Forty-ninth Regional Committee for Europe: Florence, 13 - 17 September 1999: Health for All (HFA) indicators for monitoring and evaluation of HEALTH21

WORLD HEALTH ORGANIZATION R e g i o n a l O f f i c e f o r E u r o p e C o p e n h a g e n Provisional agenda item 3(b) EUR/RC49/7 + EU R/RC49/Conf.D oc./4 17 May 1999 06859 ORIGINAL: ENGLISH H e a l t h f o r A l l ( H F A ) In d ic a t o r s f o r M o n it o r in g a n d E v a l u a t io n o f H e a l t h 21 At the forty-eighth session of the Regional Committee last year, European M em ber States approved the regional policy framework for health for all (FIFA) in the twenty-first century (HEALTH21) and the suggested areas for formulating indicators set out in Annex 2 of that document. The Regional Committee also urged M ember States, as in the past, to have in place information systems for monitoring progress in the implementation of their various HEA-related programmes and reporting their experience, making use inter alia of elaborated regional HFA indicators, to be endorsed at the C om m ittee’s forty-ninth session (resolution EUR/RC48/R5). The purpose of this paper is to feed back the results of the work which the Regional Committee asked to be done on further elaborating the generic indicators inherent in the HFA policy framework, and to outline how they will be used to simplify and streamline the HFA monitoring and evaluation process in the future. The essence of this paper was presented to and supported by the Standing Com mittee o f the Regional Committee in April 1999, and its views are summarized in the box overleaf. REGIONAL COMMITTEE FOR EUROPE Forty-ninth session, Florence, 1 3 – 17 September 1999 V i e w s e x p r e s s e d b y t h e S t a n d i n g C o m m i t t e e o f t h e R e g i o n a l C o m m i t t e e At its third meeting in April 1999, the sixth Standing Committee of the Regional Committee (SCRC) was informed that to date 21 countries had replied to a questionnaire about the indicators to be used in connection with the new HEALTH21 policy framework. Nineteen had confirmed that the proposed list was in general adequate for monitoring progress towards the HEALTH21 targets, although 14 had identified difficulties regarding data collection methods, comparability, etc. Of the 59 generic indicators proposed, data on 23 could be obtained from secondary sources, while 36 would require direct collection. Of the latter, only 16 would necessitate survey/census data, and they would be collected at six-yearly intervals. Once the differences between monitoring and evaluation had been clearly pointed out, the SCRC was asked to suggest any further action that might be needed in elaborating the indicators, and to recommend the best option to streamline the monitoring process (every three years, every two years, or annually). In response, the SCRC confirmed that the areas covered by the indicators were indeed appropriate, although further consideration should be given to socioeconomic and gender factors. It was noted that the indicators were designed to monitor progress towards HEALTH21 targets only - many other sources held detailed information on other aspects, and it would be important to coordinate closely with other United Nations agencies and the European Commission. On the question of the periodicity of the monitoring exercise, the SCRC unanimously preferred retaining the existing practice of carrying out the exercise once every three years. C O N T E N T S Page H FA indicators - developm ent and validation o f the new l i s t .................................................................................... 1 Stream lining the m onitoring and evaluation p rocess.......................................................................................................2 C onclusion ......................................................................................................................................................................................3 A nnex 1. Indicators for m onito ring progress tow ards the 21 targets in the health for all policy fram ew ork for the w ho E uropean R e g io n .................................................................................................... 4 EUR/RC49/7 page 1 H F A INDICATORS - D EV ELO PM EN T AND VALIDATION OF T H E NEW LIST 1. The indicators for health for all (HFA) serve as the main tool for the Member States and the WHO Regional Office for Europe to monitor progress towards attainment o f the HEALTH21 targets. Appropriately adapted and supplemented with additional information, these indicators are also used by many Member States for monitoring their national HFA-related health policies and programmes. 2. Technical work on the new HFA indicators started in 1997, when a working group of experts met to discuss the new draft targets and indicators. One o f the main recommendations was to preserve the continuity of the HFA indicators where relevant, while adapting them to the new HEALTH21 targets. It was also recommended that the opportunity should be taken to rationalize some o f the existing indicators, especially where data were lacking in nearly all Member States, and at the same time to streamline the monitoring process as such. 3. In response to the request o f the Regional Committee in 1998, a further elaborated list o f generic HFA indicators was prepared (Annex 1). The list shows, for each indicator, whether it is new or old, which category it is in for the purposes o f data collection, and what data sources may be used. Most o f the previous indicators are used for the new targets. The majority o f the raw data for the indicators are collected on a routine basis directly from the data sources. Therefore, collecting this information does not entail additional work on the part o f the Member States. 4. The list was subsequently presented to experts at a joint WHO/United Nations Economic Commission for Europe (ECE) meeting on health statistics (Rome, October 1998) and also sent out to all Member States for written consultation. The 21 country responses to the consultation document received by 20 April 1999 can be summarized as follows: • With regard to the main question, namely whether the revised list o f HFA indicators is, in general, sufficient and adequate for monitoring the implementation o f H E A L T H 2 1, eight Member States answered with an unconditional “yes” and 1 1 with a qualified ‘‘yes” . Two Member States responded with a qualified “no” . One of the latter countries responded that the revised list is too long. • Suggestions to add some specific indicators, and more specifications of the proposed generic indicators, were offered by 10 Member States. These suggestions will be taken into account when developing operational indicators and data collection protocols. • Comments on national data sources and data availability for various groups o f indicators were provided by 10 Member States. • Comments on difficulties related to the lack of availability and poor international comparability o f some indicators, confirming the experience of the Regional Office in this area, were submitted by 14 Member States. 5. In general, the comments and suggestions made were very supportive and helpful. However, they were not consistent enough among a sufficiently large number o f countries to assume that corresponding changes to the suggested list o f generic HFA indicators would be definitely acceptable to all or at least to the majority o f countries. Many suggestions to add additional indicators were country-specific. Their inclusion in the list would significantly increase the total number o f indicators and would therefore contradict the general requirement to keep the list as short as possible. 6. Some suggestions, such as making reference to the codes in the International Classification of Diseases, were too specific to be used at the level o f generic indicators. However, as mentioned above, all such suggestions will be taken into account during further detailed development o f operational indicators and related definitions. On the whole, the suggested list o f generic HFA indicators appeared to be the most acceptable compromise between the sometimes contradictory recommendations o f the countries. EUR/RC49/7 page 2 This is also the position o f the SCRC, which confirmed that the areas covered by the indicators are indeed appropriate. 7. One important comment was that there are no indicators directly measuring inequities in health. Unfortunately, internationally comparable and commonly accepted measurements o f inequities in health are not yet widely and constantly available. This makes it problematical to include them in the list as clearly defined HFA indicators. However, some assessment of inequities can be made using practically any o f the suggested indicators, subject to the availability o f data disaggregated by socioeconomic group, subnational area, etc. 8. A compendium o f all replies received in time to be processed for the Regional Committee will be presented in an addendum to this paper. S t r e a m l i n i n g t h e m o n i t o r i n g a n d e v a l u a t i o n p r o c e s s 9. HEALTH21 not only reconfirms the importance of monitoring and evaluation,1 it also, as in the past, explicitly earmarks the main events in that process, as presented in the following table. Year M em ber S tates and Regional Office R egional Com m ittee 2000 2001 2002 2003 2004 M onitoring started M onitoring com pleted Evaluation started Evaluation com pleted Review o f m onitoring report Review o f eva luation report in the context o f approval o f a renewed regional HFA policy fram ework 10. In previous years, however, HFA monitoring had practically the same calibre as HFA evaluation, i .e. the intended relatively limited scope and ambition o f a monitoring exercise were actually expanded to match an evaluation exercise. This development has not been generated in, or confined to, the European Region o f WHO; it has been observed in other regions, too. The resources employed in the monitoring exercise, both by Member States and by the Regional Office, have thus been at the same significant level as those for the evaluation. Furthermore, the information collected by means o f the countries’ monitoring reports, prepared in line with the framework document, has also been at the same level o f detail and extensiveness as that for the evaluation exercises. Finally, it should be noted that for monitoring purposes information from the Office’s technical units or other sources (international organizations, publications, etc.) is readily and efficiently available. 11. It is therefore suggested that the 2 0 0 0 -2 0 0 1 monitoring exercise as set out in HEALTH21 should be based on information available in the Regional Office and routinely collected statistics. This means that countries will not be asked to produce reports using a common framework. This should help to restore the proper role o f monitoring. The next evaluation in 2 0 0 3 -2 0 0 4 would of course, as in the past, be based on a full exercise in the Member States and in the Regional Office, using a common framework at country level and for reporting to the Regional Office. 1 Monitoring involves the continuous follow-up o f activities to ensure that corrective measures can be taken if needed. Evaluation is the more systematic and comprehensive assessment o f the relevance, adequacy, progress, efficiency, effectiveness and impact o f policies and programmes. The information gained from monitoring feeds into and is part o f that for evaluation. Monitoring is, in principle, a relatively lighter exercise on the basis o f routinely available information, while evaluation should aim at deriving new knowledge from the experience accumulated. EUR/RC49/7 page 3 12. The specific milestones o f the 2 0 0 0 -2 0 0 1 monitoring exercise are: • preparatory steps: finalization o f definitions, data collection protocols and database, after approval of the new HFA indicators by the Regional Committee at its forty-ninth session - RC49 (October 1999 - May 2000); • annual collection of statistical data from the countries (June - December 2000); • office-wide monitoring exercise and first draft report (October 2000 - April 2001); • first draft o f the monitoring report presented to SCRC (April 2001); • report presented to R C 5 1 (September 2001); • publication of executive summary o f the report (December 2001). 13. The monitoring report submitted to RC51 should follow the structure o f HEALTH21, but there should also be a section or annex on the extent to which the main quantifiable targets o f the 38 targets in the 1991 HFA policy were attained by the year 2000. This will probably make it possible to draw some further conclusions about progress towards HFA by the year 2000, while also watching the first steps towards HEALTH21. C o n c l u s i o n 14. The Regional Committee’s approval is sought for the revised list o f HFA indicators and the proposed main changes in the HFA monitoring process. A draft Resolution (EUR/RC49/Conf.Doc./4) is accordingly submitted for the Committee’s consideration. EUR/RC49/7 page 4 I n d i c a t o r s f o r M o n i t o r i n g P r o g r e s s T o w a r d s t h e 21 T a r g e t s in t h e H e a l t h f o r A l l P o l ic y F r a m e w o r k f o r t h e W H O E u r o p e a n R e g i o n B a c k g r o u n d The first set o f European regional HFA indicators was adopted by the Regional Committee in 1984 and subsequently revised as part of the 1991 HFA policy update. The 1991 edition comprised 112 generic HFA indicators or groups o f indicators. Data for most o f these indicators are available from the routine statistical recording and reporting systems o f countries and have been collated and disseminated by WHO for many years. Some of the indicators, however, can be measured only by means o f population surveys or other methods that are not necessarily part o f the routine collection o f health statistics in the majority of countries. HFA indicators are calculated by WHO using raw data gathered from a variety o f sources. There are three main groups o f data sources: 1. specific WHO technical programmes (e.g. mortality data, incidence o f communicable diseases) 2. other specialized international organizations, agencies or publications 3. direct collection of health statistics from national counterparts for the HFA database. As regards group 3, routinely available data are collected annually. Less readily available data for selected “difficult” indicators are requested as part o f the HFA monitoring exercises, usually every three or six years. The main principles o f the annual collection of basic health statistics for the HFA database are as follows. • Available data from the above-mentioned secondary sources (groups 1 and 2) are gathered first. Countries are then requested to provide any missing data, if available. • Countries are expected to provide only readily available data, which in most cases can be obtained from routine national health statistics. • All data collected, both from secondary sources and directly from countries, are regularly fed back to countries to assist in the monitoring o f national HFA policies. The HFA database, which is accessible through the Internet, serves as a user-friendly source o f data for comparative international analysis for various purposes and users. In general, the same data sources and principles o f data collection will be used for the new system of HFA indicators. T e c h n i c a l n o t e s As some indicators are relevant to several targets, and to avoid repetition, new HFA indicators are grouped by broad areas o f health and health-related measurements: • health status (mortality, morbidity, disability, selected indicators related to maternal and child health, other health status indicators); • health determinants (lifestyles, environment, health care); and • background demographic and socioeconomic indicators. The indicators are given at generic level. Technical details, including detailed definitions, will be specified when operational indicators are formulated for the HFA database and monitoring procedures are Annex 1 EUR/RC49/7 page 5 developed. The majority o f operational indicators and definitions are already in use and are available as a part o f the HFA database. The continuity o f the current indicators has been maintained as much as possible to preserve trends, as recommended by a working group that met in October 1997. For ease o f reference, indicators in the list are shown as “old” or “new” after the title. Indicators are also roughly assigned to the following categories, indicating the source o f data and difficulties associated with obtaining comparable data. 1. Indicators readily available from secondary sources (e.g. other international organizations) for a sufficiently large number o f countries or drawn up by the Regional Office using raw data routinely reported to specific WHO technical units. 2. Data on health statistics regularly collected from national counterparts for the HFA database. 3. Relatively “difficult” indicators that are usually not part o f routinely collected and available health statistics, or for which comparable data of acceptable quality are at present limited or not available in the majority o f countries. These indicators are included because they are relevant to HFA monitoring, the aim being to encourage countries to strengthen weak components o f their national health information systems and to ensure better data availability in future. Many o f these indicators are measured by population surveys and are available for countries that carry out such surveys. Some data are also available from certain international networks and projects. In general, data for indicators in categories 1 and 2 are collected annually, while those for category 3 are collected every three or six years. The present list has a total o f 59 generic indicators or groups o f indicators, o f which 50 are the current “old” indicators and 9 are new. Some 23 indicators are calculated using readily available data from secondary sources (i.e. other international agencies or WHO technical programmes). Data for another 20 indicators are routinely collected from countries, and 16 are considered “difficult” indicators. A portion of the 1991 version o f the HFA indicators has been dropped because o f limited availability of data and limited relevance to the new HFA targets. O f the 112 generic indicators published in 1991, 74 are retained and regrouped according to new targets and 38 have been dropped. EUR/RC49/7 page 6 1. M ortality indicators These indicators are calculated by the Regional Office (WHO/EURO) using routinely reported mortality data by cause, age and sex. Except for data for the perinatal period, therefore, countries are not requested to provide these indicators separately for the purpose o f the regional HFA monitoring. In the case o f the few countries that cannot yet provide complete mortality data, estimates from other sources are used. Mortality rates are age-standardized, using the European standard population to ensure intercountry comparability. Indicators are calculated by sex and age group as appropriate. L i s t o f H F A i n d i c a t o r s European HFA indicators Relevant to HFA targets Data sources and comments 1.1 Life expectancy at birth and at different ages and by sex (old, 1). 1, 2, 5 Calculated by W HO /EU RO using the standard life table method and routine ly reported m ortality data. 1.2 Perinatal, neonatal and infant m ortality and m ortality before 5 years of age (old, 1). 1, 2, 3 Calculated by W HO /EU RO from routine ly reported m orta lity data and data on stillb irths provided by countries as part o f the regular reporting on HFA indicators. 1.3 M aternal m ortality (old, 1). 1, 2 Calculated by W HO /EU RO on the basis o f routine ly reported m ortality data. 1.4 Mortality from all in fectious and parasitic diseases, tuberculosis, malaria, A IDS (new, 1) and acute respiratory and diarrhoea l diseases (in children) (old, 1). 1, 2, 5, 7 See com m ents above. 1.5. Mortality from noncom m unicable diseases (old, 1): - card iovascular diseases - cancer - chronic respiratory diseases - d iabetes - other diseases. 1, 2, 5, 8 See com m ents above. 1.6 Mortality from all external causes of death (old, 1): - accidents and poisonings - m otor vehicle tra ffic accidents - work-re la ted accidents - suicide and hom icide. 1-6 , 9, 12, 13 See com m ents above. 1.7 M ortality from specific causes related to the quality o f health care (old, 1): - appendicitis - hernia and intestinal obstruction - adverse effects o f therapeutic agents - other “avoidable" causes of death. 1, 2, 16 See com m ents above. EUR/RC49/7 page 7 Routine reporting of data o f relatively good quality is available only for notifiable infectious diseases and selected noncommunicable diseases that have relatively clear diagnostic criteria and/or are covered by special registers in a sufficient number of countries. 2. Morbidity indicators European HFA indicators Relevant to HFA targets Data sources and comments 2.1 Incidence of selected com m unicable diseases (old, 1): - poliom yelitis - m easles - diphtheria - tetanus - hepatitis (A, B, other) - mumps - rubella - pertussis - congenita l syphilis - malaria - tuberculosis - syphilis - gonorrhoea - HIV/AIDS. 1-3 , 7 Data w ill be collated from those already reported by M em ber States to W HO or its collaborating centres. In som e cases the m ost recent data w ill be supplem ented by annual reporting on HFA indicators. 2.2 Incidence of ischaem ic heart disease and cerebrovascular disease (old, 3). 1, 2, 5, 8 A va ilab ility and in tercountry com parability are very low ow ing to variations in d iagnostic and reg istration practices in d ifferent countries. Som e data available, m ostly from countries o f centra l and eastern Europe, are based on the registration o f new diagnoses by health services, which do not necessarily correspond to actual m orbidity. Som e estim ates are also available from specia l research projects or ep idem io log ica l studies, such as the W HO “M O NICA” project. 2.3 Incidence o f cancer: - all sites (new, 2) - trachea/bronchus/lung (new, 2) - fem ale breast (old, 2) - cervix uteri (old, 2). 1, 2, 5, 8 Data are available in a num ber o f European countries from the routine registration system or specia l registers, but in ternationa l com parability o f these data has yet to be assessed. Som e data are also available from the In ternational A gency fo r Research for Cancer. 2.4 Incidence and prevalence of d iabetes (old, 2) 1, 2, 5, 8 Data are availab le in a num ber o f European countries from the routine registration system or specia l registers, but in ternational com parability o f these data has yet to be assessed. 2.5 Incidence and prevalence of chronic respiratory d iseases and asthm a (old, 3). 1 -3 , 5, 8 See com m ents above. 2.6 Incidence and prevalence of mental disorders (old, 3): - schizophrenia - serious depression - a lcoholic psychosis - post-traum atic mental sequelae - other. 1, 2, 4 -6 , 12 Data are availab le in som e European countries from the routine reg istration system or special registers; incidence data are less available. In the past, incidence data have been reported m ostly from countries of centra l and eastern Europe. 2.7 Incidence o f in juries and poisonings (old, 1): - road tra ffic accidents - hom e- and work-re la ted accidents. 1, 2, 4, 9, 13 Data source fo r road tra ffic accidents is the ECE annual statistical publication on road traffic accidents in Europe. Data from ILO publications will be used for work accidents. C om parable routine statistics on hom e and le isure accidents are usually not available ow ing to d iffe rent reg istration practices and definitions. For EU countries, estim ates w ill be available from the European Hom e and Le isure Acciden t Surve illance System (EHLASS). EUR/RC49/7 page 8 European HFA indicators Relevant to HFA targets Data sources and comments 2.8 Incidence and prevalence o f selected congenita l diseases (old, 3). 3 Data are ava ilab le in a num ber o f European countries from the routine reg istration system s or special registers, but in te rnationa l com parability o f these data has yet to be assessed. For EU countries som e estim ates are available from the EUROCAT project. 2.9 Selected oral health indicators (old, 3): - DM FT-12 index (average num ber of decayed, m issing o r filled teeth at age 12) - percentage o f 6-year-o ld children free o f caries. 1, 2, 4, 8 Data from the oral health program m e of W HO /EU RO will be used and supplem ented with data reported by countries. Data are ava ilab le in many countries from special surveys o r the routine registration system. 2.10 Hospital adm issions or d ischarges by d iagnosis (new, 2): - card iovascular d iseases - cancer - infectious and parasitic diseases - in juries and poisonings - mental illness, including alcoholic psychosis and drug addiction - other. 3 -9 , 12 Data are availab le from routine hospital statistics in the m ajority o f countries. A lthough hospital d ischarge data cannot be used d irectly to estim ate m orbidity, they can be helpfu l in the absence o f better data or at least for estim ating the burden on the health services caused by different diseases. 2.11 Absenteeism from work owing to illness (old, 2). 6 -9 In m any countries, these data are available from existing sick leave reg istration systems, but in tercountry com parability is considered low, owing to d ifferences in legal and o ther conditions. Data for European OECD countries are ava ilab le from the OECD health database. 3. Disability indicators Aggregated data are available from the social insurance systems in many countries, although intercountry comparability is limited owing to differences between countries in legal and other conditions and in routine registration systems. These data can also be obtained from health interview surveys. These should be carried out, using standard methods, in a sufficient number o f countries to produce internationally comparable data. European HFA indicators Relevant to HFA targets Data sources and comments 3.1 Incidence and prevalence of disability, by age and cause (old, 3). 1, 2, 5, 8 See note above. 3.2 Percentage o f disabled persons engaged in regular occupational activities (old, 3). 2, 13 See note above. EUR/RC49/7 page 9 4. Selected maternal and child health indicators E uropean HFA in d ic a to rs R e leva n t to HFA ta rg e ts Data s o u rc e s and com m e n ts 4.1 Percentage of neonates w eighing 2500 g or more (old, 2). 2, 3, 11 Data available from routine registration system s in the m ajority o f countries. 4.2 Rate of Caesarean section in childb irth (old, 2). 3, 16 Data available from routine registration system s in the m ajority o f countries 4.3 N um ber o f induced abortions, by aqe (old, 2). 2, 4, 11, 15 Data available from routine registration system s in the majority o f countries. Data by age (e.g. under 20 years) are available from few er countries. 4.4 Num ber o f live births, by age of m other (below 20 and above 35 years) (old, 2). 4, 11 Data available from routine registration system s in the m ajority o f countries. 4.5 Percentage o f children im m unized against selected com m unicable d iseases (at 1 year of age or as appropriate) (old, 1): - diphtheria - tetanus - pertussis - m easles - poliom yelitis - tuberculosis - hepatitis - m umps - rubella - som e other. 1 -3 , 15 Data will be collated from those already reported to W HO or its co llabora ting centres. In some cases the m ost recent data w ill be supplem ented by the annual reporting on HFA indicators. 4.6. Percentage o f infants breastfed at 3 and 6 months of age (old, 2). 3, 11 Data are available from routine registration system s or health interview surveys from a relatively large num ber of countries, a lthough accuracy and com parability are considered low. 5. O ther health status indicators European HFA indicators Relevant to HFA targets Data sources and comments 5.1 Disability-free life expectancy, by age (old, 3). 1, 5 This is a composite indicator combining prevalence of mortality and disability, by age and sex. The indicator has been calculated for a number of countries, but intercountry comparability is limited, owing to the disability component. Prevalence of disability by age is estimated from health interview surveys, which often use different methods. Publications of the network of researchers (REVES) working on the problem of calculating and comparing disability-free life expectancy are the main source of data. 5.2 Prevalence of elevated blood pressure and serum cholesterol level, as major CVD risk factors (old, 3). 8 Estimates of the prevalence of these risk factors are virtually unavailable from routine registration systems. Some data can be made available from population surveys, which are mostly carried out on an ad hoc basis for research purposes, using different methods; comparability of results is therefore unknown. For several years, the best data have been obtained from internationally coordinated and standardized surveys such as the MONICA project. Consideration should be given to establishing mechanisms for measuring these biological risk factors more regularly in populations (along with other behavioural risk factors such as smoking). EUR/RC49/7 page 10 European HFA indicators Relevant to HFA targets Data sources and comments 5.3 A ssessm ent of perceived health, by sex and age (old, 3). 5 ,6 Data from health in te rv iew surveys are available in a num ber o f countries. 5.4 A ssessm ent of health-related quality o f life (old, 3). 1, 5, 6 Estim ates by d iffe rent m ethods are available in many countries. A harm onized m ethod fo r cross-nationally com parable m easurem ent is being developed. 6. Lifestyle indicators The majority of lifestyle-related data are not collected by routine registration and reporting systems in the health sector. Estimates are available from population surveys or national statistics on the production and sale o f appropriate products. European HFA indicators Relevant to HFA targets Data sources and comments 6.1 Sm oking prevalence by sex and age (old, 2). 4, 12 Data are available from health in terview surveys in the m ajority o f countries. Harm onized and com parable data on sm oking prevalence in m any countries will be available from the W H O /EU R O pro ject on health interview surveys (EUR O H IS). These data will be supplem ented by in form ation collected by the W HO /EURO Tobacco and Health unit and data supplied by countries as part of the annual reporting on HFA indicators. 6.2 N um ber o f c igarettes consum ed per person per year (old, 1). 12 Estim ates are based on national statistics for tobacco production, export and im port, which are regularly published in Tobacco journa l international o r are available from o ther sources (e.g. the US Departm ent of Agriculture). 6 .3 Estim ates o f the frequency and am ount of alcohol use by sex and age (old, 3). 4, 12 These can be estim ated only by m eans o f health interview surveys. The availab ility and intercountry com parability o f these data are at present low. 6.4 A verage alcohol consum ption in litres per person per year (old, 1). 12 Estim ates are based on national sales statistics. In som e countries, a lcohol consum ption can be s ignificantly underestim ated ow ing to unregistered and illegal production and im ports. Data regularly published in World drink trends (The Netherlands) are used for this indicator. 6 .5 National s ta tistics on food consum ption (old, 1): - calories per person per day - percentage o f energy available from fat - percentage o f energy available from protein - ava ilab ility o f cereals - ava ilab ility o f vegetables and fruit. 11 Data are available from the Food and Agriculture O rganization o f the United Nations (FAO) 6.6 Physical activ ity estim ates (old, 3). 11 Som e estim ates could be m ade available from health interview surveys but ow ing to m ethodological d ifficu lties in assessing the degree o f physical activity, com parable data are v irtua lly unavailable. Body mass index data can be used as a proxy indicator. EUR/RC49/7 page 11 7. Environment indicators European HFA indicators Relevant to HFA targets Data sources and comments 7.1 National housing statistics (old, 1): - average living area per person - average num ber o f persons per room. 10, 13 Data are available from appropria te publications of the United Nations Econom ic C om m ission fo r Europe. 7.2 Percentage o f population having adequate water supply in the home and hyg ien ic sewage disposal, separa te ly fo r urban and rural areas (old, 3). 10 In the past estim ates were provided through surveys carried out by the special W H O International W ater Decade programme. N ational statistics on households connected to the public w a te r supply and sewerage system s are also available in som e countries. In general, the availability and com parability o f these indicators in the European Region are low. O ne reason is that the relatively high standards o f living in the majority o f European countries guarantee these services and they are therefore not among the major public health concerns covered by routine statistical reporting. This does not mean that in Europe there are no areas and population groups with inadequate access to safe water. Com parable definitions and assessment m ethods are also a problem. 7.3 N um ber o f outbreaks and cases o f m icrob io log ica l foodborne diseases (old, 2). 10 Data are available from routine reg istration system s or through the notification o f in fectious d iseases in many European countries. In tercountry com parability is low, however, ow ing to varia tions in coverage and in d iagnostic and registration practices. 7.4 E stim ates of sulfur dioxide em ission (old, 1). 10 Data for selected countries are ava ilab le from OECD and EUROSTAT. 8. Health care resources indicators European HFA indicators Relevant to HFA targets Data sources and comments 8.1 A va ilab ility o f health care facilities (old, 2): - num ber o f hospitals - num ber o f prim ary health care establishm ents - hospita l beds by specialty and type (private/public, acute/chronic) - beds in nursing homes and hom es for the elderly. 15 Data are available in all countries as part o f routine national statistics on health care. In som e cases, in tercountry com parability is lim ited ow ing to differences in health systems, national de fin itions and registration practices 8.2 A va ilab ility o f health professionals (old, 2): - physic ians by category (at least genera l practitioners/specialists) and workp lace (PHC/hospitals) - nurses, including m idwives - dentists - pharm acists. 15, 18 See com m ents above. 8.3 Health pro fessionals graduating annually (old, 2): - physic ians - nurses and m idwives - dentists - pharm acists. 15, 18 Data are available as part o f rou tine national statistics on graduates from un iversities/schools. EUR/RC49/7 page 12 9. Health care consumption indicators European HFA indicators Relevant to HFA targets Data sources and comments 9.1 N um ber o f hospita l adm issions (new, 2). 15 Data are available in all countries as part o f routine national statistics on health care. In som e cases, in tercountry com parability is lim ited ow ing to differences in health system s, national de fin itions and reg istration practices. 9.2 A verage length o f stay in hospital (new, 2). 15 See com m ents above. 9.3 H ospita l bed occupancy (new, 2) 15 See com m ents above. 9.4 A verage num ber o f outpatient con tacts (new, 2). 15 See com m ents above. 9.5 S urg ica l opera tions performed, total and selected types (new, 2). 15 See com m ents above 10. Selected quality of care indicators European HFA indicators Relevant to HFA targets Data sources and comments 10.1 A u topsy rate for hospita l deaths and all deaths (old, 2). 16 See com m ents above 10.2 S urg ica l w ound in fection rate (old, 3). 16 Data are available in m any countries as part o f routine hospita l statistics. However, data fo r th is ind ica tor are usually less readily available since they do not usually appear am ong national health statistics trad itionally reported and published. 10.3 D iabetic com plica tion rates (e.g. b lindness, nephropathy, am putation of limbs) (old, 3). 16 See com m ents above. 11. Health financing and expenditure indicators European HFA indicators Relevant to HFA targets Data sources and comments 11.1 Total health expenditu re (old, 1). 1, 17 Data for European OECD countries are ava ilab le from the OECD health database. Data from other countries may be less com parable ow ing to d iffe rences in accounting methods, defin itions and health systems. 11.2 Selected com ponents o f health expend itu re (old, 1): - public health expenditure - recurrent hospita l costs - cap ita l investm ent in medical fac ilities - salaries - pharm aceutica ls - local health care - health research and developm ent. 17, 19 See com m ents above EUR/RC49/7 page 13 These indicators are relevant to all targets, and particularly targets 1, 2 and 21. Population and live births are used as denominators to calculate the majority o f other indicators. 12. Background demographic and socioeconomic indicators European HFA indicators Relevant to HFA targets Data sources and comments 12.1 Population by age and sex, and num ber o f live births by sex (old, 1). Routinely reported to W HO together with m ortality data or as part of the annual reporting on HFA indicators. 12.2 Fertility rate (new, 1). Data from the W orld Bank o r as reported by countries. 12.3 U nem ploym ent (old, 1). Data from the International Labour O rgan iza tion or as reported by countries. 12.4 Annual inflation (new, 1). Data from the United Nations Econom ic Com m ission for Europe or as reported by countries. 12.5 GNP and GDP (new, 1). Data from the W orld Bank, UNDP or as reported by countries. 12.6 L iteracy rate and proportion of the population w ith different levels of education (old, 1). Data from UNESCO, UNDP or as reported by countries.