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Evaluation of health services
1. By: Dr. Kavita Yadav
MPH 1st yr
Moderator:Dr.Kavitha HS
JSSMC,Mysore
2. Introduction to epidemiology
Uses of epidemiology
Definition and Need of Evaluation
Steps in evaluation
Application of epidemiological studies in
evaluation of health services
Various study designs
Merits and demerits
Conclusion
References
3. The study of distribution and determinants of
health related states or events in a specified
populations, and the application of this study
to the control of health problems.
5. To study historically the rise and fall of
disease in a population
Community diagnosis
Planning and evaluation
Evaluation of individual’s
risk and chances
Syndrome identification
Completing the natural
history of the disease
Search for cause and
risk factor
6. A systematic process to assess the
achievement of the stated
objectives of a programme,its
adequacy,efficiency, and its
acceptance by all parties involved.
7. A planned, systematic process of observation
that closely follows a course of activities, and
compares what is happening with what is
expected to happen
8. 1)It determines programme 1)It determines programme
efficiency effectiveness
2)It establishes standard of 2)It identifies inconsistencies
performance at the activity level between programme
3)It alerts the management , objective and activities.
of discrepancy 3)It suggests changes in
4)It identifies strong & programme procedure
weak points of operation & objectives
programme operation 4)It identifies the possible
side effects of programme
9. To review the implementation of services
provided by health programmes so as to
identify problems and recommend necessary
revisions of the programme.
To assess progress towards desired health
status at national or state levels and identify
reasons for gap, if any.
10. To contribute towards better health planning
To document results achieved by a project
funded by donor agencies. To know whether
desired health outcomes are being achieved
and identify remedial measures.
To improve health programmes and the
health infrastructure.
Allocation of resources in current and future
programme.
To render health activities more relevant,
more efficient and more effective.
11. The Policy makers(Those responsible for
programme development and implementation)
Adhoc research group
By the Community
(students,NGOs)
12.
13.
14. Determine what is to be evaluated
Establish standards and criteria
Plan the methodology
Gather information
Analyse the results
Take action
Re-evaluate
15.
16.
17. Structural criteria: physical criteria,facilities
equipments(cost benefit,cost effectiveness)
Process criteria: every prenatal mother must
receive 6 check ups.
Outcome criteria: alteration in patient
health status or behaviour resulting from
health care.
18. An indicator is a standardized, objective
measure that allows—
A comparison among health facilities
A comparison among countries
A comparison between different time periods
A measure of the progress toward achieving
program goals.
19. Valid: should actually measure what they
are supposed to measure.
Reliable: answer should be same if measured
by different people in same conditions
Sensitive: sensitive to change in situation
Specific: reflect changes only in situation
Feasible : ability to obtain
needed data
Relevant :contribute
to understanding of
phenomenon of interest
21. Efficacy:it is a measure in a situation in
which all conditions are controlled to
maximize the effect of the agent
Effectiveness:If we administer the agent in a
“real-life” situation, is it effective?(cost
effectiveness)
Efficiency: Is it possible to achieve our goals
in a cheaper and better way? Cost includes
not only money, but also discomfort, pain,
absenteeism, disability, and social stigma.
(cost benefit ratio)
22. Purpose of evaluation
Standards and criteria must be included
23. Data required may include political, cultural,
economic, environmental and administrative
factors influencing the health situation as
well as mortality and morbidity statistics.
24. Focus on the health service as the
independent variable, with a reduction in
adverse health effects as the anticipated
outcome (dependent variable) if the
modality of care is effective
25. Randomized design
Non randomized design
Before after design
Simultaneous Nonrandomized Design
Combination design
Case control studies
26. Eliminates problem of selection bias.
For ethical and practical reasons,randomizing
patients to receive no care is not considered.
Assign different types of care and then
evaluate.
27. Chemotherapy of tuberculosis in India, which
demonstrated that domiciliary treatment of
pulmonary TB was as effective as the more
costlier hospital or sanatorium. Results
gained international acceptance and ushered
in new era.
Evaluation of Multiphasic screening in South
East London, led to withholding of vast
outlay of resources required to mount a
national programme
28. RCT trials are logistically complex and
extremely expensive.
Ethical problems
Long time for completion, so relevance is
questionable.
Alternative approach- outcome research.
29. Denotes studies comparing the effects of two
or more health care interventions or
modalities- such as treatment, forms of
health care organization, or type and extent
of insurance coverage and provider
reimbursement on health or economic
outcomes.
Uses data from large data sets that were
derived from large population.
30. Refers to real world population and issue of
representativeness or generalizability is minimized
As the data already exists, analysis can be
completed and results generated rapidly
Sample size is not a problem except when smaller
sub-groups are examined
Cost effective.
31. Data gathered for fiscal and administrative purpose
may not suit research questions addressed in study
New questions (as knowledge is more complete
now) wouldn’t have been framed
Data on independent and dependent variable may
be limited
Data relating to possible confounders may be
inadequate or absent
Certain variables that are relevant today,were not
included in original data set
32. Investigator may create surrogate variable or
may change original question which he wanted
to address
Investigator becomes progressively more
removed from the individual being studied
33. Before –after design
Simultaneous nonrandomized design
a)Comparison of utilizers and non utilizers
b)Comparison of eligible and non eligible
Combination designs
Case control studies
34. Data obtained in each of two periods are not
comparable in terms of quality and
completeness.
Difference is due to programme or due to
other factors which changed over time like
housing,nutrition,lifestyle
Problem of selection exists
35. A cohort study in which the type of health
care being studied represents “exposure”
Problem arises as in how to select exposed
and non-exposed group for study
36. To compare a group of people who use a
health service with a group who do not.
Problem of self selection exists
Address this problem by characterizing the
prognostic profile of people in both groups.
We cant say someone
not to utilize the
programme.
37. Assumption being made that eligibility and
non-eligibility is not related to either
prognosis or outcome,
So no selection bias is being introduced
For eg:employer or census
tract of residence
May relate to
socioeconomic status
38. In all above mentioned designs that compare
the morbidity level in people who receive
care and who do not, assumption is made
that the original level of morbidity in 2
groups at time T1 were comparable before
the care was provided.
Combination of both the designs viz. before
and after ,programme and no programme
39. The case-control design has been applied primarily to
etiologic studies, when appropriate data are obtainable,
this design can serve as a useful, but limited, surrogate
for randomized trials.
But this design requires definition and specification of
cases, it is most applicable to studies of prevention of
specific diseases. The “exposure” is then the specific
preventive or other health measure that is being
assessed.
As in most health services research, stratification by
disease severity and by other possible prognostic
factors is essential for appropriate interpretation of the
findings.
40. Should take place within shortest time
feasible
Discussion of results should be done.
41. For evaluation to be truly effective emphasis
should be on actions- to support,strengthen
or modify the services.
Calls for shifting priorities,revising objectives
or developing new programmes to meet
previously unidentified needs.
42. Aims at rendering health services more
relevant, more efficient and more effective.
43. The 5 year RCH phase II was launched in
2005 with a vision to bring about outcomes
as envisioned in the Millennium Development
Goals, the National Population Policy 2000
(NPP 2000), the Tenth Plan, the National
Health Policy 2002 and Vision 2020 India,
minimizing the regional variations in the
areas of RCH and population stabilization
through an integrated, focused, participatory
programme meeting the unmet needs of the
target population, and provision of assured,
equitable, responsive quality services.
44. Goal: “Health For All”
Objective: Population stabilization by 2045
Programme: Comprehensive R.C.H services
Monitoring & Evaluation: RCH indicators/feedback
data
45. No. of eligible couples registered/ANM
No. of Antenatal Care sessions held as planned
% of sub Centres with no ANM
% of sub Centres with working equipment of ANC
% ANM/TBA without requisite skill
% of sub centres with infant weighing machine
% sub centres with vaccine supplies
% sub centres with ORS packets
% sub centres with FP supplies
46. % Pregnancy Registered before 12 weeks
% ANC with 5 visits
% ANC receiving all RCH services
% High risk cases referred
% High risk cases followed up
% deliveries by ANM/TBA
%PNC with 3 PNC visits
% PNC receiving all counselling
% PNC complications referred
% Eligible couple offered FP choices
% women screened for RTI/STDs
% Eligible couple counselled for prevention of RTI/STDs
% ARI treated
% children fully immunized
47. % Deaths from maternal causes
Maternal mortality ratio
Prevalence of maternal morbidity
% Low birth weight
Neonatal mortality ratio
Prevalence of post natal maternal morbidity
% Baby breast feed within 6 hrs of delivery
Couple protection rate
Prevalence of terminal method of sterilization
Prevalence of spacing method
%Abortion related morbidity
Prevalence of RTI/STDs
48. Gordis leon. Epidemiology. 4th edition. Philadelphia:
Elsevier Saunders:2009
Park K. Park’s Textbook of Preventive and Social
Medicine. 22nd ed.
WHO: UNFPA. Programme Manager’s Planning
Monitoring & Evaluation Toolkit. Division for
oversight services, August 2004,
UNICEF. “A UNICEF Guide for Monitoring and
Evaluation: Making a Difference?”, Evaluation Office,
New York, 1991. • ). “Framework for Program
Evaluation in Public Health”, 1999. Available in
English at http://www.cdc.gov/eval/over.htms