Indicators of health

Indicator is a variable which gives an indication of a given situation or a reflection of that situation.

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

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

1. INDICATORS OF HEALTH
DrLipilekhaPatnaik
Professor, Community Medicine
Institute of Medical Sciences & SUM Hospital
Siksha‘O’ Anusandhandeemed to be University
Bhubaneswar, Odisha, India
Email: [email protected]

2. CONTENTS
•Introduction
•Health
•Indicators ofHealth
•Characteristics
•Uses
•Classification of Indicators ofHealth
•Summary
•References

3. INTRODUCTION
•Health is defined as “a state of completephysical, mental &
social wellbeing, and not merely an absence of disease or
infirmity”(WHO)
•This statement has been amplified to include theability to lead a
“socially and economically productivelife”
•Health cannot be measured in exact measurableforms
•Hence measurement have been framed in terms of illness (or lack
of health), consequences ofill-health (morbidity, mortality) &
economic, occupation & domestic factors that promote ill health.

4. Indicators
WHOdefines Indicators as:
“variables which measure change”

5. INDICATORS OFHEALTH
•Indicatorisavariablewhichgivesanindicationofagiven
situationorareflectionofthatsituation.
•Health Indicator is a variable, susceptible todirect
measurement, that reflects the state of health of persons in a
community.
•Indicators help to measure the extent to whichthe objectives
and targets of a programme are being attained.

6. INDICATORS OFHEALTH
•Health status indicators measure different aspects of the health
of a population. Examples include life expectancy, infant
mortality, disability or chronic diseaserates.
•Health determinant indicators measure things that influence
health. Examplesinclude diet, smoking, water quality, income and
access to healthservices

7. CHARACTERISTICS
•Valid –they should actually measure what they are supposed tomeasure.
•Reliable –the results should be the same when measured by different people
in similarcircumstances.
•Sensitive –they should be sensitive to changes inthe situationconcerned.
reflect small changes in health status.
•Specific –they should reflect changes only in the situationconcerned.
•Feasible –they should have the ability to obtaindata whenneeded.
•Relevant –they should contribute to theunderstanding of the phenomenon
ofinterest.

8. USES OF INDICATORS OFHEALTH
•Measurement of the health of thecommunity.
•Description of the health of thecommunity.
•Comparison of the health of different communities.
•Identification of health needs and prioritizing them.
•Evaluation of healthservices.
•Planning and allocation of healthresources.
•Measurement of healthsuccesses.

9. CLASSIFICATION OFINDICATORS
§Mortality Indicators
§Morbidity Indicators
§Disability Rates
§Nutritional Indicators
§Health Care Delivery
Indicators
§Utilization Rates
§Indicators of Social And
Mental Health
§Environmental Indicators
§Socio-economic Indicators
§Health Policy Indicators
§Indicators of Quality of Life
§Other Indicators
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11. Crude Death Rate
•CDR 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, usuallythe mid-year population
•The usefulness is restricted because it is influencedby the age-sex
composition of the population, socioeconomic and socio-cultural
environment of the communities.
CDR India –6.3 deaths/1,000 population, 7.4 deaths/1,000 population
(SRS2017)

13. Expectation of life
•Theaveragenumberofyearsthatwillbelivedbythosebornalive
intoapopulationifthecurrentagespecificmortalityratespersist.
•It is a statistical abstraction based on existingage -specific
deathrates.
•Highly influenced by the infant mortality rate where that is high.
•Estimated for both sexesseparately.
•Good indicator of socioeconomicdevelopment
•Life expectancy atbirth:
male:67.4 years
female:70.2 years
(Source:National Health Profile 2019)

14. Infant mortalityrate
•The ratio of deaths under 1yr of age in a given year to the total
number of live births in the same year,usually expressed as a rate
per 1000 livebirths
•Indicator of health status of not only infants butalso whole
population & socioeconomicconditions.
•Sensitive indicator of availability, utilization &effectiveness of
health care, particularly perinataland postnatalcare.
•CurrentIMR:India -33/1000live births, Odisha-41/1000live birth
(SRS2017)

16. Child Death Rate
üThe number of deaths at ages 1-4yrs , per 1000 children in
that same age group at the mid-point of the year.
üCorrelates with inadequate MCH services, malnutrition, low
immunization coverage and environmental factors.
üMore refined indicator of the social situation in a country
than infant mortality rate.
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17. Under-5 Mortality rate
ØDefined as annual number of deaths occurring in the under-5
age group , expressed as a rate per 1000 live births. Reflects
both infant and childmortality
ØBest single indicator of social development and well-being
rather than GNP per capita.
ØCurrent rate India -37/1000 live births
(Source:SRS 2017)

18. Maternal Mortality Ratio
•Total of number of female deaths due to complications arising
during pregnancy , childbirth or within 42 days of delivery from
“puerperal causes” in an area during a given year per total number
of live births in the same area and year.
•Accounts for the greatest number of deaths among women of
reproductive age in developing countries.
•Current MMR India –130/100000 live births
Odisha–180/100000 live births
(Sorce: SRS 2017)
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20. Disease Specific Death Rate
is mortality rate which is computed for specific
diseases.
E.g. TB mortality is 22 per 100000 population per year .
(Source: TB INDIA 2014 RNTCP Annual Report 2014)
Proportional Mortality Rate
is the proportion of all deaths attributed to the
specific disease.
E.g. Coronary heart disease causes 25 to 30 % of all deaths in
developed world.

21. Case fatality rate
•Measures the risk of persons dying from a certain disease within
a given time period.
•Measures the pathogenicity, severity or virulence of the disease.
Years of potential life lost (YPLL)
•Defined as one that occurs before the age to which a dying
person could have expected to survive.
•Based on years of life lost through premature death.

23. MORBIDITYINDICATORS
qMorbidityisanydeparturesubjectiveorobjectivefromastate
ofphysiologicalwellbeing.
qMorbidityIndicatorsrevealtheburdenofillhealthina
community,butdonotmeasurethesubclinicalorinapparent
diseasestates.

24. Incidence
•The number of new events or new cases of a disease in a defined
population, within a specified period of time.
•No. of new cases of specific disease
during a specified time interval_____ * 1000
Population at risk during that period
•E.g. Incidence of TB (new sputum+vecases) is 176 per
100000 population per year(Source: TB INDIA 2014 RNTCP Annual Report 2014)
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25. Prevalence
•Refers to all current cases ( old & new) existing at a given point or period of time
in a given population.
•Prevalence =
All current cases existing at a given point or period of time* 100
Population at risk
•May be
-Point prevalence
-Period prevalence
•Reflects the chronicity of the disease.
•Uses -1)Helps to estimate the magnitude of disease & identify high risk population.
2)Useful for administrative & planning purposes.
•E.g. Prevalence of TB (sputum+vein population) is 230 per 100000 population .(Source: TB INDIA 2014 RNTCP Annual
Report 2014)

26. Results of Screening for diabetes
5 died
5 migrated
5 recovered
25 cases
40 cases
960 free
20 cases
940 free
1000
women
Screening
1 January
1 January
2012
31 December
2012
Incident cases
during 2012
Prevalent cases
on 31 December
Attrition

27. 2.Notification rates is 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.
3.Attendance rates at OPDs and at health centers.
4.Admission, Readmission and discharge rates.
5.Duration of stay in hospital –reflects the virulence and resistance
developed by the etiological factor.
6.Spells of sickness or absence from work or school.
-reflects economical loss to the community.
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29. DISABILITYRATES
•Disability Rates are of twocategories
•Event typeIndicators
-number of days of restrictedactivity
-bed disabilitydays
-work-loss days within a specifiedperiod
•Person typeIndicators
-limitation of mobility e.g. confined to bed,confined to house, special
aid in gettingaround.
-limitation of activity e.g. limitation to performthe basic activities of
daily living (ADL) e.g. eating, washing, dressing,etc.

30. HALE(HealthAdjustedLifeExpectancy)
üLifeexpectancyatbirthbutincludesanadjustmentfor
timespentinpoorhealth.
üNumberofyearsinfullhealththatanewborncanexpect
tolivebasedoncurrentratesofill-healthandmortality.
•HALE FOR INDIA IS 53 YEARS
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31. DALYs: Disability Adjusted Life Years
•It is defined as the number of years of healthy life lost due to ill-health ,
disability or early death.
•It is the simplest and the most commonly used measure to find the burden of
illness in a defined population and the effectiveness of the interventions.
•Two things needed to measure DALYs are
-Life table of that country, to measure the losses from premature deaths
-Loss of healthy life years resulting from disability; the disability may be
permanent (polio) or temporary (TB, leprosy), physical or mental.
•DALY = years of life lost + years lostto disability
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32. qUses ofDALYs
•To assist in selecting health servicepriorities
•To identify the disadvantagedgroups
•Targeting healthinterventions
•Measuring the results of healthinterventions
•Providing comparable measures for planning & evaluating
programmes
•To compare the health status of differentcountries
qOne DALY is one lost year of healthylife

33. QALY(Quality Adjusted Life Year)
•Commonlyusedtomeasurethecosteffectivenessof
healthinterventions.
•Numberofyearsoflifethatwouldbeaddedby
intervention.
•Eachyearinperfecthealthisassignedavalueof1down
toavalueof0fordeath.
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34. Sullivan’s Index
•Sullivan’s Index refers to “expectation of life free ofdisability”.
•Sullivan’s Index = life expectancy of the country -probable duration
of bed disability and inability to perform majoractivities.
•It is considered as one of the most advanced indicators currently
available.

35. DISABILITY-FREE LIFE EXPECTANCY
•Active life expectancy
•Average number of years an individual is expected to
live free of disability if current pattern of mortality and
disability continue to apply.

36. NUTRITIONALSTATUS INDICATORS

37. qNutritional Status is a positive healthindicator.
qAnthropometric measurements of pre-schoolchildren
i.Weight –measures acute malnutrition
ii.Height –measures chronicmalnutrition
iii.Mid-arm circumference -measures chronic malnutrition
qHeights (sometimes weights) of children at schoolentry
qPrevalence of low birth weight (less than 2.5 kg)

38. FERTILITY INDICATORS

39. FERTILITY INDICATORS
•Crude birth rate
•Fertility rate -*General fertility rate
*Age specific fertility rate
*Total fertility rate
•Reproduction rate -*Gross reproduction rate
*Net reproduction rate
•Sex ratio at birth
•Pregnancy rate
•Abortion rate

40. •Birth rate: Number of live births per 1000 estimated mid-year population in a
given year.
•General fertility rate: Number of live birth per 1000 women in reproductive
age group in a given year.
•General marital fertility rate
•Total fertility rate: Average no. of children that would be borne to a women if
she experiences the current fertility pattern throughout her reproductive
span.
•Net reproduction rate (NRR) :The number of daughters a newborn girl will bear
during her life time.
•NRR will be 1 if 2-child norm is adopted.

42. Health Care DeliveryIndicators
•These indicators reflect the equity of distribution of health resources
in different parts of the country and of the provisionof healthcare.
•The frequently used indicators are
•Doctor-populationRatio
•Doctor-nurseratio
•Population-bedRatio
•PopulationperPHC/subcenter
•Population per traditional birth attendant

43. UTILIZATION RATES
qActualcoverageisexpressedastheproportionofpeoplein
needofaservicewhoactuallyreceiveitinagivenperiod,
usuallyayear.
qDependsonavailability&accessibilityofhealthservicesand
theattitudeofanindividualtowardshealthcaresystem.
qItgivessomeindicationofthecareneededbyapopulation,
andtherefore,thehealthstatusofthepopulation.
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44. Examples
1.Proportion of infants who are fullyimmunized
2.Proportion of pregnant women whoreceive ANC care or have
institutionaldeliveries
3.Percentage of population who adoptfamily planning
4.Bed occupancy ratio
5.Average length of stay
6.Bed-turn over ratio,etc.

45. INDICATORS OF SOCIALAND MENTAL HEALTH
•As long as valid positive indicators of social and mental health are scarce, it
is necessary to use indirect measures, viz. indicators of social and mental
pathology.
•These include rates of suicide, homicide, other crime, road traffic accident,
juvenile delinquency, alcohol and substance abuse, domestic violence,
battered-baby syndrome,etc.
•These indicators provide a guide to social action for improving the health
ofpeople.
•Social and mental health of the children depend on theirparents.Ex.
Substance abuse in orphanchildren

46. ENVIRONMENTAL INDICATORS
•These reflect the quality of physical and biological environment in
which diseases occur and peoplelive.
•Themostimportantarethosemeasuringtheproportionofpopulation
havingaccesstosafedrinkingwaterandsanitationfacilities.
•These indicators explains the prevalenceof communicable
diseases in acommunity.
•Theotherindicatorsarethosemeasuringthepollutionofairand
water,radiation,noisepollution,exposuretotoxicsubstancesinfood
andwater.

47. SOCIOECONOMIC INDICATORS
qThese do not directly measure health butare important in interpreting
healthindicators.
qTheseare
•Rate of growth of population increase
•Per capita GNP
•Level of employment
•Literacy rate esp: Female literacy rate
•Dependency ratio
•Family size
•Housing –the number of persons per room
•Per capita “calorie” availability
qCountries with favorable socioeconomic indicators have reported less
health related problems

48. India's literacyrate is at 74.04%. Kerala has achieved aliteracyrate of 93.91%. Bihar is the
leastliteratestate inIndia, with aliteracyof 63.82%. Orissa -73.45%

49. Dependency Ratio:
(No. of persons in age group 0-14 years + No. of persons in age group 60 years or
more)/ No. of persons in age group 15-59 years
•Dependency Ratio gives the proportion of persons whom the persons in economically
active age group need to support
•Reduction in Dependency Ratio indicates a phase of population transition where a higher
percentage of persons in the working age group may translate into higher per capita
income for the economy
•This is also called the phase where a country may benefit from ‘Demographic Dividend’
Dependency Ratio

50. Dependency Ratio
0
100
200
300
400
500
600
700
800
900
1000
Bihar
Meghalaya
Uttar Pradesh
Jhark handRajasthan
Madhya Pradesh
Jammu & Kashmir
Arunachal Pradesh
Uttarakhand
Chhattisgarh
Nagaland
Assam
India
Mizoram
Haryana
Orissa
Manipur
Gujarat
Maharashtra
Himachal Pradesh
Kerala
Punjab
Andhra Pradesh
Karnataka
Tripura
West Bengal
Dadra & Nagar Haveli
NCT of Delhi
Tamil Nadu
Sikkim
Lakshadweep
Puducherry
Goa
Chandigarh
Andaman & Nicobar Islands
Daman & Diu
Dependency Ratio 2011 Dependency Ratio 2001
•Dependency Ratio has reduced in all the States and UTs
•At the all-India level, it has reduced by 100 points compared
to 2001

51. Dependency Ratio
India : 1991 to 2011
Dependency Ratio, India
1991 2001 2011
794 752 652

52. Health Policy Indicators
üSingle most important indicator ofpolitical commitment is
allocation of adequate resources.
1.Proportion of GNP spent on health services
2.Proportion of GNP spent on health related activities like water
supply and sanitation & housing and nutrition
3. Proportion of total health resources devoted primary health care.
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53. Indicators of Quality of Life
Physical Quality of Life Index
Itconsolidates:
1.Infantmortality,
2.lifeexpectancyatageof1yr
3.literacy.
•Foreachcomponenttheperformanceofindividualcountryisplacedonascaleof1to100.
•Compositeindexiscalculatedbyaveragingthethreeindicatorsgivingequalweightto
eachofthem.
•DoesnotconsidertheGNP.
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54. Human Development Index
qComposite index combining indicators representing 3 dimensions:
i.longevity( life expectancy at birth)
ii.knowledge (mean years of schooling and expected years of schooling)
iii.income (real GDP per capita in purchasing power parity in US dollars).
qPlaced on the 0 to 1 scale
HDI forIndia 0.640
HDI ranking of Indiais 130
New Delhi, 14 September 2018–India climbed one spot to 130 out of 189 countries in the
latest human development rankings released by the United Nations Development
Programme(UNDP). India’s HDI value for 2017 is 0.640, which put the country in the
medium human development category.
54

55. As defined by the UN Statistical Office has been divided into 12
categories: population; family formation; families & households; learning
& educational services; earning activities; distribution of income,
consumption & accumulation; social security & welfare services; health
services & nutrition; housing & its environment; public order & safety;
time use; leisure & culture; social stratification & mobility.
Basic needs Indicators
Are used by ILO and include calorie consumption, access to water,
life expectancy, deaths due to disease, illiteracy, doctors and nurses per
population, rooms per person, GNP per capita.
55
Social Indicators

56. Special indicators series

57. 1. Health For All Indicators

58. 2. MILLENIUM DEVELOPMENT GOALS -
Indicators
•Adopted by United Nations in year2000.
•Opportunity for concerted action toimprove globalhealth.
•The 8 MDGs, break down into 21 quantifiable targets that are
measured by 60indicators.

60. 3. SUSTAINABLE DEVELOPMENT GOALS
•On 25th September 2015, the United Nations General Assembly
adopted the new development agenda "Transforming our world :
the 2030 agenda for sustainable development".
•The post-2015 framework goes beyond the MDGs. It has 17 goals
and 169 targets, including one specific (3rd goal) for health with
13 targets.

62. 4. Global Reference list of Core Health Indicators (2018)
•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.
•The list includes a selection of priority indicators relating to 4 domains
that include health status, risk factors, service coverage and health
systems.

65. SUMMARY
•Health not measured directly butusing indicators.
•Indicator should be valid, sensitive,specific, reliable, relevant
andfeasible.
•Used in measuring, describing,comparing, identifying health
needs and planning and evaluation of healthservices.