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• If there is no theory behind the ICF, don’t we need
to develop theories, in particular on the interaction
of the ICF domains (e.g. interaction between parti-
cipation and environmental factors)?
• The ICF is not normative; however, some problems
still exist. One problem is that, with the use of the
ICF from the background of human rights, a highly
normative aspect comes in. And, secondly, how to
solve the problem of the absence of the classification
of the personal factors? They have not been classified
because this would have questioned the neutrality
of the classifications on the background of societal
norms. As personal factors do exist, a debate on
the dilemma of societal norms and personal factors
needs to be held.
According to Gutenbrunner it seems that a lot of work
is still needed on the theoretical foundation of the
ICF (or, at least, of its understanding and use). The
model or theory of “social productivity” (3) has been
described as being able to explain important factors of
the interaction of an individual with society. Here too,
some questions remain unanswered:
• The theory of social productivity has been (mainly)
developed and proven in industrialized countries.
The questions arise as to whether it is universal and
applicable to other societies, and what are the cultural
factors influencing productivity and its perception.
• It must be acknowledged that different theories
concerning social integration and well-being exist.
Is there an approach to integrate different theories?
• The model of social productivity uses a number of
assumptions, e.g. using terms such as well-being,
including relevant factors of influence and an action-
reaction model. How much clarity (and consensus)
do we have with regard to these assumptions?
In summary, to Gutenbrunner the theory of social pro-
ductivity is an important approach to better understand
“functioning as an interaction of persons with health
conditions and the environment”. However, many
questions remain unanswered and need both a theoreti-
cal approach and a proof of concept by collecting data.
Antti Malmivaara commented from a health econo-
mics point of view using 2 perspectives: the healthcare
perspective and the social perspective. The healthcare
perspective focuses on advancement of health among
individuals and within populations, and on resource
use and respective costs within the healthcare system.
The societal perspective also includes indirect costs:
the most important arising from sick leave and disa-
bility pensions. The healthcare perspective concords
with the perspective of an individual as a recipient of
healthcare. For an individual, perceived well-being
is of great importance, and as well as the functioning
www.medicaljournals.se/jrm
and participation operationalized by the ICF. In the
healthcare perspective cost-effectiveness and cost-
utility analyses are restricted to the benefits and costs
within the healthcare system. However, the ability to
work, whether paid or voluntary, may be an important
part of well-being and functioning. In the societal per-
spective, all benefits and costs due to the healthcare
system are included, but, in addition, also the changes
in productivity due to sickness. Also, voluntary work
may have incremental monetary value to society, and
should be considered in the societal perspective. Mal-
mivaara concluded that the EARM Academic Debate
provided points, which may also be utilized in health
economic thinking.
The open plenary discussion was started by Henk
Stam, who questioned the effect of productive activity,
such as work in a cultural context across different
regions in the world. Mauro Zampolini added that
the underlying mechanism to well-being induced by
productivity is mostly the reward, which, in fact, can
also be caused by other satisfying activities. Anne
Chamberlain stressed that there are huge individual
variations in how “the reward” is obtained, for example
in artists who may have to wait years before they are
successful (and rewarded). Finally, Diane Playford
referred to “caring” as a specific activity, citing the 20th
century philosopher Milton Mayeroff (6). Thus, caring
too could be considered as a “rewarding” activity that
could be linked to well-being.
In summary, there was no conclusion on whether
theory-based approaches may use or relate to the ICF
at this point. Whereas the ICF was meant to be theory
neutral, implementing it for data collection remains
a difficult task. The ICF, as a framework, could be
a basis for theory development. Siegrist argued with
findings from empirical research, that a theory of social
productivity can explain links between participation
and well-being. However, during the debate with the
academy members a consensus could not be obtained.
Quality of life remains difficult to measure and there
may be theories that could assist in gaining insights.
More reflection and research seem necessary to further
develop and study these concepts.
After the debate, an additional comment was written
by Stefano Negrini, who agreed that the ICF cannot be
normative or, at least, should try not to be. To Negrini,
preserving the ICF as such would anyhow be a mistake:
instead we must make it evolve. Classifications are like
languages, since they allow all of us to use the same
terms to describe the same health condition.
According to Negrini, participation topics are at the
stage probably the least well represented in the ICF,
and refinement in that area should probably be higher
than in others. In relation to the debate, the problem