Development of Health Indicators

The World Health Organization (WHO) has been involved in efforts to develop indicators over a number of years. Efforts were most intensive in the mid- to late 1990s. Although not all indicator sets developed during this period are still in use, they may be of interest to those developing health indicators for other purposes. For example, indicators (and targets) were developed to assess WHO's Health-for-All (HFA) policy (WHO 1996b).

The purpose of the HFA indicators was to guide member states in the evaluation of their national strategies for HFA and to follow up on the implementation. HFA indicators dealt with trends in policy development, socioeconomic development, health and environment, health resources, health systems, health services, and health status. The framework used was based mainly on health services, health status, health determinants, and health resources. Various regions were also involved in the efforts to develop HFA indicators, as were individual countries (van der Water and van Herten 1996). In the late 1990s a new set of targets, incorporating indicators, was developed for the renewed HFA policy (WHO 1998).

Global indicators have also been used for reporting purposes in the World Health Report of WHO (2000), and health and health-related indicators have been used extensively in various regions (WHO/PAHO 1997). Over the years WHO has also developed various program indicators to monitor the health of infants and young children, the health of women, and the health of the general population. The indicators have been categorized according to whether they are outcome related (concerned with health status or death) or process related (concerned with health care delivery and management) or whether they are determinants (e.g., behavioral factors or environment and development factors that influence health outcomes). The indicators were intended to be used by public health administrators and health program and service managers (WHO 1996a).

Much work has also been done on indicators for environmental health (WHO 1995; Corvalan et al. 1997). Linkage Methods for Environment and Health Analysis (Briggs et al. 1996) deals with methods for linking health and environmental data and the application of indicators to quantify and monitor environmental health conditions. Field studies were carried out to obtain information on aspects of environmental health status and particular environmental health problems in the study areas (WHO 1995). No uniform set of environmental health indicators has been recommended by WHO, but suites of indicators that can be selected from for various pur poses have been compiled, as have updated methodology sheets for constructing selected indicators (von Schirnding 2002a; Briggs 1999).

Work has been done at WHO on the development and use of health and environment indicators in the broader context of sustainable development, which emphasizes intersectoral planning processes and the way in which indicators have been used in elements of the planning cycle. Indicators are highlighted by media (e.g., air, water) and by sector (housing, agriculture, transport), and case studies of application at the national and local levels are presented (von Schirnding 2002a).

In addition, regions have been active in developing indicators for use in their country contexts. One such example is the European region, which has been developing a suite of environmental health indicators and, in particular, has focused on the application of these indicators in four topic areas: air pollution, noise, transport accidents, and water and sanitation. A pilot study has demonstrated the usefulness of indicators for assessment and reporting while also demonstrating the limitations of routinely collected data (WHO 2004).

The pilot study is part of the process of developing an environment and health information system by the WHO Regional Office for Europe, in collaboration with a number of countries, the European Environment Agency, and the European Commission. The process involves the selection of policy-relevant issues and the development of indicator methods as well as feasibility and pilot testing and the selection of core sets of indicators in thematic areas (Box 15.1).

Initial results from the pilot study show that indicators are powerful communication tools for policymakers, experts, and the general public. When fed into the policymak-ing process, they can evaluate and demonstrate the effectiveness of environment and health policies and facilitate the setting of priorities among competing policies.

Key lessons learned include the following:

• It is important for core sets of indicators to be chosen to minimize the additional burden of collecting and reporting data. Where indicators use existing sources, additional costs are not necessarily incurred.

• Indicators can shed light on environmental risk factors and health effects, their determinants, and the actions taken, thereby highlighting the potential impact of environment and health policy on the health of the population.

• Indicators have been able to document several examples of good practice. Across Europe, examples range from the banning of coal sales in Dublin, which led to reductions in air pollution and mortality; ecological taxation in Germany, which reduced exposure to PM10; noise reduction policy in the Netherlands, which reduced exposure to road noise despite a doubling of traffic volume; and the Bathing Water Directive, which resulted in significant improvements in recreational water quality in the EU between 1992 and 2002.

• The indicators have also helped provide a uniform approach to tracking progress in environment and health status, by monitoring time trends in individual countries or in a group of countries, and have also facilitated intercountry comparisons.

Box 15.1.

Indicators and associated DPSEEA links.

Air pollution Passenger transport demand by

Driving force

mode of transport

Road transport fuel consumption

Driving force

Emissions of air pollutants


Exposure to ambient air pollutants



Years of life expectancy lost in 1 year



Population annoyance from noise


Application of regulations, restrictions,


and noise abatement measures


Mortality from transport accidents



Road accident injuries


Water and

Urban wastewater treatment



Drinking water exceedances of


microbiological guidelines

Microbiological quality of recreational



Access to piped, regulated drinking



Outbreaks of waterborne diseases


Source: WHO (2004).

In the future, countries should be able to select indicators based on policy needs, feasibility, and scientific rationale and will be able to combine this information with other evidence to describe the potential for interventions and improvements in public health practices, including surveillance programs.

However, results to date also indicate that the level of comparability of indicators across Europe is limited, often because of deficiencies in surveillance and reporting methods in some countries. There is a need for progressive development and harmonization of data collection and processing (WHO 2004).

However, the DPSEEA model, on which the European pilot study was based, has been acknowledged as being an oversimplification of reality that, when read too literally, can seriously mislead (Briggs 2003). With its emphasis on anthropogenic causes, it is most relevant for hazards such as pollution but is less effective for other environmental health hazards and may neglect the complexity of environment and health associations and the multiplicity of risk factors and health effects involved. Many other models and frameworks exist, based on knowledge of the epidemiology of health—environment interactions and the causal pathways and complexities involved.

Work is under way to develop indicators to improve children's environmental health, with the launch of an initiative at the World Summit on Sustainable Development (WSSD). Indicators for children's environmental health are being pilot tested in various parts of the world (Briggs 2003). A model has been developed that is more flexible than the DPSEEA model and allows the consideration of multiple exposures and effects. It emphasizes that exposures in different settings can lead to many different health effects and that these are affected by contextual conditions such as social, economic, and demographic factors. Actions can be targeted at the exposures, the health effects, or the underlying contexts.

Although this might seem self-evident to environmental health practitioners, the model is perhaps of particular use to those with limited understanding or appreciation of the nature of health—environment associations and interactions, especially to non-health experts working outside the health sector. In reality, of course, exposures normally are not limited to one setting, such as home, school, or neighborhood, but rather transcend different settings and must be looked at in their totality. Thus, none of the existing models or frameworks are all-embracing, and they all have limitations (Briggs 2003).

In general, experience with the development and application of health and environment indicators to date confirms their potential usefulness in monitoring environmental health conditions, tracking progress, and informing the development and evaluation of policy. In 2000 a group of researchers, practitioners, and health professionals met in Canada to discuss the challenges in environmental health monitoring and surveillance and to discuss the possibility of developing consensus on some key issues. It was agreed that there was a need to develop environmental health indicators for rural as well as urban conditions and to expand the work done on environmental health indicators to encompass the social, economic, and political environments in addition to that of the physical environment (Furgal and Gosselin 2002).

Because the relationships between health and the environment are so complex, it is often difficult to know what to measure in any particular context when monitoring the status of environmental compartments, human health, and the relationship between them (Furgal and Gosselin 2002). Measuring all factors in the relationship chain would be too time-and resource-consuming, and it would necessitate the identification and monitoring of the health status of particular at-risk groups, such as children, who are most vulnerable. There is also a need for greater understanding of the processes of collecting, interpreting, and drawing conclusions from indicators for effective use in decision-making processes.

Capacities differ between jurisdictions, countries, and continents, calling for greater cooperation, coordination, and commitment between governments and agencies to take advantage of the benefits of new information technologies. This is of particular importance in relation to issues of global relevance. Key challenges for the future, as highlighted in the Canadian meeting on environmental health indicators, include issues of scale, capacity, data comparability, and reliability.

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