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Dr. Navya Sri. S
1st year Post graduate
Bangalore medical college and research institute.


Development of indicators
Classification of Indicators of Health
Evaluation of indicator

Definition of health: A state of complete physical, mental and social
wellbeing, and not merely an absence of disease or infirmity ( WHO ).
How healthy is a given community?
For the health administrator, nothing could be more valuable than to
have, at his command, one or more measuring roads to help him in his task
and also in assessing his specific problems relating to the health of people, in
designing his plans to deal with these, in guiding his administration and in
evaluating his scheme- WHO

What is a indicator ?
In WHOs guidelines for health programme evaluation they are defined as
variables which help to measure changes.
Difference between an indicator and index?
Indicator : anything that indicates ( revealing or diagnostic ), which could be any
counted or measured variable
Index: scaled composite variable

Steps to Develop Indicators

Step 1: identify what you want to measure .

Ex. Immunization coverage in mission indradhanush
Step 2: Develop a list of possible indicators.
Ex. Session monitoring indicators
House to house monitoring indicators- % of under 2 year children
vaccinated .

Steps to Develop Indicators

Agree on criteria of indicators :
Valid they should actually measure what they are supposed to measure.( % of under 2 year
children vaccinated )

Reliable the results should be the same when measured by different people in similar

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. (As a
strategic endeavour, the Ministry of Health & Family Welfare (MoHFW), GoI, launched Mission
Indradhanush in December 2014 to achieve more than 90% full immunization coverage in the
country in a period of five years.)

Steps to Develop Indicators

Step 4: Assess each possible indicator against criteria
Step 5: Select best indicators Session monitoring indicators.docx
Step 6: Refine indicators -check out with other stakeholders (such as funders, partners
and users) whether the key indicators that you have chosen are the most appropriate
Step 7: Test indicators
(Source: Introduction to Indicators in Public Health Planning and Evaluation June 2014,


Measurement of the health of the community.

Description of the health of the community.
Comparison of the health of different communities.
Identification of health needs and prioritizing them.
Evaluation of health services.
Planning and allocation of health resources.
Measurement of health successes.


Mortality indicators
Morbidity indicators
Disability rates
Nutritional status indicator
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
Other indicators

Measures of mortality
CRUDE DEATH RATE ( CDR ): The number of deaths in a defined community in a year per
1000 population in the middle of year ( i.e. on 1st July ).
CDR = Total deaths in a defined community or defined area in a year X 1000
Mid- year population ( 1st July ) of that community or defined area
INDIA 7 Rural- 7.5
Urban- 5.6
( Source : SRS- 2014 )
Karnataka- 7 Rural-8

CDR is useful for making quick estimates of load of mortality in a given population


Identify the risk of deaths in different subgroups or risk of death due to specific

Age specific mortality rates ( ASMR ): Defined as number of deaths in a

particular age group in a defined area over a defined time period per 1000
mid point population of particular age group in that defined area.
Ex. Infant mortality rate

Cause specific mortality rate ( CSMR ): No of deaths occurring in a

defined area due to particular disease, in a defined period of time for every
1000 mid population in the defined area

Gives the relative importance of the disease as a cause of mortality in the community.
Ex: CSMR due to pulmonary tuberculosis for a ten year period of 1 st Jan 1991 to 31st
December 2000 in entire India
CSMR= Total death due to pulmonary tuberculosis in India during
1 Jan1991 to December 31st 2000
X 1000
Population of India as on 1st Jan 1996
Current mortality rate due to Tb is 19/ lack population ( burden of tuberculosis in India
-2013 )

Case fatality rate ( CFR )

Number of persons dying due to a particular disease, during a defined
time period, in a defined area/ 1000 persons in that area, having that
particular disease.
CFR due to rabies in Mumbai during the year 2007 would be calculated
Total deaths due to rabies In Mumbai in 2007 X 1000
Total cases of rabies in Mumbai in 2007
Gives Killing power of the disease CFR- Rabies is very high ( 100 % ).

Proportionate mortality ratio ( PMR )

Proportion of total deaths that are due to a given cause, out of the total
deaths in that area over the given time and multiplying by 100 to get it as
E.g. Coronary heart disease causes 25 to 30 % of all deaths in
developed world.

Specific mortality indices used in maternal

and child health care
Maternal mortality ratio ( MMR ) : No of deaths due to maternal causes in a
given community in a year
100000 live births in the same year in the same area
MMR is a very sensitive indicator of health status of women in reproductive age group, as
well as of obstetric services.
India- 167, Karnataka- 144
Highest- Assam 300
Lowest- Kerala- 61
( Source : SRS- 2013 )

The maternal mortality ratio should not be confused with the maternal
mortality rate (whose denominator is the number of women of
reproductive age), which reflects not only the risk of maternal death per
pregnancy or birth but also the level of fertility in the population. The
maternal mortality ratio (whose denominator is the number of live births)
indicates the risk once a woman becomes pregnant, thus does not take
fertility levels in a population into consideration.
Maternal mortality rate: India- 12.4, Karnataka- 8.1


Neonatal mortality rate ( NMR ) : Number of deaths in a year, in defined area,

among children up to 28 days of age
1000 live births in same area in same year
India- 29, Karnataka- 23
Rural-33 , urban- 16
( Source : SRS- 2013 )

Infant mortality rate ( IMR ) : number of deaths among children less than 1
year in a year
1000 live births in the same year in the same area
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
The infant mortality rate is a sensitive indicator of the availability, utilization and
effectiveness of health care, particularly perinatal care.
Infant mortality rate India- 40, Karnataka- 31
Rural- 44 , urban 27
Highest MP and Assam 54
Lowest- Kerala -6
( Source : SRS- 2014 )

Under-5 Mortality rate

Defined as no. of deaths occurring in the under-5 age group per 1000 live births.
Reflects both infant and child mortality .
UNICEF considers this as the best single indicator of social development and
well-being rather than GNP per capita, as the former reflects income, nutrition,
health care and basic education etc.
India- 49, Karnataka- 37
Rural 55 , urban- 29


The number of deaths at ages 1-4yrs in a given year, per 1000 children in
that age group at the mid-point of the year.
Correlates with inadequate MCH services, malnutrition, low
immunization coverage and environmental factors
Current rate 18/1000 (NFHS-3)

Morbidity indicators are used to supplement mortality data to describe the health
status of a population.
Morbidity measures can be either in the form of incidence and prevalence
INCIDENCE: Number of new cases of specific disease during a given
period of time
X 1000
Population at risk during that period
Eg. The incidence of Tuberculosis in India is 171 per 100000.


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 or midway through the period.
Ex. The prevalence of Tuberculosis in India is 211 per 100000

2. Notification rates is 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.
3. Attendance rates at OPDs and at health centers.
4. Admission, Re-admission and discharge rates.
Duration of stay in hospital.
5. Spells of sickness or absence from work or school.
- reflects economical loss to the community

Epidemiological measures of fertility are extensively used in fields of

demography, family planning and health administration.

CRUDE BIRTH RATE: Number of live births in an area during one year
per 1000 mid year population.
India- 21.4, Karnataka- 18.3
Rural-22.9, urban-17.3
Highest- Bihar- 27.6, lowest- Goa- 13
( Source: SRS- 2014)

General fertility rate : Number of live births in a given area during a year
1000 mid year population of females in reproductive
age groups ( 15- 45 yr. ) in that area, during that year.
Age specific fertility rate ( ASFR ) : Number of live births to women in specified
age group ( 20- 25 yrs) in given area, given year per 1000 mid year population of
females in age group of ( 20-25 )
Identifies age group of women having highest reproductive potential, so that
family planning measures can be directed towards such groups


Total fertility rate ( TFR ):

This gives estimated number of children which a group of 1000 women
would bear if they were to start their reproductive life at a common point
of life and were to pass through their entire reproductive span, subject to
current ASFR.
Accurate epidemiological measure of fertility.
TFR: India- 2.4, Karnataka-1.9 (Source: SRS -2012)


Net reproductive rate ( NRR ): Measure of average number of female live

births that will occur to new born female as she grows up and passes
through her entire reproductive age, provided she was subjected to current
rates of fertility as well as mortality.
NRR is a sensitive indicator of population growth.
India- target of achieving NRR equal to 1.00, as a part of family welfare

EVENT- TYPE Indicators
No of days of restricted activity
Bed disability days
Work loss days within a specified period
( ADL )

PERSON- TYPE indicator

Limitation of mobility
( confined to bed, special
Limitation of activity


Nutritional Status is a positive health indicator.
Newborns are measured for their
i. Birthweight
ii. Length iii. Head circumference
They reflect the maternal nutrition status
Pre-school children Anthropometric measurements
i. Weight measures acute malnutrition
ii. Height measures chronic malnutrition
iii.Mid-arm circumference - measures chronic malnutrition
.Growth Monitoring of children
.Measuring weight-for-age, height-for-age, weight-for- height, head & chest
circumference and mid-arm circumference.
Adults Underweight, Obesity and Anemia are generally considered reliable nutritional
Prevalence of low-birth weight babies- 28 ( Source- UNICEF 2014 )


Doctor- population ratio - 1/1700 (Norm 1/1000)
India- 6.5/10000 population ( Source: WHO world health statistics 2012 )
Doctor nurse ratio
Population- bed ratio 9.0/10000
Population/ health or sub centre
Population/ traditional birth attendant.
The present doctor-population ratio is 0.5 per 1,000 and the target by 2025 is 0.8 per 1,000.
These indicators reflect the equity of distribution of health resources in different parts of
country and of the provision of health care.

2) Utilization rates
Relationship exits between utilization of health care services and health needs and status
Utilization is also affected by factors such as availability and accessibility of health

services and attitude of an individuals towards his health and health care system.
Proportion of infants who are fully immunized against EPI diseases.- 77.3% ( 2012 )
Proportion of pregnant women who receive ANC or have deliveries supervised by
trained birth attendant.
ANC coverage- 37%
Delivery conducted by skilled personnel (%)- 52% ( 2008-12)
% of family using various methods of family planning.
Bed occupancy rate ( i.e. avg daily in- patient census/ avg number of beds )
Bed turn over ratio

Social and mental health indicators

Homicide, suicide and other acts of violence and crime
RTA, Juvenile delinquency, alcohol and drug abuse, smoking,
consumption of tranquillizers etc.
Family violence, battered baby and battered wife syndromes and
neglected and abandoned youth.
These social indicators provide a guide for social action for improving the
health of the people.

Indicators relating to pollution of air and water, radiation, solid wastes,
noise, exposure to toxic substances in food or drink.
Most useful indicators are measuring the proportion of population having
access to safe water and sanitation facilities.
Ex: % of households with safe water in the home or within 15 min
walking distance from a water stand point or protected well.
India- safe water- 93%
Sanitation- 36%
(Source: WHO- World health statistics 2014 )


Health is the result of a complex array of interplay between the human beings and their
environment , including the various array of socio-economic factors.
Expectation of life 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.
It is a statistical abstraction based on existing age-specific death rates.
Estimated for both sexes separately.
Good indicator of socioeconomic development
It is a commonly used summary measures of the health status of a population.
Life expectancy at birth: 63.5 YEARS
Male: 64 years (WHO Global Health Observatory ,2012)
Female: 68 years
Highest- Kerala-74 yrs
Country with highest life expectancy: Japan- 82.6 years.

Percentage of people below poverty line: commonly used index of overall standard
of living and economic status of country.
Actually means inability to buy adequate food calories which is equivalent of 2400
Kcal/ day in rural and 2100 Kcal/day in urban.
New poverty line recommended by C Rangarajan committee is
Urban areas- Rs.47 per person per day and Rs.32/person/day for rural.
Poverty head count ratio ( PHCR ) is the proportion of population whose per-capita
income/ costumer expenditure is below the official threshold i.e. poverty line
Poverty estimate-India- 21.9% ( 2011-2012 )

Indicators of education level :

Adult literacy rate- 74%
Male- 82% and female- 65%
School enrolment rate.
Indicators of empowerment of women: percentage of women employed in
industry, executive jobs and in government jobs.


An emerging concept in public health practice.
These indicators are used for making comparisons of health status between countries.
To make comparison of average health levels in different population subgroups or in
same population over time.
Assessment of relative contribution of two different diseases, injuries or risk factors,
too overall population health.
Identifying and quantifying overall health inequalities with in a population thus
identifying at risk or vulnerable groups.
Provide inputs for short listing of national health priorities for national health planning.

Types of SMPH
Summary measures of health
HALE ( Healthy life expectancy )
ALE ( Active life expectancy )
DFLE ( Disability free life
expectancy )
QALE ( Quality adjusted life
expectancy )

years of potential life lost ( YPLL )

Disability adjusted life free years


Summary measures of health GAPs

Life expectancy at birth but includes an adjustment for time spent in poor health.
Equivalent number of years in full health that a new born can expect to live based
on current rates of ill health and mortality.
QALY : No of years of life that would be added by intervention.
1.0- perfect health 0.0- death
1 QUALY = 1 Year of life X 1 utility value.
It is a measure of disease burden including both the quality and quantity of life lived.
DFLE ( Syn with ALE ): Avg no of years an individual is expected to live free of
disability if current pattern of mortality and disability continue to apply.

Years of potential life lost

Defined as years of potential life lost due to premature death.
Deaths occurring at younger ages accrue most years of life lost than
deaths at later ages.
As illustration is given in table-2 below which shows the hypothetical
details of deaths due to road traffic accidents.

From table2: the YPLL due to road traffic accidents , for

this population are 1441985 years.
YPLL rate ( per 1000)=
X 1000
Population under age of 65 yr.
1441985 X 1000/ 213565000
= 6.8 YPLL / 1000 population

DALY combines in one measure the time lived with disability and time

lost due to premature mortality.

YLL ( years of life lost ): No of deaths at each age multiplied by expected
remaining years of life according to a global standard life expectancy.
YLD ( years lived with disability ): No of incident cases due to injury and
illness is multiplied by an avg duration of the disease and a weighing
factor reflecting the severity of disease on a scale from 0 to 1.
Use of social weighting, in which the value of each year of life depends
of age, reflects the societies interest in productivity.

Uses of DALY
To assist in selecting health service priorities.
To identify the disadvantaged groups.
Targeting health interventions.
Measuring the results of health interventions.
Providing comparable measures for planning & evaluating programmes.
To compare the health status of different countries.
One DALY is one lost year of healthy life.

Sullivans index
Expectation of life free of disability, computed by subtracting from life
expectancy the probable duration of bed disability and inability to perform
major activities.
Sullivans index= life expectancy- YLD
Expectation of life free of disability


The single most important indicator of political commitment is allocation
of adequate resources.
The relevant indicators are
Proportion of GNP(gross national product) spent on health services.
Proportion of GNP spent on health related activities like water supply and
sanitation & housing and nutrition.
Proportion of total health resources devoted to primary health care.


Life expectancy is now less important.
The Quality of Life has gained its importance.
Physical Quality of Life Index
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 to 100.
The composite index is calculated by averaging the three indicators giving equal weight to
each of them.
The result is placed on the 0 to 100 scale.
The PQLI does not consider the GNP.

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

Life expectancy at birth: 25 years and 85 years

- Adult literacy rate: 0 per cent and 100 per cent
- Combined gross enrolment ratio: 0 per cent and 100 per cent
- Real GDP per capita (PPP$), $ 100 and $ 40,000 (PPP $).
For any component of the HDI, individual indices can be computed according the general formula :
Index :

(Actual value) - (Minimum value)

(Maximum value) - (Minimum value)
The result is placed on the 0 to 1 scale
HDI for India was 0.59
HDI ranking of India is 130

Social Indicators:
Family formation
Families & households
Learning & educational services
Learning activities
Distribution of income
Consumption & accumulation

Social security & welfare

Health services & nutrition
Housing & its environment
Public order & safety; time use
Social stratification & mobility

Basic Needs Indicators are used by ILO and include calorie
consumption, access to water, life expectancy, deaths due to disease,
illiteracy, doctors and nurses per population, rooms per person, GNP per


Health For All Indicators

For monitoring the progress towards the goal of Health For All by 2000

, the WHO had listed the following four categories of indicators.

Health policy indicators
Political commitment to HFA
Resource allocation
Degree of equity of distribution of health services
Community involvement
Organizational framework and managerial process

2.Social and economic indicators related to health

Rate of population growth
Income distribution
Work conditions
Adult literacy rate
Food availability
3.Indicators for the provision of health care
Quality of care


Health status indicators

Low birth weight
Nutritional status and psychosocial development of children
Infant mortality
Child mortality rate (1-4yrs)
Life expectancy at birth
Maternal mortality rate
Disease specific mortality
Morbidity incidence and prevalence
Disability prevalence


The Millennium Declaration was adopted by 189 nations and signed by

147 heads of state and governments during the UN Millennium Summit in

The MDGs places health at the heart of development.
These goals are an integral part of the roadmap towards implementation of
the UN Millennium Declaration.
Three of these eight goals are directly related to health.
The eight MDGs break down into 21 targets that are measured by 60

Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and other diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a Global Partnership for Development

Goal 4: Reduce child mortality

TARGET 5: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate

G4.T5.I13 - Under-5 mortality: Probability of dying between birth and exactly five years of age,
per 1000 live births.

G4.T5.I14 - Infant mortality rate: Probability of dying between birth and exactly one year of
age, per 1000 live births.

G4.T5.I15 - Proportion of 1-yr old children immunized for measles: The percentage of infants
reaching their first birthday fully immunized against measles (1 dose)

Specific: An objective should address a specific target or accomplishment. Which is

also typically linked to an identifiable change in rate, number, percentage or frequency.

Measurable: System, method or procedure for tracking and recording change in
behaviour or action towards which the objective is directed.
Achievable: Should be feasible, limited to available resources.
Relevant: should be capable of having a impact or making a change.
Time- based- Short term ( 2 to 3 months to 2 years )
Medium term ( 3- 5 years )
Long term ( 5- 7 years )



Establish a list of prioritised

objectives/ outcomes for

Translating policy goals and

objective into SMART


Management and instrument

criteria can be used to assess


Planning for outcome

Data to be used
Data to be collected
Instruments used
Who is going to do analysis

Provide a checklist- help to prioritize which objectives and outcomes are


Health not measured directly but using indicators
Indicator should be valid, sensitive, specific, reliable, relevant and feasible
Used in measuring, describing, comparing, identifying health needs and
planning and evaluation of health services
Use of multiple indicators arranged in profiles or patterns used to make
comparisons between areas , regions and nations.

Park K. Textbook of preventive and social medicine. 23 rd ed. Jabalpur, India: Bhanot; 2011.

Col Rajvir Bhalwar Public Health and Preventive Medicine The RED BOOK Diamond
Jubilee Edition New light publishers 2008;p 184-196.
SRS bulletin September 2014. Available from Census of India : Sample Registration System
(SRS) Bulletins.
Global health indicators WHO. Available from http://
Census 2011[online].2011[cited 2011 Sep 19] Available from URL: