The Capability Approach and Disability

Sophie Mitra, Fordham University

The definition of disability is of interest to disability policymakers and analysts because it has funda-
mental implications for eligibility for public programs, for the scope of legislation, and for the way dis-
ability prevalence is measured. The purpose of this article is to assess how an approach developed in
economics to analyze issues related to the standard of living, the so-called capability approach, may
help us understand disability at the conceptual level. The article first summarizes different theoretical
models of disability (the medical model, the social model, the Nagi model, and the International Clas-
sification of Functioning, Disability and Health of the World Health Organization) and then presents
the main components of the capability approach. The capability approach allows researchers to ana-
lyze (a) disability at the capability level; (b) potential disability; and, at the functioning level, (c) actual
disability. This framework also helps explain how disability may result from three types of factors: the in-
dividual’s personal characteristics (e.g., impairment, age, race, gender), the individual’s resources, and
the individual’s environment (physical, social, economic, political). The article explores some implica-
tions of the capability approach for analyzing the employment and the standard of living of persons
with disabilities.

To the layperson, the meaning of disability is clear and simple: to others, but the multitude of models that have been devel-
It means “the inability to do something.” However, in disabil- oped may in fact reflect the multifaceted nature of disability.
ity and social science research, there is no consensus on what As noted by Pfeiffer (2001), many disability scholars recognize
constitutes disability. There are no commonly accepted ways to that no single model can totally explain disability. It is in this
define disability and to measure it. Disability has been subject context that this article should be placed: Each disability
to many definitions in different disciplines and for different model may bring a useful perspective on disability in a given
purposes. It has been described from medical, sociological, context. This article assesses whether anything can be learned
and political perspectives, and definitions of disability have from an approach that was developed in welfare economics to
been developed and used in different contexts. Various opera- analyze issues related to the standard of living and well-being.
tional definitions have been used for clinical circumstances The capability approach developed by A. K. Sen is a use-
and administrative programs, and several theoretical models ful framework for defining disability and understanding its
have been developed (Altman, 2001). Why has there been so economic causes and consequences. Although the capability
much effort dedicated to defining disability? At the theoretical approach has been used in international development to an-
level, defining disability is not simply an exercise in semantics: alyze the link between disability, gender discrimination, and
Altering the theoretical definition of disability can have far- poverty (Welch, 2002), its usefulness in defining disability
reaching social, economic, and political implications. Admin- and formulating disability policies has not been considered.
istrative programs and laws use definitions that define program This study attempts to address that gap in the literature. Sen
eligibility and legislation coverage. Those definitions, which developed the capability approach as a set of interrelated the-
directly affect the lives of persons with disabilities, are typically ses in welfare economics, particularly on the assessment of
based on theoretical models. The importance of defining dis- personal well-being, poverty, and inequality. In Commodities
ability for persons with impairments, activists, researchers, the and Capabilities (1985), Sen advocated focusing on a person’s
government, and international organizations explains the capability to function, that is, what the person can do or can be
ubiquity of this topic in social science research (Altman & versus the more standard concentration on opulence (the per-
Barnartt, 2000). son’s real income) or utility (as in traditional welfare economics).
One may also wonder if the lack of consensus on what con- Under Sen’s approach, capability does not constitute the
stitutes disability is a bad thing after all. Obviously, it would be presence of a physical or a mental ability; rather, it is under-
convenient to have a model of disability that is found superior stood as a practical opportunity. Functioning is the actual

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 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006 237

achievement of the individual, what he or she actually achieves summarized in Pfeiffer (2001): (a) the social model of the
through being or doing. Here, disability can be understood as United Kingdom, (b) the oppressed minority model, (c) the
a deprivation in terms of capabilities or functionings that re- social constructionist version of the United States, (d) the im-
sults from the interaction of an individual’s (a) personal char- pairment version, (e) the independent living version, (f) the
acteristics (e.g., age, impairment) and (b) basket of available postmodern version, (g) the continuum version, (h) the hu-
goods (assets, income) and (c) environment (social, economic, man variation version, and (i) the discrimination version.The
political, cultural). This approach helps to explain the impor- first two versions are briefly reviewed here.
tance of the economic causes and consequences of disability In general, the social model sees disability as a social con-
and is closely related to the recent International Classification struct. Disability is not the attribute of the individual; instead,
of Functioning, Disability and Health of the World Health Or- it is created by the social environment and requires social
ganization (WHO; 2001). change. Disability activists in the Union of the Physically Im-
This article is divided into five sections. The first section paired Against Segregation (UPIAS) developed the U.K. so-
presents different models of disability, in particular, the med- cial model, at the heart of which lies societal oppression
ical model, the social model, the Nagi model, and the Interna- (Oliver, 1990). The core definition of the British social model
tional Classification of Functioning, Disability and Health. comes in the UPIAS document Fundamental Principles of Dis-
The next section describes the terminology and rationale of ability, an edited version of which is reprinted by Oliver
Sen’s capability approach. The third explains that disability can (1996): “In our view, it is society which disables physically im-
be understood as a capability or a functioning deprivation un- paired people. Disability is something imposed on top of our
der Sen’s framework and presents the potential causes of dis- impairments by the way we are unnecessarily isolated and ex-
ability under this approach. The fourth section relates the cluded from full participation in society” (p. 22). As noted by
capability approach to models of disability and the fifth section Pfeiffer (2001), the U.K. social model is quite marxist in its
examines the implications of such an approach for disability view of disability, a view not often found in the United States.
policy. The last section has concluding remarks. The second version of the social model reviewed here,
that of the oppressed minority, says that persons with disabil-
ities face discrimination and segregation through sensory, at-
Disability Models titudinal, cognitive, physical, and economic barriers, and their
experiences are therefore perceived as similar to those of an
Several models have been created to define disability. Here, four oppressed minority group. Hahn (2002), among others in the
major models of disability are presented, and their relevant United States, supports this view:
concepts and meanings are examined.
Social inequalities encountered by persons with dis-
The Medical Model abilities are considered as similar to those encoun-
tered by other minorities such as “extraordinarily
The medical (or biomedical) model considers disability a prob- high rates of unemployment, poverty and welfare
lem of the individual that is directly caused by a disease, an in- dependency; school segregation; inadequate hous-
jury, or some other health condition and requires medical care in ing and transportation; and exclusion from many
the form of treatment and rehabilitation. The medical model at- public facilities.” (p. 171)
tributes the problem to the individual, who has a condition that
is unwanted and that places him or her in the “sick role” (Par- Drawing the overall picture of disability models is not as
sons, 1975). As explained by Pfeiffer (2001), “if a person has a simple as presenting a dichotomy between a medical model
permanent impairment which results in using a wheelchair to and a social model. There are other models that have devel-
move around, that person will never get ‘well’”(p. 31). This oped on their own, as extensions of the medical or the social
model is strongly normative: People are considered disabled model or as integrations of the two. In the following section,
on the basis of being unable to function as a “normal” person two of these models are discussed: (a) the Nagi model, which
does. Rehabilitation has an important role to play in bringing has wielded substantial influence for the last three decades at
the person back or close to the norm. The major concern of the the policymaking level in the United States and in the eco-
medical model at the political level is to provide health-care nomics of disability in general, and (b) the recent International
and rehabilitation services. This model has been criticized on Classification of Functioning, Disability and Health of the
different grounds, including its normative strength (Amund- WHO, the worldwide scope of which gives this model a strong
son, 2000). potential role in data collection efforts and policy development
in the years ahead.
The Social Model
The Nagi Model
The medical model is often referred to as the old paradigm
and stands in contrast to the social model of disability. The lat- Pathology is the starting point of Nagi’s (1965) model, also
ter has at least nine different versions, which are listed and called the functional limitation paradigm. Pathology refers to
238 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006

an interruption of normal body processes. An active pathology bility, self-care, education, remunerative employment, and eco-
or residuals of pathology may lead to impairments, which are nomic self-sufficiency. These individual domains can come
anatomical or physiological abnormalities or losses. Nagi iden- into play within different roles, but they are not organized as a
tifies functional limitations as the restrictions that impair- set of tasks geared toward performing a particular role. Func-
ments impose on the individual’s ability to perform the tasks tioning and disability are two umbrella terms, one being the
of his or her roles and normal daily activities. These roles in- mirror image of the other. Functioning covers body functions
clude family roles (e.g., looking after a child), work roles (hav- and structures, activities, and participation, whereas disability
ing a job), community roles, and other interactional roles as includes impairments, activity limitations, and participation
well as self-care activities. Nagi (1991) has defined func- restrictions. Interactions between the different components of
tional limitation as “an inability or limitation in performing the ICF are shown in Figure 1.
socially defined roles and tasks expected of an individual The ICF is the only conceptual model of disability that
within a socio-cultural and physical environment” (p. 315). also comes close to offering a concrete classification system of
Here, impairment is at the source of a causal chain leading to individuals. It gives two scales of 0–9 for assessing individuals.
disability, which eventually becomes a social construct. For in- A capacity qualifier measures an individual’s ability to execute
stance, say a 12-year-old girl with mental retardation does not tasks or actions in a standardized environment to neutralize
attend school but stays home with her parents helping with the impact of different environments on the abilities of the in-
household chores. If she lives in a society where young girls are dividual. A performance qualifier measures the actual lived ex-
not expected to go to school, but to stay at home, then she does perience of people in the actual context in which they live. The
not have a disability under the Nagi model. In contrast, if she ICF framework is the closest to a definition of disability found
lives in a society where girls her age attend school, then she under the capability approach.
does not perform this socially expected role and is therefore
considered disabled. The Nagi model therefore promotes a so-
cial and cultural relativistic view of disability. The Capability Approach
Sen’s capability approach was developed as a framework to an-
The International Classification alyze different concepts in welfare economics, including stan-
of Functioning dard of living, personal well-being, quality of life, and poverty.
The WHO developed the International Classification of Im- Standard of living is traditionally measured by the ability to
pairments, Disabilities and Handicaps (ICIDH) in the early buy a basket of commodities. Sen refers to this approach as the
1980s. It was recently revised and renamed the International opulence view. Standard of living is also measured in terms of
Classification of Functioning, Disability and Health (ICF). utility, where utility is meant as pleasure and happiness, or as
Conceptually, the ICF is presented as an integration of the a tool for valuation and choice. Sen argues that the standard of
medical and the social models: “ICF attempts to achieve a syn- living concept encompasses more aspects than the opulence
thesis, in order to provide a coherent view of different per- and the utility measures. Under the capability approach, Sen
spectives of health from a biological, individual and social focuses on the type of life that people are able to live, that is, on
perspective” (World Health Organization, 2001, p. 20). The ICF their capability to achieve or accomplish, on what they succeed
model is sometimes termed the biopsychosocial model of dis- in being or doing. The possession of commodities is valuable
ability (Bickensack, Chatterji, Badley, & Ustun, 1999). only to the extent that it enables the person to do or be a range
The ICF model posits that disability has its genesis in a of things. A commodity is considered to have “characteristics.”
health condition that gives rise to impairments, and then to ac- For instance, for a person with a spinal cord injury, a wheel-
tivity limitations and participation restrictions within contex- chair has the characteristic of providing transportation; it does
tual factors. Impairments are problems in body function or not have such a characteristic for a person who can walk.
structure causing a significant deviation or loss. An activity is In Sen’s approach, capability means “practical opportu-
the execution of a task or action by an individual, and partici- nity.” The ordinary meaning of functioning is an activity, some-
pation is the “lived experience” of people in the actual context thing a person does. In Sen’s approach, functioning has a
in which they live. Participation is not understood in terms of broader sense; it includes activities as well as desirable states,
a role to play but in terms of an involvement in a life situation such as “being well nourished” or “being free of malaria.” Sen
that can mean “being included or engaged in an area or being illustrates the difference between capabilities and functionings
accepted or having access to needed resources” (Altman, 2001, through the example of two people who are starving. They
p. 110). Contextual factors refer to the entire background of an achieve the same functioning, malnourishment, but they have
individual’s life, including personal factors, the environment different sets of capabilities. One is starving due to religious
(home, school, and work), services available in the community faith; she has decided to starve, whereas the other is starving
(e.g., transportation, health care, social services), and cultural from poverty.
factors (laws and attitudes). Activity and participation domains Overall, Sen is concerned with a person’s interests, more
include, among others, learning and applying knowledge, mo- than a person’s actions or behaviors. Sen distinguishes two ways
 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006 239

FIGURE 1. The International Classification of Functioning, Disability and Health. Source: World Health
Organization (2001).

of seeing a person’s interests and the person’s fulfillment: “well- teristics, capabilities, and functionings. Sen has voluntarily
being” and “advantage.” Well-being is concerned with a person’s left the capability approach incomplete to allow for plurality.
achievement: How “well” is his or her “being”? Well-being is Sen does not propose a single metric to measure well-being,
therefore concerned with the functionings, what a person ac- nor does he give a method to rank capability sets. Depend-
tually achieves being or doing. Advantage refers to the real op- ing on the issue at stake and the circumstances, a particular
portunities facing a person, from which the person will have variable can be a personal characteristic, a capability, or a
the freedom to choose. The person’s “capability set” is a set of functioning.
functioning vectors from which the person has the freedom to Because the area of interest here is disability, this idea is
choose. illustrated using examples related to disability. Education can
The foregoing concepts and the way they relate to each be considered a “personal characteristic” that influences work
other are shown in simplified form in Figure 2 (see Note 1). as a functioning (e.g., what education do working persons with
The basket of commodities available to a person, the environ- impairments have?), as a “capability” (e.g., do persons with im-
ment in which she lives, and her personal characteristics in- pairments have the opportunity to get an education?), or as a
fluence the capability set, which leads to the functionings, or “functioning” (e.g., what is the education level of persons with
what the person achieves in being or doing. The functionings impairments compared to those without?). Sen’s capability ap-
are a subset of the capability set: They are the capabilities that proach has the advantage of having wide coverage in that it in-
the person chooses to achieve. cludes all types of functionings, from basic ones (e.g., nutrition,
The cost of achieving a given capability varies depend- shelter, sanitation, health) to complex ones (e.g., self-respect,
ing on the environment of the person, including the average happiness, the ability to appear in public without shame). Sen
opulence of the society in which the person lives. Applied to shows the importance of assessing poverty on the basis of the
disability, the cost of achieving mobility for persons with ability to achieve some basic functionings, rather than on in-
mobility limitations varies tremendously from country to come only. He does not make a definite list of those basic func-
country depending on the local availability of assistive tech- tionings. Depending on the environment and the issue under
nology as well as the local physical environment. The cost of consideration, the scope and length of the list will vary. In
achieving a given level of maintenance care through per- dealing with extreme poverty in developing countries, Sen in-
sonal assistance will be higher in a society that is generally cludes life expectancy, infant mortality, the ability to be well
richer. This approach is not a rigid framework with lists of nourished and well sheltered, basic education, and medical
commodities, environmental dimensions, personal charac- care as basic capabilities.
240 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006

FIGURE 2. The Capability Approach. Note. This is a representation in chart format of some of the disabil-
ity models presented earlier. These models are described in detail in Altman (2001).

Although this voluntary incompleteness has its value at teristics that should be taken into account in assessing poverty
the conceptual level, it makes the capability approach difficult and personal well-being. Under the traditional opulence or
to implement at the operational level. Social scientists and utility approach in economics, a person is considered better off
philosophers have produced different versions of a list of di- than someone else if he or she can command more commodi-
mensions of what constitutes “the good life.” Alkire (2002a, ties, irrespective of whether the person has an impairment. For
2002b) reviewed several such lists, including John Rawls’s list instance, according to Sen (1999):
of primary goods, Doyal and Gough’s list of needs, and Martha
Nussbaum’s list of capabilities. Such lists are beyond the scope
A person who is disabled may have a larger basket
of this article.
of primary goods and have less chance to lead a nor-
mal life (or to pursue her objectives) than an able-
Understanding Disability Through the bodied person with a smaller basket of primary
goods. Similarly, an older person or a person more
Capability Approach prone to illness can be more disadvantaged in a gen-
erally accepted sense even with a larger bundle of
Health is a major concern is Sen’s capability approach, whether
primary goods. (p. 74; see Note 3)
it is considered as part of an individual’s well-being or whether
health equity is analyzed as part of the justice of social arrange-
ments (Sen, 2002). Disability has not received as much atten- Can the capability approach help to define disability at
tion as health in Sen’s work. However, his work is peppered the conceptual level? In other words, does it account for the ex-
with references to persons with impairments or chronic ill- perience of persons with disabilities effectively? Sen has not
nesses (see Note 2). His focus is on the impact of personal used the capability approach to define disability, so the answer
characteristics, including what he calls a handicap or disabil- to this question attempted here is intended simply as an inter-
ity, which is an impairment in disability theory, on a person’s pretation of Sen’s approach. It can be argued that the capa-
capabilities set and the assessment of poverty and well-being. bility approach is indeed a useful framework for defining
Impairment is considered an example of the personal charac- disability. Under the capability approach, disability may be an-
 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006 241

alyzed at two separate levels, as a deprivation of capabilities or irrespective of other personal characteristics, the amount of
as a deprivation of functionings. resources available to the individual, and the environment. For
At the level of personal characteristics, this study uses the instance, if a person’s impairment causes constant pain, due to
concept of an impairment rather than a disability, and impair- which the person is unable to have access to practical oppor-
ment is defined as a physiological, mental, or anatomical loss. tunities (e.g., go out of the house, engage in work or leisure), it
In terms of capabilities and functionings, deprivation results is the intrinsic nature of the impairment that deprives the per-
from the interaction among the resources available to the per- son of capabilities and makes him or her disabled.
son, personal characteristics (e.g., impairment, age, gender), Second, deprivation can be the result of barriers in the
and the environment. environment, in its physical, economic, social, political, and
cultural aspects. For instance, a person with a disfigurement
due to leprosy may have her own opportunity set reduced not
Potential and Actual Disability
by the condition itself but by the stigmatization or by discrim-
As noted previously, capabilities are practical opportunities ination in interpersonal relations. Third, deprivation can re-
and are not directly observable. Disability occurs when an in- sult from the economic constraints that an impairment may
dividual is deprived of practical opportunities as a result of an place on the availability of, and demand for, resources, or may
impairment. For instance, a 19-year-old who suffers a brain in- induce higher costs to achieve a given level of advantage or
jury is considered disabled if his practical opportunity to at- well-being. In this respect, Sen (1992) noted,
tend college is restricted, in contrast to an individual with a
similar basket of goods, in the same environment, and with Sometimes the same handicaps, such as age or dis-
similar personal characteristics except for the impairment. For ability or illness, that reduce one’s ability to earn an in-
the purposes of this examination, disability at the capability come, can also make it harder to convert income into
level is referred to as potential disability. The onset of a severe capability. Often, a high proportion of the poor in
physical or mental impairment will almost inevitably lead to a the advanced countries have such handicaps, and the
reduction in the range of the individual’s practical opportuni- extent of poverty in such countries is substantially un-
ties, and in the capability set, and thus to potential disability. derestimated, since it overlooks the “coupling” of
To use Sen’s terminology, it will not leave an individual’s ad- income-earning handicap and income-using handi-
vantage or freedom unchanged. cap in generating capability. For example, an old
Whether the individual is actually disabled depends on person has a much harder time in being free from
whether the impairment places restrictions on the individual’s disease, in leading a healthy life, in achieving mo-
functionings. At the functioning level, the focus is on what an bility, in taking part in the life of the community, in
individual values doing (or being), and on what the individual seeing friends, and so on. And these income-using
succeeds in doing/being. In this examination, disability at the disadvantages can tremendously compound the
functioning level is referred to as actual disability. An individ- feature of low earning power. (p. 113)
ual is disabled if he or she cannot do or be the things he or
she values doing or being. Such assessment would be entirely Taken to an extreme, the lack of resources can also be in
subjective. It would need to be dynamic and discontinuous itself the catalyst of impairment and/or disability. A person with
because a person may well adjust to an impairment if the per- a chronic condition, say diabetes, who has no health insurance
son was not born with it and acquired it later in life. Indeed, coverage and who lacks the necessary resources to be able to have
through adaptive preferences, a person may change the way an ongoing treatment, may well see his or her condition dete-
he or she values functionings and may well consider himself riorate to the point where an impairment develops and the
or herself as disabled right after the onset of an impairment person becomes deprived in terms of capabilities and function-
but not so 5 years later. This adjustment may also take the form ings. The lack of resources available to an individual constitutes
of “compensating abilities,” a term created by Qizilbash (1997) a possible cause of disability. An impairment is a prerequisite
to refer to the phenomenon whereby people, in the context to disability, but it is only one of the factors, along with the
of the capability approach, adjust their abilities in the face of person’s other characteristics (e.g., age, gender, race), the re-
deprivation. sources available, and the environment, that lead to capability
or functioning deprivation—in other words, to disability.
Causes of Disability
Determination of Disability
Under the capability approach, disability may be understood
as being the result of a combination of different factors. It may For social and political purposes, it is necessary to identify per-
result from (a) the nature of an impairment and other personal sons with disabilities in a particular region or country. There
characteristics (e.g., age, gender, race), (b) the resources avail- cannot be an individual subjective assessment of disability, as
able to the individual, and (c) the environment. First, depri- described earlier, based on valued capabilities and function-
vation can result from the very nature of the impairment, ings; but persons with impairments could well be involved in
242 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006

selecting the evaluative dimensions of disability. At a regional (Bickensack, Chatterji, Badley, & Ustun, 1999), such as socio-
or national level, reference needs to be made to a standard that economic factors. The assessment of these personal factors is
accounts for the context of the particular individual and other left to the discretion of the user of the classification if needed.
nonimpaired persons with similar characteristics (e.g., age, gen- Thus, the scope of capability and the functioning deprivation
der), with the same level of resources, and with the same envi- it addresses is limited to issues related to health.
ronment (e.g., urban, suburban, rural). In each of these contexts, Finally, among the many factors that influence disabil-
one would need to establish a set of relevant functionings, a ity, the capability approach encompasses an economic dimen-
method whereby the functionings of a person could be ranked sion of disability through an account of the economic burden
compared to others, with a minimum level below which a per- and the economic environment of the person with an impair-
son would be considered disabled. A similar standard assess- ment. It adds an intrinsic economic dimension to disability. By
ment could be performed at the capability level. For instance, definition, impairments limit the earning capacity and put
what opportunities are available in terms of work, education, constraints on the spending patterns of a person, and thus con-
leisure, and social life to an individual in the same environment stitute an economic burden at the individual and household
with a similar basket of goods and similar personal character- level and may lead to a disability at the capability or function-
istics except for the impairment? If disability is defined in terms ing level. The economic environment influences the practical
of a deprivation of capabilities (or functionings), then one needs opportunities, in terms of employment or self-sufficiency, that
to select a set of relevant capabilities (or functionings) to form persons with impairments have, as well as the costs of achiev-
an “evaluative space.” This selection of relevant functionings ing given functionings. Understanding the economic burden
will be influenced by societal norms and expectations. and the economic environment of disability is part of under-
For the purpose of defining poverty, Sen (1992) has rec- standing disability.
ognized that the selection of relevant capabilities and their Except for the social model, this economic dimension of
weighting is a value judgment and a social choice exercise. Sen disability is not fully addressed in the other models. Clearly,
does not propose a definitive list of relevant capabilities for this dimension is absent in the medical model. The Nagi
poverty assessment. A list of relevant capabilities and function- model is focused on roles, and if one is interested in the work
ings, say for a given country, is needed, however, if the capability role, one would certainly account for the restrictions an im-
approach is to be applied to the measurement of disability. In pairment may place on an individual’s capacity to work and the
the spirit of the capability approach, such a list would need to foregone earnings associated with those restrictions. The eco-
be prepared in a democratic and participatory fashion. nomic deprivation associated with a disability can therefore be
understood as the consequence of an inability to perform the
The Capability Approach and Other work role, and the Nagi model thus implicitly and indirectly
reflects this economic aspect of disability. However, in the Nagi
Disability Models model, the environment is purely social; it is there to define the
Understanding disability through the capability approach in- roles that are to be expected of individuals. The fact that the
volves several noteworthy differences that distinguish this ap- economic environment and the available resources may directly
proach from the others described earlier. First, the capability affect whether the person is disabled is not accounted for.
approach allows disability to be differentiated at two levels: at In the ICF model, consideration is given to the eco-
the capability level, or as a potential disability, and at the func- nomic achievements of individuals in terms of remunerative
tioning level, or as an actual disability. Apart from the ICF, the employment and economic self-sufficiency in the activity and
previously discussed models do not differentiate between two participation domains. However, once again, the fact that the
levels of disability. The ICF includes a capacity qualifier to resources available to the person and the economic environ-
measure capabilities and a performance qualifier to measure ment directly influence whether a person is considered dis-
functionings. abled remains unaddressed. Among the disability models
Second, there is considerable interpersonal variation in the reviewed, the social model is the only one that recognizes that
link between a given impairment and disability resulting from poverty is disabling (e.g., Bill, McBride, & Seddon, 2002). In
a variety of factors. The capability approach accounts for these the social model, disability is generally understood as the re-
factors at the individual level through the resources available, sult of social oppression, which can start in the form of poverty
the environment, and personal characteristics. The capabil- and later on lead to disability. Under the capability approach,
ity approach clearly accounts for human diversity (Sen, 1992) poverty is seen as a factor that interacts with the individual’s
through the inclusion of personal characteristics (e.g., race, gen- characteristics and environment, leading to disability.
der, impairment), which the social model and the Nagi model Can we consider existing disability models as interpreta-
do not address as explicitly. The ICF recognizes that an indi- tions of the capability approach with a list of disability-relevant
vidual may have restricted participation in a major life area for capabilities? The Nagi model might be interpreted as a model
many reasons, including personal factors (World Health Or- where the relevant functionings are “socially expected roles,”
ganization, 2001). In practice, however, in its classification the whether work, education, or play related. Similarly, the med-
ICF does not cover circumstances that are not health related ical and social models might be interpreted as models where
 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006 243

relevant functionings are, respectively, normal bodily func- research. The first general implication that arises is the need to
tional capacities and symptoms of societal oppression. The consider whether disability policymaking should be con-
only strength of the capability approach would then be to pro- cerned about capabilities or functionings. In general, Sen has
vide an overall framework where the selection of relevant eval- argued that public policy should deal with capabilities rather
uative dimensions is an explicit social choice exercise. The than functionings: For instance, “an affluent person who fasts
social, medical, and Nagi models would stand with their own may have the same functioning achievement in terms of eating
sets of evaluative criteria. or nourishment as a destitute person who is forced to starve,
However, there is a difference between these models and but the first person does have a different ‘capability set’ than
the capability approach that restricts the interpretation of the the second” (the first can choose to eat well and be well nour-
former as narrow applications of the capability approach. In ished in a way the second cannot) (Sen, 1999, p. 75). However,
the Nagi, the medical, and the social models, the concern for in practice, a person’s capabilities are difficult to observe, and
the lived experience of the individual, her achievements or as- data are usually available for functionings. Therefore, policy-
pirations, seems to be more limited than under the capability makers may have to settle for functionings. In light of the ca-
approach. Asking a person if she can work (Nagi model), or lift pability approach, two issues that have important implications
10 pounds with one hand (medical model), regardless of for disability policy, the assessment of employment capability
whether she wants to and needs to, whether there is any job for and the standard of living of persons with disabilities, are dis-
her in the economy, or whether she has anything that heavy to cussed next.
carry, appears restrictive. The same applies under the social
model when one asks a person with an impairment if she feels
oppressed by the environment she lives in.
Employment Capability and Disability
In this respect, the ICF model stands out from the other Employment is important in its own right as a source of income
disability models in that it has a concern for a wide range of as well as social participation for persons with or without im-
functionings in a person’s life. It is important to note that the pairments. For persons with impairments, it is particularly im-
term functioning has different meanings in the ICF model and portant because disability has often been assessed through a
in Sen’s capability approach. In the ICF, it includes function- work performance criterion. A person is considered disabled
ings that are directly related to health (body functions and if she is limited in the ability to work. This focus on work per-
structures) as well as activities and participation in a wide formance, that is, on work functioning, is somewhat conve-
range of life domains (e.g., education, self-care, work). Sen’s nient, because work is an observable variable from which an
concept of functionings is broader in that it includes activities individual’s disability can be inferred. As noted by Haveman
(e.g., playing soccer) as well as desirable states of persons (e.g., and Wolfe (2000), “when a paraplegic can be more successful
being fit), and it can be general (e.g., being free of thirst) or in the labor market (or selfcare) than a person with a combi-
specific (e.g., drinking wine). The range of functionings under nation of varicose veins, back problems, and low education,
consideration in the ICF includes functionings that are rele- measuring disability through assessing characteristics seems
vant to disability and is broad enough to reflect the lived expe- less satisfactory than observing performance directly.”
rience of the person. As such, the ICF may be understood as a Persons with impairments who work obviously have the
specific application of the capability approach. capability to work. Among those who do not work, there are
An additional similarity between the two approaches is persons who have the capability to work but prefer not to work
that disability in the ICF has the same meaning as actual dis- and there are persons who do not have the capability to work,
ability as it has been defined here: Both refer to functioning given constraints arising from their personal characteristics
deprivation. However, for the ICF to be a faithful application (including their impairment, age, race, gender), the environ-
of the capability approach, as noted earlier, it would need to ment (e.g., the state of the labor market), and availability of re-
be modified to account for the economic constraints and the sources.
economic environment of the person, as well as the personal Differentiating between these two types of nonworking
characteristics (e.g., gender) that may exacerbate the capa- persons has obvious merits for public policy purposes but re-
bility deprivation that results from an impairment. This is mains difficult to achieve through a questionnaire. In existing
particularly important for the ICF because it is being imple- data sets, disability prevalence is typically assessed through
mented worldwide, including in a lot of countries where dis- self-reported impairment, activity limitation, or work limita-
ability often goes hand in hand with poverty. tion questions. For instance, the Survey of Income and Pro-
gram Participation’s work limitation question is as follows: “Do
you have a physical, mental or health condition which limits
Implications for Disability the kind or amount of work you can do?” An answer provides
Policy and Research a person’s self assessment of whether her work capability is
constrained by an impairment. Other factors related to the
If the capability approach helps in understanding what dis- characteristics, resources and environment of the individual
ability is, it may have its own set of implications on policies and may also restrict work capability and may therefore influence
244 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006

the person’s response. For instance, the person may be limited Clearly, A and B have different capability sets despite hav-
in the kind of work he or she does because no employer seems to ing similar personal characteristics and resources. The local
be willing to accommodate the impairment, in which case the socioeconomic environment is a facilitator in the case of A and
interaction of the impairment with the environment is responsi- a barrier in the case of B. B may well be denied benefits on the
ble for the work limitation. Another person may be limited in basis that there are jobs in the national economy that she could
the amount of work he or she can do because the impairment perform. In this case, the capability set is evaluated within a
requires long periods of rest during the day. Both persons would standardized environment, that of the U.S. national economy,
report work limitations, but policy implications would be quite rather than the local environment in which the person actually
different in both cases once the causal factors leading to the lives, and does not take into account the constraint on re-
work limitations become known. Researchers should therefore sources a person may face should she decide to move to an-
exercise great caution while using work limitation questions to other environment.
assess trends in labor force participation of persons with dis- This example illustrates the complexity of determining
abilities to derive policy implications (see Note 4). Identifying who is disabled due to a limited capacity to work, and who is
the reasons for such trends in the employment of persons with not. Of course, the capability approach does not solve the dif-
disabilities is essential to formulate policies that encourage ficult problem of establishing a standard for the determination
persons with disabilities to participate in the labor force. of disability. However, in the context of the capability ap-
Such policies are aimed at bringing down some of the proach, the general answer to this complexity would be to have
barriers these persons face in the labor market and thus en- a personalized assessment of disability to account for the var-
hance their work capabilities. Benefit schemes such as SSI ious personal and environmental factors that lead people to
(Supplemental Security Income) or SSDI (Social Security Dis- achieve a state of employment or unemployment, and hence to
ability Insurance) compensate persons who do not have the ca- determine their eligibility for disability benefits.
pability to work. When policymakers are concerned with The capability approach also suggests that programs
providing a safety net to persons who are limited in their abil- aimed at addressing the economic implications of disability
ity to work because of a physical or mental impairment, clearly may be effective ways to promote the labor force participa-
they have to develop practices to assess the individual’s work tion and economic self-sufficiency of persons with disabilities.
capability. For instance, the Social Security Administration has Such programs may take the form of subsidies for on-the-job
complex procedures based on medical listings of impairments, accommodations made by employers or for the individual’s cost
vocational factors (age, education, work experience), and the of going to work. They may also provide assistance in the form
availability of relevant occupations in the national economy. If of temporary benefits to alleviate the constraint on resources
the relevant capability is work, then the question under the ca- resulting from an impairment until a person finds employment.
pability approach is as follows: Does the person have the prac-
tical opportunity to work given her personal characteristics
Evaluating the Standard of Living
(age, impairment, education, work experience), environment
(local economy, transportation, laws), and resources (assets, In addition to employment, the capability approach addresses
income)? the economic resources and needs of persons with disabilities.
As an example, consider the following two persons, re- Through the capability approach, disability, like poverty, can be
ferred to as A and B. They have similar personal characteris- defined as a capability deprivation. Sen’s capability approach
tics and resources: They both are 35-year-old women who provides a powerful framework for examining various forms
recently suffered a similar physical injury and are now wheel- of deprivation, such as disability, gender discrimination, and
chair users. They both hold bachelor’s degrees and used to poverty, and point toward neglected areas of research (see
work as administrative assistants prior to the injury, and they Note 5). Although poverty and disability can both be described
have approximately the same amount of assets, mainly in the in terms of capability deprivation, they are different concepts
form of savings. A and B live in different environments: A lives and should be specified over different dimensions of capa-
in Washington, DC, and B lives in rural Vermont. A and B both bilities. However dimensions of capabilities are selected, the
quit their previous jobs because the buildings of their employ- capability approach provides an important conceptual frame-
ers were not wheelchair friendly. A soon found another job in work for relating poverty and disability. Governments and
the city, and she can use public transportation to get to work. development organizations have traditionally given little at-
B cannot use public transportation and had to use most of her tention to poverty and disability. Recently, however, poverty
savings to buy a car adapted to her new needs. B cannot find and disability have been linked as part of a “vicious circle” in
another job in the area where she lives. She could move to a city the international development literature (see Note 6). “It is a
or to another county where there are more job vacancies, but two-way relationship—disability adds to the risk of poverty
she prefers not to live away from her friends and relatives, who and conditions of poverty increase the risk of disability” (El-
sometimes provide her with personal assistance. She is unsure wan, 1999, p. i). “The result of the cycle of poverty and dis-
as to whether she could find another job and afford personal ability is that people with disabilities are usually amongst the
assistance in another place, so she applies for SSDI. poorest of the poor” (Department for International Develop-
 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006 245

ment, 2000, p. 2). The capability approach provides a con- by Social Security benefits? In practice, it is difficult to assess
ceptual framework for this cycle of poverty and disability by those needs because the definition of need itself is value based
including the resources available to and the economic envi- and will vary depending on who tries to define it. However,
ronment of the person in the factors that may lead to disabil- some assessment of the costs of disability at the individual and
ity. As noted previously, poverty alone may be the catalyst for household level would help determine the income needs that
an impairment or a disability. This is especially true in devel- result from disability. Very limited work has been done to that
oping countries, where disability largely results from pre- effect, whether through studies on cost of illness or by assess-
ventable impairments associated with communicable, maternal, ing the spending patterns of persons with disabilities. Cost-of-
and perinatal diseases and injuries. For instance, UNICEF illness studies are descriptive studies that give information on
(2002) has estimated that in developing countries 10% of chil- the overall costs of a particular condition to society (Hodgson
dren are born with impairments that are the result of pre- & Meiners, 1982). Costs of illness can be estimated through a
ventable diseases or conditions, armed conflicts, or landmines. top-down or a bottom-up strategy. The top-down approach uses
Limited work has been done to show the impact of poverty on aggregate figures on resource consumption; the bottom-up
disability, in both developing and industrialized countries (see approach uses data collected from a sample of the popula-
Note 7). The capability approach points toward the need to bet- tion with the condition. Such studies generally focus on the so-
ter understand the socioeconomic determinants of impairments cietal cost of a condition, although a few of them based on the
and disabilities and to promote prevention as an essential ele- bottom-up strategy have also estimated the costs of the condi-
ment of policies jointly addressing poverty and disability. tion to the household or the individual (e.g., Berkowitz,
At the same time, the capability approach focuses atten- O’Leary, Kruse, & Harvey, 1998).
tion on the economic resources and needs of persons with dis- Even less work has been done measuring directly the
abilities, and on the economic well-being of this subgroup of the consumption patterns of persons with disabilities. A study by
population and how it compares with that of the general pop- Jones and O’Donnell (1995) appears to be the only one that es-
ulation, for example, in terms of income, asset ownership, sav- timated the costs associated with a disability at the household
ing behavior, and economic needs. The economic well-being level. Costs were assessed for households in the United King-
of persons with disabilities has received limited attention in both dom in different categories (gas, transport, food, alcohol,
developing and industrialized countries. It appears that only the clothes, and “other”), and estimates were used to construct
income aspect has been covered in previous work on the eco- equivalence scales. The results indicate that disability has a
nomic well-being of persons with disabilities. The few studies positive impact on consumption costs associated with gas and
on the economic well-being of persons with disabilities (Have- transportation. The study did not cover the health-care needs
man & Wolfe, 1989, 1999; Haveman, Holden, Wolfe, Smith, & of persons with disabilities, although these are key for persons
Wilson, 2000; Moon, 2002) have generally equated economic with disabilities. Klavus (1999) also used equivalence scales,
well-being with income, whether it comes from work earnings but for the purpose of demonstrating that health-care needs
or disability benefits. For instance, Haveman et al. (2000) com- have a considerable effect on the welfare of households in Fin-
pared the household income of women with disabilities who land. He found that a household with a chronically ill individ-
received SSDI to that of women without disabilities and as- ual needs 40% more income to reach the income level of a
sessed the extent to which SSDI has prevented women with healthy reference household. More work is required to under-
disabilities from falling below the poverty threshold. stand the economic needs of persons with disabilities and eval-
The Social Security Administration reports annually on uate their income requirements. Some countries, such as the
the poverty status of disabled beneficiaries by applying the United Kingdom, compensate persons with disabilities for the
standard poverty threshold to SSDI and SSI beneficiaries. This extra costs related to personal assistance and mobility needs.
work assumes that the minimum standard of resources encap- Although such allowances do not exist in the United States, pro-
sulated in the poverty threshold is sufficient to meet the needs of viding estimates of disability-related expenses at the household
persons with disabilities and that the full economic well-being level would allow researchers to assess the adequacy of the lev-
impact of disability can be identified from income data. Al- els of disability benefits from the perspective of beneficiaries.
though income is important, the effects of disability on eco-
nomic well-being also need to be assessed from demand data.
Returning to the capability approach, disability affects the cost Conclusion
of achieving a given level of well-being. Some commodities are
required only by persons with disabilities, whether they are This article was not intended to tout the capability approach as
fixed inputs (e.g., wheelchairs) or variable inputs (e.g., amount a superior model for investigating and understanding disabil-
of personal assistance required) and may induce higher costs ity. However, the capability approach does contribute a new
of living. and useful perspective on disability by differentiating two lev-
Related to the notion of needs assessment from demand els of the problem: the capability level and the functioning
data is the question, Do persons with disabilities have specific level. The capability framework is also useful for understand-
economic needs? If they do, are those needs compensated for ing the possible causes of disability. This approach allows re-
246 JOURNAL OF DISABILITY POLICY STUDIES VOL . 16/ NO. 4/2006

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