Accessibility statement

The inverse care law re-examined: A global perspective

Richard Cookson1, Tim Doran2, Miqdad Asaria3, Indrani Gupta4 and Fiorella Parra Mujica2

(1) Centre for Health Economics, (2) Department of Health Sciences, (3) London School of Economics, (4) Institute of Economic Growth, India


Published version (requires institutional subscription)

Free preprint version (PDF , 675kb)

Appendix 1 (PDF , 1,205kb)

Appendix 2 (MS Excel , 44kb)


An 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. Investing in more integrated universal health coverage and stronger primary care, delivered in proportion to need, can improve population health and reduce health inequality. However, trade-offs sometimes exist between health policy objectives. Health-care technologies, policies, and resourcing should be subjected to distributional analysis of their equity impacts, to ensure the health inequality reduction objective is kept in sight.