Can health justice be measured? A normative reconstruction of health equity indicators

Health systems commonly evaluate justice using quantitative health equity indicators such as healthcare coverage, financial protection, population health outcomes, and measures of the social determinants of health. These indicators are often treated as competing operationalisations of a single moral standard. This article argues that this assumption is conceptually mistaken because different indicators evaluate different normative objects rather than alternative dimensions of the same conception of justice.

Using a comparative normative methodology, the article analyses six theories of justice that have significantly shaped contemporary debates in biomedical ethics and health policy. Through the principles of justificatory attribution and the Focal Attribution Procedure, families of health equity indicators are systematically attributed to the normative domains that provide their primary moral justification.

The analysis suggests that widely used health equity indicators do not approximate a single moral construct. Instead, they identify distinct evaluative objects corresponding to different conceptions of justice, including aggregate health welfare, fair opportunity, responsibility-sensitive disadvantage, collective health goods, human functioning, and structural disadvantage. Persistent disagreement over health equity indicators therefore reflects normative pluralism rather than empirical or methodological inadequacy. Building on this analysis, the article proposes a Layered Evaluation Model that preserves the conceptual distinction between normative domains while providing a coherent framework for interpreting health equity indicators.

Because the normative domains of health justice are conceptually distinct, representing health justice through a single composite index risks obscuring the evaluative objects that different theories seek to protect unless the weights used to construct that index are made explicit and normatively defended. Health equity measurement should therefore be understood as a process of explicit normative interpretation rather than technical aggregation. By systematically relating empirical indicators to their primary justificatory foundations, the proposed framework offers a more conceptually coherent, philosophically grounded, and policy-relevant approach to the evaluation of health justice.