Measuring the health of population s:

Role of Reproductive Health

Fundamentals of Public Health Course

Dr Amna Rehana Siddiqui

December 1, 2023

1
Session outline
• Assignment II
• Measuring population health
• Population dynamics
• Reproductive health
• MNCH coverage and indicators

2
Assignment Topics
1. Expanded Program on immunization
2. LHW Program for family planning
3. LHW program for PHC
4. Tuberculosis Program of Pakistan
5. Malaria control Program
6. Dengue control Program
7. Maternal, Neonatal and Child health Program
8. AIDS Control Program
9. Program for Prevention and control of Hepatitis
10. Program for Prevention and control of Blindness
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 Assignment II
Groups Topic Name
Group A Expanded Program on immunization

Group B LHW Program for PHC and family planning

Group C Tuberculosis Program of Pakistan

Group D Malaria control Program

Group E Maternal, Neonatal and Child health Program

Group F AIDS Control Program

Group G Program for Prevention and control of Hepatitis

Group H Dengue Control Program

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 Guidelines for writing a Report by Group
Each group will write a report and each member of the group will pick up each of the listed items

1. Inception of the Program: How and why the program started? (Name of student)
2. Goals and Targets of the program (Name of student)
3. Organizational structure and financing sources (Name of student)
4. Services offered by the program and the scale of services (Name of student)
5. Performance indicators / other indicators available from reports (Name of student)
6. Trends in the indicators and their comparison with other countries (Name of student)
7. Issues and Challenges faced by the Program (Name of student)

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Measuring Population Health
Role of Reproductive Health

6
Data sources
• Surveys at regular intervals
• PDHS
• MICS
• Program based (Nutrition, TB, Malaria, Hepatitis,
EPI, STEP, …)
• Surveillance Systems
• PBS
• HMIS
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8
Global Trends
Global health landscape is under rapid transformation.

People around the world are living longer; populations are getting older.

Child deaths are declining.

Disease burden is being defined by disability as opposed to premature

mortality.

The leading causes of death and disability are shifting from communicable
diseases in children to non-communicable diseases in adults.

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 Global Trends
Global trends differ across regions. In sub-Saharan Africa, communicable, maternal,
and newborn diseases and nutritional deficiencies continue to dominate.

LMIC are tackling poverty-related diseases, and need to prepare their health services
for a growing burden of non-communicable diseases and injuries.

In high-income countries, health budgets are steadily increasing relative to gross

domestic product due to ageing of the population, an ever-expanding array of medical
technologies, and greater demands of consumers for healthcare services.

For governments and other healthcare providers to be able to respond to these

challenges, high-quality comparable data on the size and trends in mortality and
morbidity are essential.
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Population Dynamics and maternal health

Population dynamics are strongly inter-linked with

development issues such as sexual and reproductive health
(including maternal health, family planning and HIV), the
needs of young people, gender equality and poverty
reduction.

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Mortality and fertility rate
• High fertility is strongly associated with child mortality .

• Closely-spaced children, lead to increased child deaths.

• A child born 18 or fewer months after the birth of the previous sibling, will
have three times the chance of dying than one born after a 36 months
interval.

• In addition, short birth intervals are associated with chronic malnutrition,

which in turn contributes to about 50% of all child deaths.
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Mortality and MCH health services
• Countries with high fertility find it difficult to keep up with the
demand for health services that help save mother’s children’s lives.
• In some regions infant mortality has increased due to decline in
vaccination coverage (Africa)
• Health services fail to keep pace with growing numbers of births and
children eligible for vaccination.
• Family planning: the most cost-effective way of reducing infant
mortality.
• An estimated 1 million of the 11 million infant deaths each year could
be averted, simply by ensuring children are born more than two years
apart.
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Crude death rate

# Deaths
Total Population

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 Mortality Rate
Annual mortality rate from all
causes (per 1,000 population) =

Total number of deaths

from all causes in one year
Number of persons in the X 1,000
population at midyear

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Overall MORTALITY RATE DENOMINATOR
• Rates usually calculated on an annual basis
• Midpoint population used – assume that all people are
observed for 1 year
• Implicitly, the midpoint population equals the number of
person‐years
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 Age specific mortality rate
Numerator & denominator need to have age restriction

Age & Cause specific mortality rate

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 Calculating years of potential years of life lost (YPLL) =

YPLL rate per 100000 = Sum (75-age at death) x 100,000

Total # of people <75 yrs

-age at death is subtracted from predetermined age (75 yrs)

-Infant dying at 1 yr loses 74 yrs (75-1) & 50 yr person loses 25 yrs (75-50)
-YPLL for each person is added together

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Maternal mortality fell by almost half between 1990 and 2015

Ref: WHO 2015:Trends in Maternal Mortality from 1990-2015

http://data.unicef.org/wp-content/uploads/2015/12/MMR_executive_summary_final_mid-res_243.pdf 21
UNICEF Report 2018 – Every Child
Alive
Pakistan is the riskiest place to
be born as measured by its
newborn mortality rate. For
every 1,000 babies born in
Pakistan in 2016, 46 died before
the end of their first month

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Where do 4 million newborns die?

1.5 million (38%

of all newborn
deaths) occur in
4 countries of
South Asia

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4 million newborn deaths – Why?
most due to preventable conditions

Two thirds of all neonatal deaths are in LBW infants

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When do they die?
Up to 50%
of neonatal
deaths are in
the first 24 hours

75% of neonatal
deaths are in
the first week –
3 million deaths

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Coverage rates are low!

How can these be scaled-up much faster?

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 Child Mortality Rates
Country IMR/1000 LB Child deaths<5y/1000LB Neonatal deaths/1000 LB % NND

1990 2019 1990 2000 2019 1990 2000 2019 2019

Afghanistan 120 47 178 129 60 74 61 36 60%

Bangladesh 100 26 144 87 31 64 43 19 62%
India 89 28 126 92 34 57 45 22 63%
Pakistan 107 56 139 107 67 64 57 41 62%
Uganda 107 33 182 146 46 39 32 20 44%
Singapore 6 2 8 4 3 4 2 1 36%
Infant mortality rate – Probability of dying between birth and exactly 1 year of age, expressed per 1,000 live births
Neonatal mortality rate – Probability of dying during the first 28 days of life, expressed per 1,000 live births
Under-five mortality rate – Probability of dying between birth and exactly 5 years of age, expressed per 1,000 live births

United Nations Children’s Fund, The State of the World’s Children 2021: Statistical Tables [On My Mind – Promoting,
protecting and caring for children’s mental health, UNICEF, New York, October 2021]. 27
 TRENDS IN MATERNAL HEALTH CARE-PAKISTAN

According to recent Pakistan Demographic and Health Survey (PDHS) 2017-18 , there has been a significant
increase in the trends of seeking Maternal healthcare.

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MATERNAL HEALTH CARE BY
REGION
In Pakistan, there is variation across regions in the trends of Maternal healthcare.

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Health indicators
Fig. 1.1.2 Top 10 global causes of deaths, 2016 (WHO Global
Health Estimates).
• Traditionally death rates

• Some illnesses like mental

illness & accidents, may not
increase probability of
dying.

• Indicators of years of
healthy life lost estimate the
impact of these non-fatal
diseases to help prioritize
interventions & strategies to
control hazards and disease
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Physical quality of life index (PQLI)
It consolidates three indicators (Morris MD)

-infant mortality,
-life expectancy at age one, and
-literacy.

Composite index , averaging the three indicators, giving

equal weights.(scaled 0 to 100, 0 being worst and 100
best)

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Human Development Index
• HDI reflects achievements in the most basic human
capabilities, viz, leading a long life, being knowledgeable and
enjoying a decent standard of living.

• "a composite index combining indicators representing three

dimensions - longevity (life expectancy at birth); knowledge
(mean years of schooling and expected years of schooling

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35
World map representing Human Development Index categories (based on 2021
data, published in 2022) Very high (≥ 0.800) High (0.700–0.799) Medium
(0.550–0.699) Low (≤ 0.549) Data unavailable

By Allice Hunter - United Nations Development Programme: Human Development Report 2021-22: 36
Life Expectancy Country Both Sexes Females Males
Ascending order

1 Hong Kong 85.29 88.17 82.38

2 Japan 85.03 88.09 81.91
3 Macao 84.68 87.62 81.73
4 Switzerland 84.25 86.02 82.42 https://www.
worldometer
5 Singapore 84.07 86.15 82.06 s.info
109 Bangladesh 73.57 75.60 71.80 /
demographic
136 India 70.42 71.80 69.16 s/life-
expectancy/ 37
150 Pakistan 67.79 68.90 66.77
Hong Kong's survival advantage over long-living, high-income
countries.

Hong Kong's leading longevity is the result of;

- fewer diseases of poverty
- suppressing the diseases of affluence.
- unique combination of economic prosperity
- low levels of smoking
- concurrent developments
- deliberate policies
- a framework that could be replicated
The Lancet Public Health Vol 6, Issue 12, E919-E913, December 01, 2021
38
How healthy is a given community?
-Indicators measure the health status of a community,
-Compare the health status of one country with the other
-Monitor the objectives and targets of a program
-WHO's guidelines define as variables which help to measure
changes.
-When changes cannot be measured directly, as for example
health or nutritional status.
-If measured sequentially over time, they can indicate
direction and speed of change and serve to compare different
areas or groups of people at the same moment in time .

39
Index versus Indicator
Health indicator as compared to health index
(plural: indices or indexes).

The term indicator is to be preferred to index,

whereas health index is generally considered
to be an amalgamation of health indicators .

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 Disability rates
(a) Event-type indicators
(a) Number of days of restricted activity
(b) Bed disability days
(c) Work-loss days (or school-loss days) within a specified period

(b) Person based indicators

a) Limitation of mobility: confined to bed, house, needs assistance
b) Limitation of activity: eating, washing, dressing, moving about,

c) limitation in major activity, e.g., ability to work at a job, house work

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Disease burden
• Disease burden is the impact of a health problem on a
given population

• Can be measured using a variety of indicators such as

mortality, morbidity, days lost to work or financial cost.

• This allows the burden of disease to be compared

between different areas, for example regions, towns or
electoral wards

• It also makes it possible to predict future health care

needs.
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Global Burden of Disease: Approach 1990
The GBD approach is a systematic, scientific effort to quantify the comparative magnitude of health
loss due to diseases, injuries, and risk factors by age, sex, and geography for specific points in time.

GBD 2010 was published in a series of papers in The Lancet in December 2012.

Several metrics that combine mortality and morbidity are in use.

They all have in common that health loss or health gain is measured in units of time.

There are two classes of population health measures: health expectancies and health gap measures.

Health expectancies extend the concept of life expectancy, a composite measure of age-specific
mortality rates in a given year in a population,and adjust years in a life table for loss of health from
non-fatal conditions.
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Life Table
Demographers calculate life expectancy in a life table by
applying the currently prevailing mortality rates in a
population to a hypothetical birth cohort.

In each row of the life table deaths and survivors of the birth
cohort are tracked at successive age groups until a top age
category (e.g. 80+ or 100+) in which everyone is assumed to
die.

A common interpretation of life expectancy is ‘the average

number of years a child born today can expect to live’.
Accounting for the currently prevailing mortality rates at each
age would continue to apply for the total life span of the birth
cohort. 44
 Global Burden of Disease Study

• Study carried out by the World Health Organisation.

• GBD researchers first devised the concept of DALYs

• Quantified the health effects of more than 100 diseases and injuries for
eight regions of the world, generating estimates of mortality and
morbidity by age, sex and region.

• The GBD Study is regularly updated, with most recent estimates based
on data from 2016, published in 2017.
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GBD
The study produced estimates for 187 countries and
21 regions and generated nearly 1 billion estimates
of health outcomes.

GBD 2010 was a collaborative effort among 488

researchers from 50 countries and 303 institutions.

The Institute for Health Metrics and Evaluation

(IHME) acted as the coordinating centre for the
study.

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47
 Quality-adjusted life years (QALY)
QALY is a measure of disease burden including both the
quality and quantity of life lived.

It is used in assessing the value for money of a medical

intervention.

The QALY is based on the number of years of life that

would be added by intervention.

Each year in perfect health=1.0 QALY and death=0

Half a year lived in perfect health is equivalent to 0.5

QALY (1 year x 0.5 utility value). 48
 QALY

• Measures the cost

effectiveness of health
QALYS interventions

• Number of years of life added

after a successful treatment

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Disability Adjusted Life Years
Purpose: Disease burden and effectiveness of intervention

Health service priority

Identify disadvantaged group
Targeting health interventions
Planning and evaluation of a program
Compare health status of settings

One DALY=one lost year of healthy life

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 Measuring Disease Burden
• Two indicators compare disease burden accounting for both
death and morbidity in a single measure:

• Quality-Adjusted Life-Years (QALY) are a measure of the life

expectancy corrected for loss of quality of that life caused by
diseases and disabilities. A year of life in perfect health is given
a QALY of 1

• Disability-Adjusted Life-Years (DALY) reflect the potential years of

life lost due to premature death (YLL) and equivalent years of
'healthy' life lost by being in states of poor health or disability.
One DALY can be thought of as 1 year loss of 'healthy' life.

• Increased DALYs Increased Burden 51

QALYs and DALYs
• Some health interventions do not prolong life but QoL; QALY take into
account both quantity (length) and the quality of life generated by a
healthcare intervention. A year of life in perfect health is given a
QALY of 1 whilst a year of complete functional impairment (e.g.
death) has a QALY of 0.

• DALY reflect the potential years of life lost due to premature death
(YLL) and equivalent years of 'healthy' life lost by being in poor
health or disability. These disabilities can be physical or mental. One
DALY can be thought of as one lost year of 'healthy' life.

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 # of Years Lost Due to Disability

Incidence Rate (I)

Length of illness (L)

Disability weight (DW)
0 = no limitation
0.2-0.6 = limited ability
0.8 + = Need assistance
Disability weight for Post
stroke individual = 0.85
Duration lived post
stroke=6 y
New case =1

YLD = I x D x DW = 1x6x0.85= 5.1 years

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Years of Life lost (YLL) to premature
deaths by disease X
Age Group Population # of Deaths Average Average LE YLL (Av LE x
age of [LE -Av-dth of deaths)
death age]
0-19 1000 1 19 63 63
20-49 1000 3 40 42 126
50-79 1000 4 65 17 68
80+ 1000 7 81 1 7
Total 4000 - - - 264
LE=82 years

DHO conducts a
study in his district
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Years Lost due to disability (YLD) by
disease X
Age Group Population Incidence (I) Average Disability YLD
duration of weight [I x L x DW]
disability (L) (DW)
0-19 1000 2 7 0.5 7
20-49 1000 9 16 0.5 72
50-79 1000 30 20 0.5 300
80+ 1000 18 3 0.5 27
Total 4000 - - - 406

DHO conducts a
study in his district
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 DALYS = YLL + YLD

• Years lost due to premature death (YLL)= 264

• Years of life lost in disability (YLD) = 406

• Total Years lost [DALYs] = 264+406 = 670

• DALYs = (670/4000)*1000

• DALYs = 167.5 DALYs/1000 persons

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Post Intervention DALYS
• After five years DHO tests the effect of intervention program

• DALYs = 130

• 167. 5 – 130 = 37.5 DALYs averted

• Increased DALYs averted shows good program

• Increased DALYs averted better program

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QALYs =# of years survived x utility weight
Death 0 -------utility weight-------1 Best possible health
•Medicine A adds 10 yrs life •Medicine B adds 6 years life
•Cost 10K USD /person •Cost 15K USD/person
•Utility weight =0.2 •Utility weight=0.9
•QALY =10 years x 0.2 =2 •QALY=6yearsx 0.9= 5.4
•Cost/QALY •Cost/QALY
=10000/2=5000 USD/QALY =15000/5.4=2778 USD/QALY

Which Medicine is better?

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Calculate years of life lost to disease (YLD)
• A person diagnosed with Diabetes Mellitus at the age of 50 years

• Lived with disease for 10 years and died at the age of 60 years

• Disability weight for DM=0.5

Incidence x Disease duration x disability weight

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Exercises
1. Compare Maternal Mortality Rates of countries of
your choice, justifying selection of countries.
Discuss causes of Maternal Mortality
2. Causes of Infant Mortality of countries of justifying
choice of selection of countries by comparing IMR
3. Compare Human Development Index of various
countries justifying country selection
4. Compare service utilization indicators by countries
of your choice justifying selection of countries
5. Compare nutritional indicators by countries of your
choice justifying selection of countries

60
References
• Morris MD. The Physical Quality of Life Index (PQLI). Dev Dig. 1980 Jan;18(1):95-109. PMID: 12261723.

• https://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-epidemiology/mea
sures-disease-burden

• http://www.who.int/healthinfo/global_burden_disease - Accessed 20/02/16

• Hay SI, et al. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and
injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic
analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1260-1344.

• Practical guidance for assessment of disease burden at national and local levels.
http://www.who.int/quantifying_ehimpacts/national/en/ - Accessed 20/02/16
•
• Hyder A, Puvanachandra P, Morrow RH. Measuring the health of populations: explaining composite
indicators Journal of Public Health Research 2012; volume 1:e35

• HALYS AND QALYS AND DALYS, OHMY: Gold MR, Stevenson D, Fryback DG. Similarities and
Differences in Summary. Measures of Population Health Annu. Rev. Public Health 2002. 23:115–34

• Oxford Textbook of Public Health 61