On indices for the appraisal of health department activities.

Abstract This review of the development of health department appraisal indices and outline of some of the logical criteria required for the correct interpretation of variations in these indices reveal a number of points that are important for establishing quantitative measures of the effects of community health activities. The existence of information on mortality led to the utilization of mortality statistics, first, as a measure of the health status of the community; later, as a tool in the search for etiological factors and as a means of arousing the community to action; and, finally, as an index of achievement of community health work. Increase in knowledge about etiological factors of certain causes of death, demonstrations of the preventability of certain disease conditions, and a growing community realization that health is not simply absence of death were accompanied by the initiation of routine procedures to collect data on specific causes of death, sicknesses, immunity status, etc., and to utilize these data for the construction of indices to measure health needs of the community as well as the achievements of its health agency. Meanwhile, spurred on by a broadening definition of health, community health agencies have moved toward activities which are less directly or immediately concerned with death or infectious diseases. As a result, available mortality and morbidity statistics have become less useful and less appropriate for the construction of indices to measure achievement, and are being replaced by data on the amount of health department operations and on the extent of health facilities and personnel in the community. In formulating appraisal indices of activities derived from the broader concepts of public health, the focus of interest has shifted from a consideration of the health status of the community to that of volume and kinds of health services and facilities provided. Consequently, variations in these indices are difficult to interpret in terms of the adequacy with which health needs of the community are being satisfied. It is also difficult to assess, from these and other appraisal indices, the actual contribution which the activities of a health agency has made in meeting certain health and disease problems of the community. Each health agency is an integral part of the community, and changes in philosophy and activities of an agency are reflected in, and reflect, changes in philosophy and activities of its community. By the direct examination of changes in the numerical value of the indices, it is not always possible to identify which changes in health status (or whatever else is measured by the indices) are due specifically to health department activities and which are due to general community evolution. On this point, a question may well be raised as to the importance of differentiating precisely between the activities of the health department and those of its community. In answer, it is to be noted that such differentiation is important, not only for theoretic reasons but also for reasons of practical policy. When faced with the problem of recommending expenditures to improve the health of communities it would be well to know if expenditures for the expansion of health department activities are effective without corresponding efforts to accelerate social evolution. To overcome these difficulties, to formulate appraisal indices which can be correctly interpreted, requires the application of sound investigative methods. Some of the logical criteria to be considered in constructing indices and in comparing communities both in time and space have been examined and their application illustrated. The illustrations make it clear that a community agency sincerely interested in measuring the effects of its activities on the health of the people must be willing to establish a research program for this purpose . An essential step in the planning of such research is to recognize the principle that the focus of appraisal is not the volume of facilities and services but the measurement of the health needs and status. Fulfillment of this principle requires that at least two conditions be satisfied: (1) statements of the immediate objectives of specific health department activities and (2) systematic collection of data on the health problems of the community. Some health department activities are aimed directly and specifically at the elimination of certain causes of death, others at prevention of certain diseases, others at reduction of certain disabilities, others at promotion of certain health practices, and others are intended simply to observe accepted norms of administration. Explicit statements regarding the immediate aims of a number of specific activities are frequently lacking, and sometimes the impression is gained that all these aims are gradations of a single aim such as prolongation of life or promotion of health. To determine how well specific activities meet their stated objectives and how well these objectives meet the health problems of the community requires data on mortality, sickness, disability, health practices, and attitudes. The means for the collection of these data exist in all communities, but the organization and, for want of a better term, interest is often missing. A true appraisal of community health activities, measurements of achievements and goals, is obtained only when specific aims of these activities are contrasted with corresponding data on the health needs and problems of the community.