Women’s health and well-being over the life course: conceptual framing supported by a scoping review

Abstract

Abstract

As a framework to conceptualise well-being, the capability approach (CA) combines structural drivers with personal freedoms, making it a compelling approach for understanding women’s health and well-being (WHW). The WHW Project of the Exemplars in Global Health initiative chose the CA for its conceptual framing, while emphasising the influential role of gender and other intersecting inequalities (intersectional gender inequality) in shaping health and well-being over the life course. We discuss the Exemplars in Global Health – Women’s Health and Well-being (EGH-WHW) Framework and a scoping review that supports it.

Objectives

1. To identify well-established and/or validated CA-based frameworks and measures attuned to intersectional gender inequality that analyse women’s well-being over the life course and across multiple geographies.

2. If needed, to develop a new conceptual framework to analyse WHW over the life course through an intersectional gender inequality lens.

Design

The scoping review, which was carried out between January and May 2024 and re-run in May 2025, adhered to the methodology by Arksey and O’Malley, Levac et al and Daudt et al, and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. The EGH-WHW Framework was developed by a multidisciplinary Working Group comprising representatives of organisations in the WHW Project consortium.

Data sources

The review drew upon database searches (Scopus, PubMed) and targeted online hand searches for CA-based frameworks and measures.

Eligibility criteria

All CA-based frameworks and measures of multidimensional well-being were included. CA-based empirical research was considered if it applied a framework or measure; or if it analysed multidimensional well-being across multiple geographies.

Data extraction and synthesis

Information about each type of CA-based application—its choice of well-being dimensions, methods, focus on inequality, intersectionality and the life course—was recorded in a data charting form. Thematic summative syntheses of publications about each CA-based framework or measure led up to an overall evaluative synthesis of the fit between existing work and our requirements.

Results

The review culminated in 94 publications, including six frameworks and 14 measures that met only some of the WHW Project’s requirements: multidimensionality of well-being; attention to intersectional gender inequality and the life course; as well as demonstrated and intended measurements across multiple geographies.

Discussion

The review reaffirms the need for the EGH-WHW Framework, which recognises that WHW depend on their freedom ‘to be’ and ‘to do’, and proposes three interconnected clusters of dimensions depicting key capabilities, agency and functionings that are sensitive to intersectional gender inequality and the life course. Each dimension is mapped to specific indicators to support comparative assessments of country performance and drivers of progress across low-income and middle-income countries.

Conclusion

The EGH-WHW Framework distinguishes itself from other CA-based frameworks by incorporating both an intersectional gender lens and a life course perspective. The framework’s conceptualisation of multidimensional well-being allows for a rich and nuanced foundation on which to build policies and programmes that address the complex determinants of health, well-being and human rights of different groups of girls and women.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The relevance of the Exemplars in Global Health – Women’s Health and Well-being (EGH-WHW) Framework and its important contribution to a vibrant literature was reaffirmed by a scoping review of other capability approach (CA)-based frameworks and measures.

• The universality of the EGH-WHW Framework’s well-being dimensions was backed by indicators from the Sustainable Development Goal Global Database endorsed by nearly all governments in high-income and low-and-middle-income countries.

• Metrics for the EGH-WHW Framework were developed and applied to identify exemplar countries that demonstrate exceptional progress in advancing women’s health and well-being over the life course relative to peer countries in their regions.

• Our search in the scoping review for well-established and/or validated CA-based frameworks and measures may have excluded emerging work of merit in the grey literature and/or in a language other than English.

• Our requirement for robust applications of the CA across multiple geographies could have excluded instructive research conducted in specific communities or limited geographies.

Introduction

The authoritative and often quoted association of health with well-being is in the 1946 Constitution of the WHO¹, which states that “Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”. Yet a universally agreed framework for measuring well-being remains elusive. This paper describes a framework for conceptualising and measuring well-being that was developed by the Women’s Health and Well-being (WHW) Project of the Exemplars in Global Health Initiative. The WHW Project explored whether well-being can be defined and analysed to capture positive dimensions of health that are universally applicable, while also addressing gender and other intersecting inequalities (viz., intersectional gender inequality) as well as the cumulative effects of events during sensitive periods and other changes over the life course.²

While philosophical debates over what constitutes human well-being trace back centuries, modern arguments include, inter alia, those of the utilitarians,³ Kant,⁴ Hayek,⁵ Nozick,⁶ Rawls,⁷ Nussbaum⁸,¹² and Sen.¹³,¹⁶ Extant approaches to well-being focus on individual happiness or ability to fulfil desires with measures such as the Happiness Index¹⁷ or the Flourishing Index.¹⁸ These recognise individual material conditions yet ascribe well-being largely to subjective attributes such as resilience, self-determination and fulfilment. Both approaches are gender neutral. More recently, the World Bank embarked on assessments of healthy longevity, as a means of stimulating investments in life course initiatives. Others, such as the Quality Adjusted Life Year, measure quality of life as a composite score narrowly focused on health.¹⁹ In contrast, the capability approach (CA) pioneered by Amartya Sen¹³,¹⁶ and infused with a gender lens by Martha Nussbaum⁸,¹² and Robeyns²⁰ provides the most compelling basis for thinking of health and well-being from the perspective of girls and women.

The CA, which breaks away from the utilitarian focus on individual happiness, stands out for two reasons. First, it emphasises a girl’s or woman’s substantive freedoms or opportunities, and her agency to use those opportunities to attain valued states of being and doing. Second, it recognises that public policies and social institutions with associated discriminatory norms can restrict freedoms and opportunities (capabilities) differentially, and thereby give rise to inequalities in the attainment of well-being. Thus, the CA is able to combine structural drivers with individual/personal freedoms.

The CA highlights human capabilities, agency and functionings as central to well-being.⁹¹¹,¹⁵ It emphasises an individual’s ability to access and convert material and social resources into capabilities, and her agency to achieve functionings. Resources can be both tangible (such as availability of food, health facilities, schools, roads) and intangible (such as time, familial support, community networks). Capabilities themselves are the set of substantive freedoms and opportunities that a person has ‘to be’ and ‘to do’ in order to achieve a state she values. Agency is choosing to act to achieve that desired state, in so far as her choices are shaped by prevailing gender norms, values and practices. Functionings (such as living without fear, gaining an education, securing employment, or being well nourished and healthy, and so on) refer to the ways in which she realises those multidimensional freedoms through her choices and behaviours. Together, capabilities, agency and functionings determine people’s ability to survive and thrive: their well-being.

A Working Group for the WHW Project chose the CA for its conceptual framing, while emphasising the influential role of intersectional gender inequality in shaping the factors that cumulate over the life course (individual, social, environmental, etc) and contribute to WHW. It was felt that the WHW Project needed a globally resonant and measurable framework that considers well-being as multidimensional and pays attention to intersectional gender inequality and the life course. To understand whether existing applications of the CA meet the WHW Project’s requirements, we carried out a scoping review to identify CA-based frameworks and measures that analyse well-being. In this paper, we will discuss how the scoping review did not reveal any CA-based application that met the WHW Project’s requirements, which called for a new conceptual framing—the Exemplars in Global Health – Women’s Health and Well-being (EGH-WHW) Framework.

Methods

Scoping Review

Two questions motivated our review. Are there well-established CA-based frameworks and validated CA-based measures that can be used by the WHW Project for cross-country comparisons of women’s well-being? Are these frameworks and measures attuned to intersectional gender inequality and to well-being over the life course? Accordingly, our objective for the review was to identify well-established and/or validated CA-based frameworks and measures attuned to intersectional gender inequality that analyse women’s well-being over the life course across multiple geographies.

The decision to carry out a scoping review drew on the fact that we were setting out to map CA-based research activity and outputs (frameworks, measures and empirical research) in multiple disciplines, drawing on varying epistemologies and approaches to research (quantitative, qualitative, mixed methods) with diverse populations.

Our methods were guided by the work of Arksey and O’Malley²¹ with refinements by Levac et al²² and Daudt et al,²³ and adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. A thorough review was conducted between January and May 2024, building on initial explorations for CA-based frameworks and measures in 2022 and 2023. The search was re-run in May 2025. The protocol is registered with the Open Science Framework https://doi.org/10.17605/OSF.IO/4ZNA7. This desk review was conducted by researchers with no involvement by members of the public.

Information sources

In keeping with Levac et al’s suggestion, our search strategy aimed to be comprehensive yet focused. The goal was to identify well-established and validated frameworks and measures. Accordingly, the focus was on published literature alone. To make our searches effective and efficient, we identified relevant literature from two expansive databases that complement each other: Scopus, a comprehensive database with high-quality publications across multiple academic disciplines, and PubMed, another comprehensive database that covers, in greater depth, the biomedical literature. We followed this with focused online hand searches.

Search strategy and eligibility criteria

Database searches

The search strategy in Scopus and PubMed was developed by researchers who are well-versed with the CA and the algorithms of database searches. The strategy emerged in an inductive and iterative way through preliminary searches of both databases and screening of the first 20 articles from each search. Search terms and limits were tweaked after each preliminary search until it started yielding relevant results.

As depicted in online supplemental annexure 1, the strategy was to combine search terms located in three blocks: CA, well-being and girls/women across the life course (including children and adolescents). The focus was on published literature in English in a wide range of academic disciplines with no geographical and time limits.

Online hand searches

Recommendations by members of the WHW Project’s Working Group and the reference lists of publications selected from the database search served to identify additional CA-based frameworks or measures. The websites of specific well-being initiatives or projects were also scanned.

Selection of sources of evidence

Database searches

Two researchers (AI and SRS) independently screened titles and abstracts to narrow the number to publications that had applied the CA to assess well-being. Perusal of the full texts of these publications that reported on frameworks, measures and empirical research served to whittle down the number further. Publications reporting on frameworks and measures were retained for more in-depth review, while empirical research studies in limited geographies that did not apply a CA-based framework or measure, or failed to consider well-being along multiple dimensions were excluded.

Online hand searches

Full texts of the publications identified from reference lists were downloaded from journal archives or weblinks. Among all publications posted on project websites, only those describing the conceptualisation and metrics of a framework, or the development and assessment of a measure’s feasibility, validity and reliability were selected.

Data charting process and synthesis

Two researchers (AI and SRS) appraising the full texts of all selected papers and reports recorded information in two iteratively developed data charting forms. One form was designed to characterise each CA-based application in terms of its type (ie, framework, measure or empirical research), year of publication, geographical coverage and populations of interest (online supplemental annexure 2). The other form served to describe each CA application in terms of its choice of well-being dimensions, data sources and methods, the extent of its focus on inequality, intersectionality and the life course (online supplemental annexure 3). Periodic consultations between the researchers served to resolve confusions and differing interpretations while charting data.

What followed were thematic summative syntheses of all publications about multi-country frameworks (table 1 based on online supplemental annexures 2,3) and measures (table 2 based on online supplemental annexures 2,3) in the lead up to an evaluative assessment of the fit between existing frameworks and measures and the WHW Project’s requirements. Were there CA-based frameworks or measures that could be used without modification? What aspects were worth emulating if a new framework was needed?

Table 1. CA-based frameworks for cross-country analyses.

	Name	Concept of multidimensional well-being	Data sources	Measurement	Inequality & intersectionality	Life course evolution
1	OECD Framework for its Better Life Initiative24,26	Focuses on current well-being—material living conditions (income & wealth, work & job quality, housing), quality of life (health, knowledge & skills, environment quality, safety, subjective well-being), community relationships (work-life balance, social connections, civic engagement); inequalities in well-being outcomes; resources for future well-being (natural, human, economic & social capital)	Routinely available OECD databases (Note A) & other databases (Note B)	Current well-being measured as averages & deprivations; resources for future well-being as stocks, flows, risk factors & resilience	Supports analyses of inequalities in well-being outcomes by age, gender & education; between top & bottom 20% of the population	Allows age-based comparisons (young, middle-aged & old people)
2	GAGE Project Framework27108,110	Emphasises 3 interconnected Cs: capabilities (education & learning, bodily integrity, physical & reproductive health & nutrition, psychosocial well-being, voice & agency, economic empowerment); change strategies (policies & programmes to support the subjective experiences of adolescent girls across all capability domains & their achievement of ‘objective capability outcomes’); contexts (family, community, state & global forces shaping the design & effectiveness of change strategies)	Tailored prospective surveys & qualitative research with cohorts of adolescents, caregivers, teachers, siblings & community leaders. Annual participatory research with adolescents & their peer networks.	Descriptive analyses of data from mixed methods research on the experiences & perspectives of socially marginalised adolescents & on programme effectiveness	Supports analyses of inequalities by age, gender, refugee status, disability & geographic location. Explicit focus on intersectionality.	Currently focuses on adolescence alone. Proposes to address the progression from adolescence to adulthood & intergenerational effects.
3	UN H6+Technical Working Group’s Adolescent Health & Well-being Framework28 111 112	Defines well-being as the ability to thrive & achieve one’s full potential. Considers 5 domains & 27 subdomains of subjective & objective well-being reflective of gender, equity & rights: good health & optimum nutrition; connectedness, positive values & contribution to society; safety & supportive environment; learning, competence, education, skills, employability; agency & resilience. Lists out a set of requirements if adolescents are to achieve well-being in each domain.	Not specified. Country-level indicators identified so far are to get incorporated into existing global measurement initiatives & tools.	Work is underway to create a standard but adaptable approach to measurement. Includes objective & subjective indicators of well-being at both individual & national levels.	Focuses on gender inequality & rights. No focus on intersectionality so far	Focuses exclusively on adolescence; is not life course oriented

OECD databases include Affordable Housing; Agriculture & Fisheries; Average Annual Wages; Education at a Glance; Environment; Exposure to particulate matter 2.5 micrometers or less in countries & regions; Health Statistics; Health Status; Household Dashboard; Information & Communication Technology Access & Usage by Households & Individuals; Income Distribution; Indicators of Gender Equality in Employment; International Development Statistics: Gender, Institutions & Development; International Roaming Expert Group; Job Quality; Labour Force Statistics; National Accounts; Programme for the International Assessment of Adult Competencies; Programme for International Student Assessment; Structural Analysis Database; Time Use; Transition from School to Work; Wealth Distribution.

Other databases include Comparative Study of Electoral Systems; European Health Interview Survey; European Union Statistics on Income and Living Conditions; Eurostat’s Harmonised European Time Use Surveys; Gallup World Poll; Reinforcing Democracy Initiative; International Traffic Safety Data and Analysis Group; Transparency International Corruption Perception Index; United Nations Department of Economic and Social Affairs Global Sustainable Development Goal Indicator; WHO Mortality Database.

CA, capability approach; GAGE, Gender & Adolescence: Global Evidence; OECD, Organisation for Economic Co-operation and Development; UN H6, The H6 Partnership between United Nations Population Fund, United Nations Children's Fund, United Nations Entity for Gender Equality and the Empowerment of Women, World Health Organization, Joint United Nations Programme on HIV/AIDS and World Bank Group.

Table 2. Multicountry CA-based measures.

	Name	Dimensions of well-being	Geographical coverage	Data sources, measurement	Inequality & intersectionality	Life course evolution
1	Multidimensional Poverty Index29,32	Dimensions aligned to the Millennium Development Goals: Health (nutrition, child mortality); Education (years of schooling, school attendance); Living standards (cooking fuel, improved sanitation, safe drinking water, electricity, flooring, assets)	21 LICs, 47 LMICs, 40 UMICs, 4 HICs	Counts individual-level deprivations within & across dimensions with a one-third poverty cut-off using available global datasets	Recent work shows how intra-household gender analyses can complement cross-country multidimensional poverty assessments	No focus on the life course
2	ICECAP-A (Adults)33113,116	Ability to: Have love, friendship, support (Attachment); Feel settled, secure (Stability); Achieve, progress in life (Achievement); Experience enjoyment, pleasure (Enjoyment); Be independent (Autonomy)	Over 20 countries, mainly UMICs & HICs	Aggregates ratings by respondents to tailored surveys on a 4-point scale for each attribute	No explicit focus on inequality so far	Focus on adults alone
3	ICECAP-O (Older persons)19117,123	Ability to: have love, friendship (Attachment); think about the future without concern (Security); do things that make you feel valued (Role); experience enjoyment, pleasure (Enjoyment); be independent (Control)				Focus on older people alone
4	OxCAP-MH39124,126	Bodily health (daily activities, suitable accommodation); Bodily integrity (neighbourhood safety, potential for assault); Senses, imagination, thought (freedom of expression, imagination, creativity); Emotions (love, support, losing sleep); Practical reason (planning one’s life); Affiliation (respect, appreciation, social networks, discrimination); Species (appreciate nature); Play (enjoy recreation); Control over one’s environment (influence local decisions, employment discrimination)	1 LIC, 4 MICs, 4 HICs	Aggregates ratings of all capabilities on a Likert scale by patients with/without providers in tailored surveys	Amenable to analyses of age, gender, illness (type, duration) inequalities	Age-based comparative analyses of index scores

CA, capability approach; HICs, high-income countries; ICECAP, Project titled "Investigating Choice Experiences for the Preferences of Older People" (ICEpop) and its validated capability instruments (CAP); LICs, low-income countries; LMICs, lower-middle-income countries; OxCAP-MH, Oxford Capability Instrument - Mental Health ; UMICs, upper-middle-income countries.

EGH-WHW Framework Development

The EGH-WHW Framework was developed by a multidisciplinary Working Group composed of representatives from all organisations in the WHW Project consortium. The framework was reviewed by the Project’s Technical Advisory Group.

Results

The scoping review generated 94 relevant publications—47 from a total of 299 publications shortlisted from database searches and 47 from targeted online hand searches (figure 1).

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart depicting the search and selection process. CA, capability approach.

• The process of screening titles and abstracts of publications identified by the database search resulted in the removal of eight duplicates and 206 publications that did not apply the CA. The perusal of full texts of the remaining 85 publications led to the removal of 38 empirical research studies in limited geographies that did not use a CA-based framework/measure and/or failed to consider well-being along multiple dimensions. This resulted in 47 publications that reported on the development or application of a CA-based framework or measure, or analysed multidimensional well-being across multiple geographies.

• The hand searches resulted in the identification of a framework developed by the Organisation for Economic Co-operation and Development (OECD) for its Better Life Initiative,²⁴,²⁶ and reiterated our selection of adolescence-focused frameworks by the Gender and Adolescence - Global Evidence (GAGE) Project²⁷ and by the UN H6+Technical Working Group comprising the United Nations Population Fund, United Nations Children's Fund, United Nations Entity for Gender Equality and the Empowerment of Women, World Health Organization, Joint United Nations Programme on HIV/AIDS and World Bank Group.²⁸ It also led to the selection of nine measures: the Multidimensional Poverty Index²⁹,³²; five measures under the rubric ‘ICECAP’, a name derived from the project ‘Investigating Choice Experiences for the Preferences of Older People’ (ICEpop) and its validated capability instruments (CAP)¹⁹³³,³⁶; Adult Social Care Outcome Toolkit (ASCOT)³⁷; Operationalising the Capability Approach - 18 items (OCAP-18)³⁸ and Oxford Capability Instrument - Mental Health (OxCAP-MH),³⁹ which are rooted in the Oxford Capability instrument (OCAP).

The scoping review indicates that the CA has been used in many country contexts with groups at different stages of the life course (children to the elderly) – online supplemental annexure 2. Since the mid-2000s, the CA has inspired three well-being frameworks that support cross-country comparisons,²⁶,²⁸ and three that are either rooted in local realities^{40 41} or serve to guide specific activities.⁴² The CA has also informed the development of 15 measures, including instruments, scales, indices and indicators, that mainly emanate from empirical research in high-income countries (HICs)^{1929 33},^{39 43} with applications in HICs or upper-middle-income countries (UMICs). Only one of these measures is globally applicable.⁴⁶ No more than two measures emanate from UMICs^{47 48} and one from a low-income country (LIC).⁴⁹

In national and subnational studies (online supplemental annexure 3), the CA serves to shape assessments of subjective and/or objective well-being, as well as physical and mental health among entire populations^{26 46} or groups of individuals who share the same life stage,⁴¹⁵⁰,⁵⁸ medical condition⁵⁹,⁶¹ or socioeconomic, political and gendered vulnerabilities.^{5657 62},⁷⁰ Apart from this, the CA is used as an evaluative frame to judge the ethics of health and well-being technologies,⁴² the cost effectiveness of interventions,⁷¹ develop tariffs,⁷² track progress in a country’s SDG commitments⁷³ or even assess gendered vulnerability and adaptability to climate change.^{40 74} Research interrogating constituent elements of the CA includes work exploring how the ability to achieve one dimension of well-being affects the achievement of other dimensions⁵⁴; how feedback loops serve to convert resources into perceived capabilities or functionings in contextually specific ways.^{75 76} Interest in the approach can be instrumental, with maternal capabilities being of interest for child development.⁷⁷ It can also be invoked to interpret quantitative findings.⁷⁸

The frameworks and measures identified through the review consider well-being as multidimensional, with dimensions being chosen either inductively from qualitative or participatory research,¹⁹³³,37 41 44 45 48 79 or in keeping with global or national policy priorities^{29 47} and Nussbaum’s list.^{38 39 42 43} They have also either been applied or are potentially applicable across multiple geographies. Several frameworks^{24 26} and measures^{1924 33},^{39 44} reflect the living standards, lifestyles, family formations, and the infrastructural and other guarantees characterising HICs that do not resonate in lower-middle-income countries (LMICs) and LICs. Only few frameworks and measures leverage routinely available global and national datasets^{26 38 43 46}—most require data from dedicated surveys or mixed methods research in a few regions that cannot be used for global comparisons. Importantly, none of the available frameworks and measures that leverage global and national datasets are cognisant of both intersectional gender inequality and the life course.

CA-based Frameworks

One of the earliest frameworks—the OECD’s Framework for its Better Life Initiative—with the widest reach across 38 member countries and the largest collection of supporting databases does recognise inequalities in well-being by age, gender, education and economic class (table 1). Even so, it ignores gender inequality in access to services and resources, as well as vulnerability to harmful practices and gender-based violence. Importantly, the framework does not address either intersectional gender inequality or the life course. Moreover, the metrics of this HIC-focused framework require wide-ranging data from national accounts and surveys that make replication in LMICs and LICs difficult.

Two more recent frameworks on adolescent well-being—the GAGE Project framework and the one developed by United Nations H6+Technical Working Group on Adolescent Health and Well-Being are more cognisant of gender, equity and rights, which is evident in their choice of well-being domains (table 1). For example, the GAGE Project framework goes beyond education and learning, physical and reproductive health and nutrition to include domains such as bodily integrity, psychosocial well-being, voice and agency, economic empowerment. Similarly, the UN H6+Technical Working Group’s framework includes domains such as safety and a supportive environment, agency and resilience. The GAGE Project framework, which guides mixed-methods cross-sectional and longitudinal research in two LICs and four LMICs, addresses both gender power relations and intersectionality. However, both frameworks will require substantial modifications to become applicable to the well-being of pre-adolescent girls and post-adolescent women.

The Vulnerability Assessment Framework⁴⁰ in relation to climate change is equally remarkable in its focus on gender inequality and recognition of intersectionality, and similar in its absence of a life course perspective.

Two frameworks that combine the CA with other approaches are interesting but of limited applicability. The Human Well-being Framework⁴¹ that synthesises the CA and Manfred Max-Neef’s Fundamental Needs Approach narrowly focuses on children with learning difficulties and does not recognise either intersectional gender inequality or the life course. And the Capability Sensitive Design framework⁴² that combines Nussbaum’s CA with the methodology of Value Sensitive Design to guide technology design for health and well-being is also much narrower in scope than our requirements.

CA-based Measures

Among multicountry CA-based measures (table 2), the influential Multidimensional Poverty Index leverages globally available datasets and supports comparative assessments across more than 100 countries,⁴⁶ as well as in-country (gendered) applications⁶⁸ and adaptations.^{56 57} Recent work demonstrates how its methodology can be applied to assess the gendered nature of multidimensional poverty.³² Even so, the index is narrower in its scope than our requirement and is not particularly cognisant of the life course.

ICECAP, a group of instruments designed to measure capabilities as part of economic evaluations, has registered users in over 20 countries, mainly HICs and UMICs (table 2). Of these, ICECAP-A for adults and ICECAP-O for older persons are more widely used than ICECAP-CYP for children and young people,³⁶ ICECAP-SCM, a Supportive Care Measure for patients on palliative or supportive care³⁴ and ICECAP-CPM, a Close Person Measure for people providing end-of-life care.³⁵ The selected capabilities, which emanate from qualitative research in England, and the metrics, which do not build on globally available datasets but on dedicated surveys, severely limit the applicability of ICECAP for global comparisons, especially among LMICs and LICs.

Four other measures emanating from HICs and/or requiring special surveys are equally difficult to replicate in LMICs and LICs. Two of these draw from the Oxford Capability instrument, a 64-item questionnaire that operationalises Nussbaum’s list of 10 central human capabilities^{43 80} by leveraging secondary data from British household and panel surveys: OCAP-18, a validated index for assessing public health interventions³⁸ and OxCAP-MH, a validated instrument to measure mental health well-being (table 2). Good life in the Community Scale (GLiCS) that assesses the well-being of migrant women⁴⁴ and the ASCOT³⁷ are the other HIC-focused measures.

Two UMIC-focused indices developed for subnational and national well-being assessments do not meet our requirements either. First, the Multidimensional Well-being Index-Peru,⁴⁷ a weighted measure that incorporates dimensions of well-being in keeping with Peru’s national strategic vision, uses national survey data to determine a level of ‘well-being sufficiency’ and classify households. However, the index does not actively consider gender inequality or the life course. Second, the Young Adult Capability Index,⁴⁸ a locally contextualised measure with limited applicability elsewhere and focused on one specific group—young adults in Bogota—is cognisant of gender inequality but does not address the life course.

Finally, the Women’s Capabilities Index,^{49 79 81} a validated and weighted measure of multidimensional well-being that captures the worldview of reproductive-age women in Malawi, is deeply gendered but focuses only on one life stage and is too country-specific to be applicable to other LMICs and LICs.

Discussion

The scoping review revealed remarkable features of well-established or peer-reviewed frameworks and measures: viz., dimensions of well-being attuned to the implications of gender power relations, and metrics demonstrating how globally available datasets can be leveraged to operationalise the CA. Yet, the WHW Project’s requirements for a conceptualisation of health and well-being that is multidimensional, cognisant of intersectional gender inequality and the life course, with demonstrated or intended measurements across multiple geographies remained unfulfilled. The EGH-WHW Framework is an effort to fill in this gap.

The EGH-WHW Framework is measurable, with indicators representing each dimension of well-being mapped to widely available data sources. It has informed the WHW Project’s metrics to identify exemplar countries and subnational units (provinces/states) that have demonstrated exceptional progress in advancing girls’ and women’s health and well-being over the life course relative to their respective levels of socioeconomic development and those of peer countries in their regions.⁸² We discuss this framework next.

The EGH–WHW Framework

Our framework has three defining features: intersectional gender inequality shaping capabilities and functionings across multiple dimensions that have cumulative health and well-being impacts over the life course (figure 2).

Figure 2. Exemplars in Global Health - Women’s Health and Well-being Framework.

Multiple dimensions of health and well-being

Our framework recognises that girls’ and women’s health and well-being depend on different dimensions of their freedoms ‘to be’ and ‘to do’, and these can vary depending on the country/social context. It, therefore, proposes a set of interconnected and measurable dimensions that include key and universal capabilities, agency and functionings.

These dimensions build on and expand existing approaches to human development to include personal autonomy that is central to the feminist discourse. The Women’s Capabilities Index’s inductively determined list⁷⁹ served as a trigger for identifying more universally applicable gendered dimensions of well-being. In selecting dimensions, we ensured that they were mutually exclusive and distinct from one another, covered different aspects of health and well-being, and were manageable in number for the purposes of data analysis. The chosen set of 10 dimensions falls into three clusters.

The first cluster of dimensions highlights girls’ and women’s health status, work, access to education, nutrition and services. These dimensions directly support living a healthy life and are resources for developing one’s innate skills and capabilities that enhance self-fulfilment and well-being. A second cluster of dimensions, linked to personal autonomy that are particularly critical for girls and women, emphasises their ability to make decisions and choices freely, without the taboos and strictures of gender or other biases and discrimination. They include empowerment and agency, freedom from harmful practices and gender-based violence. The third cluster refers to material conditions and valued states such as freedom from poverty, a healthy environment and collective safety and security. These reflect the fulfilment of key human needs and are critical to living a life of value, free from deprivation and fear.

Developing a measurable framework required us to ground our approach in key available metrics. Therefore, a preliminary set of nearly hundred indicators drawing from the SDG (Sustainable Development Goal) Global Database (https://unstats.un.org/sdgs/dataportal) was used while identifying these dimensions. Our aim was to ground the choice of dimensions on indicators backed, as far as possible, by globally available data of acceptable quality. We used available indicators from this database because these are metrics agreed on by nearly all governments—HICs to LICs. The decision to reach for universally accepted measures seemed a worthy principle to affirm when comparing and ranking countries.

How gender inequality impacts capabilities and functionings

The framework recognises that the personal, social and environmental preconditions for developing individual capabilities are not equal. Across the world, the lives of girls and women are often shaped by disempowering gender relations from birth to death.⁸³ Multiple factors—harmful practices and discriminatory norms; onerous responsibilities for paid and unpaid work; unequal control over wealth/income; social, political, technological and financial exclusion—adversely affect their health and well-being.⁸³,⁸⁵ Girls and women often have relatively little voice or say in decision making and limited freedom to dream or live the life they value. Gender power systems are justified by ideology and held together by fear of—or actual—violence.^{83 85 86} In many societies, the gender system limits girls’ access to physical and social spaces, inculcates taboos from an early age and enforces discipline through threats of and actual violence. Gendered systems of power go beyond the individual to the structure of society itself.⁸⁵ Although these may vary in their specifics across different societies and over time, gender inequality is almost universally present in some form.⁸⁵

The CA can broaden our understanding of the importance of gender inequality as a determinant of health and well-being by bringing in the role of substantive freedoms, individual and collective actions, and intersecting inequalities for women and girls.¹⁵

For instance, capabilities refer to a woman being free to move her home away from a polluted environment. The inputs she needs for those capabilities might include information about the harm that emanates from the environment, social support from her family or neighbours. Agency means acting on her own desire despite restrictions imposed on mobility by gender, poverty or geographical segregations based on ethnicity, caste or race, etc. Such action may involve asserting voice within her household, combining with her neighbours to clean up the pollution, confronting local authorities and power brokers to shut down its source, or moving away. Functioning refers to actually living in a cleaner environment that supports better physical health as well as mental, social and economic well-being, in alignment with her own goals and values. In other words, the CA opens the door to understanding how health and well-being are imbricated with gender and other sources of power and inequality in people’s freedoms to do and be, in their agency, and in their functionings.

Gendered power relations increase girls’ and women’s risks of being poor or malnourished, and reduce their access to education, health services or income-earning opportunities, while typically burdening them with longer hours of unpaid work and less rest or leisure.⁸⁴ Evidence from the GAGE Project indicates that restrictive gender attitudes and norms in Ethiopia and Bangladesh are associated with adverse outcomes in relation to adolescent hunger, anthropometric measurements, as well as self-reported physical and psychological health and self-esteem.⁵¹ Further, adolescent pregnancies in Malawi adversely affect their capabilities with serious psychosocial consequences due to social isolation and stressors such as poverty.⁵²

The impact of intersectional gender inequality on capabilities and functionings

Gender power does not work alone. It intersects other sources of socioeconomic power and inequality such as caste, economic class, ethnicity, ability, etc that are contextually relevant.⁸⁵⁸⁷,⁸⁹ Our capabilities-based framework, therefore, incorporates the idea of intersectionality that arose from feminist activism and scholarship. Intersectionality considers intersecting relations of power with their sustaining ideologies (eg, sexism, racism, casteism, ableism) and social institutions (eg, families, communities, health systems, political and legal systems) as critical drivers of inequality in any region.⁹⁰ These inequalities derive meaning from their economic, political and sociocultural histories. For example, casteism is an important source of social inequality in South Asia, just as racism is in the USA. Our framework identifies intersectionality as being the principal constraint in girls’ and women’s ability to access material and social resources equitably; to leverage resources into capabilities; and to exercise agency to achieve desired functionings.⁹¹

Returning to the earlier example of the woman living in and disproportionately exposed to a polluted environment, our framework would allow an intersectional analysis of her situation, going beyond the economic inequality that narrows her family’s housing choices. It would show how gender inequality may kick in, since responsibilities for both paid employment and unpaid work at home can force women like her to spend more time in that polluted environment with limited opportunities for escape. The analysis would ask, additionally, how discrimination based on her caste, ethnic minority status or differential physical ability may play a role.

In sum, our measurable CA-based framework acknowledges and addresses the challenge of intersectional gender inequality and its implications for risks to health and well-being over the life course. In our in-depth studies of WHW, we will analyse intersecting inequalities in health and well-being outcomes, contingent on data availability.

Cumulative impacts of intersecting inequalities and health needs/risks over the life course

Our framework recognises that the drivers of intersectional gendered well-being vary as women advance over the life course. For example, well-being for a poor migrant in her reproductive years could be determined by whether she had and has the freedom to decide if or when to have children, whether she had or has access to contraceptive services and obstetric care, whether she was/is treated well in public hospitals, whether she received/receives emotional support from her spouse and statutory benefits from her employer. Later in life, it may depend on her financial security, physical ability and freedom to live with dignity.

Intersecting socioeconomic inequalities also leave their imprint on bodies with cumulative effects from birth to death. For girls and women, negative or ‘toxic’ life events may be experienced in ‘critical windows’ or ‘sensitive periods’ (ie, during childhood and adolescence) but also during other phases of life, leading to deficits or risks to health and well-being.^{92 93} The cumulative impact of adverse childhood experiences is well recognised to affect developmental trajectories and human capital across the life course.⁹⁴ For example, childhood exposure to gender-based violence can impact physical growth and also set the individual on a path of increased risk of exposure to violence⁹⁵ or of accepting violence as a means of communicating or resolving conflicts.⁹⁶

Later in life, inaccessible, unnecessary or botched up obstetric care can leave a young woman with lifelong disabilities or morbidities.^{97 98} Such deeply gendered experiences get embodied, indicating that we “incorporate, biologically, the material and social world in which we live, from in utero to death”.⁹⁹ For instance, cumulative health insults, including stressors, can wear out bodily systems, inculcate a sense of hopelessness and resignation among girls and women, and increase their vulnerability to chronic diseases in both LMICs and HICs.¹⁰⁰ Thus, Black women in the USA as well as Afro-descendent women and girls in the Americas experience higher levels of maternal and perinatal mortality as they grow out of their teens,^{101 102} develop non-communicable diseases early¹⁰³ and even age earlier than white women.¹⁰⁴

In sum, our framework recognises phases of the life course beyond early childhood that are important from the perspective of girls’ and women’s health and well-being. Our analysis of the SDG database led us to identify seven phases of the life course (viz., infancy, early and late childhood, adolescence, youth, later adulthood and old age) that will be populated with available data and compared, especially in in-depth country analyses.

Measurement

We recognised from the outset that data availability and measurement to simultaneously tackle 10 different dimensions of health and well-being, intersectional gendered inequalities and a life course analysis would pose significant challenges. We, therefore, took a pragmatic approach of addressing these three aspects of the framework in phases. The WHW selected exemplar countries based on aggregate analyses of their performance over time across dimensions and life course stages.⁸² This will be followed by intersectionality and life course analyses as part of deep dives into the contextual factors and forces driving positive change in selected countries.

Limitations and additional considerations

Our decision to tap into just two databases (Scopus and PubMed) for the scoping review could be seen as a limitation. However, we judged that the two databases together are generous in their coverage of the literature of particular interest for our review.

Further, our focus on well-established and/or validated capabilities-based frameworks and measures may have excluded emerging work of merit in the grey literature and/or in a language other than English. And our requirement for robust applications of the capability approach across multiple geographies could have excluded instructive research conducted in specific communities or locales.

An additional consideration is that the CA, and in particular Sen’s own work, has been critiqued as being overly individualistic and difficult to measure.¹⁰⁵ We believe that the strength of the approach is precisely its ability to combine structural factors with individual freedoms. A significant contribution of our work has been to identify measurable dimensions of women’s health and well-being that include both individual and structural factors.

Another challenge has been to articulate the framework in a way that is globally relevant. Nussbaum’s formulation provides a universally applicable list of essential capabilities that enable individuals to live with dignity. Several of these relate to subjective states and to larger moral principles that are difficult to translate into metrics. We address this problem by backing our theory-driven identification of well-being dimensions with universally accepted metrics and indicators.

Conclusion

The EGH-WHW Framework supports an understanding of individual well-being but also recognises the larger context within which well-being is experienced. As confirmed by our scoping review, this framework distinguishes itself from other CA-based applications by incorporating both an intersectional gender lens and a life course perspective. As such, it explicitly recognises that women’s health and well-being are shaped and challenged by the workings of intersectional gender power relations and also shift over the life course. The paper provides illustrations of how the workings of intersectional inequalities over the life course impact women’s choices and ability to live a life of value.

How gender inequality operates at the individual, household and community levels is reasonably well understood.^{106 107} However, the social norms and practices that undermine a woman’s freedom to achieve health and well-being also work through policies and institutional arrangements that operate at the societal and structural levels.⁸³ This paper advocates for a multilevel multisectoral approach, which addresses systemic barriers that disproportionately affect women.

Improving health and well-being and promoting gender equality as a human right have been recognised as priorities for development policy at the highest international level through the SDGs. Amid escalating global resistance to women’s health and human rights, the EGH-WHW Framework has the potential to guide policies and programmes to effectively address inequalities in health and well-being, and promote human rights and social justice.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.