Ranking Reproductive Health Problems to Define Service Priorities

The 1993 World Development Report proposed a new paradigm to priority setting in health services. Two important steps in this approach are burden of disease estimates and cost effectiveness analyses that use disability adjusted life years (DALY) as the measure of health outcome. This paper explores how this methodology can be applied to estimate the size of the burden of disease caused by conditions currently considered the domain of reproductive health. Examples from the Global Burden of Disease Study and the Mauritius Burden of Disease Study are used to illustrate the strengths and weaknesses of this approach. While most of the criticism has centred on the assumptions of discounting and age weighting in the application of this methodology to priority setting, it is of far greater importance to examine the uncertainty of epidemiological and costing estimates. The conclusion is that however fraught with uncertainty, this approach to priority setting in health is an improvement over traditional influences on the decision-making process based on ranking of mortality alone, shaky assumptions of ‘preventable’ deaths or the most vocal advocacy groups. (Afr J Reprod Health 2001; 5[1]:31-39)