Ward, Sarah (2017). 'How can an assets approach contribute to health and wellbeing, using a capabilities approach?' Paper presented at the annual conference of the HDCA, Cape Town 2017.
The structural determinants of health are well evidenced as the key causes of health inequality in the United Kingdom (McCartney et al., 2013). Indeed, ‘social injustice is killing people on a grand scale’ (WHO, 2008). In Scotland, health inequalities continue to worsen, with the gap in male life expectancy between richest and poorest geographical areas amounting to a difference of twenty-eight years (WHO, 2008), and health inequalities the widest in Western Europe (Eikemo and Mackenbach, 2012). Despite this, the majority of social and public policy continues to focus on behavioural solutions (Smith and Hellowell, 2012; Harrington et al., 2009; Smith et al. 2009). There are a number of reasons for this, including political ideology (Stevens, 2011), lack of popular support and/or understanding (Mackenbach, 2011), policy silos (Smith, 2013), lifestyle drift (Katikireddi et al., 2013), and the difficulty of translating research evidence into workable policy solutions (Bambra et al, 2011).
Recent public policy in Scotland draws attention to the failure of public service to address deep-rooted inequalities (Christie, 2011; Chief Medical Officer’s Report, 2010) and promotes three key measures in response: a streamlining of services to reduce overheads; a major shift in service delivery towards prevention; and a significant stepping-up of community involvement in service planning and delivery in the form of ‘assets approaches.’ Assets approaches have been criticised for a lack of attention to the structural determinants of health, with the link remaining weak between ‘internal’ change focused on individual and community, and ‘external’ change focused on the multiple structural barriers faced by people in disadvantaged communities (Ennis and West, 2010; Healy, 2005).
The capabilities approach aims to address social injustice by enabling disadvantaged groups to establish their own set of values for living ‘a good life’ (Sen, 2009; Nussbaum, 2011). An evaluation using capabilities is able to locate policy within the social justice context of equity and equality: key factors in addressing the gradient of health (Graham, 2009) and also allows for a complex examination of the contextual conversion factors (Brunner and Watson, 2015) which work for or against the successful achievement of domain freedoms. Capability domains align effectively with the social determinants of health (Raphael, 2010) and allow a broad articulation of health as a state of wellbeing rather than the absence of disease, and as a moral, multi-dimensional concern (Venkatapuram, 2011). The capabilities’ focus on public reason is well suited to an assets approach, which supports local decision-making and determination as key to addressing disenfranchisement.
This paper will explore the applicability of the Capabilities Approach in evaluating health policy interventions, with the aim of providing policy makers with a means of analysing the effects of an intervention on health inequalities in detail. Drawing on research within a National Health Service pilot programme using asset-based community development (ABCD) approaches in Scotland, the paper will explore the development of a capabilities framework developed through dialogue with local residents and practitioners involved in the programme. In addition to identifying the substantive capability domains most likely to be met by an ABCD intervention, the research draws out the micro, meso and macro conversion factors essential to the achievement of these freedoms. Further, in response to the need for all domains to be ‘secured and protected’ (Nussbaum, 2011:35) it explores the valued freedoms that will need to be addressed by other aspects of policy to ensure a life lived with dignity. Ultimately, the research aims to develop a practicable framework that identifies the scope for an assets approach to contribute to ‘external’ change by identifying the potentials for explicit links to the structural freedoms and barriers faced by disadvantaged communities.