Health indicators

Seminar – 9
Dr. Nabeela Basha

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

With the goal of good health in mind…think of an indicator as:
“…a measure that helps quantify the achievement of a
health goal.”
-Mark Friedman
 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.

 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.

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?

 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.

Indicators have been given scientific respectability; for example
ideal indicators
• 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.
• 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.

INDICATORS can be….
1. Count / Number- Measure without a denominator.
2. Proportion (% ) - Numerator is part of denominator.
3. Rate - Frequency of occurrence of an event during a
specific time, usually expressed per “k” population
(k=1000….).
4. Ratio - Measure for which numerator is not included in
denominator (e. g : sex ratio per 100 ; beds population
per 1000) .
5. Index - Aggregation of measurement of specific indicators.
(e. g : Health development index).

 Reports are compiled at every jurisdictional level
 State and local level - Health departments, foundations
and philanthropic organizations, businesses, educational,
law enforcement, human services providers, and other
civic leaders, faith organizations, universities, media.
 National – Federal government/private partnerships.
 International – OECD, WHO

The indicators can be classified as –
 Input Indicators
 Process Indicators
 Output Indicators
 Effect Indicators
 Impact Indicators

 Indicators may also be classified
under: ( According to Park)
 Mortality indicators
 Morbidity indicators
 Disability rates
 Nutritional status 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, and
 Other indicators.

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.

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

(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.

List by the World Health Organization (2015)

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.

(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

• 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

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.

(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.

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

• 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

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.

(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:
o Japan - less than 1 in 10 men and 1 in 20 women
o Angola – 2 to 3 in 10 men and 1-2 per 10 in women

• 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

(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.

• 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.

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

List by the CIA Factbook (2010)
1st - South Sudan 2,054
2nd- Chad 1,100
3rd- Somalia 1000
44th - Pakistan 260
49th - Bangladesh 240
55th - India 200
60th - Nepal 170

(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.

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

(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.

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.

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.

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

1. 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.

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

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.

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.

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

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.

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

 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

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.

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.

 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.

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.

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.

 A "premature" death is defined as one that occurs before the age
to which a dying person could have expected to survive if he or
she was a member of a standardized model population with a
life expectancy at birth equal to that of the world's longest -
surviving population, Japan.
 One DALY is "one lost year of healthy life“.

4. Nutritional Status Indicators
• Three nutritional status indicators are considered important
as indicators of health status:
(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).

 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

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

• 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

6. Utilization Rates
• In order to obtain additional information on health status, the
extent of use of health services is often investigated.
• 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.

7. Indicators of Social and Mental
Health
 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.
 E.g. Substance abuse in orphan children

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

• 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

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

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.

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.

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.

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.

 Human Development Index
 It is defined as a composite index combining indicators
representing 3 dimensions –
i. Longevity( life expectancy at birth)
ii. Education (mean and expected years of schooling)
iii. 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

• 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)

• 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

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.

(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.

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.

(d) Millennium Development Goal Indicators :
• The Millennium Development Goal adopted by the United
Nations in the year 2000 provides an opportunity for
concerted action to improve global health.
• The Millennium Declaration adopted by the General
Assembly of the United Nations in its Fifty-fifth session
during September 2000 reaffirmed its commitment to the right
to development, peace, security and gender equality, to the
eradication of many dimensions of poverty and to overall
sustainable development.

• These are intended for the Member Countries to take efforts in
the fight against poverty, illiteracy, hunger, lack of education,
gender inequality, infant and maternal mortality, diseases and
environmental degradation.
• The Millennium Declaration adopted
8 development goals, which are broken
down into 21 quantifiable targets that
are measured by 60 indicators.

Sustainable Development Goals (SDG):
• On 25th 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

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.

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.

 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.

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.

REFERENCES
Park K. Park’s textbook of preventive and social medicine. 23rd
ed, India: Bhanot Publishers; 2015.
Park K. Park’s textbook of preventive and social medicine. 24th
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

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/

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

Millennium development goals – 10 marks – RGUHS, May 2010
Indicators of health -10mks - RGUHS, September 2007.
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