#4a Denominators for coverage and service utilization indicators - PowerPoint Presentation

1. #4aDenominators for coverage and service utilization indicators

2. ObjectivesProduce a comprehensive assessment of the denominators for the computation of population coverage and service utilization from health facility data which includesanalysis of the population projection data in the DHIS2assessment of the total (live) births projections with reported numbers of events for high coverage interventionsanalysis of selected coverage rates at national and subnational level using the standard projections in DHIS2Decide on denominators for the analyses of population indicatorsFor: National Province/region(District)

3. Why denominators?We want to know what percent of the population is reached by the health services, based on the number of events (ANC visits, deliveries, immunizations, treatments etc.)Therefore, we have to define the population in need of a specific service; also referred to as the target populationPreventive services indicators: e.g., ANC visits, institutional deliveries, immunization Denominator: population with specific age and sex, derived from population projectionHealth service utilization indicatorse.g., Outpatient services,Inpatient admissionsDenominator: Total population (under 5, 5+)Curative services indicators(e.g. child with malaria, diarrhoea, pneumonia)Denominator:Children who are sick and need treatment

4. Indicators and denominatorsIndicatorsNumeratorDenominatorSERVICE UTILIZATION Outpatient visits, children under 5, per year (N)N of OPD visits for under-5Total mid-year population under 5Inpatient admissions, children under 5, per year (N)N of admissions for under-5Total mid-year population under 5PREVENTIVE INTERVENTIONS % of pregnant women with 4 antenatal care visits N of women with ANC 4th visitTotal N of pregnant women in the whole population% of live births in health facilitiesN of live births in health facilitiesTotal N of live births in the whole population% of infants receiving 3 doses of pentavalent vaccineN of infants receiving 3 dosesN of infants eligible for 3 doses of the vaccineCURATIVE INTERVENTIONS % of children under 5 with malaria who receive ACTN of children U5 with malaria receiving ACTTotal N of children who had malaria in the last year% of deliveries that were by C-section (population)N of C-sections reportedTotal N of deliveries in the population% of deliveries that were by C-section (institutional)N of C-sections reportedTotal N of deliveries in health facilitiesMORTALITY  % of births that were stillbirthsN of stillbirths in health facilitiesTotal N of births in health facilitiesFAMILY PLANNING Ratio FP visits to women of reproductive ageN of FP new and revisitsTotal N of women 15-49 yearsEstimated modern use of contraceptivesCouple years of protectionTotal N of women 15-49 yearsFP coverage (demand satisfied)N of women using modern methodsTotal N of women in need of FP

5. Population versus institutional indicatorsExample of C-sectionData for a hypothetical region1000 C-sections (from DHIS2 reports for one year)10,000 deliveries in health facilities (from DHIS2 reports for one year)20,000 deliveries in the whole population (from population projections)Institutional delivery coverage = 10,000 / 20,000 * 100 = 50%Institutional rate of C-sections = 1,000 / 10,000 * 100 = 10%Population rate of C-sections = 1,000 / 20,000 * 100 = 5%Notes:C-section rate is not a coverage indicator as the population in need is not knownC-section rate is often expressed per 1,000 live births, not deliveries

6. Census population projections to obtain denominatorsNational population census is the main source for population by age and sex for the country and subnational areasDenominators for health service-based statistics are derived from census population projections These projections have errorsPopulation census was not accurate (and is hotly debated)Projection assumptions about fertility, mortality, and migration were not correct Deviations from the true situation are more likely the longer ago the population census was conducted6

7. Year of the last census: all 22 countries

8. Assessment of the population projections: five stepsCompile the population projection indicators (from DHIS2): Total population, Population groups (<1, <5, F 15-49), Live births12345Compute demographic parameters by year: population growth rate, percentages in the age/sex groups, Crude Birth Rate, Crude Death RateEvaluate the demographic parameters: a) consistency over time b) comparison with UN Population projections 3) survey results on crude birth ratesCompute coverage rates for the highest coverage interventions by year: first ANC visit (ANC1) and first dose of DPT (DPT1) and graph these with the total number of live birthsSummarize and interpret the findings of the assessment in a brief document: for national and provincial/regional level

9. The data are part of country data set – excel version; by region/province and nationalA Stata version of the population data should be available as an output of running Stata Code #1 of the data quality assessment analysesProduce a data set with the national and region/province totals for the indicators (STATA and Excel templates available)1Compile the population projection indicators (from DHIS2): Total population, Population groups (<1, <5, F 15-49), Live births

10. STATA code and Excel spreadsheet analysis tools compute the demographic parametersPopulation growth (r ) = ln (P2 / P1) / (t2 – t1) * 100%Crude Birth Rate (CBR) = N of live births / Total Population * 1000Note Stillbirths are generally not includedCrude Death Rate (CDR) = N of deaths / Total Population * 1000CDR = CBR – population growth rate (per 1,000), if there is no net in- or out-migration2Compute demographic parameters by year: population growth rate, percentages in the age/sex groups, Crude Birth Rate, Crude Death Rate (national, regions)

11. Consistency over time: large changes between years are improbableUN Population projections: can be obtained from SOURCESurvey results on crude birth rates: use the most recent survey, can be obtained from Stat Compiler; or survey reports3Evaluate the demographic parameters: a) consistency over time b) comparison with UN Population projections 3) survey results on crude birth rates (national, selected regions)

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14. Ratio DHIS-2 to UN Estimates

15. Select the highest coverage indicators from the national surveys DHS, MICS): usually ANC1 and DPT1 (BCG can also be added as indicator)Step 4A: Graph the number of ANC1 visits and DPT1 vaccinations (BCG) by year, obtained from the clean final DHIS2 data file; and the number of live births from the population projections (line graph)Step 4B: Compute coverage of ANC1 and DPT1 (BCG), based on the DHIS2 numbers and the population projections 4Compute coverage rates for the highest coverage interventions by year: first ANC visit (ANC1) and first dose of DPT (DPT1) and graph these with the total number of live births (national, selected regions)

16. 4B: For ANC1 visit coverage: we need to estimate the number of pregnancies from the projected live birthsThe number of live births in DHIS2 [e.g. 1,000]Add the stillbirth (default stillbirth rate= 0.02) to obtain total births: 1000/(1-0.02) =1020Use the twinning rate to estimate the number of deliveries (default 0.015) [1020 / (1+0.015) = 1005]Add pregnancy loss between 4-6 months (after average ANC1 visit, default 0.03) to obtain the number of pregnancies [1005 / (1 – 0.03) = 1036]ANC1 coverage: N of ANC1 visits / total estimated pregnancies * 100%

17. 4B: For DPT1/BCG coverage, we need to estimate the number of eligible infants from the live births projection in DHIS2 The number of live births in DHIS2 [e.g., 1,000]Subtract those who have died before they reach the eligible age for the vaccination (DPT1, recommended 6 weeks, BCG, recommended at birth): neonatal mortality rate (default 0.03) [1,000 – 0.03* 1000 = 970]

18. 4A + 4B: Compute and graph the coverage of ANC1 and DPT1 (BCG), using the DHIS2 denominatorsANC1 = N of ANC1 visits in DHIS2 / N of pregnancies computed from live birth projections * 100%DPT1 = N of DPT1 vaccinations / N of infants eligible for vaccination computed rom live birth projections * 100%National and by (selected) regions / provinces

19. A short report for the final report and poster boardSummarize and interpret the findings of the assessment in a brief document: for national and provincial/regional level5

20. Country workSTATA codes4_Code_RHIS_DenominatorAssessment-FINAL.doProduces log file, Excel outputs and graphs for national and subnational levelsMake sure to indicate your working folderSpecify your countryChange default values as relevantFor the graphs, you may need to modify the labels to adapt to your specific countryExcel workbook“4. Denominators & Coverage Analysis.xls”Template based on Niger dataThere are data sheets and analysis sheets with graphsThe analysis sheets include formulas that need to be adapted to your countryHint: use “find and replace” to adapt the formula to your countryModify default values as relevant