Sources of health information
routine health statistics. Informátion reguirements will vàry
The ieblood of a health information system is the
according to the administrative level at which planning 1S
envisaged. For example, the information requirements of a
public health administrator will be different from the
information requirements of a hospital administrator. 1hese
ditferent contexts require different sources of information.
These are discussed in this section.
1 Census:
is taken in he census is an important source ofhealth information. It
most countries of the world at reqular intervals,
usually of 10 years. A census is defined by the United Nations
as the total process of collecting,compiling and publishing.
demographic, economic and social data pertaining ata
specified time or times, to all persons in a country or
delimited territory (7). Census is à massive
undertaking to contact every member of the population in a given time and
collect a variety of information. It needsconsiderable
organization, a vast preparation and several years to analyse
the results. This is the main drawback of census as a data
source -
ie., thefull results are usually not available quickly.
The first regular census in India was taken in 1881, ánd
others took place at 10-year intervals. The last.census was
held in March 2011: The censusis usually conducted át the
end of thefirst quarter of thefirst year in each decade, the
reason being, most people are usually resident in their own
homes during that period. The legal basis of the census is
provided bythe Census Act of 1948. The supreme officer
who directs, guides and operates the census
Commissioner for India.
the Census
Although the primary function of censusis to provide
demographic inforimation such astotalcount of population
and its breakdown into groups andsubgroupssuch as age
andsex distribution,itrepresents only a
small part of the
total inforimation collected. The census contains a mine of
information on subjects not only demographic, but also
social and economic characteristicsof the people, the
conditions under which they live, how they work, their
income and other basic information.These data provide a
research. not only in thefield frame of reference: and base line lor planning, action and
andsocial sciencesbutin the entire governmental system.
of medicine, human ecology
Population census provides basic data (such as population
by ageaidsex) needed to compute vitalstatisticalrates, and
other health,demnographic and socio-economic indicators.
Without census data, it is notpossible to obtainquantified
health, dernographicand socio-economic indicators.
2. Registration of vital events
registratiin of vitaf events {e.g., births, deaths) keeps a
Whereas censüs is aninterrnittent counting ofpopulation.
continuous check on demographic changes. lf tegistratton of
vital events is compiete and accurate,it can serve ás a
reliable sourçe of healthinformation, Much importance is
therefore given countries. It is the
precursor of health statistics.
events
years,it has dominated the health information
system.
in
Quer
to the registration of vital
he
Nations defines a vital United events
The as including "legal registration, statisticalrecoringard
registraicz
reporting ofthe occurrence system presentation, analysis and distribution of statistics
pertairing,
to vital events, i.e., live births, deaths, (oetal
deaths
of, andthe collection, complatig,
divorces, adoptions, legitimations, reCOgnitionS,
annulments and legal separations" (7). Registration
marriages, eventshas been thefoundation of vital statistics.
ofvital
India has a long tradition of registration of biirths
deaths. In 1873, the Govt, of India had passed theBBirts,
and
Deaths and Marriages Registration Act, but the Act provided
only. for voluntary registration. Subsequently, individual
Karnataka and Assam passed their
own Acts. However, the Registration systen in Indiatended
States like Tamil Nadu. to be very unreliable, the data being grossly deficient
regard to accuracy, timeliness, completeness andcoverage.
in
This is because of illiteracy, ignorance, lack of concern
and
motivation. There are also other reasons such as lacck
uniformity in the collection, compilation and transmission
of
data oi
which is different for rural and urban health
multiple registration agerncies (e.g., areas, and
agency,
panchayat agency, police agency andrevenue agency.
The Central Births and Deaths Registration Act, 1969
In an effort to improve the civil registration system,the
Govt. of India promulgated the Central Births and Desthe
Reaistration Act in 1969. The Actcame into force on lst Ana
1970. TheActprovides for compulsory registration ofbirthe
and deaths throughout the country,and compilation of vial
statistics. in the States so as toensure uniformity and
comparability of data.The implementation ofthe Act reguired
adoption ofrules for which also, model guidelines have bee
provided. The Act also fixes the responsibility for reporting
births anddeaths. While the public (e.g., parents, relatives) ane
toreport events occurring in their households, the heads of
hospitals, nursing homes, hotels, jailsordharmashalas are to
report events occurring in such institutions to the concerning
Registrar. Thetime limit for registering the event of birthsand
that of deathsis21 days uniformlyall over India. Incase of
default a
late fee can be imposed. The beginning of a new era in the history Act makes the
of vital statistics
registration in India. More recently from October 2013
Aadhaar nümber is a must for registration of death.
Layreporting
Because of slow progress in the development o
Comprehensive vital registration system, someçoui
have attempted to employ first-line health workers (e4
community. Indeed, one village health guides) to record births and deaths in the
of a
primary health worker is to collect and record data on vita'
events and other health informationCin his or her
communty
of the important functions developed in several countries. This known as been In orderto obtain this information, a new approachhas
approach is
"lay reporting of health information" 8). Lay
and its transmission to other levels of the health
systemby
non-professional health workers (9).
reportingis defined as the collection of information, its use
eventsregisters do notexist
In large majority of countries properly functioning
demographic surveys, and it is necessary to resortt
etc: demographic survey, however, can neever leadto the
alternative source.
destret
as an a vital events registration sahonin9.tho demographic survey should be regarded as
çomplete recording of all vital eventsin a country.
where system is not
substitute ratherthan a
replacement (7).
Sample Registration System(SRS)
deficient in India, a Sample
Siyistation System (SRS) was initiated inthe mid-1960s to
Since civil registration is reliable estimates Nationaland. State levels. The SRSis a dual-record system,
Ssting of continuous enumeration of births of birth and death rates at the
and enumerator and an independent survey deaths
an investigator-superVSOr. every
The half-yeariy
addition to serving as an independent check on
events recorded by the enumerator, denominator required for computing rates.
Konths by he
produces the
country. It is a RUce of health information. Since the introduction of this
major
The SRS noW covers the entire stem, more reliable information on birth and death rates,
age-specific fertility and mortality rates, infant, under-five
adult mortality, etc. have become available.
4, Notification of diseases
SOURCES OF HEALTH INFORMATION
985
pencds upon the ayailability of facilities for bacteriological,
Vrological and serological pxamination. The lack ot sucn
laclities in the rural areas of India also works against the
Correct reporting of the causes of sickness.
n spite of the above limitations. notification provides
Valuable information about fluctuations in disease frequency.
also provides early warning about new occurrences or
outbreaks of disease. The concept of notification has been
extended to maný non-communicable diseases and
Conditions notably cancer. congenital malformations, mental
illness, stroke and handicapped persons.
5. Hospital records
In a country like India, where registration ofvital eventsis
deectiyg.and notification.of infectious diseases extremely
nadequate, hospitaldata constitute.a basic and primary
sOUrc of_information about diseases.prevalent in the
community. The eighth report of the WHO Expert
Committee on Statistics (11) recommended that hospital
statistics be regarded in all countries as an integral and basic
part of the National Statistical Programme.
The main drawbacks of hospital data are :
(a) they
Hstorically notification ofinfectiousdiseaseswasthe first
health, information sub-system to be established. The
ainary purpose of notification is to effect prevention and/or
ntrol of the disease. Notification is also a valuable source
morbidity data i.e., the incidence and distribution of
ertain specified diseaseswhich are notifiable.
ists'of notifiablediseases varyfrom country to country,
and also within the same.country between the States and
etween urban and rural areas. Usually diseases which are
considered to be serious menaces to public health are
nciuded in the list of notifiable diseases, Notification system
s usualyoperative through certain legal Acts (e.g., Madras
Public HealthAct, 1930). Some State Governments in India
do not have any specific Act, except invoking the Epidemic
Diseases Act of 1897, and extending the same from year to
year. The notification system is linked up with the vital
statistics machinery and the reporter is often the village
With the introduction of village
Health Guides and multipurpose workers, the reporting
cesponsibility is now shifted from the village chowkidar to
the heaith workers. Since the legal provision is an essential
Pre-requisite for any notification system, the enactment of a
nitorm Act similar to the Regstration of Births and Deaths
chowkidar or headman. Act, 1969 is deemed necessarufor any improvement in the
notification system inIndia.
At the international level. the following diseases are
0iable to WHOin Geneva under theInternationaf Health
guiations(IHR), Viz. cholera, plague and yellow fever.
ew otherslouseborne uphus, relapsing fever, polio,
infuenza, malaria, rabies and salmonellosis are subject to
ernationa surveilance Thisinformation is published by
Hona wortdwide basis, The Expert Committee on
Health Statistics in its third Report (10) recommended that
sex.
yearly data of nötification should be detailed by age and Although seriouslimitaions nformation, it is Common knowledge that it notification is an important'source of health
suffers from
{a) notification ot rom thetota! sickness in the cormmunity (b)the systen suffers
covers only a small part
cases
a
good deal of unnder-teporting (c) many notiflcation
non-paralytic polio,
to non-recognition, e.g., iubella, te.The accuracy of diagnosts and therety of notification
pecially atypical and subclinical cases escape (f) constitute only the "tip of the iceberg" - i.e., they provide
intormation on only those patients who seek medical care,
but not on a representative sample of the population. Mild
cases may not attend hospitals: subclinical cases are always
missed (b) the admission policy may vary from hospital to
hospital; therefore hospital statistics tend to be highly
selective (c) population served by a hospital (population at
risk) cannot be defined. There are no precise boundaries to
the catchment area of a hospital. In effect,hospital statistics
provide only the numerator (i.e., the cases), not the
denominator. Extrapolation of hospital data to an entire
community is highly conjectural in estimating frequency rates
of disease. Therefore, hospital statistics are considered a poor
guide to the estimation of disease frequency in a community.
In spite of the abOve limitations, a lot of useful information
about health care activities and utilization can be derived
from hospital records. For example, hospital discharge sheets
contain much useful information on diagnosis, medical and
surgical procedures, complications, length of stay, laboratory
data, etc. A study of hospital data provides information on
the following aspects: (a) geographic sources of patients
(b) age and sex distribution of different diseases and duration
of hospital stay (c) distribution of diagnosis (d) association
between different diseases (e) the period between disease
and hoSpital admission the distribution of patients
according to different social and biological characteristics.
and (g) the cost of hospital care. Such information may be of
great value in the planning of health care services (3. 12).
Indices such as bed-occupancy rates, duration of stay, cost
effectiveness of treatment policies are useful in monitoring
the use of hospital facilities. For the development of hospital
statistics, the importance of establishing a medical record
department in each hospital cannot be overemphasized. It is
now felt that computerization ofmedical records will enable
medical care to be more effectively rendered, better planned,
and better.evaluated.
6.Disease registers
The term registration" implies something more than
notification". A register requires that a permanent record be
established, that the cases be followed up, and that basic
statistical tabulations be prepared both on frequency and on
survival. In addition, the patients on a register should
frequently be the subjects of special studies(13).
titALT INFORMMATION AND3ASIC MEDICAL STATES
10. Environmentalhealth data
Morbidity registers exist only for certain diseases and
Another area in which information is generally lacking
Conditions such as stroke, myocardial Infarction, cancer,
that relating fo fhe environment. Health statistics
are
now
s
blindhess, congenital defects and congenital rubella.
many
of ajr. waler
uberculosis and leprosy are also registered in countries where they are common.
Morbldity registors are a valuable source of information
as to the duration of illness, case fatality and survival. These
registers allow follow-up of patients and provide a
Continuous account of the freguency of disease in the
community. Even in the absence of a soughtto provide data on various aspects noise pollution; harmful food additives; industrialtoxicants,
and
inadequate waste disposal and other aspects of
of populalion explosion
with combination
and consumption of
material
increased production
Environmental data can be helpful in the identification
good;
and quantification of factors causative of disease. Collection
defined population
of environmental data remains base, useful information mav be obtained from registers on
a major problem forthe
future (3).
the natural course of disease, especially chronic diseases in
dilferent parts of the world (13). 1f the reporting system is
ettective and the coverage is on a national or representative
11. Health manpower statistics
basis, the register can provide useful data on morbidity from
Information on health manpower is by no meansleastin
the particular diseases, treatment given and disease-specific
importance. Such information relates to the number of
sex, speciality and place of work).
mortality.
7. Record linkage
physicians (by age, dentists (classified in the same way), pharmacists
nurses, medical technicians,
veterenarians, hospital Their records are maintained by the State medical/dental!
The term record linkage is used to describe the process
of bringing together records relating to one individual (or to
nursing councils and the Directorates of Medical Education,
The census also provides information about occupation,. The
one family), the records originating in different times or
places (14).The term medical record linkage implies the
Institute of Applied Manpower Research attempts estimates
assembly and maintenance for. each individual in a
of manpower, taking into account ditferent sources of d
population, of a
file of the more important records relating
mortality and out-turn of qualified persons from the ditfo
to his health (14). The events commonly recorded are birth,
institutions. The Planning Commission also gives estimat
of active doctors for different States. Regarding mat
marriage, death, hospital admission and discharge. Other
useful data might also be included such as sickness absence
education, statistics of numbers admitted, numbers
qualified, are given every year in "Health Information f
from work, prophylactic procedures, use of social services,
etc. Record linkage is a particularly suitable method of
india". published by the Government of India, in the
studying assóciations between diseases; these associations
may have aetiological significance (13).
The Ministry of Health & Family Welfare,
main problem with record linkage is the volume of
data that can accumulate. Therefore in practice record
linkage has been applied only on a limited scale e.g., twin
studies, measurement of morbidity, chronic disease
epidemiology and family and genetic studies, At the
moment, record linkage is beyond the reach of many
12. Population surveys
A
health information system should be population-based,
The routine statistics collected from the above sources do
not provide allthe informationabout health and diseasein
the community. This calls for population surveys to
supplement the routinely collected statistics. The statistics
developing countries.
8, Epidemiological surveillance
In many countries, where particular diseases are
endemic, speçial control/eradication programmes have been
instituted, as for example national disease control
programmes against malaria, tuberculosis, leprosy, filariasis,
etc.As part of these programmes, surveillance systems are
often set up (e.g. malaria) to report on the occurrence of
new cases and on efforts to control the diseases (e.g.,
immunizations performed), These programmes have yielded.
considerable morbidity andmortality data for the specific
diseases.
9. Other healthservicerecords
A
lot of. information is also found in the records of
haspital out-patient departments, primary health: centres
and subcentres, polyclinics, private practitioners, mother
and child health centres, school health records, diabetic and
hypertensive clinics, etc. For example, records in MCH
centres provideinformation aböut birth weight, weight
height, arm-circumference, immunization, disease specific
mortality and norbidity. However,the drawback with this
kind ofdata is that it relates only to a
certain segment ofthe
general population. Further the data generated by these
tecords aremostly kept for administrative purposes rather
than for monitoring.
available for cholera, malaria, plague, respiratory diseases,
fevers and diarrhoea' are of. use for public health
administration.
The term "health surveys" is used.for surveys relating to
any aspect of health morbidity, mortality, nutritional
status, etc. When the main variable to be studied is disease
sufferedby the people, the survey is referred to as
"morbidity survey".Broadly, the following types of surves
would be covered under health survey (15):
a.surveys for evaluating the health status ol
popülation, problems of health that and is community disease. It is diagnosisinformation
,
d
about the distribution of these problems over tine
and space that provides the fundamental basis tor
planning and developing neededservices {16)
Surveys forinvestigation of factors affecting heath
income, anddisease,eg. circumstances environment,
associated with occupation.
the onset
studying obtaining of illness the etc. more natural These informaion history surveys of about are disease, helpfal disease
nd
ter
aetiology andrisk factors; and
health
of
services, eg., useof health services,
expenditurd
surveys relating to administration need's
health on health, evaluation of population care, et:
and unmet needs, evaluation of.medical SOURCESOF HEALTH INFORMATION
987
be conducted in almost any
setting: sampling techniques have been developed so that
Population surveyS of can estimates at any level precision desired of available resources can constraints be achieved within the
may be (17).
surveys cross-sectional Health or descriptive analytic or both (18). Health surveys on a
or longitudinal;
permanent basis are in operation in only a
few countries, viz.
inJapan outin Singur Health Centre by Lal and sirnce 1953 USA since 1957 and The first methodological general health survey was carried
UK since 1971.
Sealin1944-46.
Surveymethods
From the point of view of the method employed for data
collection, health surveys can be broadly classified into
4
types:
Health interview (face-to-face)survey
h Health examination survey
Health records survey
d. Mailed questionnaire survey
Each method has its advantages and disadvantages.
When information about morbidity is needed, Health
surveys generally provide more valid
interviewers. The main a health
oxamination survey is that it is expensive and cannot be
carried out on an extensive scale. The method also requires
consideration of providing treatment to people found
suffering from certain diseases. The health interview
(face-to-face) examination
information than health interview surveys. The survey is
aried out by teams consisting of doctors, technicians and
disadvantage of of
survey is an invaluable method measuring morbidity, subjective phenomenà- such as perceived
disability and impairment; economic loss due to
illhess, expenditure incurred on medical care; opinions,
beliefs and attitudes: and some behavioural characteristics.
It has also the advantage of giving population-based data.
The National Sample Survey.Organization in India has
been active in conducting interview surveys; these surveys
have provided some country-wide data on general
morbidity, vital events, but the
family planning and morbidity datais not reliable because of the limitation of the
interview. method Thisis why interviews are often
withhealth examination
surveys and/or
combined laboratory measurements. An alternative method of
measuring subjective phenomena is the self-administered
an
questionnaire without Questionnaire,i.e.a Interviewer. The use may be sent, for example, by mail to
of questionnaires is simpler and
persons sampled from a given target population. Cneaper, and they A certain
expected from the
evel of education, and skill questionnaire is administered. There is
eSpondents when a is rate of non-response. Health records
Sualy a high Surveyjnvolves collection, of data from health service
Tecords.This is obviously the cheapest method of collecting
several disadvantages
data.: Thismethod obtained from the records arenot
has lck of uniforn procedures andstandardization :in
the recording of data.
niess the aim of suryeu is io derive information from à
a) the.estimates POpulation based (b) reliability of data isopen to question,
C
particular
PeCial group te:a.school children or
common
most Occupatiornal! group), the household is the of most
collection sanpling unit. It is one thatallows for the $ocial. economic and health informatiori in a
çonvenient
District Level
Way. National Family Health Survey Health Survey are some of the examples.
and Ihe size of the sample,necessarv for a household survey,
uepends upon the measurement being taken and the degree
O1precision needed, Manynational sarnples typically cover
oetween 5,000 to 10.000 households. This is usually
Considered adequate for providing national estimates on
Such variables as health care status, anthropometric
measurements, food consumption. income, expenditure,
housing, literacy, etc. (7).
Surveys.carried out bu either single or repeat visits
provide direct estimates of vital events. A single survey
Obtains the necessary information retrospectively and is
Subject to problems of recall and omission. Follow-up
Surveys on the same households within short intervals
(e.g., 6 months) appear to provide more accurate estimnates
of vital events, but mau be too expensive for monitoring
purposes (7).
Data must be gathered under standardized conditions
with quality control. The collection of data should be limited
to those items for which there is a clearly defined use or
need; the fact that data might be of interest or use to
Someone, someday, somewhere is not a valid reason for
collecting them (16). The data that is collected should be
transformed into information summarizing them and adjusting them for.variations in the
by reducing
them, age and sex composition of the population so that
comparisons over time and place are possible.
13. Other routine statistics related to health
The following list, which is not comprehensive, merely
serves to give examples of sources of data that have already
been put to good use by epidemiologists :
(1) Demographic : In addition to routine census data,
statistics on such other demographic phenomena
as
population density, movement and educational level.
(2) 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.
make it possible to study the occurrence of illnesses in the
(3)Social security schemes : medical insurance schemes
insured population. Other useful data comprise absence, sickness and disability benefit rates.
sickness
14.Non-quantifiable information
Hitherto, the health information system concentrated
mainly on quantifiable (statistical) data. Health planners and
decision makers require a lot of non-quantifiable
information, for instance, information on health policies,
health legislation, public attitudes, programme costs,
procedures and technology. In other words, a health
information system has multi-disciplinary inputs. There
should be proper storage, processing
dissemination of information.
and ELEMENTARY STA
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