50 years of the inverse care law
Authors: None The Lancet
Journal: The Lancet (2021)

“The availability of good medical care tends to vary with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” These understated opening lines of Julian Tudor Hart's paper, The Inverse Care Law, are as relevant now (50 years to the day since publication) as in 1971. The paper is one of the landmark publications in The Lancet's near 200-year history, and the resonance of Tudor Hart's definition of the inverse care law has global and timeless importance. Simply expressed, Tudor Hart observed that disadvantaged populations need more health care than advantaged populations, but receive less. Tudor Hart's life and career took him from highly privileged beginnings in London and Cambridge to decades spent in the deprived and deeply socialist Welsh valleys. His experience and work has inspired a generation of influential health-care leaders including Andrew Haines, Allyson Pollock, Cesar Victora, and Graham Watt. Today's anniversary issue of The Lancet explores both the global reach of the inverse care law and primary care initiatives in deprived areas around the UK. Although inequality in health and its many causes are widely understood, inequity in health-care service provision is enduring and fundamental: an intractable concept that lies at the heart of the inverse care law. The inverse care law is primarily about inequity (injustice) in health care that results in unfair social inequalities (imbalances) in health. Since the inverse care law was published, the UK's National Health Service (NHS) has strived to reduce inequity with mixed success. Notably, long-lasting progress was achieved through the 1970s resource allocation formula, which reduced geographical inequality in hospital and institutional expenditure. In the early 2000s, the NHS strengthened primary care provision in disadvantaged areas, leading to a temporary reduction in social inequality, although this progress has reversed following shifts in funding, a slowing of spending, and years of living with austerity. Globally, letting market forces dictate health care is still a major contributor to inequity—private health care can only be accessed by those who can afford to pay. In many countries, social care and long-term care are managed by private providers too. With populations that are living longer and with more chronic conditions, families—rather than the state—bear much of the cost of long-term care. Public funding for long-term care is more means tested (based on both income and wealth) than needs tested. However, that the inverse care law continues to be seen even with integrated universal health-care systems suggests that there are other important causes. As Richard Cookson and colleagues show in a Health Policy paper, the private expenditure share (ie, private spending on health as a fraction of total health spending) in low-income and middle-income countries explains only 11% of the variation in health-care inequality—less than the share explained by poor governance, for example. How should we reflect on the inverse care law 50 years on? Although health care is widely endorsed as a basic human right, the systems that provide it inequitably embody capitalism at its worst, where the wealthy benefit, leaving behind those most in need. Communal efforts can help. A Comment by Graham Watt and colleagues explains the Deep End Project to help improve primary care in deprived and disadvantaged communities; informal networks of primary care clinics share knowledge and activities to improve quality of care. But it will take more than bottom-up initiatives to counter the inverse care law. Growth in health spending as a proportion of total government spending is likely to continue to increase, and with that, demand for care will continue to stretch societal willingness to subsidise services through increased taxes. As laid out in the Comment by Andrew Haines and Mayara Floss, life in the Anthropocene era, with the threats of climate change and erosion of biodiversity undermining planetary health, requires policies to protect health-care systems from future shocks. In order to do so, health systems must be designed to counter inequity, not further perpetuate it. This reality, captured by Tudor Hart's inverse care law, should be at the foreground of policy and governmental decisions when re-evaluating health-care delivery for future generations. Positioning the inverse care law as a warning could ensure advances in health equity and social justice over the next 50 years. The inverse care law in the Anthropocene epochJulian Tudor Hart described the inverse relationship between the need for effective health care and its provision in compelling terms. During his career in primary care in a former coal mining community in south Wales, UK, he showed how, by integrating clinical care with an epidemiological approach, much can be done to improve health in disadvantaged populations.1 He wrote the inverse care law2 based on an analysis of the UK National Health Service (NHS) 50 years ago and yet its importance has transcended that historical period and its national context. Full-Text PDF The inverse care law and the potential of primary care in deprived areasThe inverse care law, whereby health care favours more assertive interests and in doing so compounds the disadvantage of patients and communities with the poorest health,1 exists in most health systems. 50 years after Julian Tudor Hart's landmark paper in which he first described the inverse care law in England and Wales,1 it is still going strong.2,3 In The Lancet, Richard Cookson and colleagues4 provide a global re-examination of the inverse care law. Full-Text PDF Julian Tudor Hart: medical pioneer and social advocateJulian Tudor Hart is seen variously as a researcher, an expert on high blood pressure, an epidemiologist, scientist, writer, political commentator, and social advocate. But at heart he was always a practising family doctor. Few physicians manage to be expert in so many fields and none while also looking after the primary care needs of some 2100 people, which Tudor Hart did at Glyncorrwg, a former colliery village in south Wales, UK. His dedication to general practice meant his work was relevant and valued by fellow general practitioners (GPs). Full-Text PDF The inverse care law re-examined: a global perspectiveAn inverse care law persists in almost all low-income and middle-income countries, whereby socially disadvantaged people receive less, and lower-quality, health care despite having greater need. By contrast, a disproportionate care law persists in high-income countries, whereby socially disadvantaged people receive more health care, but of worse quality and insufficient quantity to meet their additional needs. Both laws are caused not only by financial barriers and fragmented health insurance systems but also by social inequalities in care seeking and co-investment as well as the costs and benefits of health care. Full-Text PDF THE INVERSE CARE LAWThe availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources. Full-Text Open Access