1. By Hatim Jaber MD MPH JBCM PhD 5-6-2017
Faculty of Medicine Public Health ( )الصحة العامة Lecture 2 Indicators and determinants of global health By
Hatim Jaber
MD MPH JBCM PhD

2. Presentation outline 5-6-2017
Time
Indicators and determinants of global health variations
08:00 to 08:10
Relationship between socio-economic development and disease patterns in different nations
08:10 to 08:30
What are the social determinants of health?
08:30 to 08:40
What contribution do income, education, and other factors make to health
08:40 to 09:00

3. Determinants of health
Many factors combine together to affect the health of individuals and communities.
Whether people are healthy or not, is determined by their circumstances and environment.
To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health.
Access and use of health care services often have less of an impact.

4. Determinants of health
The social and economic environment,
The physical environment
The person’s individual characteristics and behaviors.
Access to quality health care

5. Determinants of health
Poverty, Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
Social support networks – greater support from families, friends and communities is linked to better health.
Education – low education levels are linked with poor health, more stress and lower self-confidence.
Gender - Men and women suffer from different types of diseases at different ages.
Culture, customs and traditions, and the beliefs of the family and community all affect health.

6. Determinants of health
Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses.
Personal behavior and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.
Health services - access and use of services that prevent and treat disease influences health

7. Determinants of health
Physical environment
- Safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health.
- Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions

8. Determinants of Health
Plus many more factors such as
Political stability, wars and conflicts
Natural disasters
Human and civil rights
Population growth and economic development in the country
Urbanization

9. Examples Malnutrition –
more susceptible to disease and less likely to recover
Cooking with wood and coal –
lung diseases
Poor sanitation –
more intestinal infections
Poverty
commercial sex work and STIs, HIV/AIDS
Advertising tobacco and alcohol –
addiction and related diseases
Untrained drivers on unsafe roads-
road traffic accidents

11. Health Indicators

12. What is Health Indicators? Definitions:
variable which help to measure changes, directly or indirectly (WHO , 1981).
A statistic which facilitate concise and balanced judgments about certain condition .
With the goal of good health in mind, think of an indicator as
“…a measure that helps quantify the achievement of a goal.”(Mark Friedman).
Health Indicators, Part I 12

13. Health Indicator is
“…a measure that helps quantify the achievement of a goal.”
-Mark Friedman
Power of indicators is comparisons
Health indicators are essential for comparing health status
- over time (trends)
geographic areas
groups of people
and the focus on the most essential domains of health
Health Indicators, Part I

14. A good indicator depends on
Availability of high quality data
Importance in measuring health status
Is well understood at the global level and various comparability options are possible.
Health Indicators, Part I

15. Health indicators are important because
They are essential for monitoring and reporting data for decision making about population health. 
To inform policy makers to formulate evidence based policies and to promote accountability among governmental and non-governmental agencies.
They are critical for setting priorities, assessing the health status at baseline, planning, allocating resources, and monitoring progress towards better health status goals
Needed for assessing the health problems and trends to create awareness, engage all the stakeholders in collaborative action and design interventions.
Health Indicators, Part I

16. Important Health Indicators for measurement of Health Status
Cause of death
Obtained from death certification but limited because of incomplete coverage
Life expectancy at birth
The average number of years a new-borns baby could expect to live if current trends in mortality were to continue for the rest of the new-born's life
Maternal mortality rate
The number of women who die as a result of childbirth and pregnancy related complications per 100,000 live births in a given year

17. Important Health Indicators for measurement of Health Status
Infant mortality rate
The number of deaths in infants under 1 year per 1,000 live births for a given year
Neonatal mortality rate
The number of deaths among infants under 28 days in a given year per 1,000 live births in that year
Under five child mortality rate
The probability that a new-born will die before reaching the age of five years, expressed as a number per 1,000 live births

18. Types of Health Indicators
Count/ Number: Measure without a denominator.
Rate: Numerator is part of denominator, Frequency of occurrence of an event during specific time, usually expressed per 1000 population.
Ratio: Numerator is not included in denominator (sex ratio).
Index: Aggregation of measurement of specific indicators.
Health Indicators, Part I 18

19. Indicators of Health

20. Global health indicators: highlighting the health inequality

21. Global health indicators are improving overall in the world… But not in all places, not for all social groups and not at the same speed

22. Health inequality
There is a difference between the health status of one population compared to another population or difference between population subgroups.

23. How to measure health inequality?
Most measurement of health inequality involves the use of indicators to measure health.

24. Health indicators within the Monitoring, Evaluation and Review framework
INPUTS AND PROCESSES
OUTPUTS
OUTCOMES
IMPACT
Health financing
Health workforce
Infrastructure
Information
Governance
Service access and readiness
Service quality and safety
Coverage of interventions
Risk factors and behaviours
Health status
Financial risk protection
Responsiveness
Source: Adapted from Monitoring, evaluation and review of national health strategies: a country-led platform for information and accountability. Geneva, World Health Organization, 2011.

25. Indicators of Health - classification
Mortality indicators
Morbidity indicators
Disability indicators
Nutritional status indicators
Health care delivery indicators
Health care Utilization indicators
Indicators of social and mental health
Environmental indicators
Socio-economic indicators
Health policy indicators
Other indicators

26. Mortality Indicators a. Crude death rate
It is defined as the number of deaths per 1000 population per year in a given community.
Reducing the number of deaths in the population is an obvious goal of medicine and health care, and success or failure to do so is a measure of a nation's commitment to better health.
Crude death rate = _Number of deaths (all causes)___* 1000
Estimated midyear population

27. Mortality Indicators
Age-specific death rate = ____number of deaths (25-44)_____ * 1000
estimated midyear population (25-44)
Cause-specific death rate = __Number of deaths (specific cause)__*
Estimated midyear population

28. Mortality Indicators b. Life expectancy
“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 is a good indicator of socio-economic development in general.
A minimum life expectancy at birth of 60 years is the goal of Health for All by 2000AD.

29. Mortality Indicators c. Infant Mortality rate
It 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.
It is one of the most universally accepted indicators of health status not only of infants, but also of whole population and of the socioeconomic conditions under which they live.
The global strategy of Health for All has suggested an infant mortality rate of not more than 50 per 1000 live births by 2000 AD.

30. Mortality Indicators d. Child Mortality Rate
It is 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-point of the year concerned.
e. Maternal Mortality Rate

31. Maternal Mortality rate
Maternal death's death of a woman
􀀹while pregnant ,or
􀀹within 42 days of termination of pregnancy
􀂾Irrespective of the duration or site of the pregnancy
􀂾From any cause related to, or aggravated by the pregnancy or its management
􀂾Not from accidental causes
Number of women who die as a result of complications of pregnancy or childbearing in a given year per 1000 live births in that year
Represents both the obstetric risk

32. Morbidity Indicators
Mortality indicators do not reveal the burden of ill health in a community.
The following morbidity rates are used for assessing ill health in the community:
Incidence and Prevalence
Attendance rates at out-patient departments, health centers, etc
Admission, Readmission and Discharge rates
Duration of stay in hospital and

33. Morbidity Indicators
Incidence rate = No. of new cases of a disease _in a certain time period___
population at risk in same time period
No. of new and old cases of a disease
Prevalence rate = _________in a certain time period________
No. of new cases in a narrowly defined
Attack rate = ______population during a specific time period______

34. Disability Rates Disability rates related to illness and injury
Used to supplement mortality and morbidity indicators.
Examples:
1. number of days of restricted activity
2. work-loss days (or school-loss days)

35. Nutritional Status Indicators
Anthropometric measurements of preschool children,
e.g.: weight, height, mid- arm circumference
Heights (and sometimes weights) of children at school entry
Prevalence of low birth weight (less than 2.5 kg)

36. Health Care Delivery Indicators
The frequently used indicators of health care delivery:
Doctor-population ratio
Doctor-nurse ratio
Population-bed ratio
Population per health center
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.

37. Utilization rates The extent of use of health services
Is expressed as the proportion of people in need of a service who actually receive it in given period, usually a year.
Health care utilization is also affected by factors such as availability and accessibility of health services and the attitude of an individual towards his health and the health care system.

38. Utilization rates Examples of utilization rates:
proportion of infants who are "fully immunized" against the 6 EPI diseases.
proportion of pregnant women who receive antenatal care, or have their deliveries supervised by a trained birth attendant.
bed-occupancy rate (i.e., average daily in-patient census/average number of beds)
bed turn-over ration (i.e., discharges/average beds)

39. Socio-economic Indicators
These indicators do not directly measure health. But they are of great importance in the interpretation of the indicators of health care.
rate of population increase
per capita GNP
level of unemployment
dependency ratio
literacy rates
family size
housing: the number of persons per room
per capita "calorie" availability

40. Health Policy Indicators
Proportion of GNP spent on health services
Proportion of GNP spent on health-related activities (including water supply and sanitation, housing and nutrition, community development)
Proportion of total health resources devoted to primary health care.

41. Who compiles health indicators?
Reports are compiled at every local level - Health departments, foundations ……
National –government/private partnerships.
International – WHO

42. Data Sources for Common Indicators
National Vital Statistics System (Birth, Mortality)
Census data
Surveys (Behavioral Risk Factor Survey--Adults and Youth, National Health Interview Survey, National Health and Nutrition Examination Survey, National Survey of Children's Health, National Immunization Survey)
Disease Surveillance Systems
Health services administrative data
Health Indicators, Part I 42

43. Keep it straight forward and simple
Indicators are like a water….
Too little of it , you die of thirst.
Too much , you drown in it By
Building Health information system able to generate a list of Essential indicators covering the basic information needs
Keep it straight forward and simple

45. Global population health and well-being are both determinants and consequences of major demographic changes
Migration within and across countries
Women in the paid workforce
Decreases in fertility and increase in life expectancy in many countries

46. Increasingly diverse with migration Increasing women in workforce
So, what’s the world going to look like in the next years…by 2025 or 2050?
Increasingly urban
Increasingly old
Increasingly diverse with migration
Increasing women in workforce

47. Global trends in longevity

48. Global Declines in Fertility

49. Doomsday scenarios Rising inequality Fragile families and communities
New urban areas that can’t catch up quickly
Environmental consequences
Social exclusion and “dis- integration”
Increased conflict