7.health indicators

indicators for health

1. HEALTH INDICATORS DR.AESHA ZAFNA 2 ND YEAR POST GRADUATE

2. Contents Introduction Definition Need for an indicator Characteristics of an indicator Classification of Health indicators Description of each indicator Oral health indicators Conclusion References Previous Year Questions

3. Indicator = Variable. A variable which helps to measure changes, directly or indirectly (WHO, Guidelines for Health Program evaluation, 1981) A health indicator is a characteristic of an individual, population, or environment which is subject to measurement (directly or indirectly) and can be used to describe one or more aspects of the health of an individual or population (quality, quantity and time). - WHO, Health Promotion Glossary 1998.

4. Need for an Indicator As the name suggests, indicators are only an indication of a given situation or a reflection of that situation. If measured sequentially over time, they can indicate the direction and speed of change.

5. Indicators help to answer important questions, such as: • How healthy is our community? • Is our community in balance? • What things affect health in our community? • Are our programs, services or policies working? • Are we moving towards or away from our vision of health?

6. To compare the health status of one country with that of another; Assessment of health care needs; Allocation of scarce resources; For monitoring and evaluation of health services, activities, and programmes .

7. CHARACTERISTICS : IDEAL INDICATOR Should be valid. They should actually measure what they are supposed to measure Should be reliable and objective. The answer should be same if measured by different people in similar situation. Should be sensitive. They should be sensitive to changes in situation concerned Should be specific. They should reflect changes only in situation concerned. Should be feasible. They should have the ability to obtain data needed Should be relevant. They should contribute to the phenomenon of interest

8. INDICATORS can be…. Count / Number . Proportion (% ) Rate Ratio . Index

9. Classification(WHO 2015) The indicators can be classified as – Input Indicators Process Indicators Output Indicators Effect Indicators Impact Indicators

10. Indicators of Health

11. 1. Mortality indicators (a) Crude death rate : This is considered a fair indicator of the comparative health of the people. It is defined as the number of deaths per 1000 population per year in a given community.

12. As of 2015 the crude death rate for the whole world is about 7.89 per 1000 per year. India- 7.3 (2016)

13. (b) Expectation of life Life expectancy at birth is "the average number of years that will be lived by those born alive into a population if the current age-specific mortality rates persist". Life expectancy at birth is highly influenced by the infant mortality rate where that is high. Life expectancy at the age of 1 excludes the influence of infant mortality, and life expectancy at the age of 5 excludes the influence of child mortality.

14. List by the World Health Organization (2015)

15. c) Age specific death rates: Total number of deaths occurring in a specific age group of the population(e.g. 20- 24 years) in a defined area during a specific period per 1000 estimated total population of the same group of the population in the same area during the same period.

16. (d) Infant mortality rate: Infant mortality rate is the ratio of deaths under 1 year of age in a given year to the total number of live births in the same year; usually expressed as a rate per 1000 live births . Number of deaths under 1 year of age in given year x1000 The total number of live births in the same year

17. It is one of the most universally accepted indicators of health status not only of infants, but also of whole population and of the socio-economic conditions under which they live. In addition, the infant mortality rate is a sensitive indicator of the availability, utilization and effectiveness of health care, particularly perinatal care

18. Infant mortality rate, INDIA 2009 2012 2014 Total 50 44 39 Rural 55 48 43 Urban 34 29 26 Source: SRS Bulletin, Sample Registration System, Office of Registrar General, India.

19. (e) Child mortality rate: Another indicator related to the overall health status is the early childhood (1-4 years) mortality rate. Number of deaths at ages 1-4 years in a given year X 1000 Children in that age group at the mid-point of the year It thus excludes infant mortality.

20. (f) Under-5 proportionate mortality rate : It is the proportion of total deaths occurring in the under-5 age group.

21. In communities with poor hygiene, the proportion may exceed 60 per cent. In some European countries, the proportion is less than 2 per cent. U5MR, INDIA 2011 2012 2013 Total 55 52 49 Source: SRS Statistical Report 2011,2012,2013

22. According to the UN – Globally, more than a third of under-five deaths are attributable to under nutrition. About half of under-five deaths occur in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China. India (24 percent) and Nigeria (11 percent) together account for more than a third of all under-five deaths.

23. (g)Adult mortality rate: Probability of dying between the age of 15 and 60 years per 1000 population. Analyses health gaps between countries in the main working groups. Probability of dying in adulthood is greater for men than women for almost all countries, but variation among countries is large. Examples: Japan - less than 1 in 10 men and 1 in 20 women Angola – 2 to 3 in 10 men and 1-2 per 10 in women

24. Globally, adult mortality rate was 149 per 1000 population in 2015. In India, it was 201 per 1000 population in 2013, which reduced to 181 in 2015. Source: World Health Organization 2015

25. (h) Maternal (puerperal) mortality rate : Maternal (puerperal) mortality accounts for the greatest proportion of deaths among women of reproductive age in most of the developing world, although its importance is not always evident from official statistics . There are enormous variations in maternal mortality rate according to countrys ' level of socioeconomic status.

26. The maternal mortality rate (MMR) is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes). The MMR includes deaths during pregnancy, childbirth, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, for a specified year.

27. MMR (per 100,000 live births) List by the WHO (2010) (2015) Africa 620 542 America 62 52 South-East Asia 206 164 Europe 19 16 Global 246 216

28. ( i ) Proportional mortality rate : The simplest measures of estimating the burden of a disease in the community is proportional mortality rate, i.e., the proportion of all deaths currently attributed to it. For example, coronary heart disease is the cause of 25 to 30 per cent of all deaths in most western countries.

29. The proportional mortality rate from communicable diseases has been suggested as a useful health indicator; it indicates the magnitude of preventable mortality.

30. (j)Years of potential life lost (YPLL): Based on the years of life lost through premature death. It is defined as one that occurs before the age to which a dying person could have expected to survive (before an arbitrary determined age, usually taken age 75 years) A 30 year old who dies in a road accident could theoretically have lived to an average life expectancy of 75 years of age, thus 45 years of life are lost.

31. SURVIVAL RATE: It is the proportion of survivors in group studied and followed over a period Method of describing prognosis in certain disease conditions. Used to assess standards of therapy SURVIVAL RATE = TOT.NO OF PATIENTS ALIVE AFTER 5 YEARS *100 - TOT.NO OF PATIENTS DIAGNOSED /TREATED

32. Mortality indicators – traditional measures, but most often used indirect indicators of health. As infectious diseases have been brought under control, mortality rates have declined to very low levels in many countries - losing their sensitivity as health indicators in developed countries. However, mortality indicators continue to be used as the starting point in health status evaluation.

33. 2. Morbidity Indicators Mortality indicators do not reveal the burden of ill-health in a community, as for example mental illness and rheumatoid arthritis. Therefore morbidity indicators are used to supplement mortality data to describe the health status of a population. Morbidity statistics have also their own drawback; they tend to overlook a large number of conditions which are subclinical or inapparent , that is, the hidden part of the iceberg of disease.

34. The following morbidity rates are used for assessing ill- health in the community . incidence and prevalence notification rates attendance rates at out-patient departments, health centres , etc. admission, readmission and discharge rates duration of stay in hospital and spells of sickness or absence from work or school

35. Incidence and Prevalence Incidence Incidence rate is defined as : “the number of NEW cases occurring in a defined population during a specified period of time”. It is given by the formula: Incidence = no of new case of specific disease during given time period х1000 Population at risk during that period E.g. The incidence of Tuberculosis in India is 210 per 100,000.

36. Prevalence The total number of all individuals who have an attribute or disease at a particular time divided by population at risk of having attribute or disease at this point of time. Reflects the chronicity of the disease. Eg. The prevalence of Tuberculosis in India is 260 per 100,000 population. Source: United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population Prospects

37. 2. Notification rates - Calculated from the reporting to public authorities of certain diseases e.g. yellow fever , poliomyelitis - They provide information regarding geographic clustering of infections, quality of reporting system etc. E.g., Notification rate of new and relapse TB cases (per 100,000 population for the year 2013) was 99.

38. 2. Hospital beds - This indicator provides a measure of the resources available for delivering services to inpatients in hospitals in terms of number of beds that are maintained, staffed and immediately available for use. - Total hospital beds include acute care beds, psychiatric care beds, long-term care beds and other beds in hospitals.

39. Hospital beds Total, Per 1 000 inhabitants, 2014 Source: Health care resources, OECD India, 2014 0.5 Japan, 2014 13.2

40. 2. Length of Hospital stay - Hospitals in most countries account for the largest part of health expenditure. - The average length of stay in hospitals (ALOS) is one measure of the efficiency with which hospital resources are used. - All other things being equal, a shorter stay might reduce the cost per discharge, and shift care from inpatient to less expensive outpatient and ambulatory settings.

41. Source: OECD Health Data 2012 Stat link: http://dx.doi.org/10.1787/888932723266

42. DISABILITY RATE Disability is defined as “any restriction or lack of ability to perform an activity in a manner or within the range considered normal for a human being.” Types : (1)Event type indicators (2)Person type indicators

43. Sullivan's index: This index (expectation of life free of disability) is computed by subtracting from the life expectancy the probable duration of bed disability and inability to perform major activities, according to cross-sectional data from the population surveys. For example, 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.

44. HALE ( Health - Adjusted Life Expectancy ) : The name of the indicator used to measure healthy life expectancy has been changed from disability - adjusted life expectancy (DALE) to health - adjusted life expectancy (HALE). HALE is based on life expectancy at birth but includes an adjustment for time spent in poor health.

45. Overall, global HALE at birth in 2013 for males and females combined was 62 years, 7 years lower than total life expectancy at birth. In other words, poor health resulted in a loss of nearly 7 years of healthy life, on average globally.

46. Quality adjusted life years( QALY ): Measure of disease burden including both quality and quantity of life lived. Used in assessing the value for money of a medical intervention. The QALY is based on the number of years of life that would be added by intervention. Each year in perfect health is assigned a value of 1.0 down to a value of 0.0 for death, i.e , 1 QALY( 1 year of life x 1 utility value=1QALY) is a year of life lived in perfect health.

47. DALY (Disability - Adjusted Life Year) : A comprehensive indicator including both losses of healthy years due to disability and premature death . DALYs is an indicator that measures the disease burden in a population, taking into account not only premature mortality but also disability caused by disease or injury.

48. 4. Nutritional Status Indicators ( a) anthropometric measurements of preschool children, e.g., weight and height, mid-arm circumference; (b) heights (and sometimes weights) of children at school entry; and (c) prevalence of low birth weight (less than 2.5 kg).

49. Underweight : weight for age < –2 standard deviations (SD) of the WHO Child Growth Standards median Stunting : height for age < –2 SD of the WHO Child Growth Standards median Wasting: weight for height < –2 SD of the WHO Child Growth Standards median Overweight : weight for height > +2 SD of the WHO Child Growth Standards median

50. Source: Kuppusamy K, Rajarathinam MK. Tracking progress towards health related millennium development goals in India. Int J Med Public Health 2015;5:253-8.

51. The frequently used indicators of health care delivery are: (a) Doctor-population ratio (b) Doctor-nurse ratio (c) Population-bed ratio (d) Population per health/ subcentre (e) Population per traditional birth attendant These indicators reflect the equity of distribution of health resources in different parts of the country, and of the provision of health care.. 5. Health Care Delivery Indicators

52. 6. Utilization Rates Utilization of services - or actual coverage - is expressed as the proportion of people in need of a service who actually receive it in a given period , usually a year. Utilization rates give some indication of the care needed by a population, and therefore, the health status of the population.

53. 7. Indicators of Social and Mental Health These indicators provide a guide to social action for improving the health of people. These include rates of suicide, homicide, other crime, road traffic accident, juvenile delinquency, alcohol and substance abuse, domestic violence, battered-baby syndrome, etc. Social and mental health of the children depend on their parents. E.g. Substance abuse in orphan children

54. 8. Environmental Indicators These reflect the quality of physical and biological environment in which diseases occur and people live. The most important are those measuring the proportion of population having access to safe drinking water and sanitation facilities. These indicators explains the prevalence of communicable diseases in a community The other indicators are those measuring the pollution of air and water, radiation, noise pollution, exposure to toxic substances in food and water

55. These indicators do not directly measure health. Nevertheless, they are of great importance in the interpretation of the indicators of health care. These include : Rate of population increase Per capita GNP Level of unemployment Dependency ratio Literacy rates, especially female literacy rates Family size Housing: the number of persons per room Per capita "calorie" availability. 9. Socio-economic Indicators

56. Per capita GNI (gross national income) – 5350 US$(World Bank 2013) Literacy rates: India - 74.04% (2011) (source:www.census.gov.in/2011).

57. 10. Health Policy Indicators The single most important indicator of political commitment is "allocation of adequate resources". The relevant indicators are: ( i ) proportion of GNP spent on health services (ii) proportion of GNP spent on health-related activities (including water supply and sanitation, housing and nutrition, community development) and (iii) proportion of total health resources devoted to primary health care.

58. INDIA According to budget of 2013-2014, 2.25% of total expenditure allocated to health sector. Allocation for social sector including education and health care –Rs.1,51,581 crore. (2016-17) New health protection scheme will provide health cover up to One lakh per family. For senior citizens an additional top-up package up to Rs.30,000 will be provided.

59. 11. Indicators of Quality of Life Increasingly, mortality and morbidity data have been questioned as to whether they fully reflect the health status of a population. The previous emphasis on using increased life expectancy as an indicator of health is no longer considered adequate, especially in developed countries, and attention has shifted more toward concern about the quality of life enjoyed by individuals and communities. Quality of life is difficult to define and even more difficult to measure.

60. Physical Quality of Life Index (PQLI) It consolidates Infant mortality, Life expectancy at age of 1yr and Literacy. For each component the performance of individual country is placed on a scale of 1- 100 . The composite index is calculated by averaging the three indicators giving equal weight to each The PQLI does not consider the GDP.

61. Human Development Index It is defined as a composite index combining indicators representing 3 dimensions – Longevity( life expectancy at birth) Education (mean and expected years of schooling) Gross national income (GNI) per capita The result is placed on the 0 to 1 scale HDI for India was 0.702 (UNDP-2013) HDI ranking of India is 135

62. To construct the index, fixed MINIMUM and MAXIMUM values have been established for each of these indicators. For any component of the HDI, individual indices can be computed according the general formula : (Actual value) — (Minimum value) Index = (Maximum value) — (Minimum value)

63. HDI= L+E+G 3 Interpretation: < 0.5- poor & > 0.8-good development. RANGE COUNTRY Top Norway,Australia , Switzerland Middle India, South Africa Bottom Niger, Central African Republic

64. 12. Other indicators series a) Social indicators : Social indicators, as defined by the United Nations Statistical Office, have been divided into 12 categories: population; family formation, families and households; learning and educational services; earning activities; distribution of income, consumption, and accumulation; social security and welfare services; health services and nutrition; housing and its environment; public order and safety; time use; leisure and culture; social stratification and mobility.

65. (b) Basic needs indicators : Basic needs indicators are used by ILO. Those mentioned in "Basic needs performance" include calorie consumption; access to water; life expectancy; deaths due to disease: illiteracy, doctors and nurses per population; rooms per person; GNP per capita.

66. c) Health for All indicators : For monitoring progress towards the goal of Health for All by 2000 AD, the WHO has listed the following four categories of indicators.

67. (d) Millennium Development Goal Indicators : adopted by the General Assembly of the United Nations in its Fifty-fifth session in the year 2000 ( september )provides an opportunity for concerted action to improve global health.

68. Source: Kuppusamy K, Rajarathinam MK. Tracking progress towards health related millennium development goals in India. Int J Med Public Health 2015;5:253-8.

69. Sustainable Development Goals (SDG): On 25 th September 2015, the UN General Assembly adopted the new development agenda “transforming our world: the 2030 agenda for sustainable development.” This new agenda is of unprecedented scope and ambition, and applicable to all countries. It comprises of 17 goals and 169 targets, including one specific goal for health with 13 targets

70. The Global Reference List of 100 Core Health Indicators The Global Reference List is a standard set of 100 core indicators prioritized by the global community to provide concise information on the health situation and trends, including responses at national and global levels. It contains indicators of relevance to country, regional and global reporting across the spectrum of global health priorities relating to the post-2015 health goals of the Sustainable Development Goals.

71. Oral Health Indicators

72. Healthy People 2020 Leading Health Indicators: Oral Health Overview : Oral diseases ranging from dental caries (cavities) to oral cancers cause pain and disability for millions of Americans. The impact of these diseases does not stop at the mouth and teeth. A growing body of evidence has linked oral health—particularly periodontal (gum) disease—to several chronic diseases, including diabetes, heart disease, and stroke. These conditions may be prevented, in part, by regular visits to the dentist.

73. OH-7: Persons visiting the dentist From 2007 to 2011, the percentage of persons aged 2 years and older who had a dental visit in the past 12 months decreased about 6 percent, from 44.5 percent (age adjusted) to 41.8 percent. This objective is moving away from the Healthy People 2020 target of 49.0 percent.

74. CONCLUSION The search for indicators associated with or casually related to health continues. It will be seen from the above that there is no single comprehensive indicator of a nation's health. Each available indicators reflect an aspect of health. The ideal index which combines the effect of a number of components measured independently is yet to be developed.

75. REFERENCES Park K. Park’s textbook of preventive and social medicine. 24 th ed , India: Bhanot Publishers; 2017. Hiremath S.S. Textbook of preventive and community dentistry. 3rd ed. Elsevier publishers, New Delhi; 2016. Global reference list of 100 Core Health Indicators 2015. Available at www.who.int

76. Health indicators definitions, relationships and attributes. Available at www.iso.itdc . OH-7 Medical Expenditure Panel Survey (MEPS), AHRQ. US Department of Health and Human Services: Office Of Disease And Prevention. Available at www.healthypeople.gov Central Bureau of Health Intelligence. Government of India. http://cbhidghs.nic.in/ SRS Bulletin .Vol 45 no.1,Jan 2011. World Health Organization. http://www.who.int/en/

77. OECD (2017), Hospital beds (indicator). doi : 10.1787/0191328e-en (Accessed on 14 July 2017) Kuppusamy K, Rajarathinam MK. Tracking progress towards health related millennium development goals in India. Int J Med Public Health 2015;5:253-8. www.census.gov.in/2011 Bulatao RA, Stephens PW. Global Estimates and Projections of Mortality by Cause, 1970-2015, Volume 1007. https://www.cia.gov/library/publications

78. Millennium development goals – 10 marks – RGUHS, May 2010 Indicators of health -10mks - RGUHS, September 2007. PREVIOUS YEAR QUESTIONS