This paper explores the implications for health policy of the segmentation of society into social groups with very different levels of income and wealth. It focuses particularly on societies undergoing rapid social change, such as southern Africa and China. Governments can influence access to health benefits but are unlikely to achieve equality in the consumption of health goods whilst access to all other resources is very unequal. They need to identify how to use their limited powers to reduce the most damaging health inequalities.
This is particularly important in societies where social groups are renegotiating their relative entitlements to health benefits. The paper concludes with a call for an international public health legal framework that might include a definition of minimum standards for certain health services. Recognising that it will be difficult to reach agreement on this kind of framework, an important first step would be to move beyond idealised visions of a future health system to a clear acknowledgement of reality and the strategic and practical options for change.
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