Health Development

S P D I S C U S S I O N PA P E R NO. ****

Beyond DALYs: Developing

Indicators to Assess the

Impact of Public Health

Summary Findings

Interventions on the Lives of

This review of World Bank lending for social funds covers fiscal

People with Disabilities

years 2000 to 2007, and comes twenty years after the establishment

of the first World Bank-funded social fund in Bolivia (1987).

The review s objective is to assess the evolution of the social

Daniel Mont

funds portfolio, with a specific focus on the fiscal years 2000 to

and

2007, and the portfolio s role in the implementation of the Social

Protection Sector Strategy (SPSS). Lending trends, the evolution Mitchell Loeb

of the social funds model, and future implications of the review s

major findings are also discussed.

May 2008

HUMAN DEVELOPMENT NETWORK

About this series...

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edited texts. The findings, interpretations, and conclusions expressed herein are those of the author(s),

and do not necessarily reflect the views of the International Bank for Reconstruction and Development

/ The World Bank and its affiliated organizations, or those of the Executive Directors of The World

Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data

included in this work.

For free copies of this paper, please contact the Social Protection Advisory Service, The World Bank,

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Beyond DALYs: Developing Indicators to Assess the Impact of

Public Health Interventions on the Lives of People with

Disabilities

Daniel Mont

Disability & Development Team

HDNSP

The World Bank

Mitchell Loeb

Office of Analysis and Epidemiology

National Center for Health Statistics

Centers for Disease Control & Prevention

May 2008

Acknowledgements

We would like to thank Barbara Altman, Linda Bilheimer, Jeanine Braithwaite, Jed

Friedman, Scott Grosse, Don Lollar, Diane Makuc, Jennifer Madans, Kelechi Ohiri, Pia

Rockhold, Julian Schweitzer, and S ndor Sipos for their comments on earlier drafts.

Abstract

Two indicators the Activity Limitation Score (ALS) and the Participation Restriction

Score (PRS) are presented in this paper for use in assessing the impact of public health

interventions on the lives of disabled people. They address a gap in the Disability-

Adjusted Life Years (DALY) approach which is not sensitive to changes in people s

functional status resulting from interventions that do not change an underlying medical

diagnosis. Household data from Zambia are used to explore the potential usefulness of

these measures.

JEL Classification: C8 - Data Collection and Data Estimation Methodology; Computer

Programs, I10 - Health General, J14 - Economics of the Edlerly; Economics of the

Handicapped

Keywords: Disability, Indicators, Health, DALY Measurement

The findings, interpretations, and conclusions expressed herein are those of the authors,

and do not necessarily represent or reflect the views of the National Center for Health

Statistics, Centers for Disease Control and Prevention, the International Bank for

Reconstruction and Development / The World Bank and its affiliated organizations, or

those of the Executive Directors of The World Bank or the governments they represent.

i

ACRONYMS

ALS Activity Limitation Score

DALYs Disability-Adjusted Life Years

ICF WHO s International Classification of Functioning, Disability and Health

PRS Participation Restriction Score

SEAs Standard Enumeration Areas

UN United Nations

WHO World Health Organization

ii

Introduction

Disability and poverty are intricately linked [1, 2, 3, 4, 5]. Roughly 10-12 percent of the

world s population has a disability [6] and they are among the poorest of the poor [5].

Including people with disabilities in economic development activities, therefore, is key to

achieving the UN Millennium Development Goals [7] of ending poverty and hunger,

providing universal education, and improving health outcomes.

Recently, as evidenced by the passage of the UN Convention on the Rights of Persons

with Disabilities [8], more attention is being focused on interventions designed to be

more inclusive and have an impact on disabled people s lives. In order to evaluate these

interventions it is necessary to have indicators capable of assessing the impact of policies

and programs on the lives of disabled people.

Disability-Adjusted Life Years (DALYs) are a frequently used indicator for assessing the

relative effect of public health interventions for disabled people. The introduction of

DALYs, as opposed to only using mortality, was an advance in that it incorporates a

measure of the impact of living with a disability [9]. With the implementation of

DALYs, conditions which were non-fatal but were at the root of significant disabilities

rose in importance in the field of public health, such as onchocersiasis (river blindness).

While an extensive literature evaluates the approach embodied in DALYs, [10,11,12],

this paper focuses on a single aspect the inability of DALYs to record improvements in

the functioning of disabled people by means that are non-curative, and thus do not

remove a person s underlying medical diagnosis [10].

DALYs do not reflect the change in people s functional status or well-being if they

receive rehabilitation services, assistive devices, accommodations, or live in a society that

has become more open and accessible to individuals with functional limitations. DALYs

only reflect the presence of a medical condition that is associated with certain functional

limitations. Therefore, public health interventions that mitigate the effects of a health

condition but do not cure it, get no credit.

This paper proposes two measures for assessing the impact of interventions on the lives

of disabled people, the Activity Limitation Score (ALS) and the Participation restriction

Score (PRS). These measures are closely linked to the WHO s International

Classification of Functioning, Disability and Health (ICF) and the social model of

disability [13]. We believe these measures could become important tools in monitoring

the implementation of the recently ratified UN Convention on the Rights of Persons with

Disabilities.

The structure of this paper is as follows: After briefly describing the social model of

disability and the ICF, we present a series of indicators for capturing the functional status

of individuals. Then, using household survey data from Zambia, we explore the

usefulness of this measure as it relates to economic development outcomes.

1

The computer software programme SPSS (Release 13.0/15.0) was used for data entry and

data analyses. Analyses comprise univariate, bivariate and multivariate techniques. The

significance of observed associations and/or differences between variables was tested

using the Student s t-test, the Pearson correlation coefficient (r), and linear regression. A

difference was considered to be statistically significant if p

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