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Background and Development of Summary
Measures of Population Health (SMPH)
Richard H. Morrow, MD, MPH
Johns Hopkins University
Section A
Development of a Summary Measure (Healthy Life) in
Ghana for Use in Policy and Planning
Approaches to Resource Allocation for Health

The usual
-  Last year’s +

The ideal
-  Benefit/cost—maximize health per dollar

CENDES (Latin America)—multi-criteria decision analysis
-  Frequency
-
-
-
-
-

Seriousness
Vulnerability
Infectiousness
Community awareness
Age group
Ghana Health Planning Unit—comprehensive combined unitary
analysis; healthy life saved/unit expenditure
4
Health Situation in Ghana,1980

Independence in 1957, Kwame Nkrumah

High priority accorded to health and impressive increases
-  3X increase in doctors and nurses
-  4X increase in hospital beds
-
5X increase in per capita expenditure
5
Health Situation in Ghana,1980

But in the last 20 years
-  Infant mortality continued at 130 per thousand live births
-
-
Maternal mortality at 140 per 100,000 live births
Birthrate at nearly 50 per 1000 population
6
Health Situation in Ghana,1980
7
Health Planning Process
Where we want to be?
“There”
Where we are?
“Here”
8
Health Planning Process—Where We Are

Need to know …
A.  Where we are: “Here”

Health assessment

Inventory of Health System resources

Health-related programs (interventions)

Community perspectives
9
Health Planning Process—Where We Are

Need to know …
A.  Where we are: “Here”

Health assessment
-  Demography, census, mapping

Inventory of Health System resources

Health-related programs (interventions)

Community perspectives
10
Health Planning Process—Where We Are

Need to know …
A.  Where we are: “Here”

Health assessment
-  Demography, census, mapping
-  Descriptive epidemiology—morbidity, mortality

Inventory of Health System resources

Health-related programs (interventions)

Community perspectives
11
Health Planning Process—Where We Are

Need to know …
A.  Where we are: “Here”

Health assessment
-  Demography, census, mapping
-  Descriptive epidemiology—morbidity, mortality

Inventory of Health System resources
-  Human resources
-  Facilities
-  Finances

Health-related programs (interventions)

Community perspectives
12
Health Planning Process—Where We Are

Need to know …
A.  Where we are: “Here”

Health assessment
-  Demography, census, mapping
-  Descriptive epidemiology—morbidity, mortality

Inventory of Health System resources
-  Human resources
-  Facilities
-  Finances

Health-related programs (interventions)
-  Preventive
-  Treatment
-  Rehabilitative

Community perspectives
13
Health Planning Process—Where We Want to Be

Need to know …
B.  Where we want to be: “There”

Explicit health policies in operational terms
-  Defined goals
-  Specific objectives
-
Time-limited targets
14
Health Planning Process—From Here to There

Need to know …
C.  How to get from “Here” to “There”

Deciding the right things to do

Doing the right things in the right way
15
Health Planning Process—From Here to There

Need to know …
C.  How to get from “Here” to “There”


Deciding the right things to do
-  Health sector priorities —> health planning
Doing the right things in the right way
16
Health Planning Process—From Here to There

Need to know …
C.  How to get from “Here” to “There”


Deciding the right things to do
-  Health sector priorities —> health planning
Doing the right things in the right way
-
Quality management
17
Deciding the Right Things to Do: Health Sector Priorities

Five steps
1.  Impact of disease (burden of disease measure)
Disability + Death —> All other consequences
Loss of healthy life
2.  Interventions effective against disease

Healthy life gained
3.  Costs of these interventions
Unit costs
4.  Work out “benefit”/cost ratios
Healthy life per $
5.  Ensure fair distribution
Full coverage
18
Measuring Disease Burden: Information Needs

Disease specific
1.  Incidence
2.  Disability
  Case disability ratio (CDR)
  Extent of disability
Duration of disability
3.  Case fatality ratio (CFR)
4.  Average age of onset (or distribution)
5.  Average age at death (or distribution)


Population specific
1.  Expectation of life at these ages
2.  Distribution according to S-E and vulnerable groups
19
Measure Healthy Life Lost and Gained
20
Measurement Components

Mortality
-  CFR
-

Expectation of life at onset and at death
Disability and its components
-  CDR
-  Extent of disability
-  Duration
21
Valuing Components
Valuing future life as
compared to present:
Discounting
Valuing a given duration
of life:
Different value for life
lived at different ages?
Valuing productivity:
Economic and social
Valuing equity in relation to efficiency
22
Measure Healthy Life Lost and Gained

Intervention programs
-  Alternatives and packages: What are they?

Prevention of factors that initiate disease process
Treatment of an ongoing process
Reduction of risk factors

Rehabilitation—resurrection


23
Measure Healthy Life Lost and Gained

Interventions—factors to assess
-
Efficacy of intervention under ideal setting (randomized trials,
evidence-based reviews)
-
Coverage (% of target population that obtains the intervention;
target population = all who should receive the intervention)
These depend upon …
-





Quality management
Provider competence (and performance)
User understanding (and action)
System factors, including education, communication, and
transportation
Therefore …
-  Community effectiveness = effectiveness of interventions as
actually used X actual coverage
-
Results from interventions
  Changes in health status attributable to them
24
Measuring Healthy Life

“Burden of disease” measures are not an end

Must relate these to health program cost to assist in decisions
concerning resource allocation and planning
25
Measuring Healthy Life

Effectiveness of interventions as used
-  Efficacy X coverage X quality assurance

Effects of interventions and their costs
-  Healthy life gained per dollar spent

Ensure that distribution of gains is fair

Priority interventions—

THE RIGHT THING !
26
Health Gaps

Health gaps quantify the difference between the actual health of
the population and some stated norm or goal for population health
27
Expectation of Life
28
Different Patterns of Healthy Life Lost in Individuals
29
Different Patterns of Healthy Life Lost in Individuals
30
Different Patterns of Healthy Life Lost in Individuals
31
Variables for HeaLY Estimation
I
Incidence rate per 1,000 population per year
Per 1,000 per
year
Ao
Average age at onset
Years
Af
Average age at death
Years
E(Ao)
Expectation of life at age of onset
Years
E(Af)
Expectation of life at age of death
Years
32
Variables for HeaLY Estimation
CFR
Case fatality ratio: proportion of those
developing the disease who die from the disease
0.00–1.00
CDR
Case disability ratio: proportion of those
developing the disease who have disability from
the disease
0.00–1.00
De
Extent of disability (from none to complete
disability equivalent to death)
0.00–1.00
Dt
Average duration of disability for those disabled
by the disease; a composite of temporary and
permanent disability based on the proportion of
cases in each category
Years
33
HeaLYs Lost per 1,000 Population per Year

I * {[CFR * {E(Ao) - [Af-Ao]}] + [CDR*De*Dt]}

Expressed as HeaLYs per 1,000 pop per year
34
Diseases of Ghana Ranked in Order of Healthy Days Lost
Ghana Health Assessment Project Team (1981). A quantitative method of assessing the health impact of different diseases in less developed countries.
International Journal of Epidemiology. 10: 73-80
Effects Interventions May Have on HLL
Sign
ΔI
ΔCFR
ΔAf
ΔCDR
Explanation
Reduction factor for Incidence among those covered by the intervention
Reduction factor for Case Fatality Ratio among those covered by the
intervention
Extension factor for Age at death
Reduction factor for Case Disability Ratio among those covered by the
intervention
ΔDe
Reduction factor for Extent of disability among those covered by the
intervention
ΔDt
Reduction factor for Duration of disability among those covered by the
intervention
PC1
Proportion of Population Covered by present health system interventions
PCn
Proportion of Population Covered by proposed health system interventions
ΔXn
Reduction factor for X among those covered by proposed
YHLG
Years of Healthy Life Gained per thousand per 1,000 population per year
= ΔI * [(CFR * (E(Ao) – (Af- Ao)) + (CDR * De* Dt)]
36
The 5th Step

The dollar value of healthy life
-  Productivity: average or marginal wage
-
-
Human capital approach
WTP: review of legislative decisions concerning safety
regulations—$50,000 to billions per life
-
-
Jeffrey Sachs: Two times the per capita gross national income
Cost-effectiveness analysis: λ, the decision maker’s willingness
to pay for the last intervention on the list of a league table
37
The 5th Step

The dollar value of healthy life
-  Productivity: average or marginal wage
-
-
Human capital approach
WTP: review of legislative decisions concerning safety
regulations—$50,000 to billions per life
-
-
Jeffrey Sachs: Two times the per capita gross national income
Cost-effectiveness analysis: λ, the decision maker’s willingness
to pay for the last intervention on the list of a league table
38