Resource inputs and conversion factors One of the distinguishing features of the human development and capability
Resource inputs and conversion factors One of the distinguishing features of the human development and capability
approach is its focus on the process of generating health. This stands in contrast to conventional approaches, which are mainly concerned with outputs we can measure and the commodities/resource inputs needed to achieve these outputs. Moreover, the capability approach recognizes that different people may have different values in terms of health and often weigh these against other dimensions in life. In acknowledging human diversity and agency, the capability approach suggests that people may require different kinds of resources to achieve the outcomes they value and have reason to value (i.e. functionings). It suggests that there are numerous factors influencing how different individuals convert resource inputs into valued functionings. These ‘conversion factors’ occur at the individual, social, institutional (formal or informal) and environmental level. Individual factors that determine how a given resource will be used include, for example, age, gender, metabolic rate, pregnancy, illness and knowledge. Social or family dynamics are also relevant in converting resource inputs to health outputs of value. Formal rules or informal regulations similarly intervene in our ability to use resource inputs to achieve desired functionings. And, lastly, our natural or man-made environment can facilitate the efficient (or inefficient) use of given inputs (see Chapter 2). As Sen writes (2002, p660):
The factors that can contribute to health achievements and failures go well beyond health care, and include many influences of very different kinds, varying from (genetic) propensities, individual incomes, food habits and lifestyles, on the one hand, to the epidemiological environment and work conditions, on the other. . . We have to go well beyond the delivery and distribution
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of health care to get an adequate understanding of health achievement and capability.
Before examining conversion factors in greater detail, let us consider what resource inputs are to be converted. Conventionally, the choice of inputs is determined by identified outputs. For example, if we focus on addressing under- nutrition as our output of interest, we would of course resort to the provision of food. In comparison, if we are specifically concerned with a particular micro- nutrient deficiency, we would concoct ways of supplementing existing food with this particular micro-nutrient. If, on the other hand, we are concerned with reducing infant mortality, we would ensure access to health facilities and medi- cines, as well as the provision of preventive interventions (such as vaccines). If we are specifically focused on preventing deaths from diarrhoea, we would make oral-rehydration therapy available. If it is the incidence of malaria we want to reduce, we would provide bed-nets impregnated with insecticide. The list can go on. In general, health resource inputs can be categorized to include food or food supplements, preventive interventions (e.g. immunization), and access to medicines and health-care personnel. Inputs might also include the provision of health education or information on particular aspects of health disseminated in a particular format (e.g. pamphlets, radio programmes, bill- boards, etc.). In the conventional approach, it is generally assumed that such inputs would necessarily result in the identified outputs (i.e. improvements in nutrition or reductions in morbidity and mortality). However, there is a broad heterogeneity in the effectiveness of such inputs, much of which can be explained by the variation in existing conversion factors. Accounting for such factors and focusing more on the process by which inputs are (or are not) trans- lated into health outputs facilitates the development of more effective and efficient health programmes.
Considerable empirical evidence exists to substantiate the importance of conversion factors in translating health inputs into valued health outputs. With respect to individual conversion factors, the evidence is largely physiological. For example, there are distinct physiological differences between men and women that render female infants with higher survival rates and longer life expectancies. Likewise, there are physiological changes that take place in the process of ageing that alter the immune systems of individuals and their respective susceptibilities to ill health. Moreover, even those of the same age and gender can differ genetically such that one individual is more susceptible to particular diseases than another. In addition, there are acquired differences between individuals that can affect their ability to use resources. For example, an individual who has intestinal infections will receive less nutritional value from the same amount of food consumed by an individual who is uninfected (since intestinal infections can disrupt one’s absorptive capacity).
Conversion factors also include a number of external conditions, such as the natural or man-made environment in which we operate, formal or informal rules and regulations to which we subscribe, and the social or family dynamics
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that determine our daily lives (which may result in part from existing rules and regulations). The WHO Commission on Social Determinants of Health has called attention to some of these factors: what they refer to as ‘social determinants’ effectively encompass a variety of conversion factors that differ between social groupings. As the commission states in its final report, ‘inequities in health … arise because of the circumstances in which people grow, live, work and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces’ (Commission on Social Determinants of Health, 2008, pi.). This, however, includes both the differentials in resource inputs as well as factors that influence how these inputs might effectively be used.
One clear example of a conversion factor in health is education. Numerous studies have demonstrated that educated individuals tend to have lower mortality and morbidity than their less educated counterparts. For example, evidence from Sweden suggests that adults with doctorates have lower mortality rates than adults with professional degrees or master’s degrees, and those with professional or master’s degrees have lower mortality rates than those with bachelor’s degrees (Erikson, 2001). Moreover, children of educated mothers fare better in terms of health than those whose mothers have less education. For example, evidence from El Salvador indicates that, if mothers have no education, their babies have a one in ten chance of dying in the first year of their life. The infant death rate falls to a quarter of that if mothers have at least secondary education (World Bank, 2006).
Another kind of conversion factor may be social status or occupational hierarchy. For example, Marmot (2006) assessed differences in mortality (specifically the 25-year mortality rates of men, aged 40–69, at death) between British civil servants in Whitehall on the basis of their occupational hierarchy (divided in order of hierarchy: top administration, professional/executive, clerical and others). He found that, despite having access to clean water and sanitation, a surplus of calories and adequate shelter, the professionals/ executives had higher death rates than top administration, and the clerical staff had higher death rates than the professional/executive staff. Marmot speculates that the observed mortality differential relates to the relative lack of control those in lower positions in the occupational hierarchy had over their own respective lives. In other words, despite the fact that all civil servants have almost equal access to resource inputs, their occupational ranks (or degree of control over their lives) provide them with different conversion factors, affecting their respective health functionings in the long term.
Yet another conversion factor may involve the authority an individual has within their household or community to access or convert a particular resource into a valued health outcome. For example, the provision of anti-retrovirals (resource inputs) to HIV-positive women in contexts where women are unequal participants in the political process, and where they have unequal rights to (and control over) property, unequal access to economic assets, or even unequal restrictions on physical mobility, reproduction and sexuality – is Yet another conversion factor may involve the authority an individual has within their household or community to access or convert a particular resource into a valued health outcome. For example, the provision of anti-retrovirals (resource inputs) to HIV-positive women in contexts where women are unequal participants in the political process, and where they have unequal rights to (and control over) property, unequal access to economic assets, or even unequal restrictions on physical mobility, reproduction and sexuality – is
The importance of conversion factors indicates that, in order to achieve health equity, health policy cannot be isolated from the overall set of public policies pertaining to the distribution of the ‘social determinants of health’. Thus, health policy is not only about providing treatment for people with diabetes but about dealing with the social and economic drivers of the obesity epidemic; it is not only about providing health treatment for children but about educating women who will become mothers; and it is not only about treating their stress-related illnesses medically but also about improving the conditions in which they live and work (Marmot, 2007).
Capabilities and functionings We have thus far discussed resource inputs and conversion factors at length.
But what is it that we are converting the resources to? In other words, what does the capability set for health look like? What ‘we value and have reason to value’ in terms of health is often related to nutrition (i.e. the ability to be well- nourished), morbidity (i.e. the ability to be free from illness) and mortality (i.e. the ability to live long lives). Health capabilities would then include the set of vectors which our resource inputs and conversion factors would allow, and health functionings would refer to the particular capability we choose (i.e. the one we identify to be of value).
There has been a dearth of discussion in the academic literature as to what constitutes health capabilities. Is it having access to a wide range of nutrition- rich foods that are socially and culturally acceptable; having a wide set of health-care options without financial, physical or cultural barriers; or a range of safe living and working environments free from harmful exposures or threats of injury? Despite discussions suggesting the contrary, the capability approach itself does not spell out a universal set of health capabilities. As with capabilities more broadly, health capabilities are determined by the population within which the capabilities are being assessed. How do they define health and what aspects of that conception of health can be achieved through available resources and conversion factors? For example, many communities may value psychological or social health above physical health. They may therefore find the resources pool to achieve this type of health to be quite different from what is needed to achieve physical health; similarly, the conversion factors required may also differ. Indeed, there may be inconsistencies between the capability to be well-nourished or free from illness and the capability to have good psychological or social health.
It is also important to consider the possible distinction between functionings more broadly and achieved functionings, which can be readily observed and measured. Being well-nourished and free from illness are good examples of achieved functionings that have a high likelihood of reflecting valued states of being. There are, however, other valuable health states, which
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may not be as easily observed or measured (e.g. psychological or social well- being). By focusing on achieved functionings, therefore, we may be misguided in assessing only a subset of valued health outcomes.
In sum, given available resources and conversion factors, an individual may secure a set of possible vectors of functionings (i.e. capabilities). From this set, an individual has the choice of realizing the functioning he values or has reason to value (in that particular space and at that particular time). Or, to put it in simpler terms, these functionings can be ‘elementary functioning’, to paraphrase Sen, such as escaping from morbidity and mortality or being adequately nourished or mobile. They can also represent more ‘complex functionings’, such as achieving self-respect, taking part in the life of the community, or appearing in public without shame. However, as we have discussed, different conceptions and values of health will affect not only how resources are converted into capabilities but also which functionings are actually achieved.
An important factor in considering health from a capability perspective is the importance of choice, which depends on information and individual values, as well as social, cultural and religious norms. It must be recognized that such choices, and the information upon which they are based, can be manipulated and modified, depending on the nature of the norms that inform them. Indeed, given the highly profitable nature of health issues, information pertaining to health or health-related consumables is highly influenced by commercial interests and economic motives. Moreover, people are not always rational when it comes to health matters. This has to do in part with the multi- dimensional nature of health but also with the fact that health values are weighted against other values. For example, there is a multitude of people who continue to smoke despite an awareness of the physical dangers of smoking. The same can be said of high fat diets and sedentary lifestyles. There is considerable literature on social choice and the complex manner in which individuals and societies go about making decisions. With respect to health, there is the added complication that individuals often have incomplete (e.g. subclinical pathologies) or biased (e.g. influenced by the pharmaceutical industry) information.