Academic journal article Bulletin of the World Health Organization

Assessing the Burden of Sexual and Reproductive Ill-Health: Questions regarding the Use of Disability-Adjusted Life Years

Academic journal article Bulletin of the World Health Organization

Assessing the Burden of Sexual and Reproductive Ill-Health: Questions regarding the Use of Disability-Adjusted Life Years

Article excerpt

Voir page 664 le resume en francais. En la pagina 665 figura un resumen en espanol


The concept of sexual and reproductive health was first fully articulated at the 1994 International Conference on Population and Development (1). It arose out of two mutually opposed impulses. Demographers and family planning experts were mainly concerned with issues of population growth, structure and change and their impact on social and economic development. Advocates of women's health and rights were focused more on gender imbalances and the health needs of people. The discussion between these two positions led to the concept of sexual and reproductive health, a paradigm that reflects a conceptual linking of the discourse on human rights with that on health. It is a concept bounded by a positive vision of good health, well-being, equity, and social justice, and not by a specific disease, pathology or set of organs.

It is generally acknowledged that sexual and reproductive health must address key disease entities -- sexually transmitted diseases (STDs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); maternal mortality. It is also argued that there is a need to pay attention to positive, life-enhancing aspects such as "a safe and satisfying sex life" and "the enhancement of life and personal relations". The language of reproductive health advocates is expressed in a style that includes terms such as "comprehensiveness", "integration", "a full range of services across the life cycle". This definition is all encompassing and vast and it remains unclear to what extent sexual and reproductive health is something that can be measured in any meaningful way and, if not, how will it be possible to translate the political imperatives into action for programmes. Is it conceivable to try to ascertain the burden of disease due to reproductive ill-health in the absence of any conceptual clarity on what it covers?

Defining sexual and reproductive health in terms of health and well-being, rather than in terms of the avoidance of death and disease, poses challenges for making measurements. A similar challenge has taxed the ingenuity of many researchers ever since the WHO concept of health as "a state of complete physical, mental and social well-being" was first developed. In 1957 WHO convened a study group on measurement of health status to examine the options for bringing this positive concept of health into operation and such work has continued intermittently ever since (2). A recent review of measurement efforts concludes that further conceptual and methodological research will be needed to describe and monitor sexual and reproductive health and well-being (3). In the meantime, attempts to measure health status usually focus on measuring ill-health or the presence of disease, disability and mortality.

At the same time as the new concept of sexual and reproductive health was being articulated, the Global Burden of Disease (GBD) study was initiated by the World Bank in collaboration with WHO to quantify the burden of disease and injury. The GBD study assessed the relative magnitude of diseases and injuries in global and regional populations, as well as the effects attributable to some major risk factors and socioeconomic determinants, although the latter analysis was relatively weak. This information was required for a variety of purposes, including the identification of major health problems and their relative magnitude, recognition of disease patterns, prioritization of health problems for research investments, and for decision-making in the allocation of health resources across different health interventions (4). A metric that would capture both fatal and non-fatal health outcomes, separately and in combination, was needed. The measurement unit used for this exercise was the disability-adjusted life year (DALY) (5).

The DALY was explicitly founded on the measurement of disease rather than the measurement of health status or health gains due to particular interventions. …

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