A participatory method for public health interventions in low-income and middle-income countries: operationalising the capability approach

Biggeri, Mario (1); Nannini, Maria (1); Ferrannini, Andrea (2) (2018). 'A Participatory Method for Public Health Interventions in Low-income and Middle-income Countries: Operationalising the Capability Approach' Paper presented at the annual conference of the HDCA, Buenos Aires, Argentina 2018.


The historical evolution of public health interventions shows a growing programs complexity. Outcome measures and, in general, measurement methods need to adapt to such complexity (Lorgelly et al., 2010). Accordingly, the conventional evaluative space based on QALY has been recently enriched by the Capability Approach (Coast et al., 2008; Greco et al., 2016).

This framework is assuming an important role in health economics and health policy, since many experts recognise its advantages in analysing complex public health interventions (Lorgelly et al., 2010; Simon et al., 2013). The Capability Approach allows social scientists to adopt a multi-dimensional perspective, which considers also immaterial aspects and gives voice and value to the people involved into the programs. The dynamic analysis takes into account the existing barriers, as well as individual, social, and environmental conversion factors. Overall, the approach aims to construct a comprehensive measure of well-being.

The economic evaluations practice of public health interventions is substantially increasing and the operationalisation of the Capability Approach tends to enlarge it. However, important methodological challenges still exist (Borghi & Jan, 2008; Lorgelly et al., 2010; Hale, 2000; Greco et al., 2016), in particular concerning the attribution of effects, the identification of valid outcomes measure, the identification of programs’ inter-sectoral costs and consequences and the incorporation of equity considerations (Weatherly et al., 2009).

The Capability Approach meets the call to develop new methods to the measurement and assessment of well-being and its operationalisation for health programs has the potential to contribute significantly to the overcoming of relevant methodological challenges (Lorgelly et al., 2010; Greco et al., 2016; Simon et al., 2013). The literature on capabilities in health concerns mainly theoretical and conceptual issues (Lorgelly et al., 2010; Ruger, 2015; Coast et al., 2008), whilst the empirical applications are relatively limited. Greco and her colleagues (2016) provide a summary review of the attempts to operationalise the Capability Approach for evaluations of health programs. Cookson (2005) first explores the possibility of applying the approach to outcome measure within economic evaluation. Anand (2005; 2009) studies how to use the information contained in large household surveys in order to identify and assess the list of core capabilities proposed by Nussbaum (2000). Furthermore, Lorgelly with other researchers (2008) refines this analysis by constructing the important capability index called OCAP 18. There exist some valid applications of capability measures for specific evaluation areas, such as the ICECAP index for elderly developed by Coast and others (2008), or the OxCAP-MH (Simon et al., 2013) for outcome measurement in mental health research. Although these examples of operationalisation represent important contributions to the methodological improvement of the Capability Approach, they have a limited generalisability. Moreover, there exist few applications to contexts of LMICs (Greco et al., 2015).

This study presents the development and operationalisation of a multidimensional capability instrument called Structured Focus Group Discussion (SFGD), introduced by Biggeri and Ferrannini (2014) for public health research. The innovative investigation tool can be applied during different program phases: prior to the intervention implementation, it constitutes a valid pre-feasibility analysis instrument aimed at identifying the main barriers and opportunities related to the program. During the intervention, it helps performing activities of monitoring and evaluation. After the end of the intervention, the SFGD contributes to capture the final impact. Given the absence of an established capability instrument to be used continuously during the public health program, this methodological improvement allows to adequately assess interventions according to a comprehensive wellbeing perspective.

The method relies on a general design flexibility and, thus, can be applied to answer various methodological challenges for different purposes, as in the case-studies discussed in this paper: pre-feasibility (Uganda), monitoring & evaluation (Uganda) and impact evaluation (India). The method thus provides an improved comparability level among different cases, and ambiguities in the capability analysis are sensitively reduced.

The paper is structured as follows. First, the method characteristics are introduced. Second, different case studies presents the operationalization of the multidimensional capability instrument, showing its adaptability to different frameworks. We conclude with a discussion on the main potentialities of the method application and its contribution to the research improvement.

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