Escaping the metric-driven governance trap in global health: how DALYs and coverage indicators mislead policymakers in LMICs

Résumé

Every year, billions of dollars in global health financing are allocated on the basis of a single number a disability-adjusted life year, a coverage rate, or a composite index generated thousands of miles from the communities that will bear the consequences of those decisions. The structural disconnect between the production of global health metrics and their application in low- and middle-income countries (LMICs) is not merely a technical inconvenience; it is a defining feature of an unequal international order. As LMIC governments face mounting pressure to demonstrate accountability to donors and multilateral institutions, the metrics that ostensibly measure their progress have come to shape not only what is measured but what is funded, prioritized, and ultimately valued. We argue that the dominant tools of global health measurement disability-adjusted life years (DALYs), quality-adjusted life years (QALYs), coverage indicators, and composite indices systematically misrepresent health realities in LMICs, distort policy priorities, and actively undermine the health system strengthening. Our argument is not that coverage indicators are without value measuring whether people access life-saving interventions remains vital but that their deployment as the primary grammar of global health governance, uncoupled from system-level and equity dimensions, actively distorts decision-making. This is not simply a technical problem of imperfect indicators; it is a metric-driven governance trap that locks LMICs into externally defined priorities and distorts the politics of health decision-making. We argue that escaping this trap requires a fundamental reorientation of the global health measurement enterprise: one that redirects investment from international modelling to national data systems, subjects the normative assumptions embedded in global metrics to genuinely participatory revision, and institutionalises locally driven measurement frameworks co-designed with LMIC governments, civil society, and communities. Only by moving methodological authority and analytical sovereignty closer to where illness is actually lived can global health metrics become tools of accountability rather than instruments of abstraction.

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