from Epidemiological Bulletin , Vol. 25 No. 3, September 2004—

Ten-year Evaluation of the Regional Core Health Data Initiative

In 1996, several meetings were held to discuss the definition, collection process, and categories for the core data, their use in the preparation of country profiles, and the methodologies for health situation analysis. An Interprogrammatic Consultative Group on Core Data and Health Analysis was formed to implement the regional plan of action and stipulate the content, definitions, and sources of the indicators. The Group also set up mechanisms for collecting and validating the data and for studying and monitoring the implementation of the process in general. Visits were also made to all the PAHO countries, Representative Offices to consult with and inform them about the Regional Initiative.5

In 1997, given the political support required, the Executive Committee and the Directing Council of PAHO respectively adopted Resolutions CE120.R7 and CD40.R10 on the Collection and Use of Core Health Data and recognized the regional effort to consolidate an automated technical information system on health that would facilitate speedy access, expanded and basic information on the health situation of the countries of the Region. They also recommended that the indicators be used in the formulation, modification, and evaluation of health policies and programs.

Since that time, it has been recognized that the RCHDI has the following goals:2
a) to orient strategic policy management;
b) to facilitate the setting of priorities for action in the health sector;
c) to improve the evaluation and adaptation of technical cooperation in each of the countries and programs, redefining priorities, strategies for action, and resource allocation;
d) to assist the countries in devising investment strategies or special programs for health policy or health services development, as well as the prevention and control of specific health problems;
e) to facilitate the mobilization of financial resources;
f) to orient research priorities;
g) to periodically distribute reports on health trends in each country and the Region as a whole, using the analytical frameworks stipulated in their mandates, such as Health for All and the Renewal of Health for All.

It should be noted that since its revival in 2000, the Regional Advisory Committee on Health Statistics of PAHO (CRAES in Spanish) has backed efforts to improve the quality, criteria for validity, and consistency of core data through specific recommendations.

Results of the Regional Core Health Data Initiative (RCHDI)
The goal of the RCHDI is to increase the capacity of PAHO and the countries to generate the knowledge that will make it possible to describe and explain the health situation and health status of the population of the Americas and to select health interventions that are both equitable and effective.2 The combined efforts of the Member States and the Secretariat to implement the RCHDI over the past 10 years have been satisfactory in terms of meeting the goal; however, this joint effort must be renewed to expand and institutionalize the initiative at the local level.

The following are application examples of the RCHDI in several categories and situations.

Strategic Management and Planning
The RCHDI has shown that it is possible to create a database of essential, standardized, valid, consistent, regular, and timely information, which is critical for health situation and trend analysis required in the management and strategic planning in PAHO. The basic indicators have also been used at the country level in the ministries of health to develop national health plans and intersectoral policies.

The use of these indicators by national authorities and other entities has raised awareness about the need for valid, consistent information for decision-making. It has also led to a critical review of the processes involved in the production, collection, integration, and dissemination of health information in both the Member States and the Secretariat. This awareness is also reflected in recognition of the need to upgrade systematic national information systems and interconnect and coordinate them to ensure a better response to information needs. In this regard, with respect to indicators and information, Brazil’s experience with its Interagency Health Information Network (RIPSA)6 based on the RCHDI model, is one of the most successful institutionalized examples of consensus, standardization, collection, coordination, and availability for different types of users, accessible on the Internet. RIPSA brings together national institutions with responsibilities in the production and analysis of health data. This effort has earned the recognition of Brazil’s Ministry of Health, which is allocating the additional resources necessary for the coordination, production, and dissemination process. Canada is another successful example of concerted action in the definition, measurement, and use of health indicators in setting priorities and gearing health system plans and programs to respond to needs and decisions in health. To this end, it has made public health the frame of reference for selecting the work areas and series of indicators for collecting information and monitoring. The collection, standardization, analysis, and dissemination of information are coordinated by the Canadian Institute for Health Information (CIHI) and serve as a complement to the activities of Health Canada and Statistics Canada.7

Another strategic aspect of the RCHDI has been its use in monitoring compliance with mandates and commitments and the progress of regional and global health initiatives. One of the most important global initiatives is the Millennium Development Goals (MDGs).8 The MDGs were adopted by 189 member states of the United Nations in 2000 and are to be met by 2015 in each of the seven designated areas, which include health. In this regard, it should be pointed out that in the RCHDI are 20 MDGs indicators related to health. Other important examples of the applications use of these indicators have been the monitoring and evaluation of the Health for All by the Year 2000 strategy and the monitoring of the goals set at the 1990 World Summit for Children.

Technical Cooperation
One of the basic values of PAHO is equity in health. The first step in the search for equity is to measure and monitor inequalities in health. The RCHDI has made it possible to measure the health situation and the changes in health status through a standardized database. The availability of basic indicators disaggregated at the subnational level since 1999 has made it possible to introduce a change of paradigm in data analysis consisting of the exclusive use of national averages in the distributions, making it possible to show health inequalities and their territorial distribution patterns. The dissemination of specific methodologies for documenting inequalities, identifying health needs, and setting priorities through the reports mentioned above has made it possible to boost national analytical capacity, promoting similar efforts within the countries.

PAHO has decided to intensify its activities, focusing them on the countries, especially those with greater technical cooperation needs. In setting priorities, the core health data and country profiles have been essential for identifying key and priority countries and areas for cooperation. For example, the current priority countries for PAHO cooperation—Bolivia, Guyana, Haiti, Honduras, and Nicaragua—are in the group with the greatest health problems and the least resources to address them.9

The impact of the RCHDI has spread far beyond the WHO Regional Office for the Americas (PAHO). Several WHO Regions have requested technical assistance to develop their own core data initiatives. For example, since 1999, the WHO Regional Office for Southeast Asia (SEARO) publishes a Brochure of basic indicators based on the PAHO model. PAHO transferred and adapted the RCHDI table generator to SEARO. Similarly, since 1999 the WHO Regional Office for the Eastern Mediterranean (EMRO) publishes its Brochure of basic indicators, based on the same PAHO model.

Considering the model and experience of PAHO, the WHO Headquarters, through its Department of Measurement and Health Information Systems (EIP/MHI), and in a joint effort with all its regions, is working on a framework of basic health indicators for short-term implant at the global level.

Mobilization and Use of Resources
In the targeting of investment resources, the donor agencies have used the basic indicators and country profiles to identify the areas with the greatest need and priority countries. In many cases, the monitoring of improvements in the basic indicators is used to evaluate the success of programs set up with donor funds. The use of basic indicators, instead of employing an exhaustive approach, allows for better utilization of resources. Since the standardized data and basic indicators are collected annually, this has cut down on the waste of resources, duplication of efforts, and requests to the countries for information.

Results of the RCHDI in the Countries
Between December 2003 and January 2004, with assistance from the PAHO Representative Offices, the technical area DD/AIS conducted a special survey to evaluate the impact of the RCHDI in the Region of the Americas. Information was obtained from 37 countries, including the French departments.

The results of the survey indicate the following:
• With respect to adoption of the RCHDI, 30 countries have a National Core Data Initiative, with national groups actively participating in its construction and updating.
• Sixteen countries mentioned that they currently use or have used the RCHDI for measuring inequalities; 21 use them for measuring needs and setting priorities; and 12 for program evaluation, which indicates the wide range of its impact.
• With respect to coherence between RCHDI monitoring efforts and those of other initiatives, 17 countries cite coordination with the MDG.
• Following the regional example, 24 countries indicate that they update and periodically distribute a Brochure/folder or other printed material with basic indicators, or else use electronic distribution methods (CD-ROM, Web-based information systems, tables in websites, etc.). Between 1995 and 2002, the number of countries with some related product tripled.
• In 25 countries, 90% of the indicator definitions in the last publication of national core data are consistent with the RCHDI glossary, reflecting the impact of the RCHDI and the consensus around it.
• Among the most significant problems mentioned in terms of implementing and maintaining the RCHDI were lack of human resources, limited access to information or data, and an absence of political backing and financing.

Among the countries’ most frequent recommendations for strengthening activities in connection with the RCHDI were improving the flow of information between the countries and PAHO Headquarters and greater promotion and dissemination of information about this initiative in the ministries of health. They also pointed out that DD/AIS can help consolidate the national RCHDI.

Specific Products of the RCHDI

Regional Brochure “Health Situation in the Americas: Basic Indicators”
In 1994, work began to prepare and assist the Member States and PAHO Representative Offices in the production of the first regional brochure of basic indicators, published in 1995. The brochure has been published every year since 1995, without exception. The 2003 version contains 58 indicators (10 demographic, 8 socioeconomic, 15 on mortality, 12 on morbidity, and 13 on resources, access, and coverage). In 1995, more than 70% of the countries had indicators in each category, except mortality, where only 20 out of the 48 countries had them. In 2003, in contrast, this information was available for 40 countries. Between 1995 and 2003, the number of basic indicators in the regional Brochures increased from 7 to 12 in the morbidity category, while the number of subregional indicators increased from 33 to 51. The 2003 version contained population pyramids for the subregions and a theme map showing the unequal distribution of infant mortality at the subnational level in countries of the Americas that have national core data initiatives; this was the first time that these were included. The 2004 version included graphs with trends in some MDGs and a thematic map for cases of rubella reported in 2002 at the first subnational level.

Health Information System: Database and Data Collection Process
The content of the RCHDI database was defined after extensive consultations between the Member States and the PAHO technical units and Representative Offices and discussions with groups of national experts. A total of 117 national indicators were selected, broken down into five categories2: demographic (10), socioeconomic (10), mortality (31), morbidity and risk factors (30), and resources, access, and health services coverage (36). Some of the indicators are disaggregated by age, sex, and urban-rural distribution, for a total of 401 items of data for each of the 48 countries and territories of the Region. Users tap into the RCHDI database through a table generator developed by DD/AIS, which can be accessed electronically on the Web.10

In terms of completeness, there is significant variation in the database with respect to the number of indicators available by country and year. A study in early 2004 indicates that the database has barely 49% of them. It has been more difficult to obtain indicators in some categories, especially because national information systems are either not operating in a relevant and timely manner or are not available. This is true mainly for the morbidity, health services, and mortality indicators. At the country level, the median coverage of indicators is 49%, with a range of 12% to 90%. At the regional and subregional level, the average availability of indicators for the period 1995-2004 is 47.6% (105, 806 values available) Table 1. This shows that, notwithstanding the commitment assumed by the countries, there still is room for improvement.

Glossary and Technical Notes for Indicators
In 1995, work began on the compilation of a glossary and technical notes for indicators. In 2003, after several revisions, standard definitions were developed, with a glossary for all the indicators that includes a description of the indicator, technical notes, the type and unit of measurement, categories, and subcategories. The definitions are complemented with additional technical notes on the interpretation, use, and calculation of the indicators. The glossary and technical notes are also available on the PAHO website.11

It should be mentioned that among the countries of the Region, Brazil has made real progress in this direction, publishing Indicatores Básicos de Saúde no Brasil: Conceitos e Aplicações12 (Basic Health Indicators in Brazil, Concepts and Applications), a manual on the use of the indicators that includes technical notes for each of them. Canada’s CIHI has done something similar with the indicators contained in its reports.7

Atlas of Basic Indicators
In 1996, the first Atlas of Health in the Americas, based on data from the Basic Indicators Brochure of 1995, was produced and put up on the web. The Atlas was conceived to document the territorial distribution of heath inequalities in the countries through 55 maps, accompanied by graphics showing the countries in the most difficult situation. In 2003, a new, more dynamic version of the Atlas was developed with data from Basic Indicators 2002. Some indicators have maps with graphic overlays to show trends, the distribution in population groups, or a related indicator. The Atlas has direct links to the data and health profiles of each country.

Country Health Profiles
In 1999, taking advantage of the release of Health in the Americas, 1998 Edition, summaries from this report, based on the country chapters, were published on the Internet. These were accompanied by a selection of indicators from the core data system. Although they had a somewhat uniform structure, comments from different types of users indicated the need to summarize them even further to facilitate their use. Even though the indicators were updated annually in subsequent years, the summaries were not. In 2003, the profiles were updated and made more uniform and compact. These more selective summaries highlight the health inequalities in the countries. In addition to the indicators mentioned, this version includes standard graphics for selected indicators. The profiles illustrate the health situation and trends in particular. However, they do not describe special situations that need to be described at particular times.

Web-based RCHDI Information Systems
When the RCHDI was created, the need for developing an information system to support it became clear. Providing interactive access to the data over the Web was made a priority, enabling users to obtain necessary information.

From 1996 to 1997, with support from the regional health library (BIREME), PAHO HDA program set up a Web-based system to facilitate access to the indicators for the latest available year. From 1998 to 1999, HDA developed a Web-based table generator that works with three dimensions of the indicators (indicator, country, and year), which can be manipulated to produce tables for analyzing the trend of an indicator or the overall situation of a country, or for comparing the indicators of several countries in a single year. This system was launched by the Special Program for Health Analysis (SHA, previously HDA) in 1999 with data from 1990 to 1999 and included the glossary and country health profiles.13 From 2000 to 2002, new components were developed to facilitate the interpolation of data and the adjustment of rates, as well as the preparation of reports. In 2003, the user interface was redesigned to make it consistent with the PAHO corporate identity and facilitate use. During this time an instrument was developed to directly generate the Excel grid for the Basic Indicators Brochure from the database.

Specific Products of the RCHDI in the Countries

Brochures and National and Subregional Information Systems
In 1995, only five of the 48 countries—Bolivia, Costa Rica, Guatemala, Honduras, and Mexico—published a brochure with national core data. Eight years later, 24 countries have published at least one brochure of basic indicators. The countries/territories that have published such brochures are: Argentina, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, United States of America, Uruguay, and Venezuela. It should be pointed out that 10 of these countries have been publishing brochures of basic indicators for over four years.

In 2002, the Folleto de indicadores básicos de salud de Centroamérica y la República Dominicana 2002 (Brochure of Basic Health Indicators for Central America and the Dominican Republic, 2002) was published, constituting the first example at the subregional level, with subnational information for 34 indicators. This brochure is the product of the joint efforts of the Central American countries under the Project of Communication and Information of Health (INFOCOM), and it was published after several consultations and subregional workshops with the national authorities.

In 2003, the Brochure Basic Indicators 2003; Health Situation on the U.S.-Mexico Border was published. This contains a set of basic indicators for the sister communities of the U.S.-Mexico border that was born of the efforts of the PAHO Field Office for the U.S.-Mexico border and the Governments of Mexico and the United States at different levels. It presents information comparing data from the national level with data from the border states and the 29 sister municipalities along the border.

At least 15 countries have developed information systems or have core data information published on the Internet. Significant among these efforts is the work of Brazil, which has an Internet-accessible system developed by Departamento de Informática do SUS (DATASUS) that includes a time series of several years for subnational indicators in different categories.14

Outlook and Challenges
The RCHDI is a process that provides valid information for health sector planning and evaluation. This process should be consolidated and expanded to the subnational level in every country in the Region of the Americas. It is the only comprehensive, integrated health information initiative that covers the entire population in the health sector of the Americas. PAHO’s experience with the RCHDI in the Secretariat and the countries has been fundamental for guaranteeing current support and the improvement of the process as a whole in the immediate future and the medium-term.

At the country level, it is recommended that more human resources be allocated to this activity, promoting access to information and its analysis and dissemination, and providing greater political and financial support for the RCHDI. At the same time, efforts should be made to boost national technical capacity in the areas of measurement, information use, and health situation analysis.

It is recommended that additional efforts be encouraged and undertaken to collect data and information disaggregated to the country level, in general, as well as information on gender and especially vulnerable groups (e.g., indigenous populations, ethnic groups, the elderly) in particular. This will facilitate better monitoring of compliance with regional and global mandates (especially the MDGs), analysis of inequalities in health, and the targeting of selective health interventions to the most disadvantaged groups.

It is suggested that support be provided for developing and upgrading the countries’ health information systems, and that information flows between the countries and PAHO be improved by promoting and disseminating information to the ministries of health and other sectors connected with health. It is also recommended that the countries use their routine information and records systems for decision-making in health, considering the use of surveys as a complement. At PAHO Headquarters, it is proposed that DD/AIS continue supporting the RCHDI to help consolidate and sustain the initiative in the future.

In order to make progress in developing and undertaking national data collection processes, it is recommended that the countries put mechanisms and instruments in place to foster greater consensus and participation on the part of the institutions responsible for producing and collecting data, indicators, and information in health, with a view to facilitating the validation, harmonization, and dissemination of national core data. The suggested mechanisms include the creation of a General Coordinating Committee for political and administrative matters; an Interagency Task Force for technical coordination; interdisciplinary technical committees for methodological and operational analysis; committees for the production and coordination of indicators; and a Technical Secretariat for determining processes, proposals, and monitoring. Other suggested mechanisms include a Matrix of Indicators and Technical Notes; operational planning of products; a database of common indicators; and interoperational information systems.

Finally, better coordination with government institutions, such as national statistics offices and institutes and civil society organizations, international banks, international organizations, and networks like the Health Metrics Network, is recommended to strengthen international public health on the basis of results, ensuring equity, quality, and effectiveness.

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References:
(1) Organización Panamericana de la Salud. Indicadores de Salud: Elementos básicos para el análisis de situación de salud. Boletín Epidemiológico OPS, 2001; 22 (4): 1-5.
http://www.paho.org/spanish/sha/be_v22n4-indicadores.htm
(2) Pan American Health Organization. Collection and Use of Core Health Data. Washington, DC: PAHO; 14 July 1997.
(Document CD40/19) http://hist.library.paho.org/Spanish/GOV/CD/25287.pdf
and Resolution CD40/R10. http://www.paho.org/Spanish/GOV/CD/ftcd_40.htm#R10
(3) PAHO Institutional Memory. PAHO Resolutions 1902-2002: 3,186 entries in English; 3,296 entries in Spanish. Principales Mandatos de los Cuerpos Directivos vinculados a Información y Análisis de Salud. 2003.
(4) Dr. Alleyne G.A.O. Perfiles de País y Datos Básicos: Funciones y Responsabilidades. Washington DC: Organización Panamericana de la Salud. Memorando [HDP/HDA/E8/28/1(986)], 1 de agosto de 1995.
(5) Castillo-Salgado C. Perfiles de País y Datos Básicos. Washington DC: Organización Panamericana de la Salud. Memorando [HDP/HDA/E8/28/1(1822)], 8 de diciembre de 1995.
(6)Rede Interagencial de Informações para a Saúde (RIPSA).
http://dtr2001.saude.gov.br/sps/ripsa.htm
(7) Canadian Institute for Health Information.
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=home_e website accessed on April 10, 2004.
(8) United Nations. United Nations Millennium Declaration. General Assembly, New York: UN; 18 September 2000 (Document A/RES/55/2)
http://www.un.org/millennium/declaration/ares552e.pdf
(9) Pan American Health Organization. Strategic Plan 2003-2007 for the Pan American Sanitary Bureau. Washington, DC: PAHO; 3 May 2002. (Document CE130/12).
http://www.paho.org/English/GOV/CE/SPP/spp36-04-e.pdf
(10) The URL for the table generator is:
http://www.paho.org/English/coredata/tabulator/newTabulator.htm
(11) The URL for the website is:
http://www.paho.org/English/SHA/coredata/tabulator/glossary.htm
(12) Rede Interagencial de Informações para a Saúde. Indicadores básicos de saúde no Brasil: conceitos e aplicações. Brasília: Organização Pan-Americana da Saúde, 2002.
http://www.opas.org.br/sistema/arquivos/matriz.pdf
(13) The various components of the RCHDI can be accessed at the following website:
http://www.paho.org/Selection.asp?SEL=HD&LNG=SPA
(14) Ministerio de Salud del Brasil. DATASUS. Indicadores e Dados Básicos Brasil–2002.
http://tabnet.datasus.gov.br/cgi/idb2002/matriz.htm

Source: Summary document prepared for 45º Directing Council (CD45/14) by Enrique Loyola, Jaume Canela, Manuel Vidaurre, Gabriela Fernández, Andrea Gerger and Carlos Castillo Salgado Health Analysis and Information System Area of OPS (DD/AIS).

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Epidemiological Bulletin , Vol. 25 No. 3, September 2004