Guidebook on Best Practices in Public Health

Annex B. Outcome indicators

This annex outlines indicators and aligning publically available data sources to assist policy makers identify and evaluate best practice public health interventions (see Table A B.1). To the extent possible, listed indicators are internationally accepted and therefore often routinely collected in a standardised way by countries across the world (“global indicators”).

Global indicators are recommended since:

• they allow policy makers to assess and compare the performance of interventions implemented in different countries or contexts

• they reduce administrative burden by relying on routinely collected data sources

• they promote and enhance sharing of information and knowledge, which is particularly important in public health given countries across the world are experiencing similar challenges (for example, heterogeneity in the design of public health intervention evaluations is often cited as a barrier to understanding their overall impact in systematic reviews and meta‑analyses).

Indicators can be broken into several categories (e.g. output and outcomes), however, this section focuses on outcome indicators, both intermediate and final, given they are of most interest to policy makers.

In reviewing the list of indicators, it is important to remember:

• the list of indicators is not exhaustive, rather, the list is designed as a ‘starting point’ for policy makers who are encouraged to review other global indicators using provided links to international databases (see Box A B.1).

• collection of indicators not specified in the list provided or within international databases are encouraged if they are deemed most appropriate within the local context (e.g. lack of required resources, data collection restrictions, specific needs of population groups).

Box A B.1. Publically available databases and resources

This box summarises key publically available sources collecting data on leading global indicators. It is important to note that the recommended databases (and resources) are provided by international organisations and therefore focus on national level statistics. Statistics at the local, municipality or state level, for example, are typically available from a country’s national statistical agency, many of which have developed online, interactive statistical dashboards. Countries may also have an organisation dedicated to collecting and/or reporting national and sub-national health statistics.

OECD Health Statistics: OECD Health Statistics provides national-level statistics for OECD and several non-OECD countries covering topics such as health expenditure and financing; health status; health care resources; health care utilisation; and non-medical determinants of health. http://www.oecd.org/els/health-systems/health-data.htm.

Pre‑prepared statistics comparing countries across various health dimensions can be found in the following OECD publications: Health at a Glance: Europe 2018 & Health at a Glance 2019 (OECD/European Union, 2018[83]; OECD, 2019[84]).

OECD Statistics: in addition to health, OECD provide data for a range of other topics such as education, the economy and productivity. https://stats.oecd.org/.

WHO Global Health Observatory: the WHO publishes data on a wide‑range of health indicators for countries across the world. https://www.who.int/data/gho/data/indicators.

World Bank Data (World Development Indicators): the World Bank and has developed a DataBank providing information on a wide range of topics such as health, education, inequality and the economy. https://data.worldbank.org/indicator.

Eurostat: Eurostat’s database, Eurobase, provides statistics on a range of topics for European countries. Topics include health, economic and finance, and population and social conditions. https://ec.europa.eu/eurostat/data/database.

European Core Health Indicators (ECHI): ECHI tool includes statistics for Member States covering demography and socio‑economic situation, heath status, determinants of health, health services, and health interventions. https://ec.europa.eu/health/indicators/echi/list_en.

European Health Information Gateway (WHO Regional Office for Europe): the European Health Information Gateway combines data for a wide range of health issues such as health literacy, mental health, obesity, pollution, and AMR. It also includes in-depth country profiles for each Member States. https://gateway.euro.who.int/en/.

European Observatory for Health Systems and Policies: the Observatory is a partnership between the WHO, various European Governments, international organisations and academia. It promotes evidence‑based decision-making through comprehensive and rigorous analysis of health systems and policies across Europe. The Observatory publish a range of material on country health systems reviews and country health profiles. It also includes an interactive tool allowing users to compare health care systems across different countries (see: https://www.hspm.org/searchandcompare.aspx).

Institute for Health Metrics and Evaluation (IHME): IHME is an independent research centre providing comparable data across a range of health indicators and countries. Data from IHME is publically available and includes information on the global burden of disease by country. http://www.healthdata.org/.

Other useful links

National statistical agencies: a list of national statistical agencies and contact details for European Member States, EFTA countries, candidate countries, potential EU countries and other: https://ec.europa.eu/eurostat/web/links.

The Commonwealth Fund is a privately run foundation designed to promote better performing health care systems. The Fund provides free‑to‑access international profiles of health care systems. https://www.commonwealthfund.org/publications/fund-reports/2017/may/international-profiles-health-care-systems.

Table A B.1. Global indicators and aligning data sources

Indicator	Category	Dataset	Source within dataset
QALYS gained (see Box A B.2 below)	Universal heath outcome	Participant surveys	n/a
DALYs averted (see Box A B.2 below)	Universal heath outcome	Participant surveys	n/a
Life expectancy	Universal heath outcome	OECD Health Statistics	Health status: life expectancy
Healthy life expectancy	Universal heath outcome	OECD Health Statistics	Health status: healthy life expectancy
Perceived heath status	Universal heath outcome	OECD Health Statistics	Health status: perceived health status
Avoidable mortality	Universal heath outcome	OECD Health Statistics	Health status: avoidable mortality
Change in body mass index (BMI) (= weight / height2))	Risk factor (obesity)	Objective measurements¹ Self-reported surveys	n/a
% of the adult population who are obese (BMI ≥30)	Risk factor (obesity)	OECD Heath Statistics	Non-medical determinants of heath: body weight
% of the adult population who are overweight (25 ≥ BMI < 30)	Risk factor (obesity)	OECD Heath Statistics	Non-medical determinants of heath: body weight
% of the adult population who are overweight or obese (BMI ≥25)	Risk factor (obesity)	OECD Heath Statistics	Non-medical determinants of heath: body weight
% of school-aged children and adolescents (5‑18 years) with a BMI +1 standard deviation from reference median (overweight)	Risk factor (obesity)	WHO Global Health Observatory	Overweight and obesity
% of school-aged children and adolescents (5‑18 years) with a BMI +2 standard deviations from reference median (obese)	Risk factor (obesity)	WHO Global Health Observatory	Overweight and obesity
% population who are daily smokers	Risk factor (tobacco consumption)	OECD Health Statistics	Non-medical determinants of heath: tobacco consumption
% population who are occasional smokers	Risk factor (tobacco consumption)	OECD Health Statistics	Non-medical determinants of heath: tobacco consumption
% population who are occasional or daily smokers	Risk factor (tobacco consumption)	OECD Health Statistics	Non-medical determinants of heath: tobacco consumption
Cigarettes smoked per day	Risk factor (tobacco consumption)	OECD Health Statistics	Non-medical determinants of heath: tobacco consumption
Grammes of tobacco per capita	Risk factor (tobacco consumption)	OECD Health Statistics	Non-medical determinants of heath: tobacco consumption
Litres of alcohol consumed per person per year	Risk factor (harmful alcohol consumption)	OECD Health Statistics	Non-medical determinants of heath: alcohol consumption
Frequency of alcohol consumption (every day, every week, every month, less than once a month, never or not in the last 12 months)	Risk factor (harmful alcohol consumption)	Eurostat	Indicator code: hlth_ehis_de10
Frequency of heavy episodic drinking (60g of pure alcohol of more in on sitting) (every day, every week, every month, less than once a month, never or not in the last 12 months)	Risk factor (harmful alcohol consumption)	WHO Global Health Observatory	Global Information System on Alcohol and Heath
% population who engage in performance enhancing physical activity at least once a week (aerobic and/or muscle strengthening)	Risk factor (physical inactivity)	Eurostat	Indicator code: Physical activity (hth_pha)
% adults (18+) reporting doing at least 150min of moderate‑intensity physical activity in a week OR 75min of vigorous-intensity (or a combination of the two)	Risk factor (physical inactivity)	WHO Global Health Observatory	Noncommunicable diseases
% children and adolescents (5‑17 years) reported doing at least 60min or moderate to vigorous intensity physical activity daily	Risk factor (physical inactivity)	WHO Global Health Observatory	Noncommunicable diseases
% of the population consuming fruits at least once per day	Risk factor (unhealthy diet)	OECD Heath Statistics	Non-medical determinants of heath: food supply and consumption
% of the population consuming vegetables at least once per day	Risk factor (unhealthy diet)	OECD Heath Statistics	Non-medical determinants of heath: food supply and consumption
% of people who consume recommended amount of fruits and vegetables per day (e.g. five portions)	Risk factor (unhealthy diet)	National heath surveys	n/a (recommended by WHO (2018[170]))
% of population whose free sugar intake is less than 10% of total calorie intake	Risk factor (unhealthy diet)	National heath surveys	n/a (recommended by WHO (2018[170]))
% of the population who consume less than 5grams of salt per day	Risk factor (unhealthy diet)	National heath surveys	n/a (recommended by WHO (2018[170]))
Relative reduction in raised blood pressure	Risk factor (unhealthy diet)	National heath surveys	n/a (recommended by WHO (2018[170]))
% of the population whose saturated fatty acid intake is less than 10% of total calorie intake (less than 1% for trans fatty acids)	Risk factor (unhealthy diet)	National heath surveys	n/a (recommended by WHO (2018[170])))
Average number of calories consumed per day	Risk factor (unhealthy diet)	European Health Information Gateway	European Health for all Database (Lifestyles)
Number of suicides 30 days after discharge for patients diagnosed with a mental disorder	Mental heath	OECD Health Statistics	Health Care Quality Indicators: Mental health care
Number of suicides 1 year after discharge for patients diagnosed with a mental disorder	Mental heath	OECD Health Statistics	Health Care Quality Indicators: Mental health care
Inpatient suicide numbers for patients diagnosed with a mental disorder	Mental heath	OECD Health Statistics	Health Care Quality Indicators: Mental health care
Suicide rate per 100 000 people	Mental Health	WHO Global Health Observatory	Mental Health

Note: For brevity reasons, only one dataset has been mentioned per indicator. However, it is likely other datasets also provide the same information.

1. BMI figures may be measured or recorded through self-reported surveys (the former being more accurate).

Source: See box on publically available data sources and resources.

Box A B.2. QALYs and DALYs

Quality-adjusted life year (QALY)

QALYs are a generic measure of a person or groups state of health. They are frequently used to evaluate the impact of an intervention in terms of change in life expectancy, taking into account quality of life (i.e. QALY = change in life expectancy x quality of life score). A QALY equal to one represents one additional year of life in perfect health (National Institute for Health and Care Excellence, 2020[12]; Sassi, 2006[19]).

Disability-adjusted life year (DALY)

DALYs measure the burden of disease using the following equation: sum of years of life lost (YLL) due to premature mortality and years lost due to disability (YLD) for those living with a specific health condition and the associated consequences: DALY = YLL + YLD where:

• YLL = number of deaths x standard life expectancy adjusted for age

• YLD = number of cases x disability weight x average duration of the case (or until death) (WHO, 2020[171]).

As outlined in under Step 1a (‘Effectiveness’ – ‘Indicators’), the validity and reliability of QALY measurements are often questioned (e.g. due to the methods in which patient data is collected). DALYs are also subject to criticism, for example, favouring immediate over future health benefits, which is disadvantageous for prevention interventions, and weighting that disfavours children and old people.