10/16/2018

Indikator Kesehatan

Disadur dari
ROUTINE HEALTH INFORMATION SYSTEMS
A Curriculum on Basic Concepts and Practice
https://www.measureevaluation.org/our-work/ routine-health-information-systems/ rhis-curriculum

Apa itu Indikator Kesehatan?

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

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Suatu indikator adalah …….

• variabel (nilainya berubah )…

• yang mengukur (perhitungan nilai yang objektif )…

• elemen kunci dari suatu intervensi kesehatan

(program, layanan, atau proyek )
o (input/proses, output, keluaran , dampak)

Types of Health Indicators

INPUTS AND OUTPUTS OUTCOMES IMPACT

PROCESSES

• Availability of • Number of • Full • Life expectancy

drugs per care children immunization at birth
level immunized rate • Infant mortality
• Basic • Number of interventions • Prevalence of
equipment per new cases • Incidence malnourished
activity type in the and children under 5
• Number of facilities prevalence of
staff per • Hospital certain
category and bed diseases, such
per capita occupation as HIV,
• Number of rate malaria, TB
drug shortages • Number of TB
• Number of cases
surgical or detected
obstetrical
acts done

Source: Adapted from WHO. Global reference list of 100 core health indicators. Retrieved from
http://www.who.int/healthinfo/indicators/2015/en/.

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EXAMPLE: Indicators for Reproductive,

Maternal, and Child Health Monitoring
INPUTS AND OUTPUTS OUTCOMES IMPACT
PROCESSES

•Health financing •Service access •Coverage of interventions •Health status

•expenditure per and readiness •antenatal care
target population •facilities that offer •births attended by skilled health •under-5 mortality
(children, women, and meet tracer personnel •maternal mortality
etc.) criteria for basic •immunization coverage ratio
•General and •family planning needs satisfied •child mortality by
government comprehensive major cause of
obstetric care, •children with diarrhea receiving oral
•expenditure on rehydration therapy death, by sex and
per 10 000 age
health as a pregnant women •children with fever receiving antimalarials
percentage of
•insecticide-treated bednet use
general government •Financial risk
expenditure •caesarean •antiretroviral prophylaxis among HIV-
section rate in positive pregnant women protection
•Health workforce rural populations •out-of-pocket
•vitamin A supplementation among
•midwives, per 10 children payments as a
000 population percentage of
•facilities that offer •postnatal care total health
•Governance and meet tracer expenditure
•presence of key criteria for child
health services, •Risk factors and behaviours
policies to promote
maternal and child per 1000 children •contraceptive prevalence
health •access to safe water
•Information •access to improved sanitation
•births registered •low birth weight among newborns
•deaths registered •early initiation of breastfeeding
(with cause) •children who are stunted or underweight

Source: Adapted from Monitoring, evaluation and review of national health strategies: a country-led platform for information and
accountability. Geneva, World Health Organization, 2011.

Jenis Indikator

• Status kesehatan
• Faktor risiko
• Cakupan Pelayanan
• Sistem Kesehatan

Source: Adapted from WHO. Global reference list of 100 core health indicators Retrieved from
http://www.who.int/healthinfo/facility_information_systems/en /

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Mengapa indikator kesehatan penting ?

Indikator penting dalam intervensi kesehatan

karena jika data dikumpulkan dan
digunakan secara teratur:
•memberikan nilai referensi untuk perencanaan,
manajemen dan pelaporan

•memungkinkan evaluasi tren dan identifikasi

masalah

•Early warning masalah

Indikator “SMART” ?

• Specific: Indicator is concrete, detailed, focused, and

well defined
• Measurable: Indicator tells how many or how much
and can be measured with identified
measurement sources
• Agreed upon: Stakeholders vested in a specific M&E
question should agree that the indicator is relevant
• Relevant: Indicator generates data that can answer
the question of interest
• Timebound: Indicator specifies time frame of what it is
measuring

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Relevan

• Answers the question of interest: too many

indicators have been defined without being
based upon a specific information need
• Linked to a public-health impact or to
achieving the objectives needed for impact
Example: Childhood vaccines program
Indicator: % of infants receiving measles vaccine
(coverage)
Example: Program to increase access to ORS for
childhood diarrhea through community-based
distributors (CBDs)
Indicator: # of ORS packets distributed in past month
by CBDs

Spesifik

Or “valid” = measures a specific disease,

service provided, practice, or task
• Indicator measures what it is intended to
measure: provides direct information about
the result it intends to measure
• If indicator not “feasible,” sometimes need
to use “proxy indicator”

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Class Activity - Specificity (or Validity)

• Is the number of antenatal care (ANC) visits a

valid indicator of a focused ANC package?
• Is the maternal mortality ratio a valid
indicator of the impact of a family planning
program on women’s health?
• Is the number of children who received the
DTP3 vaccine a valid indicator of
immunization coverage?

Characteristics: Measurable

• Quantifiable: using available tools and

methods
• Precise: operationally defined in clear terms
and documented in an Indicator Reference
Sheet
• Reliable: consistently measurable in the same
way by different observers
• Feasible: the resources (human, physical,
financial) needed are available

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Indicator Reference Sheet: Minimum

Information

• Description
• Plan for data collection
• Plan for data analysis
• Plan for data quality check
• Performance table

Characteristics: Time Bound

Provides a measurement over periods

of interest, with data available for all
appropriate intervals

Timeliness considerations:
• Reporting schedules
• Recall periods
• Length of time over which change can
be detected

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Characteristics: Agreed Upon

• Stakeholders vested in a specific M&E

question should agree that the indicator
is relevant
• Agreement between various health-system
levels
• Agreement between various national health
programs and health services managers

Common Indicator Metrics

Counts
# of providers trained
# of condoms distributed
Calculations: percentages, rates, ratios
% of facilities with trained provider
Index, composite measures
Index on infection control and prevention
DALY (disability-adjusted life years)
Thresholds
Presence, absence
Predetermined level or standard

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Factors to Consider When Selecting Indicators

ü Logic/link to framework
ü Programmatic needs/information for
decision making
ü Resources
ü External requirements (government, donor,
headquarters)
ü Data availability
ü Standardized indicators
ü Alignment with national and international
standards

Common Pitfalls in Indicator Selection

• Indicators not linked to program activities

• Poorly defined indicators
• Indicators that cannot realistically be collected
• Process indicators to measure outcomes and
impacts
• Indicators that are insensitive to change
• Too many indicators

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Pitfalls in Selecting Indicators

• Indicators not linked to program activities

• Intermediate result (IR): Expanded access to malaria

treatment services

• Activities: Train providers in current clinical protocols

• Inappropriate indicator: % of facilities with

adequate conditions to provide care

• Better indicators: # of clinicians trained; % of

facilities with a trained provider

• The program is not aiming to affect facility conditions,

only provider skills.

Pitfalls in Selecting Indicators

• Data needed for indicator not available

• Inappropriate indicator: % of days per quarter that
service delivery points have stockout of drugs

• Data issue: Information on stockouts may not be

collected daily

• Better indicator: % of service delivery points that had a

stockout of drugs at some time during the past quarter

• If relying on routine data, an indicator definition

must depend on how data are collected

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Pitfalls in Selecting Indicators

Indicator does not accurately represent desired outcome

• IR: Access to effective treatment among children <5 years old with
malaria

• Inappropriate indicators: % of children <5 years old who

received artemisinin-based combination therapies (ACTs); % of
people who received ACTs for malaria infection who are
children <5

• Better indicator: % of children <5 years old who were diagnosed

with malaria in the past 2 weeks who received ACTs

• What does it mean if inappropriate indicators increase? Decrease?

Do they reflect the desired program effect?

Indicator Systems: How Much Is Enough?

Rule of Thumb
•At least one or two indicators per key activity or result
(ideally, from different data sources)

•At least one indicator for every core activity (such as

distribution of insecticide-treated nets, indoor residual
spraying, training, behavior change communication)

•No more than 8–10 indicators per area of significant

program focus

•A mix of data collection strategies/sources

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Good Indicators

• Provide information useful for program decision

making
• Are consistent with international standards and
other reporting requirements, as appropriate
• Are defined in clear and unambiguous terms
• Are nondirectional; “independent”
• Have values that are:
o Easy to interpret and explain
o Precise, valid, and reliable measures
o Comparable across relevant population
groups, geography, and other program factors,
as needed

“Not everything that can be

counted counts, and not everything
that counts can be counted.”

― Albert Einstein

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Summary: Guiding Principles for

Selecting Indicators

• Ensure that the indicators are linked to the

information needs for health interventions
and are able to measure change.
• Ensure that standard indicators are used to
the extent possible.
• Consider the cost and feasibility of data
collection and analysis.
• Keep the number of indicators to the
minimum that are necessary, and include
only those needed for program and
management decisions or for reporting.

Data Collection & Reporting - Basic Concepts

Data Element and Data

A “data element” is a recorded event. “Data” represent an aggregation of data
elements, in the form of numbers, characters, and images.

Information

Data are organized with reference to a context, which gives data meaning.

Knowledge
When information is analyzed, communicated, and acted upon, it becomes
knowledge.
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DATA COLLECTION

RHIS Data Are Needed to….

• RHIS data are collected for the information needs and
indicators that were identified to:
• Understand the health status of the population
• Enhance health system performance through
evidence-informed decision making for all major
building blocks
o Service delivery
o Resource mobilization
o Financing
o Stewardship
• RHIS data are needed from the community all the
way up to the national level for planning,
management, and monitoring

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Data Collection
• Types of Data to Be Collected:
ü Patient/client data
ü Health facility data
ü District level data
• Data Collection Tools and Forms
ü Patient and client data forms (individual
records such as immunization cards)
ü Health facility data forms (tick register,
registry and tally sheets)
ü Community data forms (register, tally
sheets)
•
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Health Information System: Data Sources

(HMN, 2008)

Resource
Census records systems

Vital Services
registration records
systems

Pop based Individual

surveys Records
systems

Population-based Facility- and community-based

data sources information systems--also called
routine health information
systems (RHIS)

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RHIS Focuses on facility and Community Health

Information Systems

• RHIS can be structured in the following

“subsystems”
• Individual records systems (facility-based as well
as community-based)
• Service record systems (facility-based as well as
community-based )
• Resources records systems (human resources,
health commodities, financial resources,
infrastructure
• Health status data ( (facility-based as well as
community-based )
• Sentinel reporting/demographic surveillance

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Data Collection Tools and Forms Used for

RHIS Data Collection

• Patient or client data collection tools (individual

records)
ü Individual patient or client records (including
electronic records)
ü Prescription cards, patient files, immunization cards
ü Preventive record cards
ü In-patient record cards
• Health service and resource data collection tools
ü Tick registers
ü Tally sheets
ü Registers

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Data Collection: At the Point of Care

• Facility service data are collected by nurses and
doctors between sessions with patients
• Community service data: by village health
workers, traditional birth attendants, and
community- based distributors
• Usually several (manual) steps before data are in
any database/storage
o Tally sheets
o Tally sheet totals at end of month
o Monthly summary forms, which are reported to
the next level
• Often, there is too much data to collect by
already overworked staff
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Paper-Based Records Versus Electronic Medical

Records

• Paper records require • An electronic medical

additional staff to record platform requires
handle and support less staff and time and no
paper files and to physical storage space .
organize countless • It entails initial costs as it is
documents. being implemented.
• They are less costly at • However, the costs of
first but highly records over time will
vulnerable to break-in. decrease significantly .

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Paper-Based Records Versus Electronic

Medical Records
• Because everyone’s • Electronic medical
handwriting is different, records have enough
paper records are space to write what is
sometimes illegible. needed to document a
• Space to write everything patient encounter.
down is limited. • With electronic medical
• Additional staff are records, medical
needed to handle and professionals have
support paper files and to access to the data they
organize countless need instantly.
documents.

Data Aggregation and Reporting

DATA AGGREGATION
AND REPORTING

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Data Aggregation and Reporting

• Gathered and expressed in a summary form
• Where data are searched, gathered, and
presented in a report-based, summarized format
• Data aggregation may be performed manually
or electronically (using software)

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Purpose of Data Collection and Reporting

• Obtain information about health conditions and

characteristics
• Report information manually or electronically to
higher levels: from facility to district (or other local
government authority), from district to region (or
state), and from region to national government
authority
• Inform periodic self-evaluation (for example, to
monitor facility-based coverage rates)

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Data Aggregation and Reporting: Tools

• Summary in tabular form

• Graph
• Dashboard
• Information board at community level

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Data Aggregation and Reporting: Types

Routine reporting
• Health unit notifiable disease report
• Weekly epidemiological surveillance report
• Health unit outpatient monthly report
• Health unit inpatient monthly report
 
Health unit performance
• Health unit quarterly report
• Health unit quarterly assessment report
• Health unit annual report

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Data Reporting: Frequency

Reports can be:
• Weekly
• Monthly
• Quarterly
• Semiannual
• Annual

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Specific Topics around RHIS Data Collection

and Reporting Tools/Forms
• Types

• Content (comprehensive)

• Record filing (patient-retained vs. health unit-

retained)

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Issues with RHIS Data Collection and Reporting

Tools/Forms

• Layout (self-explanatory)

• Production form

• Electronic patient record

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Data Collection and Reporting: Gender

Sensitivity
Health conditions differ by
gender and age.

Design the data collection

and reporting tools to:

• Collect and report data on

females and males
• Capture gender-sensitive
indicators
• Capture gender-sensitive
health outcomes

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Data Collection

Golden Rules
• Keep data collection instruments (DCI) as
simple as possible.
• Involve users in the design.
• Standardize definitions and procedures
and include them in a user’s manual.
• Include appropriate facilitation for data
use on your DCI.
• Train care providers as data collectors and
data users.

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Data Flow

DATA FLOW

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• “Data flow”: the process of moving data

from the point where they are collected to
the point where they are processed and
used
• Data flow tracks the steps in the data
management process
• Can be described visually by means of a
data flow diagram

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Example of Data Flow

National Program / Stakeholders

National Level

Stakeholders

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Class Exercise
Constructing a Data Flow Diagram
• Graphically map the data collection and reporting system for
Country X.
• Assume that the country’s health service delivery follows the
facility, district, region, and national levels.
• Please consider the following issues:
ü Who will be responsible for data collection or completing each tool?
ü Who will be responsible for supervising data collection?
ü Who will be responsible for ensuring data quality at each stage?
ü How is data quality checked at every stage?
ü How often are the data collected, compiled, sent?
ü What tools/forms are used, if any?
ü How will data storage be handled?
ü How will confidentiality of data be maintained?
ü How will feedback related to data collection and reporting be handled?

Indicator/Data Sets Pyramid

Hierarchy of standards
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Challenges in RHIS Data Collection

and Reporting
• Group exercise Divide participants into
small groups.
• Ask them to generate a list of key
challenges of RHIS data collection and
reporting.
• For each identified challenge, ask them
to propose how to overcome it.

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Challenges in RHIS Data Collection and Reporting

(Possible Solutions to Address These Challenges)

• Complexity of data collection and reporting tools

•  Simplification of the data collection

and reporting tools
• Too much data to collect and report on

•  Refine the information needs based on

functional analysis
• Lack of supplies (frequent stockouts of tools)

•  Secure funding for standard tools

provision
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Challenges in RHIS Data Collection and Reporting

(Possible Solutions to Address These Challenges)

• Lack of written data collection and reporting

guidelines

•  Development of written guidelines (data

management and procedures manual)
• Existence of multiple data collection and reporting
forms for the same staff

•  Data integration and interoperability

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Challenges in RHIS Data Collection and Reporting

(Possible Solutions to Address These Challenges)

• Difference in reporting frequencies and deadlines

•  Harmonization of frequencies and

reporting deadlines
• Lack of staff competency

•  Organize training and supervision

• Lack of motivation and reward system

•  Introduce a motivation mechanism

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Data Collection and Reporting:

Summary
• Keep the system simple to operate and
maintain.
• Data processing and analysis begin at the
point of collection.
• Data for decision making: collection of only
essential health data used for decision
making
• Data collection for local analysis and use by
the health worker: data collected by all
health workers as they perform their day-to-
day duties
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