The Inverse Care Law and the ‘hard to reach’

In 1971 Scots doctor Julian Tudor Hart published his observation in the Lancet that the people who most need health services are the least likely to receive them: the inverse care law.

Since then, as it turns out, this law has been shown to hold true not only within countries but also between countries. Gwatkin et al (2005) for The World Bank did a series of studies in 11 countries of Asia, Latin America and Africa called ‘Reaching the Poor’. One of the problems these revealed was that even when governments try to target health services to the poor, those services are likely to be used more by middle class people.

This phenomena is of inherent interest to Social Work with our concerns for Social Justice and Human Rights. The same phenomenon is true at home in Australia. I’ve been particularly interested in the work of Gail Winkworth and the team at the Australian Catholic University (see Australian Social Work 2010 and 2012).  Their work looks at low income families with young children and makes the pertinent discovery that these people don’t have the social networks to introduce them into services. They don’t know anyone who is already using them. For them, it’s the services that are ‘hard to reach’. Moreover, the services they do use, GP’s, Centrelink and Housing, don’t harness their contacts with these people to facilitate their access to other services.

This should give those of us who work in Health cause for thought. On the one hand we have fabulous initiatives like ‘place based servicing’, ‘warm transfers’ and ‘no wrong door’ that can really improve access for the most needy. On the other hand, as our departments move to call centre entry systems that depersonalise, and maximise throughput, we further alienate those who need our services most. Facilitating access to health services for the people who need them most is a crucial arena for social work researchers and practitioners to be active in.

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