By Hatim Jaber MD MPH JBCM PhD 5-6-2017 Faculty of Medicine Public Health (31505291)الصحة العامة Lecture 2 Indicators and determinants of global health By Hatim Jaber MD MPH JBCM PhD 5-6-2017

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

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.

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

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.

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

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

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

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

Health Indicators

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

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

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

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

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

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

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

Indicators of Health

Global health indicators: highlighting the health inequality

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

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

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

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.

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

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

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)__* 100000 Estimated midyear population

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.

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.

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

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

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

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______

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)

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)

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.

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.

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)

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

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.

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

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

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

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

Increasingly diverse with migration Increasing women in workforce So, what’s the world going to look like in the next 20-40 years…by 2025 or 2050? Increasingly urban Increasingly old Increasingly diverse with migration Increasing women in workforce

Global trends in longevity

Global Declines in Fertility

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