Health Inequalities Within and Between Countries

This lesson examines how health outcomes vary not just between countries but within them — often dramatically. It addresses the Edexcel Enquiry Question: "What is human development and how does it vary globally?" by moving beyond national averages to explore the social, economic and political determinants that create health inequality at every scale. Understanding these inequalities is essential because they are not natural or inevitable — they are produced by human decisions and can be reduced by human action.

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Health Inequalities Between Countries

The previous lesson established the broad global patterns. Here we examine the structural causes of health inequality between countries.

The Legacy of Colonialism

Colonial powers systematically extracted resources, disrupted indigenous economies, imposed new political boundaries and left behind healthcare systems designed to serve colonial administrators rather than local populations. The health consequences persist:

• Infrastructure: Colonial healthcare systems were concentrated in capital cities and resource-extraction zones. Rural areas were largely neglected. Many post-colonial states inherited this spatial inequality and have struggled to address it due to limited resources.
• Training: Colonial powers rarely invested in training local medical professionals. At independence in 1960, the Democratic Republic of the Congo had only 30 university graduates in its entire population of 15 million. Mozambique had fewer than 100 medical doctors at independence in 1975.
• Cash crop economies: Colonial economic structures forced countries to specialise in cash crop production (coffee, cocoa, cotton, rubber) for export rather than food crops for domestic consumption, contributing to food insecurity and undernutrition that persists today. Countries like Ghana, Côte d'Ivoire and Kenya remain heavily dependent on a small number of cash crop exports.
• Arbitrary borders: Colonial boundaries divided ethnic and linguistic groups and forced disparate peoples together, creating the conditions for post-independence ethnic conflict — which, as we have seen, is one of the most destructive forces for health.
• Extractive institutions: Colonialism established extractive institutions (Acemoglu and Robinson, 2012) — political and economic structures designed to transfer wealth to the coloniser rather than promote broad-based development. These institutions often persisted after independence, maintained by local elites who benefited from them.

The Inverse Care Law

In 1971, British GP Julian Tudor Hart proposed the Inverse Care Law: "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 healthcare most receive the least.

This law operates at multiple scales:

• Global scale: Sub-Saharan Africa bears 24% of the global disease burden but has only 3% of the world's health workers and less than 1% of global health expenditure. Conversely, the Americas bear approximately 10% of the global disease burden but have 37% of the world's health workers and account for over 50% of global health expenditure.
• National scale: Within LICs, urban areas have better facilities, more doctors and better-equipped hospitals than rural areas. In Ethiopia, there is 1 physician per 10,000 population nationally, but the distribution ranges from 1 per 3,000 in Addis Ababa to 1 per 50,000 in rural Somali region.
• Local scale: Within cities, wealthier neighbourhoods have better access to health services, green spaces, clean air and nutritious food than deprived areas. In London, male life expectancy varies by approximately 8 years between the most and least deprived boroughs — a gradient that is visible along a single Tube line.

Exam Tip: The Inverse Care Law is a powerful analytical tool. Use it in exam answers to explain health inequality at any scale — it applies globally, nationally and locally. Name the theory and its originator (Tudor Hart, 1971) for maximum credit.

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Health Inequalities Within HICs

The UK Health Gap

The UK provides universal healthcare through the National Health Service (NHS), established in 1948 on the principle that healthcare should be free at the point of use and based on clinical need, not ability to pay. Yet health inequalities remain stark and are widening:

Life expectancy by deprivation: Males in the most deprived 10% of areas in England have a life expectancy of 73.5 years, compared to 83.5 years in the least deprived 10% — a gap of 10 years. For females, the gap is approximately 7.9 years (2018–2020 data). This gap has been increasing since 2010, reversing decades of gradual narrowing.

Healthy life expectancy: The gap in healthy life expectancy (years lived in good health) is even wider — approximately 19 years for males between the most and least deprived areas. People in the most deprived areas not only die younger but spend a much larger proportion of their shorter lives in poor health. A man in Blackpool can expect to live in good health until age 55, while a man in Wokingham can expect good health until age 72.

Regional inequalities:

Region	Male Life Expectancy (2021)	Female Life Expectancy (2021)
South East England	80.5	84.1
London	80.3	84.3
North East England	77.2	81.2
Blackpool (most deprived LA)	74.4	79.5
Hart, Hampshire (least deprived)	83.7	86.4

These regional inequalities reflect the north-south divide in England — a persistent pattern of lower income, higher unemployment, poorer housing and worse health outcomes in northern and post-industrial regions compared to southern and south-eastern England. This pattern was exacerbated by the decline of heavy industry (coal mining, steel, shipbuilding) from the 1970s onwards, and further intensified by austerity-driven cuts to public services after 2010.

The Marmot Review (2010, updated 2020): Professor Sir Michael Marmot's landmark report Fair Society, Healthy Lives identified a social gradient in health — the lower your socioeconomic position, the worse your health. This is not just about poverty vs wealth — it is a gradient that runs through the entire social hierarchy. A middle-class person has worse health than an upper-class person, even though neither is "poor."

Marmot argued that health inequalities are not caused primarily by individual lifestyle choices but by the conditions in which people are born, grow, live, work and age — the social determinants of health. His six policy recommendations included: giving every child the best start in life, enabling all children and adults to maximise their capabilities, creating fair employment, ensuring a healthy standard of living, creating and developing healthy and sustainable communities, and strengthening the role of ill-health prevention.

Marmot's 2020 follow-up report, Health Equity in England: The Marmot Review 10 Years On, found that:

• Life expectancy had stalled for the first time in over a century (2011–2018), and for the poorest 10% of women, life expectancy had actually declined.
• Health inequalities had widened since 2010.
• Austerity — cuts to public services, welfare benefits and local government — was a significant contributing factor. Local authority spending per person fell by approximately 24% in real terms between 2010 and 2020.
• COVID-19 then amplified these existing inequalities, with mortality rates in the most deprived areas approximately 2.3 times higher than in the least deprived.

graph TD
    A["SOCIAL DETERMINANTS OF HEALTH<br/>(Marmot Framework)"] --> B["Material conditions<br/>Income, housing, employment,<br/>working conditions"]
    A --> C["Psychosocial factors<br/>Stress, social isolation,<br/>control over life"]
    A --> D["Behavioural factors<br/>Smoking, diet, alcohol,<br/>physical activity"]
    A --> E["Access to healthcare<br/>Quality, availability,<br/>cultural accessibility"]
    A --> F["Environmental factors<br/>Air quality, green space,<br/>neighbourhood safety"]

    B --> G["HEALTH OUTCOMES<br/>Life expectancy,<br/>healthy life expectancy,<br/>morbidity, mortality"]
    C --> G
    D --> G
    E --> G
    F --> G

    style A fill:#1565c0,color:#fff
    style G fill:#b71c1c,color:#fff

US Racial Health Disparities

The United States spends more on healthcare per capita than any other country ($12,555 per person in 2022, approximately 17.3% of GDP) yet has worse health outcomes than most other HICs — lower life expectancy, higher infant mortality and higher rates of chronic disease. This paradox is driven largely by inequality and by the absence of universal healthcare — the USA is the only HIC without a universal public healthcare system. Approximately 27 million Americans are uninsured.

Racial disparities:

Indicator	White (non-Hispanic)	Black (non-Hispanic)	Hispanic	Gap (Black-White)
Life expectancy (2021)	77.4 years	70.8 years	77.7 years	6.6 years
Infant mortality rate (per 1,000)	4.4	10.6	4.9	2.4x higher
Maternal mortality rate (per 100,000)	26.6	69.9	28.3	2.6x higher
Diabetes prevalence	11.2%	16.4%	14.4%	1.5x higher