A strong—truly, fierce—proponent of national and global health equity, Jennifer Prah Ruger, the Amartya Sen Professor of Health Equity, Economics, and Policy in the School of Social Policy & Practice and Professor of Medical Ethics and Health Policy in the Perelman School of Medicine, has authored two books on the subject since 2009 in an effort to push forward conversations around improving health among everyone.
Beyond authorship, she is the director of Penn’s Health Equity and Policy Lab (HEPL), a globally minded research organization that uses a mixed-methods approach to study the effectiveness of policy in reducing health inequalities. According to HEPL, health equity is an individual’s or group’s freedom to achieve their or its health potential.
And Prah Ruger’s work certainly has that goal in mind.
Here, Prah Ruger explains the framework of her book, “Global Health Justice and Governance,” which identifies problems around the globe in achieving health equity while outlining recommendations for how all countries, including developed countries like the United States can own a responsibility to level the playing field in health standards within countries around the world. (See additional video, titled Global Health Justice and Governance.)
How did this book begin for you? What inspired it and how did it evolve from your past book, ‘Health and Social Justice,’ about a similar subject?
The last book advanced a theory of justice and health at the domestic level—at the country level within the nation. We advanced the health capability paradigm [HCP], which sets forth a series of principles for different societies in terms of achieving equity in health as efficiently as possible.
The HCP, that’s mentioned in your current book. Can you explain that and tease it out a bit?
The HCP is at the national level and is a paradigm of health and social justice that puts forth principles of justice and health. Succinctly, it starts with an orientation that rather than having the market, our free market, allocate resources on health and health care and decide what people should achieve, and what kind of distribution of health and health care we ought to have, that we should ground our thinking about that in the idea of human flourishing.
Human flourishing is an ancient idea, and the thought is that what we aim for when we collectively collaborate as a society is to create the conditions for people to flourish. And when we say flourishing, we mean for people to have capabilities. For people to be able to do what they want to do and be who they want to be. This is a positive notion of freedom and has deep roots in human history and across cultures. For the United States, this notion is consistent with the American dream.
That requires, certainly, the private sector. And our framework is supportive of the private sector and the free market in allocating resources and making decisions in different areas of our lives such as chairs, tables, computers, phones, bags, suitcases, and things of this nature. But when we think about health, health has a special status. It has a special moral status among humans, and why is this? It’s because health and health care are different from other topics in economics, they do not fit with the competitive model of supply and demand.
Rather, health is intrinsic to flourishing; health and health care are to be allocated based on the criteria of health functioning and agency and medical necessity and appropriateness. The free market allocates goods and services based on preferences or desires, what we are willing to pay, not functioning, agency, or need, and it is for this reason and several other market failures that health and health care require governance to shape health, health care, and health insurance markets.
The health capability paradigm integrates economics and ethics to develop fundamental principles for health, health care, and society, grounded in the dignity of all humans and respect for individuals’ agency. What we owe each other in society is the conditions for people to be healthy and to do so as efficiently as possible, because resources have opportunity costs. We need good health for ourselves, we need good health for our family members, and we need good health for our fellow citizens. This is because the individual’s capability for well-being is linked to the effective functioning of society; individual well-being requires an organized society that promotes the common good. At the same time, we need to allocate resources prudently to achieve health equity and other essential capabilities for all.
So, the HCP sets forth principles of justice and health, and what does [health equity] look like? Health equity is not equal health for everybody; it’s equal opportunity to be healthy. Health equity isn’t using all of society’s resources toward the health sector, health care—it’s applying principles of efficiency, cost analysis, and cost-effectiveness analysis, and HEPL has developed methods and conducted analyses of these topics in our work. The HCP develops the interface among economics, ethics, and governance in health.
What inspired the new book?
The current book is ‘Global Health Justice and Governance,’ and what inspired this project was a need to identify and explain fundamental problems in global health and develop a theory of justice and global health to address them.
This is very challenging, because at the domestic level, we have reasons to believe that we have obligations toward each other when we live within a single country, for example in the U.S., or people who live in other countries toward their respective country members. But the task was to develop principles of justice related to global health, health throughout the world, as compared to principles of justice and health within a particular community. Which is, ‘What are the principles of global justice?’ Do such principles exist at all? In our approach, again, human flourishing is our foundational idea because it is inherent in all humans regardless of where one lives worldwide. Here, our objective as a global society is to create the conditions for all individuals to be healthy and flourish worldwide; no matter where one lives. We do this through global policies and a global health architecture, global health system, and national and domestic health policy and systems.
These principles of justice and global health entail all individuals on the planet having an equal opportunity to be healthy, that as a global society we owe each other conditions for our health. What that equal opportunity looks like required us to identify a reference group or goal post worldwide; we did this by examining what societies have been able to achieve over time. HEPL has developed methods for measuring and analyzing global health equity by the reference group as well as the shortfall from it, reducing premature mortality to the level of the highest achieving countries. HEPL’s theoretical framework and empirical approach, employing K-means clustering and shortfall analyses, reveals a different picture from traditional aggregate and inequality measures such as average health indicators, group stratifications, the Gini coefficient or Lorenz curve. By identifying clusters of countries and a reference group, our empirical analyses demonstrate that there are different countries that have been able to achieve lower levels of mortality for men, women, and children, and this is a goal post we should set for individuals and groups. Yet we have many countries and societies within countries that do not experience such possibilities. Even in the U.S., we have large shortfalls in life expectancy and mortality. Within our global health justice framework, all people are governed by the principles of justice, including Americans, who experience low levels on several health metrics among high-income countries.
In the book you mention Liberia, and use the example of its experience with Ebola and how that was all it took to significantly set them back [developmentally]. I wonder if you think that volatility is largely unrecognized in the public sphere?
Yes, there are arguments from an economic development perspective to invest in health. It’s good for the economy. It’s good for economic growth. Those are good arguments, health and economic growth are bidirectionally linked and HEPL has done research on these connections.
However, the book argues that health is intrinsic to human flourishing and there is a morally central claim that all individuals have, by virtue of their humanity, that we should support individuals’ opportunity to be healthy. That means at the global level we should be investing in a global health governance system that works for all countries, groups, and individuals, and we should be setting up global health institutions that can help effectuate that. That’s why the book advances the Global Health Constitution [GHC] and the Global Institute of Health and Medicine [GIHM]. The GIHM is a scientific institution that creates the global master plan and global evidence base undergirding it, which independently and objectively analyzes various problems in global health. The GIHM would have the mission of developing the scientific base for solving these problems. The GHC delineates principles of justice and global health, undergirding the fundamental rules of the game. This is needed, the book argues, because it is the current governance structures or lack thereof that have advanced the interests of wealthy, powerful, and connected individuals, countries, and institutions, at the expense of the health and well-being of millions of human beings worldwide. Development assistance for health increased, but global health governance weakened or became non-existent, over the past few decades. New rules in the book make clear that if organizations are going to enter the global health space and architecture, they ought to focus their investments toward improving global health equity and opposing investments that undermine it.
In the global health space, the World Health Organization [WHO], the primary UN agency focused on health, now has a significant percentage of its funding from external donors, rather than from pooled contributions from member countries. The book argues that donors have a responsibility to target their investments toward global health equity as delineated through impartial, independent, and scientific institutions such as the GHC and GIHM. Rather than focus on their narrow self and national interests, donors and actors have a responsibility to act in the best interest of individuals, to act on behalf of individuals’ health and flourishing. Global health actors and institutions owe duties of good faith and trust in all their actions and inactions. That’s not happening right now and that’s a problem. The book identifies what those principles and responsibilities are.
What is the critique of the WHO and global organizations? How can they do better?
First of all, we need an overarching framework that focuses on justice and governance and treats the individual as a unit of analysis. This is because, as noted previously, health is a special good, having special moral status among humans. Our global health system is still heavily influenced by the UN system, with WHO at its center, comprised of organizations with states as their main members, and states’ interests as their main focus. This was previously called international health governance and many successes were achieved with this system; smallpox eradication is one example. Today, other actors and institutions are part of the system with their own sets of interests and priorities.
Going forward, in order to reach people within countries where vast disparities in health exist, we need to focus on the responsibilities of all actors and institutions towards individuals’ health and flourishing, with a particular focus on groups and countries and communities within countries who are the most vulnerable and deprived. The book argues for a fundamentally different approach, moving away from charity, humanitarianism, and donor-driven development in global health as insufficient bases for global health equity. Why? Because a charity or humanitarian or donor-driven approach does not ethically bind such entities to act in the best interest of individuals’ health and flourishing. Rather, charity, humanitarianism and donor-driven development is subject to the whim and variable preferences of donors, failing to empower recipient populations’ agency. The principles of justice and global health delineated in the GHC and the scientific evidence base of policies and programs that work through the GIHM create new rules of the game that make fulfilling duties of good faith and trust the choice for the global health community. Achieving global health equity is possible based on what already works. This is because what is possible in one part of the world or in one part of a single country is possible everywhere.
Domestically, thinking about the problems we have here, do you feel like the conversation is in the right direction? Politically, centered around Medicare for All versus private insurance and whether to keep [a private system]—are we having the right conversation?
First, I believe that we are seeing an opening up of possible policy choices because we are having a public conversation in the United States. This is a good start. Second, virtually every family is impacted by the status quo, either by a lack of access to quality health care or to conditions for good health or by the financial implications of health care.
Third, nearly $3 trillion is being spent on the U.S. health care industry, yet the U.S. compares poorly among high-income countries on several health indicators. Neither the overall health status nor the distribution of health across the U.S. compares favorably to other countries spending considerably less on health care. Moreover, we’re all impacted as the price of health care is starting to crowd out expenditures on other goods and services we have reason to want to invest in as part of our public policy. The crisis of American health care is affecting us all and we’re all in this together. We coproduce the conditions for health individually and at the household level, but also through our public investments and redistribution of resources.
While the public conversation we are having is a good start, I believe we need to dig deeper and have an even more robust conversation about the values that underlie our health system and policy. I believe a health policy and system grounded in human flourishing and health equity is actually a better fit with American values than our current approach. This is because the HCP is rooted in a positive notion of freedom. This constitutes real equality of opportunity; enabling all individuals to reach their health potential gives all Americans and America as a whole the opportunity to be the best it can be, reaching its potential for the benefit of everyone.
