1. INDICATORS OF HEALTH
Dr Lipilekha Patnaik
Professor, Community Medicine
Institute of Medical Sciences & SUM Hospital
Siksha ‘O’Anusandhan deemed to be University
Bhubaneswar, Odisha, India
Email: drlipilekha@yahoo.co.in

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

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

4. Indicators
WHO defines Indicators as:
“variables which measure change”

5. 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 reflectsthe state of health of persons in a
community.
• Indicators help to measure the extent to which the objectives
and targetsof a programme are being attained.

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

7. CHARACTERISTICS
• Valid – they should actually measure what they are supposed to measure.
• Reliable – the results should be the same when measured by different people
in similar circumstances.
• Sensitive – they should be sensitive to changes in the situation concerned.
reflect small changes in health status.
• Specific – they should reflect changes only in the situation concerned.
• Feasible – they should have the ability to obtain data when needed.
• Relevant – they should contribute to the understanding of the phenomenon
of interest.

8. USES OF INDICATORS OF HEALTH
• Measurement of the health of the community.
• Description of the health of the community.
• Comparison of the health of different communities.
• Identification of health needs and prioritizing them.
• Evaluation of health services.
• Planning and allocation of health resources.
• Measurement of health successes.

9. CLASSIFICATIONOF INDICATORS
§ Mortality Indicators
§ Morbidity Indicators
§ Disability Rates
§ Nutritional Indicators
§ Health Care Delivery
Indicators
§ Utilization Rates
§ Indicators of SocialAnd
Mental Health
§ Environmental Indicators
§ Socio-economic Indicators
§ Health Policy Indicators
§ Indicators of Quality of Life
§ Other Indicators
9

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, usually the 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
(SRS 2017)

13. Expectation of life
• The average number of years that will be lived by those born alive
into a population if the current age specific mortality rates persist.
• It is a statistical abstraction based on existing age - specific
death rates.
• Highly influenced by the infant mortality rate where that is high.
• Estimated for both sexes separately.
• Good indicator of socioeconomic development
• Life expectancy at birth:
male: 67.4 years
female: 70.2 years
(Source: National Health Profile 2019)

14. Infant mortality rate
• 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 live births
• Indicator of health status of not only infants but also whole
population & socioeconomicconditions.
• Sensitive indicator of availability, utilization &effectiveness of
health care, particularly perinataland postnatal care.
• Current IMR :India - 33/1000live births, Odisha - 41/1000live birth
(SRS 2017)

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.
16

17. Under-5 Mortality rate
Ø Defined as annual number of deaths occurring in the under-5
age group , expressed as a rate per 1000 live births. Reflects
both infant and child mortality
Ø Best single indicator of social development and well- being
rather than GNP per capita.
Ø Current 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)
18

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. MORBIDITY INDICATORS
q Morbidity is any departure subjective or objective from a state
of physiologicalwell being.
q Morbidity Indicators reveal the burden of ill health in a
community, but do not measure the subclinical or inapparent
disease states.

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+ve cases) is 176 per
100000 population per year (Source: TB INDIA 2014 RNTCP Annual Report 2014)
24

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 chronicityof 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+ve in population) is 230 per 100000 population .(Source: TB INDIA 2014RNTCP 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
authoritiesof certain diseases e.g. yellowfever , poliomyelitis
- They provideinformationregarding geographicclustering of
infections,quality of reportingsystem etc.
3. Attendancerates at OPDs and at health centers.
4. Admission,Readmission and dischargerates.
5. Duration of stay in hospital– reflects the virulenceand resistance
developed by the etiological factor.
6. Spells of sickness or absence from work or school.
- reflects economical loss to the community.
27

29. DISABILITYRATES
• Disability Rates are of two categories
• Event type Indicators
- number of days of restricted activity
- bed disability days
- work-loss days within a specified period
• Person type Indicators
-limitation of mobility e.g. confined to bed, confined to house, special
aid in getting around.
-limitation of activity e.g. limitation to perform the basic activities of
daily living (ADL) e.g. eating, washing, dressing, etc.

30. HALE (Health Adjusted Life Expectancy)
ü Life expectancy at birth but includes an adjustment for
time spent in poor health.
ü Number of years in full health that a newborn can expect
to live based on current rates of ill-health and mortality.
• HALE FOR INDIA IS 53 YEARS
30

31. DALYs: Disability Adjusted Life Years
• It is defined as the number of years of healthy life lost due to ill-health ,
disability orearly 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 thingsneeded to measure DALYs are
- Life table of that country,to measure the losses from prematuredeaths
- Loss of healthy life years resulting fromdisability; thedisability may be
permanent (polio)or temporary (TB, leprosy),physical or mental.
• DALY= years of life lost + years lost to disability
31

32. qUses of DALYs
• To assist in selecting health service priorities
• To identify the disadvantaged groups
• Targeting health interventions
• Measuring the results of health interventions
• Providing comparable measures for planning & evaluating
programmes
• To compare the health status of different countries
qOne DALY is one lost year of healthy life

33. QALY(Quality Adjusted Life Year)
• Commonly used to measure the cost effectiveness of
health interventions .
• Number of years of life that would be added by
intervention.
• Each year in perfect health is assigned a value of 1 down
to a value of 0 for death.
33

34. Sullivan’s Index
• Sullivan’s Index refers to “expectation of life free of disability”.
• Sullivan’s Index = life expectancy of the country -probable duration
of bed disability and inability to perform major activities.
• 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. NUTRITIONAL STATUS INDICATORS

37. q Nutritional Status is a positive health indicator.
q Anthropometric measurements of pre-school children
i. Weight – measures acute malnutrition
ii. Height – measures chronic malnutrition
iii. Mid-arm circumference - measures chronic malnutrition
qHeights (sometimes weights) of children at school entry
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 Delivery Indicators
• These indicators reflect the equity of distribution of health resources
in different parts of the country and of the provision of health care.
• The frequently used indicators are
• Doctor-populationRatio
• Doctor-nurse ratio
• Population-bedRatio
• Population perPHC/sub center
• Population pertraditionalbirth attendant

43. UTILIZATION RATES
q 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.
q Depends on availability & accessibility of health services and
the attitude of an individual towards health care system.
q It gives some indication of the care needed by a population,
and therefore, the health status of the population.
43

44. Examples
1. Proportion of infants who are fully immunized
2. Proportion of pregnant women who receive ANC care or have
institutionaldeliveries
3. Percentage of population who adopt family 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
of people.
• Social and mental health of the children depend on their parents. Ex.
Substance abuse in orphan children

46. ENVIRONMENTALINDICATORS
• 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 prevalenceof 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.

47. SOCIOECONOMIC INDICATORS
q These do not directly measure health but are important in interpreting
health indicators.
q These are
• 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
q Countries with favorable socioeconomic indicators have reported less
health related problems

48. India's literacy rate is at 74.04%. Kerala has achieved a literacy rate of 93.91%. Bihar is the
least literate state in India, with a literacy of 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
UttarPradesh
Jharkhand
Rajasthan
MadhyaPradesh
Jammu&Kashmir
ArunachalPradesh
Uttarakhand
Chhattisgarh
Nagaland
Assam
India
Mizoram
Haryana
Orissa
Manipur
Gujarat
Maharashtra
HimachalPradesh
Kerala
Punjab
AndhraPradesh
Karnataka
Tripura
WestBengal
Dadra&NagarHaveli
NCTofDelhi
TamilNadu
Sikkim
Lakshadweep
Puducherry
Goa
Chandigarh
Andaman&NicobarIslands
Daman&Diu
DependencyRatio 2011 DependencyRatio 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 of political 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.
52

53. Indicators of Quality of Life
Physical Qualityof Life Index
It consolidates:
1. Infant mortality,
2. life expectancy at age of 1yr
3. literacy.
• For each component the performance of individual countryis placed on a scale of 1 to 100.
• Composite index is calculated by averaging the three indicators giving equal weight to
each of them.
• Does not consider the GNP.
53

54. Human Development Index
q Composite 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).
q Placed on the 0 to 1 scale
HDI for India 0.640
HDI ranking of India is 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; distributionof income,
consumption & accumulation; social security & welfare services; health
services & nutrition; housing& its environment;publicorder& safety;
time use; leisure & culture; social stratification & mobility.
Basic needs Indicators
Are used by ILO and includecalorie consumption,access to water,
life expectancy,deathsdue to disease, illiteracy, doctorsand nurses per
population,roomsper 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 year 2000.
• Opportunity for concerted action to improve global health.
• The 8 MDGs, break down into 21 quantifiable targets that are
measured by 60 indicators.

60. 3. SUSTAINABLE DEVELOPMENT GOALS
• On 25th September 2015, the United Nations GeneralAssembly
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 but using indicators.
• Indicator should be valid, sensitive, specific, reliable, relevant
and feasible.
• Used in measuring, describing, comparing, identifying health
needs and planning and evaluation of health services.