1. Objectives of the Meeting Health Metrics Network / WHO / UNICEF / Macro Int. meeting on Health Surveys July 10-11 2007, Calverton Maryland

2. Health surveys meeting 10-11 July 2007 Objectives To discuss how Health Metrics Network and its partners can strengthen the role of health surveys in country health information systems and develop an agenda to increase harmonization and alignment in the field of health surveys.

3. Health surveys meeting 10-11 July 2007 Four Specific objectives Potential outcomesSpecific objectives Plan for the development of standardized health survey modules with clear guidelines on their implementation. Start a process for the development of a standard set of core modules for key areas of public health significance, including guidelines about content, mode and frequency of application (1)(1) Review of current approaches proposed and used by HMN and other stakeholder to integrate household surveys into long-term country health information systems Discuss how to support the development of coordinated country survey programmes that can be integrated into country health information systems (2)(2) Plan for HMN and partners to engage in this area in a more systematic way Discuss current efforts and ways to strengthen country capacity for analysis and synthesis of data from surveys and other sources to inform policy (3)(3) More clarity on the needs, role, feasibility and efficiency of cause of death surveys, health examination surveys and local coverage surveys and agreement on the way forward Discuss key gaps in public health knowledge that can be addressed using surveys, notably on causes of death, health transition and local coverage (4)(4)

4. Health surveys meeting 10-11 July 2007 Survey modules Regular survey, variable contents Module A short Module A Module J long Module H long Module E long Module A 02468..10 ………………….………………Years…………….………………………..

5. Health surveys meeting 10-11 July 2007 Specific objective 1 Health survey modules Potential outcomesSpecific objectives Plan for the development of standardized health survey modules with clear guidelines on their implementation. Start a process for the development of a standard set of core modules for key areas of public health significance, including guidelines about content, mode and frequency of application (1)(1) (2)(2) (3)(3) (4)(4)

6. Health surveys meeting 10-11 July 2007 Household health surveys Current situation – demand side Monitoring MDGs and other major health initiatives Mortality, prevalence of some conditions, risk factors, coverage; equity Health transition: complex array of MCH /communicable / non-communicable diseases and conditions Single disease information: HIV/AIDS, malaria, tobacco, risk factors for NCD etc.

7. Health surveys meeting 10-11 July 2007 Mortality data collection and reporting by source among 57 low income countries, 1980-2004

8. Health surveys meeting 10-11 July 2007 Household health surveys Current situation – supply side Demographic and Health Surveys (DHS): US government Multiple Indicator Cluster Survey (MICS): UNICEF Living Standard Measurement Survey (LSMS), CWIQ: World Bank Reproductive Health Surveys: CDC Regional survey programmes: PAPCHILD, PAPFAM (Arab League) National health surveys: OECD, Mexico, Indonesia etc. World Health Survey (WHS): WHO, single round, aging survey, GCC Disease-specific surveys: AIS, MIS – US government, Gates, WB, CDC, WHO Emergency and conflict situations – NGOs, universities, WHO, possibly HNTS

9. Health surveys meeting 10-11 July 2007 Specific objective 2 Harmonization and streamlining Potential outcomesSpecific objectives (1)(1) Review of current approaches proposed and used by HMN and other stakeholder to integrate household surveys into long-term country health information systems Discuss how to support the development of coordinated country survey programmes that can be integrated into country health information systems (2)(2) (3)(3) (4)(4)

10. Health surveys meeting 10-11 July 2007 Capacity building efforts Survey-specific: analysis and further analysis of DHS, MICS, etc. Monitoring & Evaluation: indicators, framework, basic analysis, reconciliation of data from multiple sources to multi-level analyses. MEASURE Evaluation Statistical capacity building programmes: linking health statistical work to the broader efforts – World Bank, STATCAP, UNSD etc. Estimation processes, reconciling data from different sources, filling data gaps: HIV/AIDS – UNAIDS and partners; child and maternal mortality; immunization coverage; National Burden of Disease studies Epidemiology

11. Health surveys meeting 10-11 July 2007 Capacity building: who? Research institutions, universities Statistical offices Ministry of Health NGOs: local and iNGOs International staff: UN, donor staff Private sector Health statistics centers

12. Health surveys meeting 10-11 July 2007 Specific objective 3 Analytical capacity building Potential outcomesSpecific objectives (1)(1) (2)(2) Plan for HMN and partners to engage in this area in a more systematic way Discuss current efforts and ways to strengthen country capacity for analysis and synthesis of data from surveys and other sources to inform policy (3)(3) (4)(4)

13. Health surveys meeting 10-11 July 2007 Gaps in survey contents and methods Causes of death through verbal autopsy Addressing the full scale of the health transition: adult and child health; communicable and non-communicable diseases; acute and chronic conditions – health examination surveys Local surveys: quality assurance, sampling costs and quality, data processing, data analysis and dissemination

14. Health surveys meeting 10-11 July 2007 Specific objective 4 Filling gaps in knowledge Potential outcomesSpecific objectives (1)(1) (2)(2) (3)(3) More clarity on the needs, role, feasibility and efficiency of cause of death surveys, health examination surveys and local coverage surveys and agreement on the way forward Discuss key gaps in public health knowledge that can be addressed using surveys, notably on causes of death, effective coverage and local coverage (4)(4)

15. Health surveys meeting 10-11 July 2007

16. Standardized health survey modules Health surveys meeting Calverton Md 10/11 July 2007

17. Health surveys meeting 10-11 July 2007 Why standardized health survey modules Generate comparable data over time and between populations Limit the application of poorly tested survey modules and questions, often driven by the flavour of the day Promote a more flexible system of survey implementation using standardized modules More critical and systematic assessment of the utility, reliability and validity of survey questions

18. Health surveys meeting 10-11 July 2007 Survey modules Short and long versions Module A short Module A Module J long Module H long Module E long Module A Short Long

19. Health surveys meeting 10-11 July 2007 Survey modules Types of survey Module G Module F Module C Module B Module A Module E Module A MCH survey Single topic survey Module J Module H Module I Module G Module FModule E Module DModule C Module BModule A Comprehensive survey Duration and complexity of survey

20. Health surveys meeting 10-11 July 2007 Survey modules Regular survey, variable contents Module A short Module A Module J long Module H long Module E long Module A 02468..10 ………………….………………Years…………….………………………..

21. Health surveys meeting 10-11 July 2007 Survey modules Topic areas Mortality –Child mortality; birth history, recent deaths –Adult mortality: sibling survival, recent deaths –Causes of death: medical certificate, verbal autopsy Morbidity and health states –Self reported measures (domains) –Chronic diseases: algorithms, recall diagnosis; biological test –Acute diseases: recall recent symptoms Service coverage –MCH preventive interventions: health card, recall –MCH treatment interventions: facility utilization for recent conditions –Chronic conditions: recall treatment use Risk factors –Child: proxy reporting and biomarkers –Adult: self reported and biomarkers Health resources –Health expenditure: interviews –Responsiveness health system: self reported perceptions of interactions

22. Health surveys meeting 10-11 July 2007 Selection survey modules and contents Define a set of minimum standards for inclusion Standards could include: –public health relevance of the quantity of interest –Ability to phrase the interview questionin multiple languages –ability to accurately measure the quantity of interest through epidemiological validation studies –high level of reliability proven through surveys. Should not only apply to interview questions but also to biological and clinical data collection

23. Health surveys meeting 10-11 July 2007 Possible criteria Contents –Minimal set of questions –Expanded set of questions –Key indicators Evaluation data quality –Measurement issues for quantity of interest –Accuracy at individual level –Accuracy at population level –Heaping and other measures of quality –Biases by determinants Validation studies –Gold standard –Methodological issues –External validation (plausibility) External considerations –Surveys versus other methods of data collection Languages

24. Health surveys meeting 10-11 July 2007 Example 1: Child mortality module (direct method, birth history) Relevance –The measurement of age-specific mortality rates in childhood in surveys is a core health indicator for all countries where measurement of birth and deaths through civil registration systems is not complete. Indicators –Age-specific mortality rates: under-five mortality per 1,000 live births; neonatal, postneonatal, infant, early child (1-4 years) mortality rates; rates are usually estimated for five year periods but can be estimated for shorter periods of time if samples are large. Data collection –All births and deaths over a specified time period prior to the interview; –Full birth history: questions on date of birth, survival status and age at death for all children born to a mother Truncated birth history (alternative): as in full birth history Evidence –Full birth history method: –Empirical evidence of successful application, validation studies? –Truncated birth history Data quality issues –Omission of births and deaths, more common for neonatal deaths –Displacement of births out of five year period to avoid health section elsewhere in questionnaire –Increased mortality in mothers 15-49 years, e.g. due to HIV/AIDS

25. Health surveys meeting 10-11 July 2007 Example 2: Maternal and neonatal health preventive interventions Relevance –Core set of proven interventions enhancing maternal and neonatal health - define interventions Indicators –Utilization of care: antenatal care, delivery care, postnatal care –Recall of the contents of the services: health examination received (blood pressure, blood tested for anemia etc.) –Recall period usually 3 or 5 years Data needs –For all births (child still alive or not) or pregnancies in a specified number of years prior to the survey - usually, 3 or 5 years –Visit to antenatal care provider, type of provider; number of visits; contents of care –Attendance at delivery, type of provider; place of delivery; complications at delivery –Visit to postnatal care provider, type of provider; contents of care Evidence review Data quality issues –Recall problems with number of visits –Recall problems with care contents –Poor definition of what constitutes a postnatal care visit

26. Health surveys meeting 10-11 July 2007 Process A review committee would need to be established, including technical experts on surveys, measurement etc. Mandate should be extended to later include biological and clinical tests as well. WHO / HMN could lead the review process and publish the standards jointly with partners involved