HEALTH INDICATORS :

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HEALTH INDICATORS
Basic Concepts , Design Framework
Use and Perspective
By
Dr Mhamed Ouakrim
e-mail
ouakrim_mhamed_at_yahoo.fr
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Presentation Focus

• Introduction
• I- Basic Concepts
• II- Conceptual Health Indicators
• Framework
• III- Health Indicators Uses
• IV- Health Indicators Perspective

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Introduction
Information is a dominant characteristic
of globalization process where each people is
both a provider and consumer
As such each of us is concerned with
National Health Information System and
particularly its sub-system, the National
Health Statistical Information System
(NHSIS) as well as its computerization
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Despite of progress made by some countries of
the Region in enhancing their NHSIS and its
computerization , the Finagles law is still
describing the situation of potential users of
statistical information
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FINAGLES LAW
The information you have is not what you want
The information you want is not what
you need The information you need is
not what you can get The Information
you can get costs more than you

want to pay
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Thinking in terms of
Health Indicators and
applying such FINAGLE S law , a health
decision maker would say
The indicators I have is not what I want
The indicators I want is not what I need
The indicators I need is not what I can get
The Indicators I can get costs more than I
want to pay
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For those people with a
limited information culture ,
the Information ( indicator
) is like a
bikini It
shows every things ,
except the essential ones .
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In order to justify the low levels of the
performances of their action , some decision
makers did not hesitate to apply for their
interest the very known joke on STATISTICS
of DISRAELI , the former leader of Conservator
Party in Great Britain starting last century .
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DISRAELI S JOKE
There are three kinds of lies - the
ordinary ( white ) lie , - the damned
lie and - the sophisticated lie
which is statistics
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1 BASIC CONCEPTS
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BASIC CONCEPTS
AND THEIR RELATIONSHIP

DATA specific context
INFORMATION
general context
KNOWLEDGE



DECISION

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INDICATOR ?
Definitions
A variable which helps to measure
changes , directly or indirectly
( WHO,1981) . A statistic of direct
normative interest which facilitates
concise , comprehensive, and balanced
judgments about conditions of major aspects of
the society
( H.E.W/USA,1969)
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Types of Indicators
Five types
Count / Number Measure
without a denominator
Proportion ( ) Numerator is
part of denominator .
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Rate
Frequency of occurrence of an event
during a
specific time, usually expressed
per k
population (k1000,10000, ).
Rate is used to
estimate probability or
risk of occurrence of
a disease or to
assess the accessibility or
coverage of
health care system .
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Ratio (per k) Measure for which
numerator is not

included in denominator ( e.g sex
ratio per 100
beds population per
1000 ) .
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. Index Aggregation
of measurement of
specific indicators . ( e.g Health
development
index ,summary
measures for Health Population )

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Ratio (per k) Measure for
which numerator is not

included in denominator ( e.g
sex ratio
per 100 beds population per
1000 ) . Index
Aggregation of measurement of
specific
indicators . ( e.g Health
development index ,summary
measures
for Health Population )

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III HEALTH INDICATORS DESIGN
FRAMEWORK
A - Conceptual Framework B - Identification
Methodology
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A- CONCEPTUAL FRAMEWORK

• Through applying a
• SYSTEM APPROACH
• Generic term covering body of theories
• and practices of which system analysis
• forms one part .

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A- CONCEPTUAL FRAMEWORK

• Through applying a
• SYSTEM APPROACH
• Generic term covering body of theories
• and practices of which system analysis
• forms one part .

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In system terms, a human being is not just a
collection of organs but a certain arrangement of
organs with detailed interactions
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• An organization (or a program) consists not
  merely of the boxes of an organogram but also of
  the pattern of interrelations between them and
  within them. It also involves the resources
  (INPUTS)) and the services and products (OUPUTS)
  resulting from the organizations activities .

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• The production of services and products (OUTPUTS)
  generate results or overcomes (Effects and
  Impact) in term of satisfaction of goals.

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SYSTEM ?
A system can be defined as a set of
inter-related and inter dependants parts
designed to achieve a set of goals
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System REPRESENTATION
ENVIRONMENT
INPUTS
THROUGOUT
OUTCOMES
OUTPUTS
RESULTS (Effects/Impacts)
ACTIVITIES
RESOURCES
Process
System
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Health Program as a System

• A health programme can be defined as
• an organized group of development oriented to
  acieve well defined objectives
• .

Programme
INPUTS
THROUGOUT
OUTPUTS
OUTCOMES
RESOURCES
PROCESS
RESULTS (Effects/Impacts)
ACTIVITIES
Environment
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B - HEALTH INDICATORS FRAMEWORK
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Environment
(1) National Socio-Cultural, Economic,
Demographic and Environment Indicators
Health Policy Development
Health Supply
Health Demand
(2) Inputs Indicators
(3) Process Indicators
(4) Outputs Indicators
(5) Outcomes Indicators
Resources
(a) Effects Indicators
Activities Management Quality
(b) Impact Indicators
Products Services
Change in health status
Change in behaviour
Health system
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FIVE INDICATORS CATEGORIES

• (1) SOCIO-ECONOMIC ENVIRONMENT
• Indicators focusing on population
• structure, economics, education,
  employment,
• water, sanitation, pollution, etc.

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• 2) INPUTS Indicators focusing on health resources
• Including human , material and financial
  resources

• (3) PROCESS Indicators refers to quality of
• health activities.

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• (4) OUTPUTS Indicators refers to the results
  achieved in terms of services, cares or goods.
  They could be divided in following three types

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THREE OUTPUTS INDICATORS TYPES

• (a)Functional output indicators which measures
  the number of activities conducted in each
  functional area.
• (b)Service outputs indicators which measures the
  adequacy of the service delivery system in terms
  of accessibility, quality and image.
• (c)Service utilization indicators which measures
  the extent to which the services are used.

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The INPUTS and PROCESS indicators and secondly
the OUTPUTS indicators are used for MONITORING
process.
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• 5- OUTCOMES Indicators refer to changes
• observed at the population as a
  result of
• given interventions.

• There are two following types of outcomes

- EFFECT Indicators
- IMPACT Indicators
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• (a) Effects Indicators relating to measure of
  change in knowledge, attitude and practice
  (behavior change including coverage) occurred in
  short and medium term (2-5 years).

• (b) Impact Indicators focusing on change in
  health
• status due to the effects of
  interventions/actions
• and occurred over the long-term (over 5
  years).

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• The OUTCOMES Indicators are especially used for
  EVALUATION process which uses also the general
  findings of Monitoring particularly the outputs
  indicators achievements.

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- B -
METHODOLOGY For Identifying and
developing Health Indicators
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( a ) STRATEGY OBJECTIVES

• ( 1 ) To break the vicious circle
• based on the
• FINAGLE principle
• by meeting the information\
• indicators needs of the potential
  users

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( 2 ) To address the
following crisis and burden of
information

• Indicators are like water
• Too little of it and you die of thirst.
• Too much and you drown in it .

by re- building a
friendly HSIS able to generate a list of
essential indicators covering the BASIC
INFORMATION NEEDS .
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(b) ( b )
Use of Participatory Approach to Identify
and Develop Indicators

• (1) Health System/Health programme
• should be seen as a system with
• Inputs-Process-Outputs-Outcomes
• Components.
• (2) Use of KISS Approach as basis for
• indicators developments.

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• K Keep
• I It
• S Simple and
• . S Straight forward

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( Keep It Straight Forward and Simple )

• (3) Use of national workshop
• for identifying
• essential health indicators

-
KISS approach

• - Participatory approach (date providers-
  producers, users dialogue)
• - Democracy and group team spirit
• - Reaching of a consensus on basic
• list of essential indicators.

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• K Keep
• I It
• S Simple and
• S Straight for ward

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METHODOLOGY FOR IDENTIFY ESSENTIAL HEALTH
INDICATORS (EHI)

• 
  

EHI
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WORKSHOP PROCESS

( 1 ) INDEPH REVIEW AND DISCUSSION OF A
PRE-PREPARED LIST OF HEALTH INDICATOR BY
CATEGORY (
plenary session ) ( 2 ) ADDITION, IF NEEDED ,
OF OTHER HEALTH INDICATORS NOT INCLUDED
IN THE ABOVE LIST AFTER THEIR DISCUSSION
(plenary) ( 3 ) SELECTION OF EHIs By
CATEGORY USING SCORE VALUATION AND
CRITERION SELECTION
( Individually )
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( 4) GENERATION OF PRELIMINARY BASIC LIST OF EHIs
ON THE BASIS OF INDIVIDUAL PARTICIPANTS
SELECTIONS ( BY
FACILITATORS ) (5) DISCUSSION O FPREPARED
PRELIMINARY BASIC LIST OF EHIs AND ADDITION
, IF ANY , OF SOME INDICATORS CONSIDERED AS
ESSENTIAL BUT ELIMINATED THROUGH THE PROCESS
. ( PLENARY ) (6)
DISCUSSION OF AMENDED BASIC LIST OF EHIs TO REACH
A CONSENSUS ON A NATIONAL LIST .
( PLENARY )
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III HEALTH INDICATORS USES
A System Analysis tool B Health Managerial
Process
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A System Analysis Tool

• The interest of use of system analysis is because
  it permits the utilization of a common logic and
  vocabulary across organizational and disciplinary
  line

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• SYSTEMS ANALYSIS may be defined as
• such methods which seek
• to define the relationship existing in a system
  and
• to calculate and assess the effects of altering
  either the elements of the system or the ways in
  which they interact

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The System Analysis is useful that it provides
for management

• 1) Consideration of all variables, over and above
  biological and technical that affect health
  intervention programs
• 2) A planning approach that relates INPUTS to
  OUTPUTS
• 3) An emphasis on quantification
• 4) Based on analytical methods

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5) Orientation towards health problems rather
than towards categories of services 6) Easy
communication with other key government decision
making center 7) Early attention to planning and
priority setting 8) Improved inter disciplinary
collaboration and
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• As a result, SYSTEM ANALYSIS enables health
  planning at the policy, strategic and operational
  levels to be seen as a continuation of
  interrelated process .

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B USE OF HEALTH INDICATORS IN
HEALTH MANAGERIAL PROCESS ( with
emphasis on monitoring and Evaluation )
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• B - MANAGERIAL PROCESS FOR
• NATIONAL HEALTH DEVELOPMENT

HEALTH AND RELATED SOCIOECONOMIC SYSTEMS
PROGRAMME BUDGET
INFORMATION SUPPORT
FORMULATION OF NATIONAL HEALTH POLICIES
Planning
BROAD PROGRAMMING
Planning
EVALUATION
DETAILED PROGRAMMING
MONITORING
IMPLEMANTATION
REPROGRAMMING
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GOAL,OBJECTIVE and TARGET CONCEPTS
CLARIFICATION
GOAL
TARGET
OBJECTIVE
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Objectives and Targets are expressed In terms of
expected values of Indicators by the reference
time of the plan \programme
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• Trends Assessment equals Trends Evaluation .
• It is used in health managerial process on
• - one side for the Situation Analysis (entry
  point
• of Planning \ Programming ) to setting up
• health priorities and
• the other for the monitoring and particularly
• the evaluation of the implementation of plan
  or
• programme

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(2) Socio-economic Development Trends
(4) Health Resources Trends (Inputs)
(5) Health system Development Trends
(Process ) (6) Health Activities
Trends (Outputs )
(7) Health Status Trends (Outcomes)
(1) Policy Development trends
(8) Future Strategic Directions
(3) Health and Environment Trends
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MONITORING AND EVALUATION FRAMEWORK OF A
HEALTH PROGRAMME

• Monitoring and Evaluation are
• integral part of the managerial
• process for national health
• development as shown in the
• present planning-programming-
• budgeting and implementing
• cycle.

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MONITORING

• It is the day-to-day follow-up of activities
  during their implementation to ensure that they
  are proceeding as planned and are on schedule.
• It measures PROGRESS of the Programme as it makes
  it possible to identify deviations so that
  activities can be put back on the right track.

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EVALUATION

• It is a systematic way of learning from
  experience and using the lessons learned to
  IMPROVE current activities and promote better
  planning by selection of alternatives for future
  action.

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The Evaluation Process consists of the
following 6 components

• 1.RELEVANCE
• 2.ADEQUACY
• 3.PROGRESS
• 4.EFFICIENCY
• 5.EFFECTIVENESS
• 6.IMPACT

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MANAGERIAL PROCESS FOR NATIONAL HEALTH
DEVELOPMENT
Adequacy
HEALTH AND RELATED SOCIOECONOMIC SYSTEMS
PROGRAMME BUDGET
INFORMATION SUPPORT
Relevance Adequacy
FORMULATION OF NATIONAL HEALTH POLICIES
Relevance
BROAD PROGRAMMING
Progress Adequacy
EVALUATION
DETAILED PROGRAMMING
MONITORING
IMPLEMANTATION
Progress, Efficiency, Effectiveness Impact
REPRPGRAMMING
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• MONITORING AND EVALUATION PROCESS COMPONENTS IN
  HEALTH MANAGERIAL PROCESS AND RELATED INDICATORS

Planning Process
Relevance
Programming Process
Implementing Process
Adequacy
INPUTS
PROCESS
OUTPUTS
OUTCOMES
Programmed Resources--------------- AllocatedRes
ources
Norms and Procedures--------------- Applications
of Norms and procedures
Fixed Objectives and Targets----------------- Ach
ieved Objectives and Targets
Effect
Impact
Effectiveness
Progress
Efficiency
PLAN or PROGRAM
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Health Indicators Perspectives
IV
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The 80s were marked by the emergence of
debates on new health composite indicators
, at academic and scientific cycles .
The first half of 90s had seen WB and WHO
involved in carrying out Global Burden of
diseases studies which open the door to
disseminate the the knowledge base on such
indexes . WB initiated same few national BD
studies in developing countries .
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The second half of 90s enabled the
publication of GBD study and allowed WHO to
include part of findings in the second
issue of WHR . From 1997 WHO took the lead
of advocating the use of key new indexes ,
world wide and the refining of their
consistency to reduce criticism on their value as
tools for situation analysis and
priority setting . WHO increased its
efforts by developing new methods and
indexes on health system performance assessment
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Summary Measures of Population Health
(SMPH )
Definition SMPH are measures that combine
information on
mortality and non-
fatal health outcomes to represent
the health of a particular
population as a simple
number .
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Summary Measures of Population Health
(SMPH )
Applications Eight domains 1- comparison
of health of one population to health of another
2- comparison of health of same population at
different times 3- identify and quantify
overall health inequalities within pop. 4-
provide appropriate and balanced attention to
effects of non-fatal health outcomes on
overall population health .

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5- Inform debates on priorities for health
services delivery and planning 6-
Inform debates on priority for research and
development in health sector 7- Improve
professional training curricula in public health
8- Analyze benefits of health interventions for
use in cost-effectiveness analyses
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SMPH Typology
Two types All constructed on the basis of a
simple
survivorship curve analysis
( 1 ) Health Expectancy (
2 ) Health gap
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SMPH Typology
Examples ( 1 ) Active Live
Expectancy ( ALE ) ( 2 )
Disability Free Life Expectancy ( DFLE )
( 3 ) Health- Adjusted Life Expectancy (
HALE ) ( 4 ) Disability
Adjusted live Years ( DALYs ) (
) etc
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DALE Estimation
Made from the three following kinds of
information 1. Fraction of population surviving
to each age, calculated from birth and
death rates         2. Prevalence of each type of
disability at each age.         3. Weight
assigned to each type of disability which
may or may not vary with age.  
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The survival at each age is there adjusted
downward by the sum of all the disability
effects, each of which is the product of a weight
and the complement of a prevalence (the share of
the population not suffering that disability)
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The survival at each age is there adjusted
downward by the sum of all the disability
effects, each of which is the product of a weight
and the complement of a prevalence (the share of
the population not suffering that disability)
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2- Health System performance indicators
2-1- Responsiveness measures It is not a measure
of how the system responds to health needs which
shows up in health outcomes, but of how the
system performs relative to non-health aspects,
meeting or no meeting a populations expectation
of how it should be treated by providers of
prevention, care or non-personal services.
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The responsiveness component measures are
as follows   2-1-1- Respects for human
beings as persons (subjective and
judged primarily by the patient)  
-        Respect for dignity of the person.
                                    
-       Confidentiality of personal
health information.
- Autonomy
in choice relating
to own health provider
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2 -1-2- How a health system meets certain
common expressed concerns of patients
and there families as client of
health system , some of which can
be directly observed at health
facilities.   These include the
followings                 -  
Prompt attention (emergency, waiting
time).                -  Amenities
of adequate quality.               
-  Access to social support networks.            
      -  Choice of provider (freedom
to select
individual or organization deliver one care.  
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2-2- Fair financing (this means that risks
each one households faces due to the
costs of the health system are
distributed according to ability to pay
rather than to the risk of illness ). A
fairly financed system ensures
financial protection for everyone.  
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There are two measures concepts (1)  
Fair financing ratio measured by
dividing total health expenditure to total
non-food expenditure.
(2) As the fairness of financial contribution
index is designed to measure
both fairness of financial
contribution and financial
risk protection, its form is as
follows

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3
1-4 SUM
HFCI HFC Financial Contribution
INDEX
0.125
n where HFCi is financial contributing
of given household.   HFC is the
average financial contributing across
households. n number of household
in the survey.
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END...and
Thanks for your patience ...
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DISCUSSION TOPJCS
1 Current Health Information Policy 2
National Statistical Information system
situation Organization and
structure , coverage ( public , private sector )
3 Information \Indicators needs
identification process -
methods \approaches used ? -
basic list identified ? 4 Information
culture in health decision making process ,
particularly in health system
operational levels (hospital , health centers ,
etc) 5 Priority areas for future technical
assistance in strengthening of
national health Statistical information System .
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• RELEVANCE relates to the rationale to having
  programme, activities, services or
  institutions in terms of their response to
  essential human needs and social and health
  policies and priorities.

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• ADEQUACY implies that sufficient attention has
  been paid to certain previously determined
  courses of action such as the various issues to
  be considered during the broad programming
  (planning).

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• PROGRESS is concerned with the comparison of
  actual with scheduled activities the
  identification of reason, for achievement or
  shortcomings, and indication for remedies for a
  any shortcomings.

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• EFFICIENCY is an expression of the relationship
  between the RESULTS obtained from the programme
  and the efforts expanded in terms of human,
  financial and other resources, health process and
  technology and times.
• Use of cost-benefit approach.

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• EFFECTIVENESS is an expression of the Desired
  Effect of the programme in reducing a health
  problem or improving an unsatisfactory health
  .
• the Degree of attainment of the pre-determined
  objectives or targets of the programme (use of
  qualitative analysis through assessment of
  satisfaction or dissatisfaction expressed by the
  community concerned).
• Use of Cost-effectiveness.

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• IMPACT is an expression of the overall effect of
  a programme on health and related socio-economic
  development. The assessment of impact is aimed at
  identifying any necessary change in the directing
  of health programme so as to increase its
  contribution to overall health and socioeconomic
  development.
• Such Evaluation process components are used as
  follows at level of components of managerial
  process as follows

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• DISTINCTION BETWEEN COST-EFFECTIVENESS AND
  COST-BENEFIT ANALYSIS

Health programme
consumer resources
Gives improvements in health
Costs What is forgone?
Benefits What is obtained?
Cost-benefit approach (economic appraisal)
Benefits not in money terms
Costs and benefits in money terms
Cost-benefit analysis
Cost-effectiveness analysis
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