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With the wellbeing agenda now firmly on the map, the Scottish Government and partners, are exploring alternative ways to GDP to measure national performance. Dr Karen Lorimer, Reader in Social Science and Health at Glasgow Caledonian University, looks at the potential role of the capability approach for public health…

"As attention shifts towards values like wellbeing, freedom and justice it’s only natural for partners to explore ways of measuring the impact of their actions. And while there may be a clamour for something new, there are many existing methods that could point the way. For me, Amartya Sen’s tried and tested capability approach has a lot to offer public health in 2020.

The capability approach is a multidimensional framework that enables an evaluation of wellbeing in terms of people’s freedoms and opportunities to lead a life they have reason to value. Functionings and capabilities are core concepts of the capability approach. Amartya Sen’s well-known example of the fasting priest compared to the starving man reveals the difference between the two – although each arguably has similar deficiencies in nutrition (functioning) their capabilities differ, with one of them able to eat.

For those of us working in public health, we know that the so-called ‘choice’ of health behaviours occurs within the limits of various constraints of social structures. Imagine having a bag in which all of our potential functionings are contained (all of what we are able to do and be), and we reach in, rummage around and select one. Some will have a very full bag, with a lot of wellbeing freedom; others may find their bag mostly empty. That imaginary bag that contains all of what we are able to do and be is our capability set. The capability approach allows us to pay attention to all of the factors which influence the size of a person’s bag, or their capability set. Public health interventions can play an important role in expanding that capability set, so that a person can go from having an almost empty bag to a fuller one and help expand their freedom to live a life they truly value.

The capability approach can be used in a narrow way to identify the functionings and capabilities of individuals, allowing it to be used for descriptive purposes. However, the capability approach can also be used in a much broader way to evaluate policy design and offer normative arguments, which is how things should be.

So, as public health interventions have become more complex, in terms of the intervention, outcomes and evaluation, how do we capture this complexity? My colleagues and I, led by Prof Paula Lorgelly, sought to develop a validated instrument for use in public health interventions.

Our starting point was Nussbaum’s ten essential capabilities which our final OCAP-18 measure mapped on to. Our mixed method project, using both quantitative and qualitative methods across multiple phases, enabled us to reduce and refine our measure, so that we had a useable tool; anything excessively long might not be very useful for those who also wish to ask other questions in their evaluation.

Looking back at this work, and the use of the capability approach, I came to two conclusions. Firstly, it’s possible to ask people if they feel they can live a life they have reason to value. Secondly, our measure appeared to capture something beyond health and wellbeing.

Being able to capture a much richer set of dimensions, ones that go beyond health, is extremely powerful for public health. It gives us a lens through which to assess inequalities that are health-impacting, that are having an impact on the intervention – providing a much broader and richer evaluative space.

An important path forward will be to ensure we pull in decades of insights from social science disciplines, to enrich our understandings and ensure we maintain a focus on wellbeing, freedom and justice."

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