Health indicators an overview

Health Indicators
Dr. Ahmed-Refat AG Refat (01/12/2012) www.SlideShare.net/AhmedRefat

‫املؤشرات‬

‫الصحية‬

Health Indicators
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Health Indicators

Knowing is not enough, we must
apply
Willing is not enough, we must do
!!!
Goethe

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Health Indicators

Contents
 Definitions of indicator
 Uses of indicators
 Types of indicators
 Indicators as tools in health management
 Categorization of indicators
 Core health indicators
 WHO classification
 European Community classification
 Canadian classification
 Features of a good indicator
 Limitations of indicators
 Data Sources for indicators
 Anatomy/ components of indicator

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Health Indicators

Definitions

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Health Indicators

Indicator
 A key statistic that indicates or points to another
measure.


 “A summary measure that aims to describe -
in a few numbers as much detail as possible-
about a system to help understand, compare,
predict, improve, and innovate.”
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Health Indicators

Health indicator
 is summary measures that are designed to
describe particular aspects of health or health
system performance.
 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).

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Health Indicators

Health indicator-cont's
 A quantitative or qualitative variable that
provides a valid and reliable way to measure
achievement, assess performance or reflect
changes connected to an ( intervention) activity,
project or program

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Health Indicators

Health indicator-cont's
In the context of monitoring and evaluation,
An indicator is a quantitative metric (data) that provides
information to monitor performance, measure achievement and
determine accountability.

Quantitative metric – Data can measured on a numerical scale
Performance – The effective or efficient operation of an activity,
Achievement – The successful accomplishments of an activity,
Accountability – Responsibility for the performance and/or
achievements of an activity, project or program

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Health Indicators

INDICATORS can be
• Count (number of..)
• Proportion (percentage, number/per x)
• Rate (frequency of an event during a specified period expressed
as per 1,000 or 100,000) in a defined population
• Ratio (numerator not included in the denominator)
• Average
• Index
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Health Indicators

Uses of health indicators
1. Indicators are powerful tools for monitoring and
communicating critical information about
population health.

2. Indicators are used to support planning (identify
priorities, develop and target resources, identify
benchmarks) and track progress toward broad
community objectives.

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Health Indicators

Uses of health indicators-cont's
3. Engagement of partners into a collaborative
action (build awareness of problems and trends,
generate interventions).
4. Inform policy and policy makers, and can be used
to promote accountability among governmental
and non-governmental agencies.
5. Health indicators help governments and
community organizations analyze health needs in
the community so they can set priorities for action
and develop appropriate services.
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Health Indicators

Types of Indicators
Some definitions
Basket (of indicators): A group of indicators that aims
to cover a wide range of issues as validly as possible.
A common way of using a basket is for people to
choose which indicators they need locally.

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Health Indicators

Some definitions-cont's
Balanced (set of indicators): A set of indicators which,
taken together, reflect as much of a system as possible
without duplication, overlap or gaps

Composite indicator: An aggregation of numerous
indicators which aims to give a one-figure indicator in
order to summarizes measures even further.

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Health Indicators

Qualitative vs Quantitative
• Quantitative
 Directly measurable
 One-dimensional
 Types: counts, continuous
• Qualitative
 Descriptive
 May be statement of opinion or feeling
 Often multi-dimensional

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Health Indicators

Composite Indices (Summary Indicators)
PROS
 Summarize complex issues for decision-makers.
 Easier to interpret one number than to look for
trends across multiple indicators.
 Highlight a health care organization or system’s
performance and progress on improvement.
 Facilitate assessing a health care organization
or system performance over time.

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Health Indicators

 P R O S-cont's
 Reduce the total number of indicators.
 Facilitate ranking of health care organizations or
system on complex issues.

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Health Indicators

CONS
 Could lead to wrong policy decisions if the
composite indicator is poorly constructed or
misinterpreted.
 Could suggest simplistic policy solutions if the
composite indicator is viewed in isolation from
the individual indicators on which it is based.
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Health Indicators

Indicators
as a tool in health
management systems
model
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Health Indicators

Indicators
in health management systems model

The systems model is a management framework that allows
managers to focus on the process of providing PHC
services in order to produce better results. It helps them to
identify the key elements of a program, which include
resources (the inputs) for carrying out a set of activities
(the process) in order to achieve the expected results
(the outcomes),

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Health Indicators

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Health Indicators

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Health Indicators

According to system model, there are four types of
indicators: input, output, outcome and impact.
1- Input. A resource used in a program, including
financial and human resources from a variety of
sources, as well as curricula, materials, etc.
2- Output. The immediate results of program activities.
This term relates to the direct products or deliverables
of program activities, such as the number of

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Health Indicators

counselling sessions completed, the number of people
reached and the number of materials distributed.

3- Outcome. The intermediate changes that a program
effects on target audiences or populations, such as
change in knowledge, attitudes, beliefs, skills,
behaviours, access to services, policies and
environmental conditions.

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Health Indicators

4- Impact. The longer range, cumulative effect of
programs over time on what they ultimately aim to
change.
Interpretation of the impact indicators
Often, the long range effect ( impact ) will be a population-
level health outcome, such as a change in HCV infection,
morbidity and mortality.

Impacts are rarely, if ever, attributable to a single program,
but a program may, with other programs, contribute to
impacts on a population
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Health Indicators

Exercise
Use the System Model to indicate which type of the
indicators can match each of the following statements:
1. indicate resources invested in the system.
2. number of doctors per 100,000 people.
3. indicate activities of the health system
4. percentage of doctors trained in safe delivery skills.
5. indicate achievements made in specific health strategies
6. funds that are used to implement the project.

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Health Indicators

7. The immediate products or results of the activities
implemented
8. the number of personnel trained,
9. number of deliveries conducted,
10. number of contraceptives distributed.
11. Indicator that measured at the program level is called
12. The intermediate results of the activities implemented,
13. contraceptive prevalence rates

14. percent of births with skilled birth attendants. Unlike
outputs

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Health Indicators

15. outcomes are measured at the population level is …
16. MMR or infant mortality rate.
17. achievements of a health program or health system
18. institutional delivery rate
19. breastfeeding in one hour rate
20. achievements in health status of particular group of people
21. Maternal Mortality Ratio, Infant Mortality Rate, Total Fertility
Rate etc.
22. number of training sessions organized or number of
educational materials developed.

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Health Indicators

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Health Indicators

Categorization of health Indicators
Core health indicators are needed to assess change
in three major domains .
1. Determinants of health. These include
socioeconomic, environmental, behavioural and
genetic determinants or risk factors. Such
indicators also characterize the contextual
environments within which the health system
operates.

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Health Indicators

2. Health system. These include: inputs to the health
system and related processes such as policy,
organization, human resources, financial
resources, health infrastructure, equipment and
supplies; outputs (e.g. health service availability
and quality, information availability and quality);
and immediate health system outcomes (e.g.
coverage of the population with key health
services).
3. Health status. These include mortality, morbidity,
disability and well-being.

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Health Indicators

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Health Indicators

Indicator Types :WHO Classification
http://www.who.int/whosis/indicatordefinitions/en/index.html
 Health Status Indicators: Mortality
 Health Status Statistics: Morbidity
 Health Services Coverage Statistics
 Risk Factors Statistics
 Health Systems Statistics

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Health Indicators

http://www.who.int/whosis/indicatordefinitions/en/index.html

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Health Indicators

Indicator Types :EC Classification 88 Indicator
 Demography and socio-economic situation
 Health status
 Determinants of health
 Health interventions: health services
 Health interventions: health promotion

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Health Indicators
http://ec.europa.eu/health-eu/health_in_the_eu/ec_health_indicators/index_en.htm

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Health Indicators

http://ec.europa.eu/health/indicators/echi/list/index_en.htm

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Health Indicators

Canada Canada’s Health Indicator Framework:

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Health Indicators

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Health Indicators

Good Indicator
What makes a good indicator?
Good metadata makes a good indicator !!

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Health Indicators

Good Indicator
A poorly designed, or poorly chosen indicator with reliable data, or
a well designed indicator with unreliable and /or untimely data,
has very little value (and is sometimes positively dangerous).

Among the dozens of factors at play in data collection for
indicators, there are at least three that should always be
addressed because of their impact on the credibility of the data:

(1) validity, (2) reliability and (3) bias.

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Health Indicators

Validity: The extent to which a measurement or test accurately
measures what is intended to be measured.

Reliability: The consistency of the data when collected repeatedly
using the same procedures and under the same conditions.

Bias: Any effect during the collection or interpretation of
information that leads to a systematic error in one directionguide
in deciding if an indicator is a good indicator:

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Health Indicators

Characteristics of good Indicators:
The Good indicator Should be:

a. valid, i.e., they should actually measure what they
are supposed to measure;
b. reliable and objective, i.e., the answers should be
the same if measured by different people in similar
circumstances;
c. sensitive, i.e., they should be sensitive to changes
in the situation concerned,

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Health Indicators

Characteristics of good Indicators: -cont's

d. specific, i.e., they should reflect changes only in
the situation concerned,
e. feasible, i.e., they should have the ability to obtain
data needed, and;
f. relevant, i.e., they should contribute to the
understanding of the phenomenon of interest.

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Health Indicators

Characteristics of good Indicators: -cont's

• Acceptable: is the indicator acceptable to both those
being assessed and those undertaking the assessment?

Action focused. Indicators should lead to action.
Measurable. Not only must the data collection methodology be
defined, it must also be feasible to collect the data.

Simple. Although he was not talking about indicators

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Health Indicators

Five characteristics define
SMART Indicators:
 Specific – focused and clear
 Measurable - quantifiable and reflecting change
 Attainable - reasonable in scope and achievable
within set time-frame
 Relevant - pertinent to the review of performance
 Time-Bound/Trackable - progress can be charted
chronologically

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Health Indicators

Facts about indicators
 Indicators only indicate: They do not capture or convey the
many dimensions of a given situation and/or activity.
 They are directional: They provide basic information on the
past, present and possible future course of an activity, program
and/or behaviour.
 They are also very context-specific: Higher values or
lower values can be either good or bad, depending on the
situation.

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Health Indicators

 Indicators are not designed to replace more detailed
investigations of specific issues, nor should they be used
to do so Indicators are an essential part of effective monitoring
and evaluation.
 They can provide vital information on performance,
achievement and accountability. However, indicators are
only one part of a comprehensive M&E system.

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Health Indicators

Some limitations of
indicators:
Indicators rarely indicate specific cause of the
problem and possible comparison over time and
across facilities and Districts to show trends in
order to be useful.
INDICATORS NEED TO CHANGE WITH TIME
Any set of health indicators should evolve
in response to the changing needs of the people
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Health Indicators

WHAT HEALTH INDICATORS CANNOT DO
As useful as health indicators are, it’s also important
to know what they cannot do:
 They raise questions, but do not usually provide
direct answers
 They should not be used in isolation to interpret a
complex health issue
 They should not be used for unintended purposes

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Health Indicators

Data sources
Given the broad range of data requirements, no
single method of data collection can meet all needs.
The most appropriate data source depends on the
information required, cost-effectiveness and
feasibility of the method, human and technical
capacity to collect, manage and disseminate the
data, and financial and time constraints.

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Health Indicators

Linking indicators and data sources

Each essential indicator should be linked with
one or more suitable data sources. Different
sources can be used to generate similar indicators,
and decisions should be made about the most
suitable data source given the circumstances .

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Health Indicators

Data
Knowledge
Information
wisdom

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Health Indicators

Better Information Better Decision
Better Decision Better Health
An indicator can be defined as a data element
placed in a given context so that it becomes
information that can be acted upon and can be used
for program monitoring and management

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Health Indicators

 Data: is a fact that alone is not significant, as is
doesn’t relate to other data.

 Data—specific quantitative and qualitative
information or facts that are collected and
analyzed.

 Data: Information that is fed into indicators.
 Without context and comparators, data rarely
have significant meaning.
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Health Indicators

 Information: data that are processed to be useful;
provides answers to "who", "what", "where", and
"when" questions.
 Knowledge: application of data and information;
answers "how" questions.
 Understanding: appreciation of "why"
 Wisdom: evaluated understanding. -Wisdom is
complete understanding of the effects and
outcomes of Knowledge.
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Health Indicators

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Health Indicators

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Health Indicators

Anatomy
of an Indicator

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Health Indicators

Indicator components
When new indicators are being developed, they must be fully defined.
No indicator should be deployed without a full definition. So it is critical to
understand the terms used to define the components of an indicator.

Title. A brief heading that captures the focus of the indicator.
Definition. A clear and concise description of the indicator.
Purpose. The reason that the indicator exists; i.e. what it is for.

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Health Indicators

Indicator components-cont's
Rationale. The underlying principle(s) that justify the development
and deployment of the indicator; i.e. why the indicator is needed
and useful.
Method of measurement. The logical and specific sequence of
operations used to measure the indicator; e.g. data collection tools,
sampling frame and quality assurance.
Numerator. The top number of a common fraction, which indicates
the number of parts from the whole that are included in the
calculation.

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Health Indicators

Denominator. The bottom number of a common fraction, which
indicates the number of parts in the whole
Calculation. The specific steps in the process to determine the indicator value.
Data collection method. The general approaches (e.g. surveys,
records, models, estimates) used to collect data.
Data collection tools. The specific tools, patient registers, antenatal clinic
surveillance) used to collect data.

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Health Indicators

Data collection frequency. The intervals at which data are collected;
e.g. quarterly, annually, bi-annually.
Guidelines to interpret and use data. Recommendations on how
best to evaluate and apply the findings; e.g. outlining what it means if
the indicator shows an increase or a decrease in a particular measure.
Strengths and weaknesses. A brief summary of what the indicator
does well and not so well.
Challenges. Potential obstacles or problems that may have an impact
on the use of an indicator or on the accuracy/validity of its findings

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Health Indicators

Exercise
MDG
GOAL 5: IMPROVE MATERNAL HEALTH
TARGET 6 :Reduce by three quarters, between 1990 and 2015,
the maternal mortality ratio
Indicators: 16. Maternal mortality ratio
Indicators 17. Proportion of births attended by skilled health
personnel

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Cited References
 http://ec.europa.eu/health/indicators/echi/index_en.htm
 A guide on indicators for monitoring and reporting on the health
sector response to HIV/AIDS-WHO 2009
 http://www.who.int/hiv/data/ua10_indicator_guide_en.pdf
 http://www.who.int/whosis/indicatordefinitions/en/index.html
 http://gis.emro.who.int/HealthSystemObservatory/DataBase/Fo
rms/IndicatorsIndex.aspx
 http://ec.europa.eu/health/indicators/echi/index_en.htm

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 http://ec.europa.eu/health/indicators/echi/list/index_en.htm
 http://nrhm-
mis.nic.in/UI/FormatsFolder/HMIS%20Manual/Health%20Progra
mme%20Manager%27s%20Manual.pdf
 http://www.who.int/gho/publications/world_health_statistics/W
HS2012_IndicatorCompendium.pdf
 http://toolkits.urbanreproductivehealth.org/toolkits/measuring-
success/indicators
 http://data.worldbank.org/topic/health
 http://datatopics.worldbank.org/hnp/

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Health indicators an overview

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