World Journal of Surgery

, Volume 37, Issue 11, pp 2507–2511 | Cite as

A Square Peg in a Round Hole? Challenges with DALY-based “Burden of Disease” Calculations in Surgery and a Call for Alternative Metrics




In recent years, surgical providers and advocates have engaged in a growing effort to establish metrics to estimate capacity for surgical services as well the burden of surgical diseases in resource-limited settings. The burden of disease (BoD) studies have established the disability-adjusted life year (DALY) as the primary metric to measure both disability and premature mortality. Nonetheless, DALY-based approaches present methodological challenges, some of which are unique to surgical conditions, not fully addressed through the multiple iterations of the BoD studies, including the most recent study.

Methods and Results

This paper examines these challenges in detail, including issues around age-weighting and discounting, and estimates of disability-weights for specific conditions. Surgical burden measurements of specific conditions, or through the assessment of hospital wards as platforms for service delivery, still have unresolved methodological hurdles. The 2010 BoD study addresses some of these issues, but many questions still remain. Other methods estimating surgical prevalence, backlogs in treatment, and disability incurred by delays in care may provide more practical approaches to disease burden that can be useful tools for clinicians and health advocates.


These approaches warrant further exploration in LMICs and these debates require active engagement by surgical providers and advocates globally.


  1. 1.
    Murray CJ, Lopez AD, Jamison DT (1994) The global burden of disease in 1990: summary results, sensitivity analysis and future directions. Bull World Health Organ 72:495–509PubMedGoogle Scholar
  2. 2.
    Murray CJ (1994) Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health Organ 72:429–445PubMedGoogle Scholar
  3. 3.
    McCord C, Chowdhury Q (2003) A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 81:83–92PubMedCrossRefGoogle Scholar
  4. 4.
    Gosselin RA, Thind A, Bellardinelli A (2006) Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 30:505–511PubMedCrossRefGoogle Scholar
  5. 5.
    Alkire B, Hughes CD, Nash K et al (2011) Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg 35:1194–1201PubMedCrossRefGoogle Scholar
  6. 6.
    Vos T (2009) Improving the quantitative basis of the surgical burden in low-income countries. PLoS Med 6:e1000149PubMedCrossRefGoogle Scholar
  7. 7.
    Walker D, Fox-Rushby J (2001) Allowing for uncertainty in economic evaluations: qualitative sensitivity analysis. Health Policy Plan 16:435–443PubMedCrossRefGoogle Scholar
  8. 8.
    Mooney G, Wiseman V (2000) Burden of disease and priority setting. Health Econ 9:369–372PubMedCrossRefGoogle Scholar
  9. 9.
    Arnesen T, Nord E (1999) The value of DALY life: problems with ethics and validity of disability adjusted life years. BMJ 319(7222):1423–1425PubMedCrossRefGoogle Scholar
  10. 10.
    King CH, Bertino AM (2008) Asymmetries of poverty: why global burden of disease valuations underestimate the burden of neglected tropical diseases. PLoS Negl Trop Dis 2:e209PubMedCrossRefGoogle Scholar
  11. 11.
    Haagsma JA, Polinder S, Lyons RA et al (2012) Improved and standardized method for assessing years lived with disability after injury. Bull World Health Organ 90:513–521PubMedGoogle Scholar
  12. 12.
    Salomon JA, Vos T, Hogan DR et al (2010) Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study. Lancet 380(9859):2129–2143CrossRefGoogle Scholar
  13. 13.
    Murray CJ, Ezzati M, Flaxman AD et al (2012) GBD 2010: design, definitions, and metrics. Lancet 380(9859):2063–2066PubMedCrossRefGoogle Scholar
  14. 14.
    Taylor HR, Jones JB, Keefe J et al (2013) Disability weights for vision disorders in Global Burden of Disease study. Lancet 381(9860):23PubMedCrossRefGoogle Scholar
  15. 15.
    Kapiriri L, Arnesen T, Norheim OF (2004) Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda. Cost Eff Resour Alloc 2:1PubMedCrossRefGoogle Scholar
  16. 16.
    Duda RB, Hill AG (2007) Surgery in developing countries: should surgery have a role in population-based health care? Bull Am Coll Surg 92(12–18):35Google Scholar
  17. 17.
    Fox-Rushby JA, Hanson K (2001) Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis. Health Policy Plan 16:326–331PubMedCrossRefGoogle Scholar
  18. 18.
    Debas H et al (2006) Surgery. In: Jamison D (ed) Disease control priorities in developing countries. Oxford University Press, New YorkGoogle Scholar
  19. 19.
    Corlew DS (2010) Estimation of impact of surgical disease through economic modelling of cleft lip and palate care. World J Surg 34:391–396PubMedCrossRefGoogle Scholar
  20. 20.
    Petroze RT, Groen RS, Niyonkuru F et al (2012) Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery 153:457–464PubMedCrossRefGoogle Scholar
  21. 21.
    Groen RS, Samal M, Stewart KA et al (2012) Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 380(9847):1082–1087PubMedCrossRefGoogle Scholar
  22. 22.
    Capes T, Ascher-Walsh C, Abdoulaye I et al (2011) Obstetric fistula in low and middle income countries. Mt Sinai J Med 78:352–361PubMedCrossRefGoogle Scholar
  23. 23.
    Poenaru D (2012) Getting the job done: analysis of the impact and effectiveness of the Smile Train Program in alleviating the global burden of cleft disease. World J Surg 37:1562–1570CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  1. 1.Department of Public HealthUniversity of CaliforniaSan DiegoUSA
  2. 2.Department of Pediatric SurgeryYale University HospitalNew HavenUSA
  3. 3.Department of Pediatric SurgeryMcMaster UniversityHamiltonCanada

Personalised recommendations