This article considers the increasing challenge of the fair allocation of scarce public health care resources by focusing on services for women and girls. It considers different ways of thinking about fairness in health care reform, the role of courts in promoting fairness, and the use of affirmative action measures to remedy health disparities. The health of individuals and populations is shown to be affected by clinical services, the organization and functioning of health systems, and underlying socio-economic determinants. Different theories of justice are addressed that affect assessments of fairness, considering availability, accessibility, acceptability of and accountability for services. The transition in judicial dispositions is traced, from deference to governmental resource allocation decisions to evidence-based scrutiny of governmental observance of constitutional and human rights legal obligations. The appropriate use of affirmative action measures to improve equality in health status is explored, given the increasingly unacceptable disparities in health among subgroups of women within countries.