The focus on health capability and role of states in Ruger's global health justice framework.

In “Global Health Justice and Governance,” Jennifer Prah Ruger (2012) presents a compelling framework for evaluating and reforming the standing global health system. The framework is in many ways an extension of Ruger’s health capability paradigm and work on domestic health governance, most fully articulated in her recent book Health and Social Justice (2009), to the global order. The two components of Ruger’s framework are provincial globalism (PG) and shared health governance (SHG). Provincial globalism is a theory of global health justice that can be coupled with various models specifying means through which actors in the global health system can meet the theory’s demands and realize its ends. Shared health governance is one such model, and the one that Ruger argues should be chosen. PG is a health capability approach to global health justice. For Ruger and other capability theorists, flourishing is an aim shared by all persons that social institutions ought to promote, and the flourishing of persons involves their possession of capabilities. Capabilities are, roughly, freedoms understood as real opportunities to achieve functionings—living, moving around, reading, writing, expressing oneself, and so on—that one values. Ruger’s (2012) health capability approach focuses on the capabilities involved in being and remaining healthy, and the “central health capabilities” in particular. The central health capabilities are those without which further capabilities, and thus flourishing, cannot be realized. Ruger’s two central health capabilities are the capabilities to avert premature mortality and to escape morbidity. The familiar thought here is that remaining alive and meeting some basic threshold of healthiness are preconditions for anything else we might wish to do. PG holds that the focal variable or, in Amartya Sen’s terms, “primary informational base” (Sen 1993) for assessing the justness and efficiency of global health policy is the possession of health capabilities and particularly the central health capabilities by all living persons (Ruger 2012). We have a general duty to address threats to and reduce the extent to which individuals anywhere fall short of possessing the central health capabilities. Although this captures, in large part, the global aspect of PG, the theory is provincial in that it assigns special responsibilities to co-nationals and states for achieving domestic health goals. A multilevel system of roles and responsibilities for individuals, states, nongovernmental organizations (NGOs), inter-