Rethinking Equal Access: Agency, Quality, and Norms

Global Public Health, Vol. 2, No. 1, pp. 78-96, 2007

19 Pages Posted: 18 Jan 2007

See all articles by Jennifer Prah Ruger

Jennifer Prah Ruger

University of Pennsylvania - School of Social Policy & Practice; University of Pennsylvania - Perelman School of Medicine


In 2005 the Global Health Council convened healthcare providers, community organizers, policymakers and researchers at Health Systems: Putting Pieces Together to discuss health from a systems perspective. Its report and others have established healthcare access and quality as two of the most important issues in health policy today. Still, there is little agreement about what equal access and quality mean for health system development. At the philosophical level, few have sought to understand why differences in healthcare quality are morally so troubling. While there has been considerable work in medical ethics on equal access, these efforts have neglected health agency (individuals' ability to work toward health goals they value) and health norms, both of which influence individuals' ability to be healthy. This paper argues for rethinking equal access in terms of an alternative ethical aim: to ensure the social conditions in which all individuals have the capability to be healthy. This perspective requires that we examine injustices not just by the level of healthcare resources, but by the: (1) quality of those resources and their capacity to enable effective health functioning; (2) extent to which society supports health agency so that individuals can convert healthcare resources into health functioning; and (3) nature of health norms, which affect individuals' efforts to achieve functioning.

Keywords: Healthcare quality, capability approach, equal access, health agency, health norms, Amartya Sen, Medical ethics

JEL Classification: H51, H53, I10, I18, I31

Suggested Citation

Prah Ruger, Jennifer, Rethinking Equal Access: Agency, Quality, and Norms. Available at SSRN:

Jennifer Prah Ruger (Contact Author)

University of Pennsylvania - School of Social Policy & Practice ( email )

3701 Locust Walk
Philadelphia, PA 19104-6214
United States

University of Pennsylvania - Perelman School of Medicine

423 Guardian Drive
Philadelphia, PA 19104
United States

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