Sources of Public Health Data

SOURCES OF PUBLIC
HEALTH DATA IN
EPIDEMIOLOGY
Presented by-
Dr. Ankit Mohapatra
DEPARTMENT OF PUBLIC HEALTH
DENTISTRY
1

CONTENTS
 Data
 Information
 Intelligence
 Health information system
 Sources of data
 Census
 Registration of vital events
2

 Sample registration system
 Notification of diseases
 Hospital records
 Disease registers
 Record linkage
 Epidemiological surveillance
 Other health service records
3

 Environmental health data
 Health manpower statistics
 Population surveys
 Other routine statics related to health
 Non – quantifiable information
 Health management information system
4

 Central Bureau of health Ingelligence
 National health profile
 WHO Reports
 Global Health Observatory
 World bank
 Health stats
5

 Summary
 Conclusion
 Reference
6

DATA
• It is a piece of information, discrete observations of attributes or
events, especially those that are apart of a collection to be
analysed.
7

INFORMATION
• Data that is accurate and timely, specific and organized for a
purpose, presented within a context that gives it meaning and
relevance, and can lead to an increase in understanding and
decrease in uncertainty.
8

• The manipulated and processed form of data is called
information.
• More meaningful than data.
• Used for making valuable decisions.
Data is used as input for processing and
information is output of this processing
9

INTELLIGENCE
• It is the transformation of information through integration and
processing with experience and perceptions based on social
and political values.
DATAINFORMATIONINTELLIGENCE
10

Health Information System ( HIS )
It is a mechanism for the collection, processing, analysis and
transmission of information required for organizing and
operating health services, and also for research and training
11

Primary Objective
• Provide reliable, relevant, up-to-date, adequate, timely and
reasonably complete information for health managers at all
levels.
• Sharing of technical and scientific information by all health
personnel participating in the health services of a country.
12

• Also to provide at periodic intervals, data that will show the
general performance of the health services
• Assist planners in studying their current functioning and trends
in demand and work load.
13

Requirements to be Satisfied by
Health Information Systems
14
• Be population-based.
• Avoid the unnecessary agglomeration of data.
• Be problem-oriented.
• Employ functional and operational terms.
• Express information briefly and imaginatively (e.g. tables,
charts, percentages).
• Make provision for the feed-back of data.

Components of a Health
Information System
15
• Demography and vital events
• Environmental health statistics
• Health status : mortality, morbidity, disability, and quality of
life
• Health resources : facilities, beds, manpower utilization and
non-utilization of health services attendance, admissions,
waiting lists

• Indices of outcome of medical care
• Financial statistics ( cost, expenditure) related to the
particular objectives
16

Why is it Important?
• Good management is a prerequisite for increasing the
efficiency of health services.
• Improved health information system is clearly linked to good
management.
• Information is crucial at all management levels of the health
services from periphery to the centre.
17

• It is required by policymakers, managers, health care
providers, community health workers.
• “Changing the way information is gathered, processed, and
used for decision-making implies changing the way an
organization
18

• The ultimate objective of health information
system is not “to gain information” but “to
improve action”
19

USES of Health Information
• To measure the state of health of a community, and to identify
its health problems , and medical and health care needs .
• For comparison
• For planning , administration and evaluation of health care
services and programmes.
• For research into community health problems
20

• For assessing accomplishment of effectiveness and efficiency
of health services.
• Assessing level and attitudes of satisfaction of beneficiaries
with health system
21

• Census is an important source of health information.
• It is the complete count of a country population.
• Taken in most countries of the world at regular intervals,
usually of 10 years.
24

• Census means “to enumerate”.
• It consists of a sequence of activities concerned with
collection, collation and factual presentation of data pertaining
to social, demographic and health related factors, in respect of
a nation (or large population group), undertaken periodically,
and having some sort of statutory back - up for it to be
undertaken.
25

• The periodicity of census is generally kept as once in ten
years, and it is generally undertaken during the first quarter of
the first year of the decade. It was started in 1881.
• A legal authority constituted by the government is generally
made responsible for the collection, collation and publication
of census data.
26

28
It’s the biggest source of comprehensive data on :
• Demography
• Economic Activity
• Literacy & Education
• Housing & Household Amenities
• Urbanization
• Fertility and Mortality
• Scheduled castes and Scheduled Tribes
• Language, Religion & Migration

29
LEGAL PROVISIONS
CENSUS OPERATIONS
Census Act , 1948
&
Census Rules, 1990

methods of collection of data
in a census :
 facto method : Persons are enumerated according to their
location at the time of enumeration.
 Extended de-facto method used in india since 1941.
30

(b) de - jure method : This method is used in developed
countries like U.S.A. The persons are assigned according to
their “usual” place of residence and not according to their
location at the time of census, as practiced in de - facto method.
 This method provides a better indication of permanent
population and related socio - demographic factors of an area,
though it is more expensive and needs much better level of
training of census data collectors
31

Background
32
• This is the first set of final data from the population enumeration
exercise was held in February 2011
• So far the data released from census 2011 pertained to
houselisting and housing census covering
• All households
• SC & ST households
• Female headed households
• Slum households

Data Release – List of
Indicators
33
 Population
 Density
 Population (0-6)
 Scheduled Castes Population
 Scheduled Tribes Population
 Number of Literates
 Number of Workers (Total, Main, Marginal)
 Category of Economic Activity (Cultivators, Agricultural
Labourers, Household Industry Workers, Other Workers)
 Non Workers

• The primary function of census is to provide demographic
information such as total count of population and its
breakdown into groups and subgroups such as age and sex
distribution, it represents only a small part of the total
information collected.
34

• Census contains information which are not only demographic,
but also social and economic characteristics of the people, the
conditions under which they live, how they work, their income
and other basic information.
• These data provide a frame of reference and base line for
planning, action and research not only in the field of medicine,
human ecology and social sciences but in the entire
governmental system.
35

• Without census data, it is not possible to obtain quantified
health, demographic and socioeconomic indicators.
36

37
2001 2011
States/UTs 35 35
Districts 593 640
Tehsils 5463 5767
Towns 5161 7742
Villages 593732 608786
Households 194 Million 240 Million
EBs 19.82 lakhs 23.56 lakhs
Population 1.03 Bn 1.20 Bn
Administrative units

STRENGTHS
• Covers the whole population; small geographic units
• Equity information
• Data for mortality and fertility for different levels of
geographic areas
• Important source for planning and implementation of various
activities and programs at smallest geographic unit
38

39
Census 2011 was held in two
phases
PHASE 1
• House listing & Housing Census and
• Collection of data on National Population Register
April to September 2010

House listing Phase
Two forms – Each household
First form
(House listing form)
Second form
(NPR form)
New initiative in 2011
40

Predominant material of roof,
wall & floor of the Census
House
• Use & Condition of Census
House
• Name of Head of HH
• Ownership status
• Number of living rooms
• Number of married couples
• Amenities available:
• Main source and availability
of drinking water
• Main source of lighting
• Latrine within the premises
• Type of latrine
• Waste water outlet
connected to
• Amenities available (contd):
• Bathing facility within the
premises
• Availability of kitchen
• Fuel used for cooking
• Assets possessed by the
household
• Radio/Transistor
• Television
• Computer/Laptop
• Telephone/Mobile phone
• Bicycle
•
Scooter/MotorCycle/Moped
• Car/Jeep/Van
• Availing banking services
QUESTIONS (35)
41

It is a register of usual residents
of the country.
Comprehensive data base.
Comes under citizenship act
1955 and citizenship rules 2003.
NPR (National Population Regis
42

BIOMETRICS COLLECTED FROM PERSONS 5 YEARS
AND ABOVE
( Photograph, 10 fingerprints , 2 Iris prints )
DETAILS FOR ALL PERSONS
43

PHASE 2
Population Enumeration
In snow bound areas
• Population Enumeration: 11th to 30th Sep 2010
• Revision Round : 1st to 5th Oct 2010
(Reference Date: 0:00 Hours of 1st October 2010)
In all other areas
• Population Enumeration: 9th to 28th Feb 2011
• Revision Round : 1st to 5th Mar 2011
(Reference Date: 0:00 Hours of 1st March 2011)
45

Revisional Round
Enumerator goes back - household
2 Questions
Any new visitor (not
enumerated already) since
last visit but before
0.00hrs of 1st March 2011
If Yes
fill in fresh form
Any birth / death
since last visit but before
0.00hrs of 1st March 2011
If yes
 Update form - birth
 Cancel entry - death
47

Census in School
• Sensitize the school students about the ensuing Population
Enumeration in Census 2011
• Covers about 60 to 80 schools in each of the 640 Districts in the
country and is specifically designed for participation by the
students of the entire school and the students of class VI, VII
and VIII in particular.
48

Activities
• Reading the message on the Census and its importance during the
School Assembly.
• Census Awareness Quiz .
• Display of Maps and Data Sheets.
• Poster Making Competition on the topic ‘Population
• Census Week
7th to 12th February 2011
49

LIMITATIONS
• Two types of error
-coverage and content error.
• Age misreporting.
• There is no direct question on deaths in Indian census.
• Unable to give the demographic estimates for the period
between two censuses.
51

Registration of Vital Events
• It keeps a continuous check on demographic changes.
• If registration of vital events is complete and accurate, it can
serve as a reliable source of health information.
• Importance is therefore given to the registration of vital events
in all countries.
• It is the precursor of health statistics and it has dominated the
health information system.
52

Defination
• “Legal registration, statistical recording and reporting of the
occurrence of, and the collection, compilation, presentation,
analysis and distribution of statistics pertaining to vital events,
i.e., live births, deaths, foetal deaths, marriages, divorces,
adoptions, legitimations, recognitions, annulments and legal
separations"
-- UNITED NATIONS
53

• The origin of vital registration begins as early as 1869 and
death by social class was recorded in England beginning in
1921.
54

• Vital events are
 Live births
 Deaths
 Foetal deaths
 Marriages
 Divorces
 Adoptions
55

• In 1873, the Govt, of India had passed the Births, Deaths and
Marriages Registration Act, but the Act provided only for
voluntary registration.
• Registration system in India tended to be very unreliable, the
data being grossly deficient in regard to accuracy, timeliness,
completeness and coverage.
56

Reasons
• Lack of uniformity in collection, compilation and transmission
of data which is different for rural and urban areas.
• Most importantly multiple registration agencies (e.g., health
agency, panchayat agency, police agency and revenue agency).
57

The Central Birth & Registration
Act 1969
It came in force on 1st April 1970.
 Act provides for compulsory registration of birth & deaths &
other Vital events throughout the country.
The time limit for registration of birth is 14 days & that of
death is 7 days.
In default a fine of Rs. 50/- can be imposed.
58

Still there is lack of registration of birth (38-97%) & in death
(3-83%).
It is because of illiteracy, ignorance, lack of concern &
motivation.
The Act also fixes the responsibility for reporting births and
deaths. While the public are to report events occurring in their
households, the heads of hospitals, nursing homes, hotels, jails
or dharmashalas are to report events occurring in such
institutions to the concerning Registrar. 59

LAY REPORTING
• Lay Reporting is the collection of information , its use, and its
transmission to other levels of the health system by non-
professional health workers.
• Due to slow progress in the development of a comprehensive
vital registration system, some countries have attempted to
employ first-line health workers (e.g., village health guides) to
record births and deaths in the community.
60

• Important functions of a primary health worker is to collect
and record data on vital events and other health information in
his or her community.
61

• In large majority of countries properly functioning vital events
registers do not exist and it is necessary to resort to
demographic surveys, etc. as an alternative source.
• But they never lead to the desired goal of complete recording
of all vital events in a country.
• Therefore it may be regarded as a temporary source rather than
a primary one.
62

Use of Vital Records
Some common uses of vital records in vital statistics are:
1. Preparing population estimates and projections;
2. Cohort and period studies;
3. Construction of life tables;
4. Preparing health indicators, such as infant mortality rates,
neonatal mortality rates, post‐neonatal mortality rates, maternal
mortality rates, etc.
63

5. Starting points in retrospective epidemiological studies;
6. Public health programmes in the absence of morbidity data, or
for health education;
7. Maternal and child health services for planning and evaluation;
8. Fertility data in family planning.
64

Sample Registration System (SRS)
• One of the largest continuous demographic household sample
survey in the world.
• The Government of India, in the late 1960s, initiated the
Sample Registration System that is based on a Dual Recording
System as Civil Registration is deficient in India.
65

• In the Sample Registration System, there is a continuous
enumeration of births and deaths in a sample of villages/urban
blocks by a resident part‐time enumerator and then, an
independent six monthly retrospective survey by a full time
supervisor.
66

• The eighth report of the WHO Expert Committee on Statistics
recommended that hospital statistics be regarded in all
countries as an integral and basic part of the national statistical
programme.
67

68
Objectives:
• To provide annual reliable estimates of birth and death rates at
the state and national levels for rural and urban areas
separately.
• To provide other measures like fertility and mortality(TFR,
IMR, CMR, etc).
• To study risk factors and household determinants through
causes of deaths.

The main components of SRS are:
• Base-line survey of the sample unit
• Continuous (longitudinal) enumeration of vital events
pertaining to usual resident population by the enumerator
• Independent retrospective half- yearly surveys
• Matching of events
• Field verification of unmatched and partially matched events.
69

STUDY DESIGN
• Uni-stage stratified simple random sample without
replacement
• A simple random sample of enumeration Block is selected
without replacement from each of the size classes of
towns/cities in each State/UT.
70

SAMPLE DESIGN
71
The sample unit in
• Rural areas -village or a segmented village
 Population ≤ 2000- Forming stratum-I
 Population ≥ 2000- Forming stratum-II
• Urban area- census enumeration block
Divided in 4 strata based on size
 Population ≤ 100000- stratum-I
 Population ≥ 100000 ≤ 500000 - stratum-II
 Population ≤ 500000- stratum-III
 Four metro cities of Delhi, Mumbai, Chennai and Kolkata
-separate strata

72
Number of sample units at
different replacement period
The revision of SRS sampling frame is undertaken
in every ten years based on the results of latest
census.

73
SRS Reports
Publication-Annually by Office of the Registrar General, GOI.
The present report ‘SRS Statistical Report, 2014’ is the seventh
report of the new sample based on Census 2011 frame
Report contents-
• Age-sex Structure
• Age specific fertility rate
• Other fertility indicators
• Age specific death rates by sex
• Other selected mortality indicators
• Medical attention at birth
• Medical attention received before death

74
SRS bulletin
• Regular - half yearly intervals
Provide estimates of –
• Birth and death rates
• State & national level separately for
Rural & Urban

Features of the New SRS
75
• Provide vital rates at NSS Natural Division level (which is a
group of contiguous districts) for rural areas.
• It will also provide reliable estimates of IMR at NSS Natural
Division level for rural areas.
• Use of female literacy as a stratifying factor in urban areas
• Separate estimates for four metros viz. Delhi, Kolkata,
Chennai & Mumbai.

• However it is not a substitute for CRS. It does provide
estimate at lower level of aggregation.
• Even at the state level questions are being raised about the
sample size of the SRS to provide reliable estimate.
• The sampling units in SRS are revised at an interval of 10
years.
(Registrar General of India,2011).
76

• The SRS in India now covers most of the country. It is a major
source of health information.
• Since the introduction of this system, more reliable
information on birth and death rates, age-specific fertility and
mortality rates, infant and adult mortality, etc. have become
available.
77

Civil Registration System (CRS)
• Civil Registration System (CRS) is a system of continues
recording of vital events such births, deaths, marriages and
divorces etc.
• It is generally a compulsory recording done according to legal
requirements of country as per provisions made by official
order or rule.
78

• Unlike census which gives idea of a population of a given area
at point of time, it helps in understanding in a continues
manner the additions and exits of people in the area apart from
maintenance of per month records on births, deaths and
marriages as legal documents and estimates of changes in the
population.
79

• Helps in understanding of the progress of different
socioeconomic programmes including maternal and child
health care programmes.
• In India the registration of vital events has been in vogue for
more than a century. In 1969 registration of births and death
act was implemented.
• The registration of births and deaths was made compulsory
and the act unified the system of registration replacing the
diverse laws existed earlier
80

• CRS in India at the national level works under the Registrar
General of India (RGI).
• He coordinates the activities of the chief registrars of the states
who are the chief executive authorities in the state for carrying
out the provisions made in the act of 1969.
81

• It collects a variety of information on each birth and death
recorded.
• For birth we have date of occurrence/registration; place of
birth; order of birth; sex of child; age of mother; literacy;
occupation and religion of parents and type of medical
attendance at birth are noted.
82

• In case of death the system provides the data on date of
occurrence/registration; place of death; age; sex; marital status;
religion; and occupation of the deceased; cause of death and
whether it is medically certified and type of medical
attendance received
83

• Civil registration collects this information on a continuous
basis and is the only source that provides individuals with a
legal document.
• United Nations Children’s Fund (UNICEF) and a number of
non-governmental organizations (Plan International, Save the
Children Fund, World Vision, etc.) have particularly promoted
the human rights aspects of registration.
84

• While the United Nations Statistics Division (UNSD), United
Nations Population Fund (UNFPA) and World Health
Organization (WHO) focus more on the statistical aspects of
civil registration.
85

Current Senario
• Level of reporting helps in reviewing the registration system
and defining measures that would be necessary to improve
registration levels across the country.
• The level of reporting is 95.6% at National level during 2013.
• Such reporting level by rural and urban registration units are
about 95.5% and 98.0% respectively
86

BIRTH REGISTRATION
• The number of registered births has reached to 22.5 million in
2013 as compared to 8.4 million in 1982.
• 17 States/UTs have achieved the target of cent per cent level of
registration of births during 2013.
• 13 among 20 major States have crossed 90 percent level of
registration of births. These are Andhra Pradesh, Assam,
Gujarat, Haryana, Karnataka, Kerala, Maharashtra, Odisha,
Punjab, Rajasthan, Tamil Nadu, Telangana and West Bengal.
87

• After excluding 2 most populous and poor performing States
namely Bihar and Uttar Pradesh, the level of registration of
births comes out to be 96.8%.
• The level of registration of births for other States/UTs is
higher than that of Southern as well as EAG States & Assam
persistently over the period of 2004-2013.
• The birth rate worked out to 18.1 per thousand populations
during 2013 as compared to 22.1 from SRS birth rates.
88

• The gap between the birth rates based on CRS and SRS is
narrowing down over the year which is a good indication of
improvement in the functioning of CRS.
• Birth Rate reported under CRS in some of the better
performing States namely Assam, Gujarat, Kerala,
Maharashtra and Punjab is on higher side than that of SRS
birth rate.
89

• This difference may be due to the fact that SRS estimates are
based on usual residence while events registered at the place of
occurrence irrespective of the place of residence under CRS.
90

DEATH REGISTRATION
• 8 States/UTs have achieved the target of cent per cent level of
registration of deaths during 2013.
• 8 among 20 major States have crossed the level of registration
of deaths of 90 percent. These are Andhra Pradesh, Haryana,
Karnataka, Kerala, Maharashtra, Punjab, Tamil Nadu and
Telangana.
91

• 2 most populous and poor performing States namely Bihar and
Uttar Pradesh, the level of registration of deaths comes out to
be 85.2%.
• More infant deaths have been registered in urban area than the
rural area.
92

Medical Certification of Cause of
Death (MCCD)
• Reliable cause-specific mortality statistics is required on a
regular basis by Administrators, Policy Planners, Researchers
and other Professionals for evidence-based decision-making
with regard to resource allocation, monitoring of indicators,
identifying the priorities for programs and other related
activities in the area of Public Health.
93

• Keeping this in view, the scheme of Medical Certification of
Cause of Death (MCCD) was introduced in the country under
the provisions of Registration of Births and Deaths (RBD) Act,
1969.
• During the Third Five Year Plan period, Office of the
Registrar General, India launched a programme of action, both
short term as well as long term through a plan scheme, for
development of a comprehensive system of vital statistics in
the country
94

USES
• Civil registration has a dual purpose − legal on the one hand,
and statistical, demographic and epidemiological on the other.
95

STRENGHTS
• Yearly data for causes of death disaggregated by age, sex, type
of residence
• Data on trends related to vital events
96

LIMITATIONS
• Incompleteness and poor quality of data on causes of death
recording
• Lack of proper implementation at lower geographical unit
97

Notification of Diseases
• Historically notification of infectious diseases was the first
health, information sub-system to be established. The primary
purpose of notification is to effect prevention and/or control of
the disease.
• Notification is also a valuable source of morbidity data i.e., the
incidence and distribution of certain specified diseases which
are notifiable.
98

• Usually diseases which are considered to be serious menaces
to public health are included in the list of notifiable diseases.
• Lists of notifiable diseases vary from country to country, and
also within the same country between the States and between
urban and rural areas.
• As per International Health Regulation , Cholera, Plague ,
Yellow Fever are to be notified to WHO, Geneva.
99

• The primary purpose of notification is to effect prevention &
control of disease.
• Mainly Health workers at grass-root level report the disease.
• International Surveillance is required for Louse borne
Typhus, relapsing Fever, Polio, Influenza, Malaria, Rabies,
Salmonellosis.
100

• The notification system is linked up with the vital statistics
machinery and the reporter is often the village chowkidar or
headman.
• With the introduction of village Health Guides and
multipurpose workers, the reporting responsibility is now
shifted from the village chowkidar to the health workers.
101

• Notification is an important source of health information,
• Limitations :
(a) notification covers only a small part of the total sickness in
the community
(b) the system suffers from a good deal of under-reporting
(c) many cases especially atypical and subclinical cases escape
notification due to non-recognition, e.g., rubella, non-
paralytic polio, etc
102

• Notification provides valuable information about fluctuations
in disease frequency.
• It also provides early warning about new occurrences or
outbreaks of disease.
• The concept of notification has been extended to many non-
communicable diseases and conditions notably cancer,
congenital malformations, mental illness, stroke and
handicapped persons.
103

Hospital Records
• The eighth report of the WHO Expert Committee on Statistics
recommended that hospital statistics be regarded in all
countries as an integral and basic part of the national statistical
programme.
• In India, where registration of vital events is defective and
notification of infectious diseases extremely inadequate,
hospital data constitute a basic and primary source of
information about diseases prevalent in the community.
104

USEFULNESS
• Geographic sources of patients
• Age and sex distribution of different diseases and duration of
hospital stay
• Distribution of diagnosis
• Association between different diseases
• The period between disease and hospital admission
• The distribution of patients according to different social and
biological characteristics,
• The cost of hospital care. 105

Drawbacks
1. They consitute the “tip of the ICE-BERG.”(they provide
information on only those patients who seek medical care,
but not on a representative sample of the population. )
2. Admission policy varies from hospital to hospital.
3. There are no precise bondaries to the catchment area of the
hospital.
4. Population served by a hospital.
106

Disease Registers
• "Registration" implies something more than "notification".
• Permanent records are established, those cases are followed
up, and that basic statistical tabulations be prepared both on
frequency and on survival.
• Patients on a register should frequently be the subjects of
special studies
107

• Morbidity registers exist only for Stroke, MI, TB, Leprosy,
Congenital Rubella & congenital defects.
• If the reporting system is effective, & the coverage is on
national basis, than register can provide useful data on disease
specific morbidity & mortality.
108

• Disease registers allow follow-up of patients and provide a
continuous account of the frequency of disease in the
community.
• In the absence of a defined population base, useful information
may be obtained from registers on the natural course of
disease, especially chronic disease in different parts of the
world.
109

Disease Registry in India:
National Centre for Disease Informatics and Research, ICMR
operates following disease registries in the country:
• National Cancer Registry Programme
• Registry of people with diabetes in India with young age at the
onset
• National stroke registry program
110

National Cancer Registry
Programme
• History of the registries in India can be traced long back since
1963 with the establishment of Bombay Cancer Registry.
• The National Cancer Registry Programme (NCRP) was
commenced by the Indian Council of Medical Research
(ICMR) with a network of cancer registries across the country
in December 1981.
111

• Three Population Based Cancer Registries (PBCRs) at
Bangalore, Chennai and Mumbai and three Hospital Based
Cancer Registries (HBCRs) at Chandigarh, Dibrugarh and
Thiruvananthapuram were commenced from 1 January 1982
• The PBCRs have gradually expanded over the years and as of
now there are 23 PBCRs under the NCRP network.
112

Registry of People with diabetes in
India with young age at the onset
• Registry of People with diabetes in India with young age at the
onset (YDR) was started in the year 2006 with five
collaborating centres recruiting patients across India.
• Three more centres were added to the programme later, in the
year 2009.
• These centres were selected on the basis of the anticipated
quantum of enrolled patients with young onset diabetes.
113

• The eight collaborating centres recruited patients from their
own hospital/institution as well as from the interacting
reporting centres.
114

National stroke registry program
• The plan by the National Centre for Disease Informatics and
Research, Bangalore to set-up a stroke registry website and
invite registrations is based on the recommendations of the
Research Area Panel on Stroke meeting held on 26 April 2012.
• Accordingly on 11 December 2012 a website
“strokeregistryindia.org” was been created.
• No specific method or module for setting up of Population
Based Stroke Registry (PBSR) has been finalized as yet.
115

STRENGTHS
• Used for service management
• Yearly data on services rendered, Monthly data possible and in
few cases monthly data are being compiled
• Basis for disease surveillance systems to detect outbreaks
• Useful in measuring performance of facilities and its
monitoring
• Generates data on state specific schemes for local planning and
surveillance
116

LIMITATIONS
• Excludes those not accessing the services (inbuilt selection
bias)
• Incompleteness and data quality, Reporting problems,
irregularity and Data duplication & inconsistency
• Private sector often not included
• Lack of data analysis including disaggregation and use of
service statistics in local area planning
117

Record Linkage
• It is the process of bringing together records relating to one
individual.
• “Medical Record Linkage” is the assembly & maintenance
for each individual in a population , of a file of the more
important records relating to his health.
• The main drawback is the volume of data it can accumulate.
118

• The events commonly recorded are birth, marriage, death,
hospital admission and discharge.
• Other useful data might also be included such as sickness
absence from work, prophylactic procedures, use of social
services, etc.
• It is used only on limited scale e.g. in twin studies & genetic
diseases, morbidity, chronic disease epidemiology and family.
119

Epidemiological Surveillance
• Surveillance systems are often set-up in case where a disease
is endemic e.g., Malaria, tuberculosis, leprosy, filariasis, etc.
• To report New cases.
• To know the result of efforts to control the diseases.
• These programmes have yielded considerable morbidity and
mortality data for the specific diseases.
120

Integrated Disease
Surveillance Project
Overview
121

Integrated Disease Surveillance
Project (IDSP)
 Launched in November 2004.
Aims:-
• To detect early warning signals of impending outbreak and help
initiate an effective response in time
• To provide essential data to monitor progress of on-going
disease control program and help allocate resources more
efficiently
122

Methods of Data Collection
• Routine reporting; Passive surveillance
• Sentinel surveillance
• Active surveillance
• Vector surveillance
• Laboratory surveillance#
• Sample Surveys
• Outbreak investigation
• Special studies
125

Frequency of Reporting
Many epidemic prone dis. has short Incubation Period
therefore monthly review might delay the timely identification
of an outbreak
• Weekly reporting – if clustering of cases (Test & Pair wise),
immediate field visit to avert outbreak
• Daily report – once outbreak is identified (neighboring areas need
to set up surveillance activities to rule out spread)
• After outbreak subsided weekly report should be continued
for at least double the IP
126

Reporting Forms
• Form ‘S’ (Suspect Cases) by Health Workers (Sub Centre)
• Form ‘P’ (Probable Cases) by Doctors (PHC, CHC, Pvt.
Hospitals)
• Form ‘L’ (Lab Confirmed Cases) from Laboratories
127

Types of case definitions in use
Case
definition
Criteria Users
Syndromic
(suspect)
“S” forms
Symptoms/ Clinical
pattern
Paramedical personnel and
members of community
Presumptive
(Probable)
“P” forms
Typical history and
clinical examination
Medical officers of PHC
and CHC
Confirmed
“L” forms
Clinical diagnosis by a
medical officer and
positive laboratory
identification
Medical officer and
Laboratory staff
128

129
Target Diseases Covered under IDSP
1. Regular weekly Surveillance
Vector Borne Disease : 1. Malaria
Water Borne Disease : 2. Acute Diarrheal Disease (Cholera)
3. Typhoid
4. Jaundice
Respiratory Diseases : 5. Tuberculosis
6. Acute Respiratory Infection
Vaccine Preventable Diseases : 7. Measles
Diseases under eradication : 8. Polio
Other Conditions : 9. Road Traffic Accidents
(link up with police computers)
Other International commitments: 10. Plague, Yellow fever
Unusual clinical syndromes : 11. Menigoencephalitis/ Respiratory
Distress, Hemorrhagic fevers, other
undiagnosed conditions

130
2. Sentinel Surveillance:
Sexually transmitted diseases
/Blood borne : 12. HIV, HBV, HCV
Other Conditions : 13. Water Quality
14. Outdoor Air-Quality
3. Regular periodic surveys:
NCD Risk Factors : 15. Anthropometry,
Physical Activity,
Blood Pressure,
Nutrition, Tobacco
4. State specific diseases: e.g. Dengue, JE,
Leptospirosis

Other health service records
• A lot of information is found in the records of hospital out-
patient departments, primary health centres and subcentres,
polyclinics, private practitioners, mother and child health
centres, school health records, diabetic and hypertensive
clinics, etc.
131

Environmental Health Data
• It may be the data of air water & noise pollution, industrial
intoxicants, inadequate waste disposal and other aspects of the
combination of population explosion with increased
production and consumption of material goods.
• Environmental data can be helpful in the identification and
quantification of factors causative of disease.
132

Health Manpower Statistics
• Information related to the number of physicians (by age, sex,
speciality and place of work), dentists (classified in the same
way), pharmacists, veterenarians, hospital nurses, medical
technicians, etc.
• Their records are maintained by the State
medical/dental/nursing councils and the Directorates of
Medical Education.
133

• The Institute of Applied Manpower Research attempts
estimates of manpower, taking into account different sources
of data, mortality and out-turn of qualified persons from the
different institutions.
• Regarding medical education, statistics of numbers admitted,
numbers qualified, are given every year in "Health Information
of India", published by the Govt, of India, in the Ministry of
Health & Family Welfare.
134

POPULATION SURVEY
• A health information system should be population-based.
• The routine statistics collected from the above sources do not
provide all the information about health and disease in the
community.
• The term "health surveys" is used for surveys relating to any
aspect of health - morbidity, mortality, nutritional status, etc.
135

• Surveys, where information is collected on sample basis are
used to provide variety of information with fair degree of
precision.
• Using a scientifically adopted sample design the sampling
error can be controlled to a large extent.
• Also careful planning, elaborate training of investigators and
supervisors and effective monitoring and supervision can help
in controlling non-sampling error.
136

Following types of surveys would be covered under health
survey:
• Surveys for evaluating the health status of a population, that is
community diagnosis of problems of health and disease.
137

• Surveys for investigation of factors affecting health and
disease (environment, occupation, income, circumstances
associated with the onset of illness, etc.)
• These surveys are helpful for studying the natural history of
disease, and obtaining more information about disease
aetiology and risk factors
138

• Surveys relating to administration of health services, e.g., use
of health services, expenditure on health, evaluation of
population health needs and unmet needs, evaluation of
medical care, etc.
139

Health surveys can be broadly classified into 4 types :
a. Health interview (face-to-face) survey
b. Health examination survey (here treatment is also provided to
the people suffering from the disease.)
c. Health records survey (cheapest method)
d. Mailed questionnaire survey (Has a high rate of non-response.)
140

Large Scale Surveys
• Govt. Of India has been conducting large scale surveys
periodically to assess the level and impact of health
interventions.
• These surveys include National Family Health Survey
(NFHS), District level Household Survey (DLHS), Annual
Health Survey (AHS) etc.
• The main aim of these surveys is to assess the impact of the
health programmes and to generate various health related
indicators at the District, State and National level. 141

National Family Health Survey
(NFHS)
142

• Large-scale, multi-round survey conducted in a representative
sample of households throughout India.
• Provides state level and national data.
• Conducted by Ministry of Health and Family welfare.
• Nodal agency- IIPS, Mumbai
NFHS-1 :1992-93
NFHS-2 :1998-99
NFHS-3 :2005-06 143

 Technical assistance by ORC Macro (USA).
 Funding by USAID, DFID, the Bill and Melinda Gates
Foundation, UNICEF, UNFPA, and MOHFW, GOI.
 NACO and NARI provided assistance for the HIV component
 NFHS-3 fieldwork was carried out
by 18 Research Organizations including
some Population Research Centres
between December 2005 and August 2006.
144

GOALS
• To provide essential data on health and family welfare needed
by the Ministry of Health and Family Welfare and other
agencies for policy and programme purposes
• To provide information on important emerging health and
family welfare issues
145

Scope of NFHS-3
 All 29 states are covered
 Slum and non-slum areas of eight cities, i.e. Chennai, Delhi,
Hyderabad, Indore, Kolkata, Meerut, Mumbai, Nagpur
 Interviews were conducted with
 Women age 15-49
 Men age 15-54
146

Biomarkers Measured in NFHS-3
 Height and weight
 Haemoglobin content in the blood to measure anaemia
 Collection of blood samples for HIV testing
147

Provides data regarding
• Household and Individual
Characteristics
• Fertility, Marriage and
Family Planning
• Maternal Health
• Immunization and Child
Health
• Nutritional Status of
Children and Adults
• HIV Knowledge,
Behaviour and Prevalence
new and emerging issues
• Perinatal mortality,
• male involvement in family
welfare,
• adolescent reproductive health,
• high-risk sexual behaviour,
• family life education,
• safe injections,
• Tuberculosis, and
• malaria;
148

Survey method
• Three questionnaires used : (translated into 18 Indian
Languages)
• The Household Questionnaire,
• The Eligible men & Woman Questionnaire
• The Village Questionnaire (rural areas )
149

Procedure
1. Household survey
2. As a part of it, cooking salt is tested for iodine Content.
3. Individual respondent interview
4. Measurement of height, weight, Hb % in women, men, children
born in Jan 2000 or later
5. Collection of blood samples on filter paper in men and women
for HIV testing.
150

SAMPLING DESIGN
• In each state, the Rural sample was selected in two stages
1. The selection of Primary Sampling Units (PSUs), which are
villages, with probability proportional to population size (PPS)
2. Random selection of an equal number of households within
each PSU in the second stage.
151

• In urban areas, a three‐stage procedure was followed.
1. Wards were selected with PPS sampling.
2. One Census Enumeration Block (CEB) was randomly selected
from each sample ward.
3. An equal number of households were randomly selected
within each sample CEB.
SAMPLING DESIGN
152

NFHS-3 Sample
from 29 states
Number
Interviewe
d
Response
Rate
Households 109,041 97.7
Women (age 15-
49)
124,385 94.5
Men (age 15-54) 74,369 87.1

Summary and Highlights
• NFHS‐3 is the first nation‐wide community based survey
to provide an estimate of HIV prevalence in the general
population.
• Substantial improvements have been seen in child
survival
154

• Fertility continues to decline
– Urban women have already reached the replacement
level of fertility, but rural women even now have an
average of three children
• For the first time more than half of the currently married
women are using some contraceptive method
155

Summary and Highlights (contd.)
• There have been improvements in antenatal care,
institutional deliveries, and assistance at delivery by a
health professional, but the changes over time have been
slow
• Immunization coverage for children has improved for all
vaccines except DPT
156

• Under nutrition and anaemia among children remain major
challenges
• Adults suffer a dual burden of under nutrition and
overnutrition .
157

District Level Household
Survey (DLHS)
158

• The district is the basic nucleus of planning and
implementation of the RCH programme.
• To provide district level estimates on health indicators to assist
policy makers and program administrators in decentralized
planning, monitoring and evaluation.
159

The Ministry of Health and Family Welfare (MoHFW), Government
of India has designated International Institute for Population
Sciences (IIPS), Mumbai as the nodal agency for conducting the
District Level Household and facility Survey (DLHS)
DLHS -1in 1998-99
DLHS-2 in 2002-04.
DLHS-3 in 2007-08
160

OBJECTIVES
• To provide RCH indicators at the district level
• Coverage of antenatal care and immunization services
• Proportion of institutional/safe deliveries
• JSY beneficiaries
• Contraceptive prevalence rates
• ASHA’s involvement
• Unmet need for family planning
• Awareness about RTI/STI and HIV/AIDS
• Family life education among unmarried adolescent girls
• Linkage between health facility and RCH indicators
161

• DLHS-3 is one of the largest ever demographic and health
surveys carried out in India, with a sample size of about seven
lakh households covering all districts of the country.
• A systematic multi-stage stratified sampling method was used
• Ever-married women (aged 15-49), unmarried women (aged
15-24) are also added as Respondants.
DLHS 3
162

Ever married women ?
• Ever married women or men are persons who have been
married at least once in their lives although their current
marital status may not be “married”.
163

FACILITY BASED SURVEY
An important component of DLHS-3 is the integration of Facility
Survey of health institution (Sub centre, Primary Health Centre,
Community Health Centre and District Hospital) accessible to the
sampled villages.
Purpose : To assess the existing situation of the health Care
facilities available in the government health Care establishments at
different levels in terms of infrastructure, staff, equipments and
drugs.
164

The main objectives of the facility survey are to
assess
• Percentage of Infrastructure facilities as per the IPHS norms.
• To identify the gaps of manpower as per IPHS norms.
• Percentage availability of equipments as per IPHS norms.
• Percentage availability of Drugs as per IPHS norms.
165

National Sample Survey Office
(NSSO)
• The National Sample Survey Office (NSSO) was known as
National Sample Survey Organisation.
• It is a unique setup to carry out surveys on socio-economic,
demographic, agricultural and industrial subjects for collecting
data from households and from enterprises located in villages
and in the towns.
• It is a focal agency of the Govt. of India for collection of
statistical data in the areas which are vital for developmental
planning. 166

• The National Sample Survey Directorate was first setup in the
country in the ministry of finance in 1950.
• The directorate was subsequently transferred to the cabinet
secretariat in 1957 and subsequently in 1970 it became a part
of NSSO in the department of statistics under the ministry of
planning.
• Since 1999 it is under the Ministry of Statistics and
Programme Implementation (MOSPI). (NSSO, 2001
167

Annual Health Survey (AHS)
• The Ministry of Health and Family Welfare, in collaboration
with the Registrar General of India (RGI), had launched an
Annual Health Survey (AHS) in the erstwhile Empowered
Action Group States (Bihar, Jharkhand, Madhya Pradesh,
Chhattisgarh, Uttarakhand, Uttar Pradesh, Orissa and
Rajasthan) and Assam.
168

• The annual health survey (AHS) was conceived in 2005 to
monitor the performance of health interventions carried out
under the National Rural Health Mission (NRHM) at annual
intervals.
• Three rounds of Annual Health Survey (AHS) were conducted
during 2010-11, 2011-12 and 2012-13 for providing district
level estimates on major health indicators.
169

The Longitudinal Ageing Study in
India (LASI)
• LASI is a multidisciplinary, internationally harmonized panel
study designed to be nationally representative of India’s
population aged 45 and older.
• Fieldwork for a four-state pilot study funded by the National
Institute on Ageing (NIA, USA) was successfully
implemented in late 2010.
170

• LASI will be a national landmark in scientific research that
will allow a better understanding of India’s adult health
problems and population ageing processes and will inform the
design of appropriate evidence-based policies for adults and
older people in India.
• The main objective of LASI is to provide comprehensive
evidence base on health and wellbeing of elderly population in
India.
171

LASI is designed to cover five major subject and policy domains
of adult and older population of India namely:
• Health: Disease burden & risk factors (reported and measured),
• Health care and health financing,
• Social: Family and social network,
• Economic: income, wealth and expenditure
• Work and employment, Retirement and Pension
172

Study on Global Ageing and Adult
Health (SAGE)-India, 2006
• SAGE collects data on adults aged 50 years and older,
including a smaller comparison sample of younger adults aged
18–49 years, from national representative samples in six
countries: China, Ghana, India, Mexico, Russian Federation
and South Africa.
• WHO Multi-Country Studies unit coordinates the Study on
global AGEing and adult health(SAGE)
173

• In India, SAGE is being conducted in six states – Assam,
Karnataka, Maharashtra, Rajasthan, Uttar Pradesh and West
Bengal. SAGE will cover a sample of 10600 households
across the six states.
• The International Institute for Population Sciences, Mumbai in
collaboration with the World Health organization, Geneva has
undertaken the Study on Global Ageing and Adult Health
(SAGE), 2007 in India.
174

• SAGE is expected to run for up to 10 years with follow-up
waves for every two years.
175

STRENGTHS
• Information on the entire population and covering a wide
range of health issues.
• Major vehicle for biological and clinical data collection
• Data disaggregation and data analysis possible mainly at state
level (using NFHS) and at district level (using DLHS)
• Data in the public domain with clear standards possible
176

LIMITATIONS
• Reporting biases for several health conditions
• Low prevalence conditions or rare events needs excessive
survey sample size
• High resource requirements to ensure high quality data
177

Other routine statistics related to
health
• Demographic : In addition to routine census data, statistics on
such other demographic phenomena as population density,
movement and educational level.
178

• Economic : consumption of such consumer goods as tobacco,
dietary fats and domestic coal; sales of drugs and remedies;
information concerning per capita income; employment and
unemployment data.
179

• Social security schemes : medical insurance schemes make it
possible to study the occurrence of illnesses in the insured
population. Other useful data comprise sickness absence,
sickness and disability benefit rates.
180

Non-quantifiable information
• Information on health policies, health legislation, public
attitudes, programme costs, procedures and technology.
• Health information system has multi-disciplinary inputs.
• There should be proper storage, processing and
dissemination of information as health planners and decision
makers require a lot of non-quantifiable information.
181

Health Management Information
Systems (HMIS)
• Ministry of Health and Family Welfare, GOI, has established a
dedicated Health Management Information System (HMIS)
portal for all Public Health related information.
• The HMIS web portal was launched in October, 2008 to
enable capturing data from both public and private institutions
in rural and urban areas across the country.
• The portal is envisaged as a “Single Window” for all public
health data for the Ministry of Health and Family Welfare.
182

• HMIS has been initially rolled out up to the district level and
as it stabilises, it will then be expanded to sub-district/block
level.
• At present, 640 districts (out of 676) across 35 States/UTs are
reporting facility wise data while rest are uploading district
consolidated figure on the HMIS web portal.
183

DRAWBACKS OF CURRENT HMIS
• Irrelevance of the information gathered
• Poor quality of data
• Duplication and waste among parallel health information
system
• Lack of timely reporting and feedback
• Poor use of information
• The difference in culture between data people and decision
makers:
184

Central Bureau of Health Intelligence
• Established in 1961, Central Bureau of Health Intelligence
(CBHI) is the National nodal Institute in the Directorate
General of Health Services, Ministry of Health & Family
Welfare, Govt. of India.
185

• CBHI an agency involved in collection, compilation, analysis
and dissemination of information on broad range of indicators
related to health status and health services in the country.
• CBHI apart from creating a credible database, it regularly
brings outs its annual publication in the form National Health
Profile based on the health data collected from all Health
Directorates of states and union territories.
186

National Health Profile
• It is published by CBHI on an annual basis since 2005.
• It consists of six chapters and provides information about the
Millennium Development Goals, WHO collaborating centres
for the family of International Classification for diseases and
also gives information about CBHI.
• NHP highlights most of the relevant information about the
various health indicators in different chapters.
• NHP is a major data source of information about diseases that
are not covered under any other major programme. 187

Global Health Observatory
• The Global Health Observatory (GHO) is an initiative of the
World Health Organization to share data (through their
website) on global health, including statistics by country and
information about specific diseases and health measures.
• The GHO website is organized around themes.
189

The themes include:
• Millennium Development Goals
• Estimates of mortality and global health
• Health systems
• Public health and environment
• Health Equity Monitor
190

• International Health Regulation Monitoring framework
• Urban health
• Women and health
• Non-communicable diseases
• Substance use and mental health
• Infectious diseases
• Injuries and violence
191

Weekly epidemiological record,
World health statistics quarterly,
World health statistics
Annual:
192

• WHO's annual World Health Statistics reports present the most
recent health statistics for the WHO Member States.
• These reports disseminate immense variety of morbidity and
mortality statistics.
• All reports are available for download in Adobe PDF and
excel when applicable.
193

WORLD BANK
• Data from World Bank cover health systems, disease
prevention, reproductive health, nutrition, and population
dynamics.
• Data are from the United Nations Population Division, World
Health Organization, United Nations Children's Fund, the Joint
United Nations Programme on HIV/AIDS, and various other
sources.
194

Health Stats
• It is World Bank’s comprehensive database of Health,
Nutrition and Population statistics.
195

SUMMARY
• The Indian census has been a goldmine for the population
data including vital events.
• To avoid the limitation of larger interval between two censuses
in getting information on vital statistics, CRS has been the
most important source providing a constant data base even at
lower administrative levels like cities/towns.
196

• But, even after a constant effort to strengthen the CRS it
suffers heavily with the coverage errors.
• SRS is fulfilling the gap created by CRS, but it has limitation
that it is not able to provide below state level indicators.
197

• NFHS provide reliable estimates at national & state level.
• DLHS , VES (IN TN ) provides district level data required for
micro-level planning and programme implementation.
• Surveillance in India has taken a new turn after the
introduction of IDSP, but the major challenge ahead is Lack of
integration of Private Sector in surveillance activity & Poor
Laboratory capacity.
198

CONCLUSION
• We are entering into a new era in global health.
• The country is witnessing the process of rapid health
transition, which not only includes demographic and
epidemiological transition but nutritional and socio-cultural
transitions as well.
• The present health information systems in the country are not
sufficiently equipped and often fail to respond adequately to
this complex health transition.
199

• Healthcare organizations are increasingly operating in data-
rich and information-poor environments. In today’s high-
tech era, we are constantly gathering and storing data, only to
never use it because it is inaccessible, improperly formatted or
presented in an irrelevant way.
200

• So Integration of hospital based statistics with health
information generated from peripheral health facilities.
• Developing a coherent health information system which can
quickly produce and make data available on a real-time basis
through reduced data turnaround time for immediate response
and decision making.
201

• The establishment of a dedicated Health Management
Information System (HMIS) portal for all Public Health
related information incorporating data triangulation for
validation of data, by GOI is a welcome step.
• Its also equally important for the states to adopt similar
measures in strengthening and improving HMIS at various
levels within the states and subsequently build capacities at all
levels.
202

• Integrating health information is not just about getting
databases to communicate with each other.
• It’s about moving toward a nationwide trend in healthcare
reform—integrated care.
203

References
• Park K. Parks textbook of Preventive and Social Medicine.
23rd ed.
• Hiremath S S. Textbook of Preventive and Community
Dentistry. 2nd ed.
• Detels R, McEwen J, Beaglehole R, Tanaka Heizo. Oxford
Textbook Of Public Health. 4th ed.
• Aschengrau, Ann. Essentials of Epidemiology in Public
Health. 2nd ed.
204

• National Centre For Health Statistics. National Vital Statistics
System. Available at http://www.cdc.gov/nchs/nvss.htm.
Accessed October 2016
• Bernier, RH, Watson, VM, Nowell, A, et al. (eds.). Episource:
A Guide to Resources in Epidemiology. 2n ed. Roswell, GA.
• R. Bonita, R. Beaglehole, T. Kjellström. Basic epidemiology
2nd edition. World Health Organization 2006.
• PennyWebb and Chris Bain. Essential Epidemiology 2nd ed.
cambridge university press. Cambridge. 205

• Agarwal et al MCCD. Journal Indian Academy Forensic
Medicine, 30(4)
• MCCD Report 2013 http://www.censusindia.gov.in/2011.
Assessed on 18 October 2016.
207

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