and sex across a wide variety of disease categories and geographic regions. The DALY's development has beenand undoubtedly will continue to besomewhat embattled, as has every past effort to develop composite indicators that go beyond measuring mortality. The conceptualizers of the DALY have been at some pains to state that it is one more step in a process, not some ideal methodologic endpoint, and have invited critical comment as a way to enhance its utility. At the same time, the DALY advances the field by incorporating several new features. First, it explicitly incorporates some ethical dimensions and value choices by taking into account the meaning of loss of welfare and the implications of time lived with a disability, weighing the severity of the disability, treating health outcomes equitably, and measuring the value of human life at different ages by using an exponential function that reflects the dependence of the young and the elderly on adults. The inclusion of these value choices serves to make the indicator applicable across a wide range of environments, by age group and by gender. For comparable reasons, the indicator can also be used in conjunction with the literature on cost-effectiveness of health interventions. At the same time, it is primarily these value choices that are at the heart of the ongoing debate about the DALY approach.
The analysis of changes in distributions of global health expenditures and flows of external assistance to the health sectors in developing countries raises large and challenging questions, especially when the relative volumes of those expenditures are poised against the structure of the global burden of disease. For example, given its small size relative to overall health expenditures in developing countries, what is the appropriate role for external assistance and how can that role be maximized realistically, respectfully, and usefully? What will be the effects of the de facto shift in the ODA portfolio away from bilateral dominance to dominance by multilateral banks? What might be said about the small proportion of GPD in the established market economies that is dedicated to ODA, recognizing that some of those countries have their own economic problems and that previous attempts to seek global formulas and standard funding commitments have been almost totally unsuccessful? What might be done about the lack of compatibility between the burden of certain diseases or conditions and the corresponding proportions of ODA and research dedicated to them?