About

Jennifer Prah Ruger, Ph.D., M.S.L., M.Sc., M.A., is a Professor of Medical Ethics and Health Policy at the University of Pennsylvania's Perelman School of Medicine. She is also a Senior Fellow at the Leonard Davis Institute of Health Economics. Her educational background includes a B.A. in Political Economy from the University of California Berkeley, an M.A. in International Relations from the Fletcher School of Law and Diplomacy at Tufts University, an M.Sc. in Comparative Social Research from Oxford University, a Ph.D. in Health Policy from Harvard University, and an M.S.L. in Law from Yale University. Her research focuses on health policy, medical ethics, and health economics, with key contributions to understanding the right to health care, health capability paradigms, and health system governance. She has published extensively on topics related to global health governance, reproductive health, development aid, and health law, and her work emphasizes the importance of equitable health policies and social justice in health.

Research topics

• Political science
• Medicine
• Business
• Economic growth
• Sociology

Selected publications

• Applying the health capability profile: an analytical study of leading causes of death in the USA and of pressing public health issues

  Journal of Epidemiology & Community Health · 2025-01-02

  articleOpen accessSenior authorCorresponding

  Public health problems are complex; investigating them requires a framework that both accounts for multiple interactions among individuals and their intermediate and broader environment and also integrates equity concerns. Incorporating internal and external influences at the individual level, the health capability profile (HCP)'s 15 different health capabilities address this need.Using a systematic three-step deductive content analysis process, we examine hypothetical case studies representing leading causes of death in the USA (eg, heart disease, cancer and diabetes) as well as pressing public health issues such as COVID-19, alcohol use disorder, stigma and discrimination, intimate partner violence and firearm violence. After reviewing the profile (1), each case study is analysed through the framework of the HCP and developed into a flow diagram, through which we identify shortfalls between the observed and optimal levels of each health capability, as well as detrimental or enabling interactions among capabilities (2). We then determine factors and interventions that could help improve overall health capability (3).The HCP harnesses the multitude of unique individual profiles, and through aggregation and analysis, reveals common vulnerabilities (eg, discriminatory social norms and non-evidence-based information), and strengths. It recommends cross-cutting structural policy and programme reforms for institutions, schools, community resources and for individuals to develop a positive set of norms, knowledge, goals, attitudes and habits to chart the path towards health and well-being for all.

  PublisherOA PDFDOI

• Essay: Theoretical and normative foundations for global health law

  Journal of Global Health Law · 2024-12-31 · 1 citations

  article1st authorCorresponding

  The Provincial Globalism (PG) and Shared Health Governance (SHG) frameworks established in Global Health Justice and Governance (Oxford University Press, 2018), provide theoretical and normative foundations for global health law. They ground global health law in human flourishing and health capabilities and require standards and legal and non-legal measures to ensure global health equity and justice. Specified roles and responsibilities for international organizations, states, and non-state actors provide a clear and structured approach for achieving global health equity, replacing the current fragmented international and global health law landscape.

  PublisherDOI

• A Mixed-Methods Study of Social Determinants and Self-care in Adults With Heart Failure

  The Journal of Cardiovascular Nursing · 2023-05-19 · 18 citations

  articleOpen access

  BACKGROUND: The burden of heart failure (HF) is unequally distributed among population groups. Few study authors have described social determinants of health (SDoH) enabling/impeding self-care. AIM: The aim of this study was to explore the relationship between SDoH and self-care in patients with HF. METHODS: Using a convergent mixed-methods design, we assessed SDoH and self-care in 104 patients with HF using the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) and the Self-Care of HF Index v7.2 with self-care maintenance, symptom perception, and self-care management scales. Multiple regression was used to assess the relationship between SDoH and self-care. One-on-one in-depth interviews were conducted in patients with poor (standardized score ≤ 60, n = 17) or excellent (standardized score ≥ 80, n = 20) self-care maintenance. Quantitative and qualitative results were integrated. RESULTS: Participants were predominantly male (57.7%), with a mean age of 62.4 ± 11.6 years, with health insurance (91.4%) and some college education (62%). Half were White (50%), many were married (43%), and most reported adequate income (53%). The money and resources core domain of PRAPARE significantly predicted self-care maintenance ( P = .019), and symptom perception ( P = .049) trended significantly after adjusting for other PRAPARE core domains (personal characteristics, family and home, and social and emotional health) and comorbidity. Participants discussed social connectedness, health insurance coverage, individual upbringing, and personal experiences as facilitators of self-care behavior. CONCLUSION: Several SDoH influence HF self-care. Patient-specific interventions that address the broader effects of these factors may promote self-care in patients with HF.

  PublisherOA PDFDOI

• Micro-costing in health and medicine: a critical appraisal

  Health Economics Review · 2021-01-06 · 131 citations

  reviewOpen accessSenior authorCorresponding

  BACKGROUND: Concerns about rising health care costs require rigorous economic study to inform clinical and policy decision-making. Micro-costing is a cost estimation methodology employing detailed resource utilization and unit cost data to generate precise estimates of economic costs. Micro-costing studies have not been critically appraised. METHODS: Critical appraisal of micro-costing studies in English. Studies fully or predominantly employing micro-costing were appraised for methodological and reporting quality through economic evaluation guidelines (Evers, Drummond, Consolidated Health Economic Evaluation Reporting Standards (CHEERS), Fukuda and Imanaka checklists). Following the Panel on Cost Effectiveness in Health and Medicine, micro-costing studies were defined as involving "direct enumeration and costing out of every input consumed in the treatment of a particular patient." RESULTS: Full or predominant micro-costing studies included neoplasms (18.5%), infectious and parasitic diseases (17.9%), and diseases of circulatory systems (10.8%) as the most studied diseases. 36.9% were in the United States and 34.9% were in Europe. 33.8% did not report analytic perspective, 32.8% did not report price year, 3.6% did not inflation adjust cost data, and 44.1% did not specify inflation adjustment. 86.2% did not separately report unit costs and resource utilization quantity, 14.9 and 19.5% did not provide sufficient detail to assess appropriateness of measured physical units or valued costs. CONCLUSIONS: Micro-costing studies vary widely in methodological and reporting quality, highlighting the need to standardize methods and reporting of micro-costing studies and develop tools for their evaluation.

  PublisherOA PDFDOI

• Additional file 1 of Micro-costing in health and medicine: a critical appraisal

  Figshare · 2021-01-01

  datasetOpen accessSenior author

  Additional file 1.

  PublisherDOI

• Social justice as a foundation for democracy and health

  BMJ · 2020-10-23 · 18 citations

  articleOpen access1st authorCorresponding

  Jennifer Prah Ruger uses the covid-19 pandemic to show the importance of countries implementing a justice framework for health and equality

  PublisherOA PDFDOI

• The injustice of COVID-19: we need a moral constitution for our planet's health

  The Lancet Planetary Health · 2020-07-01 · 11 citations

  articleOpen access1st authorCorresponding

  COVID-19 and other diseases strike with inequality both within and between nations. Geographic, racial, social, and economic status affect COVID-19 risk.1Szabo L Recht H The other COVID-19 risk factors: how race, income, ZIP code can influence life and death.https://www.usatoday.com/story/news/health/2020/04/22/how-coronavirus-impacts-certain-races-income-brackets-neighborhoods/3004136001/Date: 2020Date accessed: May 23, 2020Google Scholar These factors dictate whether one receives quality care, substandard care, or no care at all—often the difference between full recovery and death. Did we have a moral obligation to prevent coronavirus? To contain it? To protect all or those within national boundaries? Whose responsibility was it? Who, if anyone, is to be held accountable for the worst human tragedy since World War 2? Despite urgent warnings, the world was unprepared for coronavirus because our global health system is grounded in what John Rawls called a modus vivendi, a consensus based on self-interests and national-interests rather than on principles of justice.2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar This modus vivendi fails to focus our reasoning and institutional development on common interests like shared health threats and vulnerabilities. We all have an interest in health protection and promotion—a common interest. Serving common interests requires global health governance rooted in principles of justice and governed by the common good. We need an institution to represent and serve these common interests. We need a moral constitution for our planet's health. Rawls warned of political agreements lacking a principled basis because parties involved can abandon such agreements if they believe they can achieve their own interests at others' expense.2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar This scenario is precisely our predicament today. Our global health system was created to control contagions—yellow fever, cholera, plague—to protect trade, travel, and security of wealthy and powerful nations. Now nations are blaming each other for the coronavirus while WHO is threatened with financial ruin.3Reddy SK Mazhar S Lencucha R The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals.Global Health. 2018; 14: 119Crossref PubMed Scopus (46) Google Scholar 80% of WHO funding is voluntary, member nations' dues are 20%.4Kaiser Family FoundationThe U.S. Government and the World Health Organization.https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-the-world-health-organization/Date: 2020Date accessed: May 23, 2020Google Scholar The USA is the largest WHO donor at $893 million, 15% of WHO's budget. A modus vivendi agreement is less stable than a consensus on principles of justice because it rests on “happenstance and a balance of relative forces,” Rawls said.2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar An international consensus on pandemic preparedness did not signify a true consensus and guarantee goal achievement. Major reports following H1N1, influenza, SARS, Zika, MERS, yellow fever, and Ebola raised alarms and offered proposals to prepare for global health emergencies. More warnings and recommendations appeared in a 2019 report by the Global Preparedness Monitoring Board (GPMB), “[a]n independent monitoring and accountability body to ensure preparedness for global health crises,” created by the UN Secretary General's Global Health Crises Task Force.5Global Preparedness Monitoring BoardAbout us.https://apps.who.int/gpmb/about.htmlDate: 2020Date accessed: May 23, 2020Google Scholar “Preparedness and response systems and capabilities for disease outbreaks are not sufficient,” GPMB concluded, “to deal with the enormous impact, rapid spread and shock to health, social and economic systems of a highly lethal pandemic…”6Global Preparedness Monitoring BoardA world at risk: annual report on global preparedness for health emergencies.https://apps.who.int/gpmb/assets/annual_report/GPMB_annualreport_2019.pdfDate: 2019Date accessed: May 23, 2020Google Scholar Still, GPMB resolved, the global community has “the tools to save ourselves and our economies.”6Global Preparedness Monitoring BoardA world at risk: annual report on global preparedness for health emergencies.https://apps.who.int/gpmb/assets/annual_report/GPMB_annualreport_2019.pdfDate: 2019Date accessed: May 23, 2020Google Scholar We needed moral leadership and action to enact global recommendations. We got complacency and indifference instead. The world ignored both portents and recommendations. Successful pandemic preparedness requires every nation to prepare its public health, health care, and animal systems, even if it does not think it is at risk. Collaboration of all nations is essential. Our global pandemic preparedness system is only as strong as the weakest link. Rawls adds that a modus vivendi is a consensus on “accepting certain authorities, or on complying with certain institutional arrangements, founded on a convergence of self- or group interests” and thus “contingent on circumstances remaining such as not to upset the fortunate convergence of interests.”2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar If power relations shift or if powerful nations can no longer hold others to the bargain, the international agreement disintegrates. This situation is what we are seeing today with tension between China and the USA. WHO's international legitimacy, its right to exercise authority, is vulnerable to power relations underlying it. The current approach has left our world fragile and vulnerable. But if not a modus vivendi, then what? Fundamentally, justice lies at the root of global health issues. On an alternative view, provincial globalism,7Ruger JP Global health justice.Public Health Ethics. 2009; 2: 261-275Crossref Scopus (62) Google Scholar justice in global health requires equal respect for all humans' flourishing and capabilities for all. Capabilities, what people and societies are able to do and be, enable flourishing. We have a moral duty to safeguard individuals' and communities' health capabilities, particularly their core health capabilities –to be free from premature death and avoidable morbidity. Justice requires creating the conditions for all to be healthy. We have a moral obligation to care for others' health and to fulfil our own roles and responsibilities in doing so. This is authentic cooperation in global health. The tragedies of COVID-19 have demonstrated that health capabilities are indispensable to our flourishing, a shared moral aim, particularly as other functionings and agency are premised on being alive and being protected from severe illness and death. Still COVID-19 is only the latest evidence against the current rational actor approach to global health, based on a modus vivendi rather than on principles of justice. Accumulating evidence proves that creating an effective global architecture oriented toward human flourishing and health capabilities in the common interests of all requires collaboration. The global health community must strive to meet health needs and enhance justice. Responsibility is global and national. Threats to persons' health capabilities measure the effectiveness of global and domestic institutions and actors. These are claims of justice, not charity. Humanitarianism and charity are insufficient bases for achieving health justice. The world knew a pandemic was coming. COVID-19 has revealed the injustices and amplified the deficiencies in our global health institutions. The pandemic proves the failures of the current global health approach. Our indifference toward our fellow humans has constrained our capabilities to implement the policies and programmes necessary to prevent such global pandemics. A lethal respiratory infectious agent poses a shared threat that requires a shared response to achieve health security through shared resources, shared sovereignty, and shared responsibility. This shared response requires shared health governance8Ruger JP Global health governance as shared health governance.J Epidemiol Community Health. 2012; 66: 653-661Crossref PubMed Scopus (30) Google Scholar with specific roles and responsibilities for individuals, communities, national and sub-national governments, and global institutions. Public institutions and private actors engage to coproduce conditions for health and flourishing of all. Instead of relying on individualistic rationality, shared health governance employs social rationality to effect global health justice. Rather than pitting self-interest and other-regarding behaviour against each other, social rationality recognises that health is good for both self and other. Shared health governance aims to achieve global health justice through actors' genuine efforts in collective action. Without a world health government with global authority and enforcement powers, a global health system requires multiple actors performing disparate functions to solve global health problems. This enterprise can be fostered with a global health constitution—a moral constitution—that provides an overarching structure to coordinate interdependent, yet independent actors. A global health constitution holds global and domestic actors accountable to duties of cooperation arising from duties of developing and protecting health capabilities. Actors' conduct aligns with principles of justice. A global health constitution offers common principles and common ground. It offers a basis for coordinating actors and actions; brings coherence, clarity, and legitimacy to formerly chaotic conditions; and generates and limits authority. Solving the world's health problems and shaping effective health policy will require new approaches to coordinate interdependent yet independent actors. Quite literally, our lives and livelihoods depend upon it. I declare no competing interests. I acknowledge funding, in part, from the Vice Provost for Research University Research Foundation at the University of Pennsylvania.

  PublisherOA PDFDOI

• Justice and health: The Lancet–Health Equity and Policy Lab Commission

  The Lancet · 2020-05-01 · 7 citations

  article1st authorCorresponding
  PublisherDOI

• Well-Being as a Pathway to Equity

  2020-11-09 · 2 citations

  book-chapterSenior author

  Abstract This chapter explores the relationship between well-being and equity, and makes the case for well-being approaches as a powerful pathway to advance equity. In a world without equity, well-being is impossible. Inequities in income, health, education, environmental conditions, access to opportunity, and other factors hinder individual, community, and civic well-being. Pursuing a well-being approach centered on equity—from what gets measured and how, to the way stories are told and the voices that tell them, to what gets prioritized and acted upon and by whom—can reduce these inequities. And in the symbiotic relationship between well-being and equity, as well-being improves, so does equity; likewise, as equity improves, so does well-being. The chapter addresses three intersecting components of well-being and equity: economic equity, human rights, and social cohesion. Through these lenses, it looks at implications and opportunities for social and policy change and illuminates work that remains to be done.

  PublisherDOI

• Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

  The American Journal of Bioethics · 2020-06-02 · 55 citations

  articleOpen access1st authorCorresponding

  The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the COVID-19 pandemic is a global health injustice due to moral failures of national governments and international organizations to prepare for, prevent and control it. Global and national health communities had a moral obligation to act in accordance with the current state of knowledge of pandemic preparedness. This obligation—a positive duty to develop and implement systems to reduce threats to and safeguard individuals’ and, communities’ abilities to flourish—stems from theories of global health justice and governance. The COVID-19 pandemic revealed and amplified the fragility and deficiencies in our global and domestic health institutions and systems. Moving forward, positive public health ethics is needed to set ethical standards for building and operating robust public health systems for resilient individuals and communities.

  PublisherOA PDFDOI

Recent grants

• NIH Grant K01DA016358

  NIH · $717k · 2010

• NIH Grant R01DA025555

  NIH · $2.6M · 2015

Frequent coauthors

• Nora Ng

  Guy's and St Thomas' NHS Foundation Trust

  12 shared

• Lawrence M. Lewis

  Washington University in St. Louis

  10 shared

• Christopher Richter

  The University of Texas Medical Branch at Galveston

  10 shared

• Karen M. Emmons

  Harvard University

  10 shared

• Oanh Thi Hai Khuat

  Center for Creative Initiatives in Health and Population

  9 shared

• Xiao Xu

  Columbia University

  9 shared

• Sarah Wood Pallas

  Centers for Disease Control and Prevention

  8 shared

• Giang Thi Hong Khuat

  Institute for Social Development Studies

  8 shared

Labs

• Jennifer Prah Ruger LabPI