Developing an Evaluation Tool for Health Systems in Low and Middle-Income Countries using Sen’s Capability Approach

At a national level, social determinants of health can be understood as ‘Social Freedoms’, such as educational attainment and civil rights. Exploring the role of health institutions in counteracting effects of social inequalities has often made comparisons that rank countries ‘performance’ on public health outcomes, or ‘cost-effectiveness’ of resources. This provides little evidence for informing policy. This thesis proposes a revised set of criteria for evaluating health systems in low- and middle-income countries (LMICs). Amartya Sen’s Capability Approach was used to define a set of capabilities that are required for achieving desired states of health. Capabilities for health are physical (i.e., accessibility and travel), social (i.e., inclusion), psychological (i.e., beliefs, experiences, and incentives), and economic (i.e., affordability). The thesis explored whether healthcare capabilities explain public health outcomes; what policies in high-income settings are related to healthcare capabilities; and whether these criteria are applicable for evaluating health institutions in LMICs.
Hierarchical regression reported that healthcare capabilities explained a further 5% of global disability-adjusted-life-expectancy and infant-mortality-rate-inequality, after accounting for Social Freedoms, which explained around 80%. Second, a qualitative comparative analysis indicated that policies for improving healthcare capabilities, such as financial safety-nets, supported choice in care provider, protective laws, and patient engagement in service commissioning, were related to fewer unmet healthcare needs. Yet, policy pathways to good health outcomes were varied, with a mix of decentralised incentives or centralised management for: GP-registration, staff recruitment and renumeration, clinical monitoring, and clinical management.
Third, a case study of healthcare in Karachi, Pakistan reported that a lack of policies for patient distribution, financial safety-nets, rural-working incentives, pharmaceutical and clinical governance resulted in access inequity, mistrust in providers, and low patient retention. Implications are presented as a tool using participatory evaluation for evaluating healthcare capabilities, consisting of societal health freedoms, fair resource generation and distribution, fair accessibility and service quality, clinical continuity, and accountability. The CISTEM tool facilitates evaluation of fairness in LMIC health systems.