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Toward Establishing a Universal Basic Health Norm

  • Arnab K. Acharya

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.

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1 World mortality figures by countries, region, and the associated national income closely correspond to measures of disabilities. See Murray, Christopher J. L. and Lopez, Alan D., eds., The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 (Cambridge: Harvard University Press, 1996).

2 This term is borrowed from Pogge, Thomas, “Can the Capability Approach Be Justified?” in Nussbaum, Martha and Flanders, Chad, eds., “Global Inequalities,” Philosophical Topics 30, no. 2 (2002), pp. 167228.

3 Yach, Derek, “Health for All in the Twenty-First Century: A Global Perspective,” National Medical Journal of India 10 (1997), pp. 8289; available at

4 Evans, Timothy et al., eds., Challenging Inequities in Health: From Ethics to Action (New York,: Oxford University Press, 2001), p. xiii. Most methods for measuring inequality emphasize giving higher weight to the least well-off; some ignore the closeness of the difference altogether and focus only on the relative position of well-being. Technically, inequality measures from two different regions are comparable in welfare terms only if the average well-being is the same; in practice this is often ignored. See Sudhir Anand and S. Nanthikesan, “A Compilation of Length-of-Life Distribution Measures for Complete Life Tables,”Harvard Center for Population and Development Studies Working Papers 10, no. 7 (2000); and Wagstaff, Adam, “Inequality Aversion, Health Inequalities, and Health Achievement,” Journal of Health Economics 21, no. 4 (July 2002), pp. 627–41.

5 Gwatkin, Davidson R., “Assessing Inequalities in Maternal Mortality,” Lancet 363, no. 9402 (January 3, 2004), pp. 2327.

6 Why the rate for the highest level of income should be considered the ideal, and not some higher level of maternal health for all, is left unexplained.

7 For a focus on health inequality, seeWHO, World Health Report 2000 (Geneva: WHO, 2000); and Timothy Evans et al., eds., Challenging Inequities in Health. For measurements, see, e.g., Gakdiou, Emmanuela, Murray, Christopher J. L., and Frenk, Julio, “Defining and Measuring Health Inequality: An Approach Based on the Distribution of Health Expectancy,” Bulletin of the World Health Organization 78, no. 1 (2000), pp. 4254; and Wagstaff, Adam, Paci, P., and VanDoorslaer, E., “On the Measurement of Inequalities in Health,” Social Science and Medicine 33, no. 5 (1991), pp. 545–77.

8 Horizontal equity refers to treatment of like conditions in a like manner. It is not clear what relevant factors make up the like conditions.

9 It has been argued that agents are responsible for rectifying serious deprivations when and to the extent that they have contributed to bringing about these deprivations. I will not argue here against this “contribution” principle for allocating responsibility. For a discussion of this principle and its practical implications, see Barry, Christian, “Applying the Contribution Principle,” Metaphi-Iosophy 36, no. 1 (2005), forthcoming. It must be pointed out, however, that in a poor region it could be that agents who suffer from deprivation may have brought about, even if unwittingly, each other's deprivations. Assigning responsibility according to this principle brings about no change unless, as in many cases, such culpabilities also lie with well-off people, some of whom may live outside the region. If we nevertheless find these deprivations to be morally unacceptable, a view that assigns obligations of distributive justice to rectify outcomes irrespective of how these outcomes came about would be better able to assign responsibilities that can bring about significant reductions in incidences of these deprivations. Such responsibilities would extend beyond borders. I cannot defend the claim that such responsibilities exist here, but I shall provide a plausible account of responsibilities regarding international health where health budgets are limited and where any reduction in the health of those who are well-off induces significant reduction in well-being.

10 Bank, World, World Development Report 1993 (New York,: Oxford University Press, 1993).

11 Londono, Juan Luis and Frenk, Julio, “Structured Pluralism: Towards an Innovative Model for Health System Reform in Latin America,” in Lloyd-Sherlock, Peter, ed., Healthcare Reform and Poverty in Latin America (London,: Institute of Latin American Studies, 2000).

12 Dreze, Jean and Sen, Amartya K., eds., Indian Development: Selected Regional Perspectives (Delhi,: Oxford University Press, 1997).

13 Thankappan, K. R. and Valiathan, M. S., “Health at Low Cost—The Kerala Model,” Lancet 351, no. 2 (1998), pp. 1274 – 75.

14 Bank, World, World Development Report 2004 (Washington,, D.C.: World Bank, 2004), Indicator Table 3, CD-ROM.

15 I am sidestepping the debate regarding the correlation between income and health. I believe there is no convincing argument to dispute that in many parts of the world the poor are the most ill and that the gradients in improved health status and income move in the same direction.

16 Scanlon, Thomas M., “The Diversity of Objections to Inequality,” Lindley Lecture . Department of Philosophy, University of Kansas, 1996.

17 Nagel, Thomas, Mortal Questions (Cambridge,: Cambridge University Press, 1979); and Parfit, Derek, “Equality or Priority?” Lindley Lecture, Department of Philosophy, University of Kansas, 1991.

18 Nagel, , Mortal Questions , p. 123.

19 The magnitudes of losses are understood here not in terms of years but in terms of their intuitive moral importance. A decrease in life expectancy of fifteen years for society A may be less of a loss than a decrease of life expectancy of ten years for society B if society A is a great deal better off than society B is at present.

20 Parfit, “Equality or Priority?”

21 It also differs from the difference principle as elaborated by John Rawls by noting that not just any least-well-off person qualifies for assistance; the least well-off has to be in bad condition in order to be helped.

22 Kamm, Francis, “Deciding Whom to Help: Resource Prioritization, Population Health Measures, and Disability,” in Peter, Fabienne, Anand, Sudhir, and Sen, Amartya, eds., Public Health, Ethics, and Equity (Oxford,: Oxford University Press, 2004).

23 Nagel, , Mortal Questions , p. 125.

24 Nussbaum, Martha C., Women and Human Development: The Capabilities Approach (New York,: Cambridge University Press, 2000), p. 139. See also Elster, Jon, “Sour Grapes: Utilitarianism and the Genesis of Wants,” in Sen, Amartya and Williams, Bernard, eds., Utilitarianism and Beyond (Cambridge: Cambridge University Press, 1982); and Sen, Amartya, “Positional Objectivity,” Philosophy & Public Affairs 22, no. 2 (1993), pp. 126–45.

25 Doyal, Len and Gough, Ian, A Theory of Human Need (Basingstoke,: Macmillan Press, 1991), p. 73.

26 Brock, Daniel, “Quality of Life Measures in Health Care and Medical Ethics,” in Nussbaum, Martha C. and Sen, Amartya, eds., The Quality of Life (Oxford,: Clarendon Press, 1993). This view is also expressed in Sen, Amartya, The Standard of Living (Cambridge: Cambridge University Press, 1987).

27 Goals in life cannot require a large amount of resources relative to societal constraints on resources; similarly, good health cannot be defined as being fit to climb Mount Everest. See Rawls, John, “Social Unity and Primary Goods,” in Sen, and Williams, , eds., Utilitarianism and Beyond, pp. 159–86.

28 Daniels, Norman, “Health-care Needs and Distributive Justice,” Philosophy & Public Affairs 10, no. 2 (1981), pp. 146 – 79.

29 Ibid., p. 185.

30 Food and Agriculture Organization of the United Nations, “ Mapping Undernutrition ” ( Rome,: FAO, 2000).

31 See Murray and Lopez, eds., The Global Burden of Disease-, table 6.2 (p. 311), table 6.3 (p. 312).

32 Young, Helen, “Nutrition and Intervention Strategies,” in Devereux, Stephen and Maxwell, Simon, eds., Food Security in Sub-Saharan Africa (London,: ITDG Publishing, 2001).

33 Sen, “Positional Objectivity.”

34 Some poverty lines are set in terms of cutoff points in a distribution; we suggest a poverty line to mean being able to afford a bundle of goods, as elaborated by Molly Orshansky; see Harrington, Linda, “Estimating Earnings Poverty in 1939: A Comparison of Orshansky-Method and Price-Indexed Definitions of Poverty,” Review of Economics and Statistics 79, no. 3 (August 1997), pp. 406–14.

35 Nussbaum, Martha, in “The Costs of Tragedy: Some Moral Limits of Cost-Benefit Analysis,” Journal of Legal Studies 29, no. 2 (June 2000), pp. 1005 – 36, points out that a superior outcome in terms of cost-benefit analysis may still impose a terrible outcome, and this should be considered a tragedy.

36 Sen, Amartya, “Poor Relatively Speaking,” in Resources, Values and Development (Cambridge,: Harvard University Press, 1984), p. 342.

37 To take another example, in 1986 the child mortality rate in Bangladesh stood at 173 per 1,000 among the poorest group, while for the richest group it stood at 98. Abbas Bhuyia, ICDDRB, Bangladesh, quoted in Adam Wagstaff, “Inequalities in Health in Developing Countries: Swimming against the Tide?” World Bank, Working Paper no. 2795, March 5, 2002; available at Compare the last number for the similar figure in the industrial countries: an estimate of 14 or 9. While it is possible to argue that statistics for Bangladesh are informative for policy purposes, when compared to the industrial countries these inequality figures induce no moral imperative.

38 Hospitalization among the poor is rare and most of the middle class reported receiving significantly costly and sometimes insufficient care. Reported in Mahal, Ajay, Singh, Janmejaya, Afridi, Farzana, Lamba, Vikram, Gumber, Anil, and Selvaraju, V., “Who Benefits from Public Health Spending in India?” NCAER Special Report (New Delhi: NCAER, 2000).

39 The high prevalence of theses chronic illnesses is well documented for developing countries; see Murray and Lopez, eds., The Global Burden of Disease. The account of availability of care can be found in Narayan, Deepa, Voices of the Poor (New York: Oxford University Press, 2000); see also Thankappan and Valiathan, “Health at Low Cost,” and personal accounts given to the author in India in his fieldwork and in Tanzania accounts given by government and NGO officials.

40 See WHO, World Health Report 2000.1 have argued the scope for redistribution within developing countries is limited, although there are many dramatic cases of insensitive behavior of the extreme rich in such countries. I note that the scope for achieving a desirable distribution of well-being exists through greater emphasis on inter country redistribution rather than through intra country redistribution.

* 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.

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