Review of a Seminal Article in Health Promotion
Review Written By Sidney Ortun Flament:
THE INVERSE CARE LAW
Hart JT. The Inverse Care Law. Lancet 1971; i: 405-12.
The poor face many barriers to services (not only health services but also all types of social services), such as, the cost of getting there, distance, the time involved, and knowledge of what is available and how to access resources. These barriers invokes a concept originally proposed in 1971 by a Welsh general practitioner, Julian Tudor Hart, who argued that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’: in other words, those who need health care most are least likely to have access to it (the inverse care law). This phenomenon was first described by Titmuss in 1968: ‘We have learnt from 15 years’ experience of the Health Service that the higher income groups know how to make better use of the service, they tend to receive more specialist attention, occupy more of the beds in better equipped and staffed hospitals, receive more elective surgery, have better maternal care, and are more likely to get psychiatric help and psychotherapy than low-income groups – particularly the unskilled.’ It was recognized, even then, that those of a lower socio-economic background tended to have poorer health and so Hart formalized these observations with his theory. The second part of Hart’s theory is that the Inverse Care Law ‘operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced’, namely that this pattern of inequality is driven by profit.
Hart draws on the findings of others to support his theory, such as Ann Cartwright’s study which found that middle class patients were ‘both more critical and better served’. Middle classes expect and demand more from the health service and they are also likely to have the best general practitioners (GP). Hart concludes this to show that doctors most able to choose where they work tend to opt to work in more affluent areas, making it unlikely to ‘distribute the doctors with highest morale to the places where that morale is most needed’. This leads to an accumulation of superiority in more affluent (and thereby usually more healthy) areas, as Hart describes: ‘the better-endowed, better-equipped, better-staffed areas of the service draw to themselves more and better staff, and more and better equipment, and their superiority is compounded’. The ‘morale’ of the doctors in disadvantaged areas is then further weakened by the stress caused by expanding lists, presumably also affecting the quality of their work. Hart gives a useful summary of his Inverse Care Law: In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, than in the healthiest areas. Hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings, and suffer recurrent crises in the availability of beds and replacement staff.
Although Hart’s original paper has been described as a ‘not a systematic review of evidence but a polemic describing the effect of market forces on health care’ (1), since 1971 much evidence has been collected in favor of the ‘Inverse Care Law’ and it has even been said to have become ‘conventional wisdom’ (2).
Hart was principally concerned with the effects of market forces on health care. Then, as now, the private sector was implicated in providing solutions to problems in health-care delivery, but, as Hart stated, ‘no market will ever shift corporate investment from where it is most profitable to where it is most needed’. The inverse care law remains true today, for in every society where market forces determine who gets what in health care, inequalities grow in the system.
The neo-liberal agenda, with privatization of services and commercial consolidation in some countries, has often exacerbated this situation. In many countries, health care and social reforms may make access more difficult. For example, the growth of supermarkets has led to closures of small shops and rural bus services collapsed following privatization. Consequently, in some parts of the US, such as run-down suburbs of some large cities, it is almost impossible to obtain fresh fruit and vegetables at affordable prices; in these cases the term ‘food deserts’ has been coined. Health care reforms have often led to more centralized specialist services, creating access difficulties for those people who have no means of transport. These ‘medical deserts’ can be found in France: for example, in Parisian north suburbs more and more GPs abandon because they are being frequently attacked. The NGO Médecins du Monde opened a center in the Auvergne region, another medical desert, in order to bring health care to isolated rural populations. Because of this medical desertification a mother lost her child in October 2012 in the Limousin rural region. She delivered her baby in her car on her way to the maternity. The nearest health care facility was at 100km from her home.
Although, in his article, Hart described the situation of Great Britain, the Inverse Care Law is widely recognized as applying to other regions of the world. It is important to be aware that this law affects the impact of even those initiatives designed to serve disadvantaged population groups in developing countries. Even initiatives like these tend to reach the better-off more often than they do the impoverished people they were designed to serve.
- Watt G. The inverse care law today. Lancet 2002; 360:252–4.
- Asthana, S. and Gibson, A. (2008). Deprivation, demography and the distribution of general practice: challenging the conventional wisdom of inverse care. British Journal of General Practice, 58 (555): 718-27.
Published: October 2012, Health Promotion Connection