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Objectives of the Meeting
Health Metrics Network / WHO / UNICEF / Macro Int. meeting on Health Surveys
July 10-11 2007, Calverton Maryland
Health surveys meeting10-11 July 2007
ObjectivesObjectives
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.
Health surveys meeting10-11 July 2007
Four Specific objectivesFour Specific objectives
Specific objectivesPotential outcomes
(1)
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
Plan for the development of standardized health survey modules with clear guidelines on their implementation.
(2)
Discuss how to support the development of coordinated country survey programmes that can be integrated into country health information
systems
Review of current approaches proposed and used by HMN and other stakeholder to integrate household surveys into long-term country health information systems
(3)
Discuss current efforts and ways to strengthen country capacity for analysis and synthesis of data from surveys and other sources to inform policy
Plan for HMN and partners to engage in this area in a more systematic way
(4)
Discuss key gaps in public health knowledge that can be addressed using surveys, notably on causes of death, health transition and local coverage
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
Health surveys meeting10-11 July 2007
Survey modulesRegular survey, variable contents
Survey modulesRegular survey, variable contents
Module AModule AModule AModule AModule AModule AModule AModule AModule A
shortModule A
Module Jlong
Module Hlong
Module Elong
Module A
0 2 4 6 8 ..10
………………….………………Years…………….………………………..
Health surveys meeting10-11 July 2007
Specific objective 1Health survey modules
Specific objective 1Health survey modules
Specific objectivesPotential outcomes
(1)
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
Plan for the development of standardized health survey
modules with clear guidelines on their implementation.
(2)
(3)
(4)
Health surveys meeting10-11 July 2007
Household health surveysCurrent situation – demand side
Household health surveysCurrent 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.
Health surveys meeting10-11 July 2007
Mortality data collection and reporting by source among 57 low income countries, 1980-2004
Mortality data collection and reporting by source among 57 low income countries, 1980-2004
0
10
20
30
40
50
1980-84 1985-89 1990-94 1995-99 2000-04
Surveys Civil reg.
Health surveys meeting10-11 July 2007
Household health surveysCurrent situation – supply side
Household health surveysCurrent 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
Health surveys meeting10-11 July 2007
Specific objective 2Harmonization and streamlining
Specific objective 2Harmonization and streamlining
Specific objectivesPotential outcomes
(1)
(2)
Discuss how to support the development of coordinated country survey
programmes that can be integrated into country health information
systems
Review of current approaches proposed and used by HMN and other stakeholder to integrate household surveys into long-term country health information systems
(3)
(4)
Health surveys meeting10-11 July 2007
Capacity building effortsCapacity 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
Health surveys meeting10-11 July 2007
Capacity building: who?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
Health surveys meeting10-11 July 2007
Specific objective 3Analytical capacity building
Specific objective 3Analytical capacity building
Specific objectivesPotential outcomes
(1)
(2)
(3)
Discuss current efforts and ways to strengthen country capacity for analysis and synthesis of data from surveys and other sources to inform policy
Plan for HMN and partners to engage in this area in a more systematic way
(4)
Health surveys meeting10-11 July 2007
Gaps in survey contents and methodsGaps 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
Health surveys meeting10-11 July 2007
Specific objective 4Filling gaps in knowledge
Specific objective 4Filling gaps in knowledge
Specific objectivesPotential outcomes
(1)
(2)
(3)
(4)
Discuss key gaps in public health knowledge that can be addressed using surveys, notably on causes of death, effective coverage and local coverage
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
Health surveys meeting10-11 July 2007
Standardized health survey modules
Health surveys meeting
Calverton Md
10/11 July 2007
Health surveys meeting10-11 July 2007
Why standardized health survey modules
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
Health surveys meeting10-11 July 2007
Survey modulesShort and long versions
Survey modulesShort and long versions
Module AModule A
Module AModule A
Module AModule A
Module AModule AModule A
shortModule A
Module Jlong
Module Hlong
Module ElongModule A
Short
Long
Health surveys meeting10-11 July 2007
Survey modulesTypes of surveySurvey modulesTypes 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 F Module E
Module D Module C
Module B Module A
Comprehensive survey
Duration andcomplexity of
survey
Health surveys meeting10-11 July 2007
Survey modulesRegular survey, variable contents
Survey modulesRegular survey, variable contents
Module AModule AModule AModule AModule AModule AModule AModule AModule A
shortModule A
Module Jlong
Module Hlong
Module Elong
Module A
0 2 4 6 8 ..10
………………….………………Years…………….………………………..
Health surveys meeting10-11 July 2007
Survey modulesTopic areas
Survey modulesTopic 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
Health surveys meeting10-11 July 2007
Selection survey modules and contentsSelection 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
Health surveys meeting10-11 July 2007
Possible criteriaPossible 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
Health surveys meeting10-11 July 2007
Example 1: Child mortality module (direct method, birth history)
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
Health surveys meeting10-11 July 2007
Example 2: Maternal and neonatal health preventive interventionsExample 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
Health surveys meeting10-11 July 2007
ProcessProcess
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