Open Access

Public health indicators for the EU: the joint action for ECHIM (European Community Health Indicators & Monitoring)

  • Marieke Verschuuren1Email author,
  • Mika Gissler2,
  • Katri Kilpeläinen2,
  • Antti Tuomi-Nikula2,
  • Ari-Pekka Sihvonen2,
  • Jürgen Thelen3,
  • Rita Gaidelyte4,
  • Silvia Ghirini5,
  • Nils Kirsch3,
  • Remigijus Prochorskas4,
  • Emanuele Scafato5,
  • Pieter Kramers2 and
  • Arpo Aromaa6
Archives of Public HealthThe official journal of the Belgian Public Health Association201371:12

DOI: 10.1186/0778-7367-71-12

Received: 23 February 2013

Accepted: 20 April 2013

Published: 30 May 2013

Abstract

Background

Public health policies aim to improve and maintain the health of citizens. Relevant data and indicators are needed for a health policy that is based on factual information. After 14 years of work (1998–2012), the multi-phase action on European Community Health Indicators (ECHI) has created a health monitoring and reporting system. It has generated EU added value by defining the ECHI shortlist with 88 common and comparable key health indicators for Europe.

Methods

In the 2009-2012 Joint Action for ECHIM project the ECHI shortlist was updated through consultation with Member State representatives. Guidelines for implementation of the ECHI Indicators at national level were developed and a pilot data collection was carried out.

Results

67 of the ECHI Indicators are already part of regular international data collections and thus available for a majority of Member States, 14 are close to ready and 13 still need development work. By mid-2012 half of the countries have incorporated ECHI indicators in their national health information systems and the process is ongoing in the majority of the countries. Twenty-five countries were able to provide data in a Pilot Data Collection for 20 ECHI Indicators that were not yet (fully) available in the international databases.

Conclusions

The EU needs a permanent health monitoring and reporting system. The Joint Action for ECHIM has set an example for the implementation of a system that can develop and maintain the ECHI indicators,, and promote and encourage the use of ECHI in health reporting and health policy making. The aim for sustainable public health monitoring is also supported by a Eurostat regulation on public health statistics requiring that health statistics shall be provided according to the ECHI methodology. Further efforts at DG SANCO and Eurostat are needed towards a permanent health monitoring system.

Keywords

Public health indicators Public health monitoring Public health reporting

Background

The major aim of public health policies is to improve and maintain the health of citizens and to reduce health inequalities. These policies have to be based on factual information drawn from relevant data and comparable indicators. Relevant health indicators enable correctly targeted policy measures and assessment of their impact.

To reach this goal, health indicators have to be based on representative population-based health data and need to be comparable between points in time, countries and areas. Observed differences between countries can stimulate the improvement of national health systems. Therefore, a joint international health information system will help Member States to implement their public health monitoring and reporting system and thus enable them to carry out their public health responsibilities. For the EU, the implementation of relevant health indicators is an essential starting point for a common health monitoring and reporting system that is essential for supporting EU level public health policies.

The European Parliament has called for an effective health information system since the 1990s. The first step on the road to harmonisation was the launch of the European Commission’s first Health Monitoring Programme in 1993. Under this Programme projects were financed to develop harmonized health indicators [1]. In 1996, the European Commission set up a working group to draft a proposal on how to organise health monitoring in the European Union [2]. The following year, the Amsterdam Treaty provided harmonised instructions on the public health responsibilities of the Member States [3].

The multi-phase action on European Community Health Indicators (ECHI) has been one of the core actions of the European Commission’s Health Programmes for 14 years (1998–2012). Its main task was the development, maintenance and implementation of a set of general public health indicators, the ECHI shortlist. Several international indicator- and datasets already exist, both broad (e.g. Eurostat, WHO Health for All database, OECD health data) and topical (e.g. data collections by the EMCDDA and ECDC). Yet the ECHI shortlist provides added value because it has been developed as a concise yet comprehensive tool for policy support, rather than as a (data driven) database. The first two projects (ECHI 1998–2001 and ECHI-2 2002–2004) focused on the selection and definition of indicators, and established the first version of the ECHI shortlist in 2005 [4, 5]. The 3rd (ECHIM 2005–2008, M stands for Monitoring) [6] and the 4th phase (Joint Action for ECHIM 2009–2012) shifted the focus towards the implementation of the ECHI indicators in the Member States and at EU level. A Joint Action is a specific financing mechanism that was newly introduced together with the EU Health Programme Together for Health in 2008. It involves a closed call from the Commission to the Member States to present a proposal, in contrast with normal project calls, which are open. In 2012, Prof. Aromaa described his personal reflections on the progress of the ECHI(M) projects in the broader perspective of past as well as necessary future developments [7].

The incorporation of ECHI Indicators into national health information systems is essential to ensure the continuous development and improvements in ECHI data availability, quality and comparability in the EU. During the 3rd project phase (2005–2008) a start has been made with this implementation of the ECHI Indicators at national level by, among other things, setting up a network of ECHI contact persons in the EU Member States and assessing availability of national data for ECHI Indicators in international databases [6]. The Joint Action for ECHIM continued this implementation work. Next to enhancing implementation of ECHI Indicators at national level, its main objectives comprised updating and documenting the ECHI shortlist, and the assessment of availability and quality of data for ECHI Indicators that are not yet part of existing international data collections by means of a data collection pilot. In this article, we will describe the main results and experiences of the Joint Action for ECHIM.

Methods

There were five project partners in the Joint Action: the public health institutes of Finland (main partner), the Netherlands, Germany, Lithuania and Italy. Twenty-four Member States in total gave an official declaration of intent to participate in the Joint Action [8]. In practice, though, 36 countries (EU Member States, accession and candidate countries, and EFTA countries) participated. The Joint Action started on 1 January 2009 and ended on June 30th 2012. Further methods applied are described according to the following three main objectives of the Joint Action:

An updated and fully documented shortlist of ECHI indicators

A new procedure for updating the shortlist was developed in 2010–2011, together with the Member State representatives of all countries participating in the Joint Action. Application of this new procedure resulted in the 2012 version of the ECHI shortlist. Clear criteria for additions or removals of indicators to/from the shortlist are at the core of the new updating procedure. Furthermore, the strong focus of the Joint Action on implementing the indicators is reflected in the criteria as well. The updating procedure has been described in detail in the final report of the Joint Action part II [9].

Implementation of the ECHI shortlist indicators in participating EU countries

The project partners created a model for the implementation plans for ECHI indicators, consisting of several elements (e.g. communication, data availability). Based on this model, guidelines for the Member States were developed at the beginning of the project. Progress of national implementation was monitored. The guidelines are described in detail in the Joint Action final report part I [10].

Pilot data collection

The existing international databases of Eurostat, the WHO Health for All database and OECD Health Data together with topic-specific international databases (e.g. ECDC and EMCDDA) are the recommended data source for 44 shortlist indicators. An ECHIM Pilot Data Collection was performed in 2010–2011 to obtain comparable data for 20 ECHI shortlist indicators that were unavailable or incomparable in these international databases. For many of these 20 indicators the European Health Interview Survey (EHIS) is the preferred data source. Therefore, ECHI-conform data were obtained from Eurostat for Member States for which EHIS micro-datasets were available from EHIS wave I, which was carried out in the period 2006–2010 [11]. These were complemented with data from national Health Interview Surveys from Member States that had not participated in EHIS wave I. Out of the 36 countries participating in the Joint Action, in 34 suitable contact persons were identified for receiving a Pilot Data Collection questionnaire.

Results

An updated and fully documented shortlist of ECHI indicators

After introducing the ECHI shortlist in 2005 [5], the indicator metadata for all 88 indicators in the ECHI shortlist has been documented and continuously improved, and the ECHI shortlist has been updated in 2008 [6] and 2012 [9]. The 2008 version comprised an implementation and a development section. During the Joint Action, however, a more precise definition of the indicators and a stronger focus on implementation led to splitting the development section into a work-in-progress section in addition to the development section. Therefore, the 2012 version of the ECHI shortlist is divided into three rather than two sections.

The 67 ECHI Indicators in the implementation section are already part of regular international data collections, and data are available for a majority of Member States, and thus ready for implementation. The 14 ECHI indicators in the work-in-progress section are almost ready to be included in regular international data collections. In most cases, however, no concrete plans exist for this at present. The remaining 13 ECHI indicators in the development section contain topics that are needed for policy support, but that are not ready yet for incorporation in international regular data collections and for implementation. Please note that there are 88 indicators in the ECHI shortlist. However, six of these have two different operationalizations: one based on self-reported data and one based on administrative or register-based data. Both operationalizations have been assessed separately here, resulting in a total of 67 + 14 + 13 = 94 indicators. An overview of the 2012 version of the ECHI shortlist is presented in Table 1.
Table 1

ECHI shortlist, 2012 version

ECHI shortlist indicators

Data source

Status indicator

1. Population by sex/age

Eurostat

Implementation section

2. Birth rate, crude

Eurostat

Implementation section

3. Mother’s age distribution

Eurostat

Implementation section

4. Total fertility rate

Eurostat

Implementation section

5. Population projections

Eurostat

Implementation section

6. Population by education

Eurostat (LFS)

Implementation section

7. Population by occupation

Eurostat (LFS)

Implementation section

8. Total unemployment

Eurostat (LFS)

Implementation section

9. Population below poverty line and income inequality

Eurostat (EU-SILC)

Implementation section

10. Life expectancy

Eurostat

Implementation section

11. Infant mortality

Eurostat

Implementation section

12. Perinatal mortality

WHO-HFA

Implementation section

13. Disease-specific mortality

Eurostat (and CISID for AIDS-related mortality)

Implementation section

14. Drug-related deaths

EMCDDA

Implementation section

15. Smoking-related deaths

n.a.

Work-in-progress section

16. Alcohol-related deaths

n.a.

Work-in-progress section

17. Excess mortality by extreme temperatures

n.a.

Development section

18. Selected communicable diseases

ECDC

Implementation section

19. HIV/AIDS

EURO-HIV/CISID

Implementation section

20. Cancer incidence

Globocan

Implementation section

21. (A) Diabetes, self-reported prevalence

Eurostat (EHIS)

Implementation section

21. (B) Diabetes, register-based prevalence

n.a.

Work-in-progress section

22. Dementia

n.a.

Work-in-progress section

23. (A) Depression, self-reported prevalence

Eurostat (EHIS)

Implementation section

23. (B) Depression, register-based prevalence

n.a.

Work-in-progress section

24. Acute Myocardial Infarction

n.a.

Work-in-progress section

25. Stroke

n.a.

Work-in-progress section

26. (A) Asthma, self-reported prevalence

Eurostat (EHIS)

Implementation section

26. (B) Asthma, register-based prevalence

n.a.

Work-in-progress section

27. (A) COPD, self-reported prevalence

Eurostat (EHIS)

Implementation section

27. (B) COPD, register-based prevalence

n.a.

Work-in-progress section

28. (Low) birth weight

WHO-HFA

Implementation section

29. (A) Injuries: home/leisure, self-reported incidence

Eurostat (EHIS)

Implementation section

29. (B) Injuries: home/leisure, register-based incidence

IDB

Implementation section

30. (A) Injuries: road traffic, self-reported incidence

Eurostat (EHIS)

Implementation section

30. (B) Injuries: road traffic, register-based incidence

UN ECE

Implementation section

31. Injuries: workplace

Eurostat (ESAW)

Implementation section

32. Suicide attempt

n.a.

Development section

33. Self-perceived health

Eurostat (EU-SILC)

Implementation section

34. Self-reported chronic morbidity

Eurostat (EU-SILC)

Implementation section

35. Long-term activity limitations

Eurostat (EU-SILC)

Implementation section

36. Physical and sensory functional limitations

Eurostat (EHIS)

Implementation section

37. General musculoskeletal pain

n.a.

Development section

38. Psychological distress

n.a.

Development section

39. Psychological well-being

n.a.

Development section

40. Health expectancy: Healthy Life Years (HLY)

Eurostat

Implementation section

41. Health expectancy, others

EHEMU/EHLEIS project

Work-in-progress section

42. Body mass index

Eurostat (EHIS)

Implementation section

43. Blood pressure

Eurostat (EHIS)

Implementation section

44. Regular smokers

Eurostat (EHIS)

Implementation section

45. Pregnant women smoking

n.a.

Work-in-progress section

46. Total alcohol consumption

WHO (GISAH)

Implementation section

47. Hazardous alcohol consumption

Eurostat (EHIS)

Implementation section

48. Use of illicit drugs

EMCDDA

Implementation section

49. Consumption of fruit

Eurostat (EHIS)

Implementation section

50. Consumption of vegetables

Eurostat (EHIS)

Implementation section

51. Breastfeeding

WHO-HFA

Work-in-progress section

52. Physical activity

Eurostat (EHIS)

Implementation section

53. Work-related health risks

EUROFOUND

Implementation section

54. Social support

Eurostat (EHIS)

Implementation section

55. PM10 (particulate matter) exposure

Eurostat

Implementation section

56. Vaccination coverage in children

WHO-HFA

Implementation section

57. Influenza vaccination rate in elderly

Eurostat (EHIS)

Implementation section

58. Breast cancer screening

Eurostat (EHIS)

Implementation section

59. Cervical cancer screening

Eurostat (EHIS)

Implementation section

60. Colon cancer screening

Eurostat (EHIS)

Implementation section

61. Timing of first antenatal visits among pregnant women

n.a.

Work-in-progress section

62. Hospital beds

Eurostat

Implementation section

63. Practising physicians

Eurostat

Implementation section

64. Practising nurses

Eurostat

Implementation section

65. Mobility of professionals

n.a.

Development section

66. Medical technologies: MRI units and CT scans

Eurostat

Implementation section

67. Hospital in-patient discharges, limited diagnoses

Eurostat

Implementation section

68. Hospital day-cases, limited diagnoses

Eurostat

Implementation section

69. Hospital day-cases as percentage of total patient population (in-patients & day-cases), selected diagnoses

Eurostat (necessary discharge data available but ratio is not centrally computed yet)

Implementation section

70. Average length of stay (ALOS), limited diagnoses

Eurostat

Implementation section

71. General practitioner (GP) utilisation

Eurostat (EHIS)

Implementation section

72. Selected outpatient visits

Eurostat (EHIS)

Implementation section

73. Selected Surgeries

Eurostat

Implementation section

74. Medicine use, selected groups

Eurostat (EHIS)

Implementation section

75. Patient mobility

Eurostat is regularly collecting data on patient mobility but is not yet publishing these.

Work-in-progress section

76. Insurance coverage

OECD

Implementation section

77. Expenditures on health

Eurostat

Implementation section

78. Survival rates cancer

EUROCARE

Implementation section

79. 30-day in-hospital case-fatality Acute Myocardial Infarction and stroke

OECD

Implementation section

80. Equity of access to health care services

Eurostat (EU-SILC)

Implementation section

81. Waiting times for elective surgeries

n.a.

Development section

82. Surgical wound infections

n.a.

Development section

83. Cancer treatment delay

n.a.

Development section

84. Diabetes control

n.a.

Development section

85. Policies on ETS exposure (Environmental Tobacco Smoke)

WHO-Euro tobacco control (computation of indicator not done centrally yet)

Implementation section

86. Policies on healthy nutrition

n.a.

Development section

87. Policies and practices on healthy lifestyles

n.a.

Development section

88. Integrated programmes in settings, including workplace, schools, hospital

n.a.

Development section

A report documenting the indicators and the work performed has been published [9]. This ‘cookbook’ for the ECHI shortlist indicators is aimed at serving persons working with the indicators, computing them, or making them available. In addition, the European Commission made an up-to-date presentation of data and metadata for multiple indicators in its HEIDI tool [12].

Implementation of the ECHI shortlist indicators in participating EU countries

During the Joint Action for ECHIM, ten countries already started incorporating ECHI into their national databases: Austria, Czech Republic, Estonia, Germany, Greece, Italy, Lithuania, Latvia, the Netherlands and Spain. Some countries have created national offline data presentations of ECHI indicators, for example using national customised versions of the WHO Data Presentation System (DPS), as has been done in Lithuania [13]. In addition, a number of other countries have started using the ECHI framework in their health reports, e.g. the Netherlands [14] and France [15]. A number of countries in June 2012 reported having concrete plans to incorporate ECHI in the national indicator and/or data presentation system (e.g. Malta, Finland, Ireland, and Norway). This shows for example from stating in future action plans of National Public Health Institutes or strategies of the Ministries of Health that there is an intention to use ECHI indicators in national health monitoring and reporting systems.

Pilot data collection

In total 25 countries provided data in the pilot (see Figure 1). No pilot data at all were received from nine countries (Bulgaria, Greece, Luxembourg, Portugal, Sweden, Slovenia, Slovakia, Hungary and Turkey). However, none of the participating countries was able to provide all requested indicators and breakdowns. Furthermore, conceptual and methodological differences among national HIS data hampered valid mutual comparisons, as well as clear-cut comparisons with the EHIS-based data. A separate final report of the Joint Action documenting in detail the ECHIM Pilot Data Collection, data received and the analyses has been published in 2013 (part III) [16].
Figure 1

Participation in the ECHIM pilot data collection in 2011–2012 and wave I of European Health Interview Survey (EHIS) in 2006–2009.

Discussion

The European Parliament has highlighted the need for a public health information system. High quality health information serves the EU and Member States by helping to direct health, welfare and other policies and planning toward meeting peoples’ health needs. Comparative health information is of great practical use not only for policy makers and planners, but also for health professionals, teachers, students, researchers, journalists, and the general population.

There is ample evidence from many European countries about the usefulness of policy relevant and comparable health information. The Joint Action for ECHIM contributes directly to the 2008–2013 Health Strategy of the European Commission [17].

DG SANCO has improved dissemination of ECHI indicators at the EU level by developing the HEIDI tool [12]. Another positive development is the Eurostat regulation on statistics on public health and health and safety at work [18], including the implementing regulation on EHIS [19], which refer to the ECHI shortlist. These will support the improved comparability of data across countries. Furthermore, increasing cooperation between the European Commission, WHO Regional Office for Europe and OECD, for example in the field of health expenditures statistics, is resulting in better data quality and comparability and less administrative burden for the Member States. Finally, the Member States have been involved in all the development steps of ECHI/ECHIM, and they increasingly use the ECHI shortlist for their own health information strategies. Nevertheless, despite years of work, substantial efforts are still needed at both Commission and national level to build-up and maintain a sustainable, high quality and easy-access evidence base for policy makers and other professionals. An important reason for this is that EU activities related to the development of elements of a health information system (e.g. indicators, standards for data collection, reporting mechanisms) are usually funded on an ad hoc project basis, resulting in a scattered and unsustainable situation.

Therefore it may not come as a surprise that after the ending of the Joint Action for ECHIM in June 2012, no follow up structure was put in place by the Commission. The Commission is performing a formal evaluation of the use and usefulness of ECHI in/for the Member States in 2013 and thereafter a decision about ECHI’s future will be taken. The success and future of ECHI, however, depends on the ability of a central EU organization to organise and implement the collection and use of ECHI data at EU level in health monitoring and reporting. A health information system like ECHI needs constant maintenance, e.g. in the form of metadata compilation and indicator improvement. In addition, the countries need to be able to provide required data in a timely way and with sufficient quality, preferably through international data collection systems. The Member States have a major role to play, since they have to implement the ECHI Indicators in practice.

The Joint Action faced several obstacles that call for improvements. Most importantly, a stronger leadership at EU level and enhanced funding, dedicated personnel, and commitment at national level are needed in order to speed up the action. In the future, the logical and viable perspective would be to integrate the work on ECHI‒defined data both with the collection of national health data and with the delivery of data to other international databases, such as those of Eurostat, WHO and OECD. Such a solution would be a coherent investment of resources, aimed at constantly improving the availability and cross‒national comparability of health data.

Finally, health information and knowledge should be emphasized in the forthcoming Health for Growth Programme for 2014–2020. The Joint Action for ECHIM has prepared good documentation and methods to support the national and international work on health indicators, health monitoring and health reporting.

Conclusions

The ECHI Indicators were developed as the core of a European health information and reporting system, and have proven their usefulness and added value in practice. Sustained efforts at EU and national level are needed to keep the system functional and up to date.

Abbreviations

DG SANCO: 

European commission´s directorate general for health & consumers

DPS: 

Data presentation system

ECDC: 

European centre of disease prevention and control

ECHI: 

European community health indicators

ECHIM: 

European community health indicators and monitoring

EHIS: 

European health interview survey

EFTA: 

European free trade association

EMCDDA: 

European monitoring centre for drugs and drug addiction

EU: 

European union

Eurostat: 

Statistical office of the European union

HEIDI: 

Health in Europe: information and data interface

OECD: 

Organisation for Economic Co-operation and Development

WHO: 

World Health Organisation.

Declarations

Acknowledgements

Joint Action ECHIM has received funding from the European Commission / Directorate General for Health and Consumers (Grant agreement number 2008 23 91), as well as from the national authorities of the five partner countries in the Joint Action for ECHIM. In the Netherlands, the Netherlands Organisation for Health Research and Development (ZonMw) also provided part of the co-funding, next to the MoH. The views expressed here are those of the authors and they do not represent the Commission’s official position. This article is based on the Final Reports of the Joint Action for ECHI [8, 9, 16].

Authors’ Affiliations

(1)
RIVM, National Institute for Public Health and the Environment
(2)
THL, National Institute for Health and Welfare
(3)
Robert Koch Institute
(4)
Center of Health Information, Institute of Hygiene
(5)
ISS, Istituto Superiore di Sanità
(6)
Ratakatu 1a, Helsinki

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Copyright

© Verschuuren et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.