Developing a wellbeing measure for public health evaluations: integrating capabilities and happiness

Public health programmes are considered to be complex because they often require people to change their behaviour and involve interventions that cut across multiple sectors. For this reason, public health programmes are more likely to generate a wide range of benefits, including health gains. This makes the evaluation of such programmes a challenge, particularly when compared to clinical interventions that are focused on testing a spcific drug, for example. Conventional measures used in economic evaluations focus on one dimension of wellbeing (health) and there are concerns that assessing public health programmes with such measures may be too narrow. Important benefits of the programme could be missed which could result in a failure to capture the full value of the intervention.

To respond to this challenge, there are calls to develop new methods to measure wellbeing. Two main approaches to the measurement of wellbeing have thus far gained traction: the capability approach and happiness research. Despite their promising features for the assessment of wellbeing, the use and interpretation of these approaches face significant challenges, especially in a low-income settings. This study aims to tackle these challenges and to answer the following questions:

1) Do materially deprived people report high or low level of happiness? Are happiness measures developed for high-income countries suitable in a low-income context?
2) Do these two concepts of wellbeing (capabilities and happiness) complement each other, or are they the same thing?
3) Can we combine capabilities and happiness into a unique measure of wellbeing?
4) Can we use this wellbeing measure for evaluating public health programmes in a low income setting?

The wellbeing measure developed during the fellowship will be able to provide a broader picture of the effects of complex public health interventions, such as mental health programmes, which are not easily captured with standard evaluation methods. While the measure is intended to support evaluators in low-income countries, the methodology developed in this study will also be of interest for researchers and policy makers in middle-and high-income countries. It will contribute to the global debate on how to measure progress in society.

The nature of public health interventions raises methodological challenges for their evaluators. One of the challenges is how to measure and value outcomes 'beyond health'. The aim of this fellowship is to develop a broad outcome measure based on two wellbeing approaches (capabilities and happiness) for the evaluation of public health interventions in a low-income setting. The research is structured in four sections.

1. To explore the determinants of happiness in Malawi. A microeconometric model will be built using happiness as outcome and with a number of explanatory variables. A series of multivariate regression analyses will be performed to explore the association between happiness and health status, material wealth and socio-economic background.
2. To examine the conceptual and empirical relationship between the capability approach and happiness. The methods will draw on latent variable structural models to explore whether and which capabilities have an impact on happiness. The model will specify a system of equations for jointly explaining happiness and capabilities. It will also allow for latent personality traits affecting both, to take account of any unobservable heterogeneity.
3. To develop a multidimensional measure that combines both approaches to wellbeing. Building on methods developed during my PhD, a series of focus groups with women of reproductive age will be organised with the Public Health Foundation of India to explore the concept of wellbeing.
4. To explore the feasibility of using the wellbeing measure in the evaluation of a community based maternal depression programme in India. One of the methodological challenges will include how to aggregate the changes in wellbeing for people whose initial wellbeing is low with the changes for those whose initial wellbeing is high.

The wellbeing measure developed during the fellowship will be ready to be used for the evaluation of public interventions targeting women of reproductive age.

The research carried out during the fellowship is anticipated to benefit to a large audience beyond the academic community, including international organisations and decision-makers and through these, the wider public. The research will benefit the following people and institutions:
a) Myself: through the knowledge and skills acquired during the training that this fellowship will provide I will be able to continue developing to become an independent researcher leader in health economics. It will also help me to develop and reinforce networks with other researchers with the same interests, and this will lead to future collaborations and joint projects.
b) LSHTM. It will benefit from this research through a more diversified research portfolio, and high-quality research outputs. I will also attend the health economics monthly meeting in order to share the methods and the results.
c) Academia. The measurement of wellbeing is of strong interest to health economists, but also to a wider audience including political scientists, welfare economists, and statisticians. This research will contribute to knowledge producing new insights into the measurement of wellbeing and deprivation. It will offer new methodological approaches and will contribute to the wider debate on how to measure progress in society. as detailed in the Communication Plan, I intend to present the findings at several UK and international workshops and conferences.
d) Policy makers. The findings of the research will address the shortcomings of standard evaluation tools in the identification, measurement and valuation of non-health outcomes in public health. The final output of the research will be an instrument capable of capturing the broader effects of complex programmes that can be used by policy makers to aid decision over value-for-money. The instrument will be designed to capture multi-sector effects thus interested policy makers are not only in the health sectors, but also in education, labour, economy etc.
e) UNDP and OECD. The Human Development report is willing to include happiness measures alongside the standard human development indicators (health, education, GDP) although there is little evidence on the validity of these measures in low-income countries. The OECD has developed guidelines on how to measure happiness, but so far these have been used only by high-income countries. This research will bring new evidence of the suitability of happiness measures in low-income settings, and their relationships with human development indicators.