The triadic capability nexus: why justice requires more than free access to healthcare

Free access to healthcare, defined as the provision of clinically indicated healthcare services without direct financial charges at the point of use, is widely defended as a cornerstone of social justice, grounded in commitments to equality and the right to health. Yet in practice, free access is often provided under conditions that generate ethical costs for those who deliver care and for the institutions that sustain it. Existing evaluations of free access to healthcare, including those informed by the capability approach, tend to prioritise patient access and outcomes, leaving provider- and institution-related costs under-theorised. This paper argues that these costs reflect a deeper limitation in prevailing conceptions of healthcare justice. We propose an expanded evaluative framework, the triadic capability nexus, which treats patients, healthcare providers, and institutions as interdependent capability domains linked by shared conversion conditions. From this perspective, free access is ethically defensible and just only when the triadic conversion conditions necessary to sustain capabilities across these domains are jointly preserved, rather than secured through systematic capability depletion in any one of them. Focusing on providers as the most visible bearers of capability loss, we show how chronic overload, moral injury, time scarcity, and exposure to hostility constitute justice-relevant capability deprivations, and how these losses can accumulate at the institutional level, gradually eroding organisational capacity, workforce sustainability, and quality of care, even when "access" remains formally intact. Through the triadic capability nexus we reframe healthcare justice as a relational and institutionally mediated achievement, with the intention of strengthening the ethical case for free access by clarifying the conditions under which it can be sustained without redistributing injustice across the system.