1. INDICATORS OF HEALTH
Presenter – Dr. suryakant 1st year PG student of
depart. of C.M of MMIMS&R Mullana
Moderator – Dr. pushapindra kaushal
Assoc. professor of depart. Of C.M of MMIMS&R
Mullana

2. Definition
In WHO’s guidelines for health programme evaluation
health indicators are defined as –
variables which help to measure changes. Often
used particularly when these changes cannot be measured
directly, for e.g. Health or nutritional status.

3. Importance Of Health Indicators :-
1.) To measure the health status
2.) Indicate the direction & speed of change
3.) Serve to compare different areas, country or
groups of people at the same time.
4.) To create health indices.
5.) Identification of health needs and prioritization
6.) Evaluation of health services , success

4. INDICATORS can be
• Count (number of..)
• Proportion (%, number/per x)
• Rate (frequency of an event during a specified period
expressed as per 1,00 or 100,00) in a defined population)
• Ratio (numerator not included in the denominator)
• Average
• Index

5. CHARACTERISTICS OF HEALTH INDICATORS
 Should be valid, as they should actually measure what they are
supposed to measure.
 Should be reliable and objective, as the answers should be the
same if measured by different people in similar circumstances.
 Should be sensitive, as they should be sensitive to changes in the
situation concerned.
 Should be specific, as they should reflect changes only in the
situation concerned.
 Should be feasible, as they should have the ability to obtain data
needed
 Should be relevant, as should contribute to understanding of
phenomenon of interest.

6. CLASSIFICATION OF HEALTH INDICATORS
• 1. Mortality indicators
• 2. Morbidity indicators
• 3. Disability rates
• 4. Nutritional indicators
• 5. Health care delivery indicators
• 6. Utilization rates
• 7. Indicators of social and mental
health
• 8. Environmental indicators
• 9. Socio-economic indicators
• 10. Health policy indicators
• 11. Indicators of quality of life, and
• 12. Other indicators

7. SOURCES OF DATA
> National family health survey/NFHS
. NFHS-1 1992-93
. NFHS-2 1998-99
. NFHS-3 2005-06
. NFHS-4 2015-16
> District level household and facility survey/DLHS
. DLHS-1 1998-99
. DLHS-2 2002-04
. DLHS-3 2007-08
. DLHS-4 2012-13
> The sample registration system/SRS
> Census

8. 1. Mortality indicators
It indicates about death, these can be the
following types:
1.1. Crude death rates :
> Is defined as the number of deaths/1000
population/year in a given community.
> indicates the rate at which people are dying.
> Now CDR India – 6.4death/1000population(SRS2016);
5.9 Haryana state.

9. 1.2. Life expectancy at birth:
> Is the average number of years that will be
lived by those born alive in to a population.
> Is a positive H. indicator & used most
frequently.
> Also adopted as a global H. indicator.
> Is a good indicator of socio-economic
development in general.

10. > Is estimated for both sexes separately.
> Is highly influenced by the infant mortality rate.
> At the age of 1 excludes the influence of infant mortality
& at age of 5 excludes influence of child mortality.
> current life expectancy in India is -68.8 years
for Indian male -67.4 years &
for Indian female-70.3 years
(WHO2017)

11. 1.3. Age-specific death rates :
> This rate Is defined as total number of
deaths occurring in a specific age group of the
people, e.g. (20-24 years) in a defined area during
a specific period per 1000 estimated total
population of the same age group of the population
in the same area during the same period.

12. 1.4. 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.
> Is a one of the most universally accepted
indicators of health status for whole population as
well; current IMR of India is -34/1000 L.B,
33Haryna.
> Is a sensitive indicator of perinatal care.

13. 1.5. Child death rate/early
childhood(1-4yrs) mortality rate
> It defined as the number of deaths at ages 1-4 years
in a given year, per 1000 children in that age group at the
mid year concerned.
> It excludes the infant mortality rate.
> It also correlate with inadequate MCH services,
nutrition, immunization, adverse environmental
exposure and other exogenous agents.
> Current rate – is 18/1000(NFHS-3)

14. 1.6. Under-5 proportionate mortality
rate:
• It is the proportion of total deaths occurring in the
under-5 age group in a community per 1000 live
births .
• It can reflect both infant and child mortality rates.
• High rate reflects - high birth rate, high child
mortality and shorter life expectancy.
• Current rate is – 39/1000live births(SRS 2016)

15. 1.7. Adult mortality rate :
• Is defined as the probability of dying between
the age 15-60 years per 1000 population.
• It Offers a way to analyze health gaps between
countries in the main working groups.
• Is greater for men than women, e.g. in Japan
<1/10 men, 1/20 women die in this productive
age group.

16. 1.8. Maternal/puerperal mortality ratio :
• Is a ratio of number of deaths arising during
pregnancy or puerperal period/100000 live births.
• It shows the country’s level of socio-economic
status.
 Current MMR of india-130/100000 live
births(world bank 2015),
 Haryana – 101/100000 live births(SRS2016)

17. 1.9. proportional mortality rate :
• > The simplest measure of estimating the burden
of a disease in the community is proportional
mortality rate. For e.g. CVD causes 15-20% of all
deaths in the country.
• > PMR for communicable disease is a useful
health status indicator as it indicates the
magnitude of preventable mortality

18. 1.11. Case fatality rate
> Measures the risk of persons dying from a certain
disease within a given time period.
> Calculated as number of deaths from a specific
disease/a number of cases of that disease during a same time
period.
> Usually expressed as /100
> CFR is used to link mortality to morbidity.
> Also measure various aspects/properties of a disease
such as-pathogenicity, severity/virulence.
> Can be used in poisonings, chemical, exposures, or
other short-term non-disease cause of death.

19. 1.12. Years of potential life lost/YPLL
• YPLL is based on the years of life lost through
premature death.
• For e.g. A 30 years old man who dies in a road
accident – could theoretically have lived to an
average life expectancy of 75 years of age; thus
45 years of his life are lost.

20. 2. MORBIDITY INDICATORS
• Are used to supplement mortality data to describe the
health status of a population.
following morbidity rates are used for assessing ill-
health in the community:-
• 2.1 Incidence and prevalence
• 2.2 Attendance rate at OPD, health centers, etc.
• 2.3 Admission, readmission and discharge rates
• 2.4 Duration of stay in hospital, and
• 2.5 Spells of sickness or absences from work or school.

21. 3. Disability rates
• Are based on the premise or notion that health
implies a full range of daily actives .
The commonly used disability rates have two
groups :-
3.A Event-type indicators
3.A.1 Number of days of restricted activity
3.A.2 Bed disability days
3.A.3 Work-loss/school-loss days within a specified
period

22. 3.B Person-type indicators
3.B.1 Limitation of mobility:
for e.g. confined to bed, confined to the house,
special aid in getting around either inside or outside
the house.
3.B.2 Limitation of activity:
for e.g. limitation to perform the basic activities
of daily living-as eating, washing, dressing, going to
toilet;
limitation in major activity-as ability to work at
job, ability to housework.

23. HALE/Health-Adjusted Life Expectancy :
• HALE is now changed from DALY(Disability-
Adjusted Life Expectancy) ; based on life expectancy
at birth but includes an adjustment for time spent
in poor health.
• > It is equivalent number of years in full health that a
newborn can expect to live based on current rates of
ill-health and mortality.

24. Quality-adjusted life years(QALY) :
QALY is a measure of disease burden including both the
quality and quantity of life lived.
• > Used in assessing the value for money of a medical
intervention.
• > based on the number of years of life that would be added
by intervention
Disability-free life/active life expectancy :
> DFLE is the average numbers of years an individual is
expected to live free of disability.

25. Disability-adjusted life years(DALY) :
DALY is also a measure of overall disease burden,
expressed in number of years lost due to ill-health, disability
or early death; DALY combines :-
Years of lost life(YLL) – calculated from the number of
deaths at each age multiplied by the expected remaining
years of life according to a global standard life expectancy.
Years lost to disability(YLD) – number of incident cases
due to injury and illness is multiplied by the average duration
of the disease and a weighting factor.
Formula is, DALY = YLL+YLD

26. 4. Nutritional status indicators
• Is a positive health indicator, there are three
main nutritional status indicators :-
• 4.1 Anthropometric measurement of preschool
children, e.g. weight & height, mid-arm
circumference.
• 4.2 Heights (sometimes weights) of children at
school entry; and
• 4.3 Prevalence of low birth weight.

27. 5. Health care delivery indicators
Frequently used indicators of health care
delivery – these are :
5.a Doctor-population ratio
5.b Doctor-nurse ratio
5.c Population-bed ratio
5.d Population per subcentre/health
5.e Population per trained birth attendant

28. 6. Indicators of social & mental health
• These social indicators provide a guide to social
action for improving the health of the people
• Valid positive indicators are scarce , so
necessary to use indirect measures for social &
mental pathology-
• these include suicide, homicide, violence , other
crime; RTA, alcohol, juvenile delinquency, drug
abuse, battered-baby & battered-wife syndrome

29. 7. Environmental indicators
• Reflect the quality of physical and biological
environment in which disease occur and people live.
• they include indicators relating to pollution of air,
water, radiation, solid wastes, noise, exposure to toxic
substances in food or drink.
• E.g. access to safe water and sanitation facilities-
like % of household with safe water in home or
within 15 minutes walking distance from a water
standpoint or protected well.

30. 8. Socio-economic indicators
• These indicators indirectly measure health. They have
great importance in the interpretation of the health
indicators . These are:
• 8.a- Rate of population increase
• b- Per capita GNP
• c- Level of unemployment
• d- Dependency ratio
• e- Literacy rates, especially female literacy rates
• f- Family size
• g- Housing: the number of persons per room, and
• h- Per capita “calorie” availability.

31. 9. Health policy indicators
Single most important indicator of political
commitment is – ‘allocation of adequate resources’.
The relevant indicators are:
9.1 Proportion of GNP(gross national production) spent on
health services
9.2 Proportion of GNP spent on health–related activities (
including water supply and sanitation, housing, nutrition,
community development
9.3 Proportion of total health resources devoted to primary
health care

32. 10. indicators of quality of life
As quality of life is difficult to define and even
more difficult to measure
So physical quality of life index is consolidates
three indicators-infant mortality , life expectancy
at age of one and literacy.

33. 10.1 Physical quality of life index(PQLI)
It consolidates three Indicators;
1) Infant mortality
2) Life expectancy at age of 1 year
3) Literacy
> It measure the results rather than inputs and lend
themselves to international & national comparison
> The performance of individual countries is placed
on a scale of 0 to 100, where 0 is Worst and 100 is
best

34.  PQLI has not taken per capita GNP into
consideration, showing thereby that “money is not
everything” for Exm:-
 The oil-rich countries of middle east with high per
capita income have in fact not very high PQLIs-
while Sri Lanka & Kerala state have low per capita
incomes with high PQLIs
 >PQLI does not measure economic growth, it
measures the results of social, economic and
political policies.

35. 10.2 Human development index(HDI)
Focusing on three basic dimensions of human
development : to lead a
1.Long and healthy life measured by – life
expectancy at birth,
2.Ability to acquire knowledge measured by –
mean years of schooling and expected years of
schooling,
3.Ability to achieve a decent standard of living
measured by – gross national income per capita in
PPP US $.

37. 11.1 Social indicators
• As defined by the united nations statistical office, have
been divided in to 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, nutrition, housing and its
environment, public order, safety, time use, leisure
and culture, social stratification and mobility

38. 11.2 Basic needs indicators
• basic needs indicators are used by ILO . Those
mentioned in “Basic needs performance”
• include calorie consumption, access to water,
life expectancy, death due to disease, illiteracy,
doctors and nurse per population, rooms per
person, GNP per capita.

39. Special indicators
• 1. Millennium development goal (indicators)–
Adopted in year 2000 by united nations to improve
global health by using following indicators:
• Goal-1.Eradicate extreme poverty & hunger
• >Proportion of population below minimum level
of dietary energy consumption
• Goal-4.Reduce child mortality
• > Proportion of 1-year-old children immunized
against measles

40. Goal-5.Improve Maternal Health
> Proportion of births attended by skilled health
personnel
Goal-6.Combat HIV/AIDS, Malaria and others
disease
> HIV prevalence among young people aged 15-
24 years
> Condom use rate of the contraceptive
prevalence rate
> Prevalence and death rate associated with TB

41. Goal-7. Ensure environmental sustainability
> Proportion of population using solid fuel
> Proportion of population with sustainable
access to improved water source & sanitation
Goal-8. Develop a global partnership for
development
> proportion of population with essential drugs
on a sustainable basis

42. 2. Sustainable development goals

43. On 25th sept. 2015, the united nations general assembly
adopted the new development agenda
“Transforming our world : the 2030 agenda for
sustainable development”
It has 17 goals & 169 targets, including 1 specific
goal (3rd one)- which is as following:-
3.1 by 2030 reduce the global MMR to < 70/lack live
births
2 by 2030 reduce neonatal mortality at least
<12/1000 & U5M <25/1000L.B

44. 3.3 By 2030 end the epidemics of AIDS,TB,
Malaria,Waterborn and other C.Ds
4 BY 2030 reduce 1/3rd premature mortality from
NCDs by p/t, t/t and promoting mental health and
well-being
5 Strengthen the p/t , t/t of substance abuse
including narcotic & alcohol
6 By 2020 halve the number of global death &
injuries from RTA

45. 7 By 2030 ensure universal access to sexual and
reproductive health-care services, family planning in
national strategies and programs
8 Achieve universal health coverage, including
financial risk protection and affordable essential
medicines & vaccines for all.
9 By 2030 substantially reduce the number of
deaths and illnesses from hazardous chemicals and
air, water, soil pollution and contamination.

46. 3. Global reference list of core health
indicators –
is a standard set of 100 core indicator as per regional,
national and global levels to obtain objectives, these are:
1. Health status:-
1.1 Mortality by age and sex
 Neonatal mortality rate
Stillbirth rate

47. 1.2 Mortality by cause
TB,AIDS-related mortality rate
Suicide rate
Mortality rate from road traffic injuries
AIDS-related mortality rate
Malaria mortality rate
Mortality between 30-70 years of age from CVD,
cancer, diabetes or chronic respiratory diseases

48. 1.3 Fertility
>Adolescent fertility rate , > Total fertility rate
1.4 Morbidity
New cases of vaccine-preventable diseases
HIV incidence & prevalence rate
Hepatitis B surface antigen prevalence
STIs incidence rate
TB incidence & prevalence rate

49. 2. Risk factors
2.1 Nutrition
>Exclusive breastfeeding rate 0-5 months of age
>Incidence of low birth weight among newborns
>Children under 5 years who are stunted & who are wasted
>Exclusive breastfeeding rate 0-5 months of life
>Anemia prevalence in children & in women of reproductive
age

50. 2.2 Infections
>Condom use at last sex with high-risk partner
2.3 Environmental risk factors
>Air pollution level in cities
>Population using safely managed drinking-water &
sanitation services
>Population using modern fuels for
cooking/heating/lighting, Etc.

51. 2.4 NCDs
>Total alcohol per capita (age 15+ years)
> Tobacco use among persons aged 18+ years
>Children aged under 5 years who are overweight
>Overweight and obesity in adults & adolescents
>Raised BP, sugar among adults
>Salt intake
>Insufficient physical activity in adults & adolescents

52. > Intimate partner violence prevalence
3. Service coverage
3.1 Reproductive, maternal, newborn, child and
adolescent
> Demand for family planning satisfied with modern
methods
> Contraceptive prevalence rate
> Antenatal, postpartum care coverage
> Vitamin A supplementation coverage
> Care-seeking for symptoms of pneumonia

53. 3.2 Immunization
> Immunization coverage rate by vaccine for each vaccine
in the national schedule
3.3 HIV
> People living with HIV who have been diagnosed
> Prevention of mother-to –child transmission
> HIV care coverage
> ART coverage
> HIV viral load suppression

54. 3.3 Tuberculosis
> TB patients with results for drug susceptibility testing
> TB case detection rate
second-line t/t coverage among MDR-TB
3.4 Malaria
> Interment preventive therapy for malaria during
pregnancy
> Use of insecticide treated nets
> Indoor residual spraying (IRS) coverage
> T/t of confirmed malaria cases

55. 4. Heath Systems
4.1 Quality and safety of care
> Perioperative mortality rate
> Institutional MMR
> Maternal death reviews
> TB t/t success rate

56. 4.2 Access
> Service utilization
> Health service access
> Hospital bed density
4.3 Health workforce
> Health worker density and distribution
> Output training institutions
4.4 Health information
> Birth & death registration coverage
> completeness of reporting by facilities

57. 4.5 Health financing
> Total current expenditure on health
> Out-of-pocket payment for health
> Externally sourced funding
> Total capital expenditure on health
> Headcount ratio of catastrophic health expenditure
4.5 Health security
> International health regulations (IHR) core capacity index

61. Limitations
> Indicators need to change with the time
> Rarely indicate specific cause
> In real life only few indicators are ideal
indicators