Vast improvements in human health have been made during the past century. Indeed, gains in increased life expectancy and reduced physical impediments for much of the population were greater than in any previous century. Yet the gains were not uniform across the world or even within individual countries. The variations in health status among people cannot for the most part be explained through genetic differences. Instead, in most instances the variations in the last century and at the turn of the current century correspond to the variations in the distribution of control over material resources.
A cursory overview of the worldwide distribution of health status confirms that there are many who experience a low level of health. Restricting the discussion to mortality as an indicator of health, (1) we find that the distribution of life expectancy can be described in the following way: It is higher than seventy-two years for nearly a to 2 billion people living mostly in wealthy industrial countries, newly rich countries of East Asia, and the upper income class of middle-income, emerging-market, and the rapidly growing developing countries. Nearly 3 to 4 billion people, consisting of the vast majority of people living in middle-income countries, including those of emerging-market economies and the middle class of rapidly growing developing countries, can expect to live sixty to sixty-five years. Life expectancy is below sixty years for nearly 1 billion to 1.5 billion people living mostly in South Asia and Sub-Saharan Africa. Large groups of people can live beyond the age of seventy-two, but most people currently can improve their health significantly, especially those who expect to live for less than sixty years and those who can expect to live to between sixty and sixty-five years.
Given these facts, what norms should guide us in examining potential changes in policies and institutional arrangements that affect health status? One approach that figures prominently in recent policy discussions is what might be called an equality-demanding norm. (2) This norm stipulates that we
* This article has been significantly improved due to comments by Christian Barry, Peter Davis, Stephen Devereux, Madelyn Hicks, Peter Houtzager, Paul Howe, Connie Rosati, the anonymous referees for this journal, and the participants of the workshop "Public Health and International Justice," Carnegie Council on Ethics and International Affairs, New York, April 2002. I would also like to thank Ezinda Franklin and Arthur Smith for significant editorial assistance. None but the author is responsible for any errors in this paper. should strive to make health outcomes or access to health care more equal. A World Health Organization (WHO) official emphasizing the intercountry differences cited above writes: "It is particularly important to assess whether inequalities in health outcomes are increasing or decreasing over time and to make comparisons between countries." (3) Similarly, an influential publication on health equity that stresses inter- and intra-country inequalities states that it was "motivated by a common concern about unacceptable differentials in health." (4) In a recent commentary in the Lancet, Davidson Gwatkin emphasizes the importance of differences in maternal mortality rates within, as well as between, countries and regions. (5) Focusing on Indonesia, Gwatkin argues that the goal of health policy should be to bring the mortality rate of all lower-income quintiles to the present level of the highest-income quintile. (6)
I argue that the locus of debate in public health and international justice should move away from discussions that stress the importance of achieving some form of equality in health status. (7) Given the available resources, I deny that there is a moral imperative to pursue equality of health status or access to care. Under current resource constraints, a just international public health policy is not best served through demanding equality in health status or horizontal equity in access to health care across the world, and particularly within developing countries. (8) Resource constraints--the domestic budget together with foreign aid--are always severe in developing countries. If institutional mechanisms are arranged under these constraints in order to ensure commonly accepted egalitarian goals, such as horizontal equity, then the likely outcome would be to decrease the health status of many who do not currently enjoy particularly high levels of health. I believe this to be enough of a reason, for now, to abandon an equality-demanding norm regarding health status at the global level. An alternative to an equality-demanding norm is the prioritarian norm, which demands that the least well-off be served first. Although this view may avoid in practice some of the negative implications of the egalitarian view, I argue that it too is untenable given the resource constraints we currently face. We should instead develop a threshold norm that characterizes minimally adequate health status. People enjoy minimally adequate health status when they are capable of fully participating in carrying out their own life plans within a fairly lengthy time horizon. It is this norm, and not equality of health status or even granting priority to the least healthy, that should guide international health resource allocation. (9) I shall claim that an institutional order is just with respect to health to the extent that participants in this order do not (avoidably) fail to reach this threshold.
Two policy conclusions follow when one tries to meet the threshold norm while faced with current resource constraints: First, the scope for redistribution is limited within developing countries, since it will adversely affect the health of those who would be considered to be enjoying health just above the threshold level. Second, the potential for relaxing the resource constraints lies in our abilities to redirect resources from developed countries, perhaps even through reduction in domestic health expenditure in these countries.
THE GLOBAL DISTRIBUTION OF HEALTH STATUS
It might be suggested that there is a low-cost solution that would bring everyone to a high level of health and that only commitment is lacking. If such a solution existed, nearly everyone would agree to bring about a scenario where equality at a high level of health prevails. Since the cost is low, developing countries themselves would undertake this policy easily without facing a significant fiscal burden, hence without having to experience the slowdown of progress in literacy rates, buildup of infrastructure, and growth of job opportunities. Unfortunately, no such solution has yet been identified.
It is generally recognized that there are low-cost health interventions that can improve life expectancy considerably, as well as evidence that low-cost dietary supplements would remedy stunting and other physical incapacities. The landmark World Development Report 1993 on health policy prepared by the World Bank reported that significant health gains can be made by making available $21 annually (in 1992 U.S. dollars) per capita public expenditure on preventing and treating infectious disease. For many of the lower-income countries, $21 was approximately 7 percent of the GDP per capita in 1992, just about the average percentage of income spent in Europe for health. (10) Very few developing countries have undertaken this level of public expenditure; but even if they were to spend this much, the World Bank report indicated that the level of care would not extend beyond the treatment and prevention of infectious diseases.
Although the middle classes in many developing countries have made considerable health gains, they also face chronic noncommunicable illnesses at the onset of middle age, such as heart diseases, various forms of cancer, and diabetes, that require better medical infrastructure and greater access to well-trained physicians. None of this was budgeted within the 7 percent of GDP health budget recommendation, which cautioned against investment in tertiary care that usually delivers care for noncommunicable illnesses. The simultaneous high prevalence of chronic noncommunicable and communicable illnesses--a situation known as epidemiological transition--is common in many Asian and Latin American countries. (11) Thus, where significant improvement has been made for some people, further overall improvement is only possible through attending to high-price care while continuing to offer low-cost care. Given the fiscal constraints most developing countries face, the public expenditure of 7 percent recommended by international agencies on easy-to-treat illnesses would entail a reduction in free tertiary care services supplemented by some private expenditure on which the middle classes critically depend.
Much has been achieved in Kerala, India, and Cuba at low cost. (12) However, in recent years it has been noted that many of the poor and the near poor do not receive adequate care for noncommunicable illnesses in Kerala, as much of the care is only privately available. The government has initiated many well-placed programs for communicable diseases with higher public expenditure than the all-India level, but such illnesses as cardiovascular problems and diabetes among the working-age population often go untreated and remain a major cause of impoverishment in Kerala. (13) Bringing the public expenditure at the all-India level to the Kerala per capita level would still leave many Indians without adequate care for most noncommunicable illnesses. It may even in the process deny some free tertiary care to the poor and near poor.
There is, thus, a practical restriction on increasing health expenditure and on what can be achieved at currently allocated levels of expenditure through this increase. Even if the budget is increased to a higher amount without imposing too much of a...