The Utility of DALYs for Public Health Policy and Research: A Reply

By Murray, C. J. L.; Lopez, A. D. | Bulletin of the World Health Organization, July-August 1997 | Go to article overview

The Utility of DALYs for Public Health Policy and Research: A Reply


Murray, C. J. L., Lopez, A. D., Bulletin of the World Health Organization


The Global Burden of Disease (GBD) study was initiated in 1992 at the request of the World Bank for use in its World development report 1993: investing in health (1); the work involved over the last four-and-a-half years has been undertaken with the full collaboration and participation of WHO. The final results were published in The Global Burden of Disease (2) and Global Health Statistics (3). The GBD study was designed to address some of the major limitations to obtaining comparable health information and had the following specific objectives: to develop internally consistent estimates of mortality for 107 major causes of death by age and sex for the world total and broken down into eight geographic regions; to develop internally consistent estimates of the duration and the incidence, prevalence, and case-fatality rates for 483 disabling sequelae caused by these 107 causes of disease and injury, by age, sex and region; to estimate the fraction of mortality and disability attributable to 10 major risk factors by age, sex, and region; and to develop various protection scenarios of mortality and disability, by cause, age, sex and region. The methods developed in the GBD study have now been applied or are being applied by a number of countries in national burden of disease studies, including Algeria, Chile, Colombia, Ghana, Japan, Republic of Korea, Mauritius, Mexico, Morocco, Netherlands, South Africa, Sweden, Tunisia, Turkey, and the USA.

The results of the GBD study have been analysed using a wide array of indicators such as life expectancy, probabilities of death, cause-specific mortality rates, health-adjusted life expectancy as well as disability-adjusted life years (DALYs), with the last-mentioned being a composite measure of the burden of each health problem. The DALYs for a given condition are the sum of years of life lost due to premature mortality and the number of years of life lived with disability, adjusted for the severity of the disability. Time lived with various short-, medium-, and long-term disabilities is weighted by a severity weight, which is based on the measurement of social preferences for time lived in various health states. DALYs, like all health outcome indicators used to inform health resource allocation debates, incorporate social preferences on the value of future health compared with current health and the value of a healthy year of life lived at different ages. Alternative views on these social values have already been competently debated in the literature (2,4-6).

The WHO Advisory COmmittee on Health Research (ACHR), through its DALY REview Group, has recently criticized the use of DALYs (7) for the following major reasons:

-- There are ethical involved in the development of health outcome measures;

-- DALYs as an aggregate measure of health status may suppress information on regional heterogeneity;

-- data for estimating DALYs are insufficient;

-- the multifactorial nature of mortality and disability cannot be captured by DALYs; and

-- the methodology has not been validated.

All health measures, such as infant mortality rate, life expectancy or DALYs implicitly (or in the case of DALYs explicitly) incorporate a series of social values. The normative aspect of a health indicator becomes evident when the measure is used as an aid to allocating health sector resources. In the course of developing DALYs and subsequently (2, 5), the ethical dimension of all health outcome measures and consequently of DALYs has been explicitly recognized. The egalitarian framework on which DALYs have been developed has been laid out to foster a constructive debate on the social choices that must be made to inform health resource allocation. We strongly support and encourage further efforts to debate these value choices.

DALYs are a summary measure of the underlying age-sex-cause and region-specific mortality, morbidity and disability rates -- as are other summary indicators of health status, such as life expectancy or age-standardized death rates (both of which are limited to mortality only). …

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