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date: 05 March 2021

Health Equity Metricsfree

  • Juan Garay, Juan GarayDepartment of Bioethics, Universidad Autonoma de Chiapas
  • David ChiribogaDavid ChiribogaDepartment of Medicine, University of Massachusetts
  •  and Nefer KelleyNefer KelleySchool of Public Health, The University of California, Berkeley


This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Global Public Health. Please check back later for the full article.

There is one common health objective by all nations, as stated in the constitution of the World Health Organization of 1947: the progress toward the best feasible level of health for all people. This goal captures the concept of health equity: fair distribution of unequal health. However, 70 years later, this common global objective has never been measured. Most of the available literature focuses on measuring health inequalities, not inequities, and tends to concentrate on comparisons among population subgroups, specific health risks, diseases, or health services, thereby indirectly contributing to the high fragmentation of health policies, actions, and even constituencies and resulting in competition for funds and/or priority.

A method to identify standards for the best feasible levels of health through criteria of healthy, replicable, and sustainable (HRS) models is needed. The avoidable death toll has not improved significantly since the 1970s. Younger age groups (though gradually shifting toward older age groups) and women are most affected. Data analysis of smaller sample units (such as provinces, states, counties, or municipalities) increases the sensitivity of measurement and detects higher levels of health inequity.

Most of the burden of health inequity takes place in countries with levels of income per capita below the average of the HRS countries, which is called the “dignity threshold” (the economic condition threshold necessary to enjoy the best feasible levels of health). Based on this threshold, it is possible to estimate the necessary distribution of the world’s resources compatible with the universal right to health—“the equity curve.” Income above the upper thresholds, and hence wealth accumulation, prevents others from living in conditions of dignity compatible with the universal right to health, is correlated with a carbon footprint above the ethical sustainable threshold, and does not translate into better health nor well-being. The international redistribution of wealth required to enable all nations to have at least an average per capita income above the dignity threshold would be around 8%, much higher than the present, nonbinding, and volatile levels of international cooperation, which currently lack an equity approach.

At subnational levels, the burden of health inequity can be the most sensitive barometer of socioeconomic justice among territories and the population, informing and directing fiscal and territorial equity schemes to enable all people within and between nations to enjoy the universal right to health. HRS models can also inspire lifestyles, political, and economic frameworks that increase efficiency, replicability, and sustainability of ethical well-being without undermining the rights of others in present and future generations.

Health Equity

Concept and Commitment

Equity is the fair distribution of inequality. Fairness has different meanings across cultures, religions, and ideologies. But there is one common global health objective for all nations since 1947: the foundation article of the constitution of the World Health Organization (WHO) aimed at the achievement of the best feasible level of health for all people. This common objective was restated in the World Health Assembly resolution on social determinants, calling on all countries to measure and act on health inequities.1

Inequity Versus Inequality

Beyond its very concept (inequities, i.e., unfair inequalities, vs. inequalities, i.e., any differences), measuring and acting on inequities vs. inequalities has distinct implications. The inequality approach has an arbitrary nature, selecting indicators and disaggregating variables by which to measure differences, which already incorporates a bias in the universality of the right to health. The measurement of inequalities often produces partial evidence, which can lead to arbitrary or biased interpretation and goal setting (e.g., global former Millennium Development Goals and present Sustainable Development Goals, which are skewed towards non-replicable development models). The inequality approach often leads to addressing and targeting extreme inequalities through the concept of “poverty.” To alleviate the extremes of need or burden, some level of redistribution is required. This inequality-driven vision empowers the “donor” to arbitrarily determine the type and scale of “aid required to mitigate the lowest levels in the unequal distribution without compromising its dominant position, expecting praise for its “charity,” which is voluntary in nature and void of commitment (Ottersen et al., 2014). This approach reinforces and perpetuates the vertical relations between affluent and “wise” donors and recipients in chronic need of support and guidance (Garay, Harris, & Walsh, 2013).

In contrast, the inequity approach recognizes the overall (unfragmented and unbiased) universal right to health (e.g., through its expression in life expectancy) and sets the best feasible levels as a right for all people. This ethical threshold enables the identification of unacceptable levels of ill health and challenges the system to go beyond the extreme inequality (poverty) approach, to achieve decent and sustainable living conditions above the dignity threshold for all, hence enabling those best feasible levels of health for all people. Ensuring dignity for all requires a higher redistribution of wealth. It challenges privileged levels of wealth above an excess accumulation threshold. It also directs the distribution of income, wealth, and other means towards an ethical equity curve into a normal distribution, as most variables in nature behave. This concept empowers all people with universal rights, feasible above the dignity threshold. It changes the concept of donor to that of the “responsibility of privilege” in a horizontal, equal rights relation and a binding duty of redistribution.

The Neglect

Neither WHO nor any government has defined “best feasible level of health,” hence progress towards this goal cannot be measured. Instead, health has been seen through the lens of healthcare (coverage of treatment), or from a fragmented epidemiological perspective as disease, risk, or certain population groups, or through comparison with best performers, independent of feasibility or reproducibility and its associated environmental impact.

Those partial approaches to prevent ill health compete with one another, and some claims of progress have been made in comparison with retrospective static baseline levels (Chiriboga et al., 2014). The WHO Health Equity Monitor and most of the existing national health equity surveillance systems and ad hoc studies or reports tend to measure inequalities based on often subjectively selected or lobby-driven health indicators (of diseases, services, or population subgroups).2 In this context, the word equity is used as a principle and an objective by multilateral, national, and private initiatives, yet it is translated into measuring and acting on often isolated or arbitrary health inequalities.

The Reasons for Neglect

Before proposing a method to identify or at least estimate the never-before-identified best feasible levels of health, it is worth reflecting on why this has never been attempted before.

The positive rationale may be that “the best” is always desirable for all, and that what may not be feasible for all today may very well be tomorrow. This positive thinking is behind front-line research and humanity’s attempts to advance the frontiers of knowledge. Humankind applauds the exploration of Mars, even if hundreds of millions of people lack access to basic nutrients or water. Besides the aspiration for innovation for the common good (eventually reaching all), these good intentions may also be an attempt—often unconscious—to escape from the grim present by imagining a brighter future. This mindset is also linked with the economic concept of continuous growth which, through a trickle-down effect, would eventually enable the least privileged to benefit from the fruits of development. Inequity, however, is a relational concept, and progress without redistribution towards universal dignity not only perpetuates the levels of inequity but most often rewards those who are better off, given their enhanced chances to benefit from constant progress and economic growth.

The negative rationale has also played a role in denying equal conditions for all. This is inherent in most societies that are organized in hierarchical structures. It is also embedded in the competition-driven economy in the so-called West. The influence of the latter is worth some elaboration. The Industrial Revolution aimed at freeing people from want through scaled production. It theoretically based its individualism (and competition) on the post-medieval European principles of freedom such as free thinking (Galileo), free believing (Luther), free non-believing (existentialism), and freedom from hierarchies (the French Revolution). As those liberating principles evolved, they were intermingled with increasing scales of production, market, and consumption. While the former allowed space for the uniqueness of each person to develop her/his ideas and thoughts, the latter seemingly allowed a parallel space for individual effort-based reward and collective access to security and comfort (the basic freedom: freedom from want). However, material individualism gradually generated competition and rewarded greed, which replaced the former imposed feudal or religious masters. Since the Industrial Revolution, individual or collective (national) success, that is, accruing the means to cover needs and access to evolving means of comfort, was initially based on the scale of production, later on marketing, and more recently on financial speculation. This dynamic is based on the rationale that such success rewards “effort” in the competition game. The countries praising such a dynamic have succeeded in the global competition game and influence global dynamics accordingly. In this domain freedom is mainly associated with property ownership, while human rights are considered “aspirational” and subject to income through competition. For this reason, defining feasible levels of health (or any other rights) for all would confront the competition-driven society and therefore has been rejected or, at best, ignored.

The Burden of Health Inequity

Identification of Best Feasible Levels

The following methodology aims at identifying the best feasible levels of health in order to enable progress towards the common global health objective, and attempts to measure the existing gap. The methodology can be applied to other dimensions of rights and well-being as well.

To set the feasibility criteria, the variables influencing health need to be identified. Almost any political, ecological, social, or lifestyle variable may influence health. To rationalize this selection, potential factors influencing health were grouped into four comprehensive domains: (1) natural resources, (2) economic means, (3) knowledge and its flow through social participation, and (4) legal frameworks. The latter two are unlimited in nature: knowledge and imagination defy all boundaries, and legal frameworks aim at ensuring equal rights for all. The former two, however, have a limited supply: natural resources are restricted by the planetary boundaries, and economic means are also limited by their overall size and relation to the population.

Once the main limiting factors influencing human health were identified, the best feasible levels that could be reached by people could be estimated. These were called the healthy (best health indicators), replicable (economically feasible for all), and sustainable (preserving ecological conditions for coming generations)—HRS—criteria (Rockström et al., 2009).

In our initial analysis (Garay & Chiriboga, 2017), which included analyses for the period 1960–2010, the proxy variables used included life expectancy constantly above the world’s weighted average (H), GDP per capita (constant value 2010) below the world’s weighted average, and CO2 emissions below the planetary recycling capacity, as a fixed annual average lower than 2.5 metric Tons per capita (in this case for the period 2000–2010 of available data).

Figure 1. Criteria used in the international identification of healthy, replicable, and sustainable (HRS) models.

The proxy variables were fine-tuned to take account of the gender bias in life expectancy, the discussion of GDP pc constant value (CV) vs. purchasing power parity (PPP), and new knowledge on the trillion-ton theory (Raworth, 2009). Updated data sources (new quinquennium 2010–2015 for all and carbon emissions pc as from 1960) were also used., The HRS selection criteria, as Figure 1 shows, now include: (1) healthy models (H) when life expectancy and healthy life expectancy (for men and for women) was higher than the world’s weighted average; (2) economically replicable models (R) when GDP pc (both by constant value and by purchasing power parity) was below the world’s weighted average; and (3) ecologically sustainable models (S) when the CO2 emissions per capita were below the planetary boundary (Raworth, 2009).

The latter was estimated at 1.7 metric Tons pc (as opposed to 2.5 mT pc in the previous model). This level would avoid reaching 1 trillion cumulative carbon emissions since the industrial revolution and hitting the 2°C global warming within the 21st century (ref trillion tons). This was calculated by dividing the remaining CO2 emissions until the cumulative 1 trillion tons of carbon emissions by the population which will live until 2100 (UN Population Division estimates).

Only seven countries (with a total population of 171 million) constantly met the three criteria from 1960 to 2015. These were Costa Rica, Colombia, Paraguay, Armenia, Sri Lanka, Vietnam (excluding the genocide-related drop in male life expectancy in 1970–1975), and Tonga. In 2015, their average life expectancy was almost 75 years, more than three years above the world’s average (by two years for men and more than four years for women); their GDP pc is lower than half the world’s weighted average ($9,924 CV); and their CO2 emissions pc are three times lower than the world average (4.3 metric Tons pc).

As there are only comparable data on the above-mentioned criteria and time period from national averages, this analysis could not be expanded to subnational levels. However, an exploratory analysis of subnational data of the most populated countries in the world (China, India, Russia, and Brazil) was performed utilizing subnational data at the state or province level for life expectancy and GDP pc, and estimating CO2 emissions, through the correlation of GDP pc with CO2 emissions pc at the national level. The results allowed us to identify four provinces in China, one in India, two in Russia, and seven states in Brazil, with a total population of approximately 400 million, that could also meet the HRS criteria.3 The present analysis of national average indicators is a first attempt to identify HRS models that may set best feasible (and sustainable) levels of health. As the sample size is extended to subnational levels, healthier (higher life expectancy), more efficient (lower GDP pc), and more sustainable (lower carbon emissions) models would likely be identified.

Estimating the Burden of Health Inequity Referring to Global HRS Models

Population and death data were taken from the UN Population Division (annual average quinquennial 1950–2015, five-year age groups 0–100, and sex disaggregation) to calculate age- and sex-specific annual average mortality rates.

The weighted mortality rates (by population size) of the seven HRS countries was taken as reference.

By adjusting these reference HRS mortality rates to those of each country’s population by the same age and sex disaggregation, the expected number of deaths by the mentioned age, sex, and time period could be estimated.

The observed mortality in-excess-of the calculated expected mortality by HRS rates is the excess mortality—which can be characterized as avoidable deaths due to global health inequity; this is the net burden of global health inequity (NBHiE). The NBHiE is then divided by the total number of age- and sex-specific deaths, and this proportion is called the relative burden of health inequity (RBHiE), a comparable indicator across countries, ages, sex groups, and time periods with different population sizes. As Table 1 shows, the number of avoidable deaths increased in the post-war period, reaching 21 million in the 1960–1965 period; decreased thereafter to 15 million in the 1970s; increased gradually to 18.5 million by the turn of the century (mainly at the expense of women); and decreased to 17 million (mainly due to the decreasing mortality rate among men) in the last 10 years. These figures were significantly higher among women, with close to 10 million deaths every year during the last recorded period compared with 7 million deaths among men.

Table 1. World Net Burden of Health Inequity (NBHiE) by Sex and Time Period.


TOTAL 0–100























































As regards the more comparable indicator of RBHiE, Table 2 and Figure 2 show how these levels also increased after World War II, and have been fluctuating between 33% and 35% (with peaks in the mid-1970s, mid-1980s, and throughout the 1990s), decreasing in the last 10 years to present levels around 30%. Again, these figures are some 50% higher for women (most recently 37%) than for men (most recently 24%).

Table 2. World Relative Burden of Health Inequity (RBHiE) by Sex and Time Period.


TOTAL 0–100























































The world distribution of the relative burden of health inequity is represented in the following video for the period analyzed, 1950–2015: “Equity in the XXIst century”.

It shows how the highest burden of health inequity affected the whole of sub-Saharan Africa and Yemen, Pakistan, Afghanistan, and Papua New Guinea, with major variations in Southern Africa (due to AIDS) and the former Soviet Union in the 1990s, and a significant decrease in China since the 1980s. It also shows how certain regions were void or had a very low relative burden of health inequity when compared with global HRS rates. These are, besides the HRS models, the affluent economies of the northern region and the southern cone in the Americas, most of the European Union, Turkey, Japan, Australia, and New Zealand, that is, the OECD high-income countries (excluding the oil economies of the Middle East).

Figure 2. Relative burden of health inequity 2010–2015, all ages and sexes.

As there are no available data on carbon emissions pc at subregional (NUTS2 regions) level in the EU and subnational (county) level in the United States, only healthy and replicable models (HR) were estimated. Preliminary analyses suggest levels of RBHiE four to six times higher using the subnational or regional references than with global HRS references, as represented in Figure 3.

Figure 3. Burden of health inequity in the EU and the United States by levels of disaggregation 2010–2015.

The overall NBHiE when calculated using as a reference the best HR regions in the European Union (13 EU NUTS2 regions) found over 40 million avoidable deaths per year within the EU.

This finding indicates that the higher the level of disaggregation (larger sample size of regions and smaller regional unit size), the higher the sensitivity of the RBHiE. However, it is important to note that the HR EU regions are not globally replicable models as their GDP pc is higher than the world’s weighted average and the levels of carbon emissions are not sustainable.

Economic Equity and Health

Income Distribution Compatible with the (Universal) Right to Health

Once HRS models were identified, the average (d) income level required to enable the best feasible health for all could also be estimated. Below this level (the GDP pc of the HRS models) no country (except Vietnam and Sri Lanka, the most efficient HRS countries) between 1960 and 2015 could achieve such HRS (feasible and replicable) levels of health (by proxy of life expectancy in men and women), with a large sample size (some 11,000 data) rendering a significant statistical power. The HRS average income level was called the dignity threshold, as it would enable (but obviously not guarantee, as many other factors are involved) the right to health (best feasible levels of health) and possibly many other universal rights. When the dignity threshold and the average level of GDP pc are considered, a normal symmetric distribution of resources with an excess accumulation threshold in the upper end can be estimated, as seen in Figure 4. At global level, the dignity (average HRS) threshold for 2015 was $3,762 pc in CV, some $10/day, over five times the poverty level proposed by the World Bank, and $9,285 pc in PPP. As the weighted GDP pc average was around $10,500 pc CV ($15,239 pc in PPP), the symmetric normal distribution of resources meant an excess accumulation threshold of some $17,000 pc ($20,659 pc in PPP). On the other hand, no country with GDP pc at that level (compared at constant value units) has been able to have an ecologically sustainable economy (therefore undermining the health of coming generations). Likewise, above the excess accumulation level, life expectancy does not increase.

By disaggregating at subregional and subnational levels, it can be found—as in the EU—that the healthiest models, while not replicable for all (as their GDP pc are higher than the world average), are amenable under the equity-normal distribution (below $20,659 pc PPP). These data suggest that a world where all persons live above the dignity threshold and none live above the excess accumulation threshold could prevent over 17 million deaths every year due to inequity (injustice) and allow for the best health levels (and other well-being indicators) under the equity curve. Increasing income (and accumulating wealth) beyond the mentioned excess threshold would deprive people who are below the dignity threshold of their right to health, and undermine that right for coming generations as well, while being redundant for higher levels of health or well-being for the privileged (Wilkinson & Pickett, 2009).

Figure 4. Economic equity curve compatible with the universal right to health 2010–2015.

Redistribution Required to Aim at Global Health Equity

Considering the dignity and the excess accumulation thresholds described above, the countries with average GDP pc in the deficit zone (below the dignity threshold and hence deprived of the universal right to health), those in the equity zone (between the dignity and the excess accumulation thresholds), and the richest in the excess or surplus zone (above the excess accumulation threshold) can be identified. The proportion of world population and of global income during the 1960–2015 period are shown in the figure. Only approximately 15% of the population lived in the equity space until the last decade, when (due to China joining that group) it increased to 30%, while between 50% and 70% (and more recently 50% due to the China effect) lived in the deficit zone, and a shrinking proportion (from 40% to 15%) in the surplus zone, as Figure 5 shows. The distribution of income depicts a speculative picture, with 70% of income in the hands of the 15% surplus countries while only 10% of income is shared by half of the world’s population, those living in countries within the deficit zone, as represented by Figure 6.

Figure 5. Population and GDP by deficit, equity, and excess accumulation zones 2010–2015.

It is worth noting that while over 70% of the NBHiE takes place in countries in the deficit zone (with 50% of the world’s population), 10% of the avoidable deaths occur in countries with sufficient average resources to emulate the HRS health levels, yet with inefficient or inequitable subnational distribution, allowing for the burden of health inequity.

The following graphs show in detail, and disaggregating population and income by subnational territories in the main populated countries (China, India, the United States, Brazil, and Russia), the distribution of population and income by GDP pc intervals of the equity curve and the present reality.

Figure 6. Ethical equity population and GDP curve by GDP pc intervals vs. international distribution 2015.

It shows a high peak (clustering provinces in India and similar income countries) of population below (yet close to) the dignity threshold, and a second peak of resources (clustering around many of the states in the United States and similar income countries) well above the excess accumulation threshold. Resources need to be redistributed towards the equity curve by transfers from the excess accumulation zone to the deficit zone (through fiscal equity and territorial cohesion), while the population deprived of the right to health (half of the world’s population) is in need of higher income and empowerment to exercise their rights and have access to a life with dignity under the equity zone. The level of redistribution required is 7.8% of the world’s GDP, some 10% of the GDP in the excess zone and some 15% of the redundant income in that zone (above the excess accumulation threshold), far beyond the 0.7% unmet target of official development assistance (Clemens, Kenny, & Mons, 2007) and in an equitable way according to needs (Organisation for Economic Cooperation and Development [OECD], 2016). Table 3 compares the present international cooperation framework with the one required to progress towards health equity and the universal right to health.

Table 3. Differences Between Present International Cooperation Framework and the One Required for Global Health Equity.


Present International Cooperation (OECD, 2015)

Redistribution x GHE



Excess threshold (2015: > $15,239 pc)


Developing countries (World Bank)

Minimum dignity threshold (2015: $3,762)


0.208% of GDP (2015) (target 0.7% in OECD/DAC)

8.08% of GDP


Non-correlated with GDP deficit

Correlated with GDP deficit for DTh


Low (1–2 years)

Stable and adjusted to GDP evolution

Binding Nature

Voluntary (volatile)

Binding global mechanism

The Burden of Health Inequity: A Powerful Indicator of Social Justice

The research described in this article is based on the ethical principles—and neglected international commitments—of the universal right to health through the common global objective of health equity. This approach identifies national models of good health that are replicable (use resources below the world’s average) and sustainable (do so with carbon emissions below the most urgent planetary boundary). These healthy, replicable, and sustainable (HRS) models allow us to estimate the burden (gap from objective) of health inequity and reflect its distribution by country, sex, age group, and time in the last 65 years. The analysis shows that the levels of health inequity have remained almost stable since the mid-1970s, with more than 17 million excess deaths per year (NBHiE), meaning more than one in three deaths every year (RBHiE) are in excess of the health levels that could be feasible and sustainable for all people. These avoidable deaths take place mainly in countries with income below the average HRS levels (the dignity threshold), and more often among women and the younger age groups.

The burden of health inequity (BHiE) may be the best indicator of socioeconomic inclusion (justice) within and between generations. The setting of the dignity threshold (since their dignity and right to live are not being respected) calls for the equitable redistribution of the world’s resources, which would uphold the universal and equitable right to health. This can be achieved by limiting the excess accumulation above such threshold as it prevents sufficient resources enabling basic health needs for all. On the other side, above the mentioned upper threshold, excess carbon emissions affect the health and other well-being indicators of coming generations. Finally, income above the excess accumulation threshold does not translate in better health or well-being.

The world has enough natural and economic resources to ensure the universal right to health. However, this requires fair distribution of resources and investing in global common goods as those which could reverse the carbon accumulated in the atmosphere. This challenges the insufficient equity and sustainability targets of the 2030 Sustainable Development Goals.4

Further Reading

  • Garay, J. (2017). The ethics of health inequity: Global burden of health inequity: Trend from 1950 and prospects in the XXIst century. Editions universitaires europènnes, Riga, Latvia: SIA OmniScriptum Publishing.
  • Piketty, T. (2014). Capital in the twenty-first century. Cambridge, MA: The Belknap of Harvard University Press.
  • Stiglitz, J. (2013). The price of inequality: How today’s divided society endangers our future. New York, U.K.: W. W. Norton & Company.


  • Chiriboga, D., Buss, P., Birn, A.-E., Garay, J., Muntaner, C., & Nervi, L. (2014). Investing in health. Lancet, 383(9921), 949.
  • Clemens, M. A., Kenny, C. J., & Moss, T. J. (2007). The Trouble with the MDGs: Confronting Expectations of Aid and Development Success. World Development, 35(5), 735–751.
  • Garay, J., Harris, L., & Walsh, J. (2013). Global health: Evolution of the definition, use and misuse of the term. Face a Face, 2013.
  • Garay, J. E., & Chiriboga, D. E. (2017). A paradigm shift for socioeconomic justice and health: From focusing on inequalities to aiming at sustainable equity. Public Health, 149, 149–158.
  • OECD. (2015). Development aid stable in 2014 but flows to poorest countries still falling.
  • OECD. (2016). History of the 0.7% ODA target. Original text from DAC Journal 2002, 3(4), III%0A-9–III-11.
  • Ottersen, O. P., Dasgupta, J., Blouin, C., Buss, P., Chongsuvivatwong, V., Frenk, J., . . . . Scheel, I. B. (2014). The political origins of health inequity: Prospects for change. Lancet, 383(9917), 630–667.
  • Raworth, K. (2009). A safe and just space for humanity: Can we live within the doughnut? Nature, 461, 472–475.
  • Rockström, J., Steffen, W., Noone, K., Persson, Å., Chapin, III, F. S., Lambin, E. F., . . . Jonathan A. (2009). A safe operating space for humanity. Nature, 461(7263), 472–475.
  • Whitehead, M., & Dahlgren, G. (1991). What can be done about inequalities in health? Lancet (London, England), 338(8774), 1059–1063.
  • Wilkinson, R. G., & Pickett, K. (2009). The spirit level: Why more equal societies almost always do better. London: Allen Lane.



Fair distribution of inequality

Best feasible health:

Minimum level of health (measured here in life expectancy) which could be economically feasible for all people and ecologically sustainable for coming generations


Burden of health inequity: the unfair gap below the feasible levels of health for all


Net BHiE, which measures the excess mortality from the feasible levels of health for all


Relative BHiE, which measures the proportion of all deaths due to health inequity


Healthy (H), replicable (R), and sustainable (S) references at national or subnational levels of analysis

Dignity threshold:

Average of HRS income per capita below which no country (or subnational region in subnational analysis) was able to enjoy the feasible levels of health for all

Equity curve:

A symmetrical normal distribution between the dignity threshold at the bottom and the average income at the middle

Excess accumulation threshold:

Threshold above which higher income per capita undermines the right of others to live above the dignity threshold and aspire to the feasible level of health for all. This threshold is also at present incompatible with ecological sustainability and does not increase life expectancy or human well-being