How should scarce health-related resources be distributed at the population level? How should society prioritize whose health needs should be met? These are questions all health systems must grapple with. In Distributing Health, Anders Herlitz introduces the most common normative approaches to this issue and outlines an original approach that builds on insights from both procedural and substantive approaches.Procedural approaches focus on the process by which distributive decisions are made and put forward conditions that these processes should meet. Herlitz argues that these approaches are attractive because they reflect the idea that those affected by distributive decisions should have influence over them. However, these approaches cannot explain why certain decisions are bad, irrespective of how they have been made. Substantive approaches focus on the features of different alternatives and put forward principles which inform decision-makers of how to rank options. These approaches are attractive because they provide action-guidance. However, any plausible substantive approach must be pluralistic in the sense that several substantive, distributive principles are endorsed. Plausible substantive approaches run into comparability problems because the principles sometimes suggest conflicting rankings.A hybrid approach would rely on elements from both procedural and substantive approaches. Herlitz suggests a hybrid approach that includes three substantive principles: health maximization, lifetime equality, and time-slice sufficiency. These principles will sometimes be fully action-guiding, but sometimes they will fail to be so. To complement the substantive principles when they fail to be action-guiding, a criterion of the second order should be invoked. This criterion should reflect the collective will of the affected people, which is expressed through a decision process that meets a set of procedural conditions.
