (2.05%) 2.03% (2.05%)

• Contraceptive useContraceptive use 30% (27%) 30% (27%)

Health Policy IndicatorsHealth Policy Indicators

The single most important indicator of The single most important indicator of political commitment is political commitment is allocation of allocation of adequate resourcesadequate resources

The relevant indicators are The relevant indicators are

• Proportion of GDP spent on health Proportion of GDP spent on health services- services- 0.27% (2011-12)0.27% (2011-12)

• Proportion of GDP spent on health related Proportion of GDP spent on health related activities like water supply and sanitation activities like water supply and sanitation & housing and nutrition& housing and nutrition

• Proportion of total health resources Proportion of total health resources devoted primary health care devoted primary health care

Indicators of Quality of LifeIndicators of Quality of Life Life expectancy is no longer importantLife expectancy is no longer importantThe Quality Of Life has gained its importanceThe Quality Of Life has gained its importance

Physical Quality of Life IndexPhysical Quality of Life Index• It consolidates It consolidates Infant mortality, Life Infant mortality, Life

expectancy expectancy at age of 1yr andat age of 1yr and Literacy. Literacy.

• For each component the performance of For each component the performance of individual country is placed on a scale of 1- individual country is placed on a scale of 1- 100.100.

• The composite index is calculated by The composite index is calculated by averaging the three indicators giving equal averaging the three indicators giving equal weight to each weight to each

• The resulting is placed on the 0 to 100 scale.The resulting is placed on the 0 to 100 scale.

• The PQLI does not consider the GDP. The PQLI does not consider the GDP.

Indicators of Quality of LifeIndicators of Quality of Life

Human Development IndexHuman Development Index

– Life expectancy at birthLife expectancy at birth– Literacy rateLiteracy rate– Income- GDP per capita incomeIncome- GDP per capita income

The resulting is placed on the 0 to 1 The resulting is placed on the 0 to 1 scalescale

Other indicatorsOther indicators

Social indicatorsSocial indicators– Population, families, educational, Population, families, educational,

earningearning

Basic Needs indicatorsBasic Needs indicators– Calories consumption, access to Calories consumption, access to

water, illiteracy, Dr per populationwater, illiteracy, Dr per population

Health for All IndicatorsHealth for All Indicators

SummarySummary

• Health is not measured directly but Health is not measured directly but using indicatorsusing indicators

• Indicator should be valid, sensitive, Indicator should be valid, sensitive, specific, reliable, relevant and specific, reliable, relevant and feasiblefeasible

• Used in measuring, describing, Used in measuring, describing, comparing, identifying health needs comparing, identifying health needs and planning and evaluation of and planning and evaluation of health serviceshealth services

??