This document discusses the inverse care law and its relevance to health inequalities in Canada. It argues that while the Canadian healthcare system aims to provide equal access to all citizens, those with lower socioeconomic status who have greater health needs tend to receive less care. Health facilities are distributed evenly rather than based on demand and need, so vulnerable populations have the same access but receive lower quality care due to greater health burdens. The inverse care law persists in Canada as the system fails to provide services proportional to populations' varying needs.

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GEG 3303: Health Geography
RESEARCH PAPER
Question 2: The Inverse Care Law and its Relevance in Canadian
Health Care Access Inequalities among Socioeconomic Classes
Submitted to: Professor Eric ​crighton
GEG 3303
November 18, 2013
Submitted by: Gabrielle Snow
6818517
GSNOW022@uottawa.ca
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2. In the past, the Canadian health care system had been recognized for its success in
satisfying the medical needs and concerns of its citizens in a manner that ensured that everyone
received equal amounts of care relative to their individual needs (Matcha, 2003). This was
principally achieved by providing health insurance coverage to all citizens, and by employing
many health care specialists made possible by the payment of taxes. Free health care access was
seen to be the solution to health inequalities in Canadian society in a general sense and more
specifically it was seen as the solution to the gap in health found between those of high and low
socioeconomic statuses (SES) (Squires, 2010). Unlike the high levels of satisfaction with
Canadian health care services apparent in past decades, many Canadian citizens are not pleased
with the direction the system has taken as government­insured health care services are no longer
available everyone to the same degree (Soroka, 2007). Today, it is believed by many researchers
and civilians alike that those who require the most medical care in order to achieve good levels
of health are the least likely to receive it. This view refers to Julian Tudor Hart’s hypothesis that
the market distribution of quality medical care is sold as a commodity and therefore is accessed
by the advantaged in higher quantities than the vulnerable and disadvantaged. Generally, people
of low SES are challenged by linguistic barriers, low income, poor education and unsafe
employment opportunities which makes them more vulnerable to disease and illness than the
advantaged yet they are less likely to receive quality medical attention. Hart named this presence
of inequality in health care accessibility the inverse care law ​(Hart, 1971)​. While basic health
care resources in Canada are not sold as commodities as Hart explains, the notion of the Inverse
Care Law still exists and thrives due to the growing health gaps among different SES classes in
Canadian society ​(Watt, 2002)​. In this essay, the characteristics of the Canadian health care
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3. system will be discussed and then the discussion of uneven access to Canadian health care
resources among populations of high and low socioeconomic classes and with linguistic barriers
will be examined to reveal how the inverse care law continues to strongly apply to the health
care system in Canada today.
The Canadian health care system, similar to the systems used in countries like France,
Germany and Japan, have adopted socialized approaches to health care which aim to benefit all
citizens equally (Matcha, 2003). It is not fair to say that the Canadian system is completely
socialized; the country uses a form of universal health insurance called Medicare to ensure that
all Canadians receive the care they need (Squires, 2010). While all citizens are given Medicare,
the conditions of this form of medical insurance in terms of coverage varies from one province to
another as both Federal and Provincial governments have control over it. The services covered in
all provinces, which are understood to be basic forms of care such as physician hospital visits,
are funded by provincial and municipal taxes (Matcha, 2003). While many think of this system
as ideal and “universal” there are many limits to it. Specialized or additional private services
such as dental care, eye care, prescription drugs and diverse therapies are not covered by
medicare and must be funded by one’s private insurance or out­of­pocket payments (Squires,
2010). Over the last two decades, public health care expenditures have decreased significantly,
however prescription drug spending per capita has almost doubled between 1979 and 1999,
indicating that privatized health care services and private insurance are becoming increasingly
necessary for the conservation of good health among Canadian citizens (Matcha, 2003). This
step toward the dominance of private healthcare is a major concern as only two thirds of the
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4. Canadian population has private health care insurance to cover the costs of these additional
services (Squires, 2010). As a response to the shift in service use and drops in government
funding, Canadian citizens are becoming more concerned with the sustainability of their
country’s healthcare system and many more are turning toward private health care services
offered in Canada or the United States to avoid long wait times and poor quality services
(Soroka, 2007).
In Canada, health care facilities are distributed throughout Canadian communities in a
way that promotes improved levels of health among populations with high SES status and further
deprives those of low SES status who are more in need of such resources ​(Watt, 2002)​. This
common trend of poorer health among low SES populations has been observed in Canadian
society and in other countries with similar health care systems. In Scotland for example, it was
found that “Twenty­one percent of the population in poorer areas have limiting long­term
illnesses or disabilities, compared with only 8.5% in affluent areas.” ​(Watt & Mercer, 2007)​.
Similar to the Canadian system, services and clinic visits in Scotland are free and available to its
entire population. This point indicates that health is not sold as a commodity however
inequalities in health still exist as the health care system is not properly distributing its services.
The study found that in Scottish communities, service distribution “... remains flat across
socioeconomic indices.” meaning that services are distributed evenly among communities in
such a way that neglects the reality that different classes have different levels of need and require
different levels of care to maintain the same level of health ​(Watt & Mercer, 2007)​. While this
‘universal and free’ health care system sounds ideal on the surface, it must be realized that
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5. vulnerable populations have the same quantity of accessible health care facilities but are
nonetheless receiving less care as their need exceeds the resources they have access to. Instead
of distributing health care services based on need and demand, they are evenly spread among the
affluent and poorer areas ​(Doorslaer & O'Donnell, 2011)​. This poses a major problem as the rate
of population need is not proportionate to the quantity of general practitioners and clinics
available in the area. For example, it is commonly overlooked by policy makers when planning
where to establish community health care facilities that deficiencies in health are “...concentrated
within families, such families are concentrated within practices, and, in many parts of the
country, such practices are concentrated within areas.” ​(Watt, 2002).​ It is seen that communities
of middle to high SES status normally require much less medical care in order to be healthy than
populations of low SES status. Due to this ineffective method of health care facility distribution,
it is likely that high SES populations with fewer health concerns and limitations are able to
receive longer and higher quality appointments more frequently with shorter wait times than
populations of low SES status. As a result major inequalities in health and accessibility have
been established between populations of high and low SES status ​(Watt, 2002)​. In brief, although
access to healthcare is free for all citizens in Canada, the Canadian health care system fails to
provide equal rates of services relative to the vulnerability and the needs of populations of
varying SES status’ thus revealing the thriving nature of the inverse care law in the Canadian
health care system ​(Hart, 1971)​.
Vulnerable populations of low socioeconomic status are not only subject to poorer access
to healthcare services and facilities but they also receive poorer quality services. According to
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6. Hart, the increased demand and severity of health­related issues among vulnerable populations
challenges general practitioners and prevents them from achieving high quality work and
improving their medical skills ​(Hart, 1971)​. He gives the example of mining communities to
illustrate this issue. It had been found that in mining communities people are faced with
significantly higher levels of social and health­related illnesses due to low SES conditions such
as limited income, low levels of job security, few benefits associated with employment and
polluted environments ​(Hart, 1971)​. All these factors cause mining populations to have higher
needs for medical attention and healthcare services. Although Hart’s example does not reflect the
current conditions in mining communities today, the example still effectively demonstrates how
conditions in low SES communities require greater health care investments ​(Doorslaer &
O'Donnell, 2011)​. When doctors are busy caring for large and unhealthy populations, they are
forced to neglect other aspects of their career that would benefit their patients such as additional
training and research in their field. In order for doctors to improve their practices, “...they must
be free enough from pressure of work to stand back and look at it critically.” which is almost
impossible for those who work in deprived areas where many patients are in need of critical care
(Hart, 1971)​. It is evident that specialized and individualized care is needed everywhere but it is
especially needed in areas where people are the most unhealthy and vulnerable to disease ​(Watt,
2002)​. In most cases unfortunately, this care is only available for healthy affluent populations as
they have less pressing needs which allows healthcare providers with the time to invest in
different forms of improvement such as research, training and critical evaluations of the nature
of their practices ​(Hart, 1971)​. These opportunities are often impossible in disadvantaged
low­SES communities as doctors have large workloads that demand all of their time; leaving
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7. them with no extra time to make improvements or spend more time with their patients ​(Watt,
2002).​ To summarize, when doctors working in low SES areas have many patients with many
needs and very little time to spend with them it causes patients of low class to grow increasingly
unhealthy with time which exposes the true nature of the inverse care law in the Canadian health
care system.
While the majority of Canadian citizens have access to nearby primary health care
facilities, the inability to speak an official Canadian language and other social barriers can be
equally as much of an issue when seeking health care (Raphael, 2000). The inverse care law
explains the disproportionate levels of health care accessed by vulnerable immigrant populations
and Canadian­born populations ​(Hart, 1971)​. Upon their arrival, immigrant populations in
Canada should be provided comprehensive and specialized health care services in order to
reduce possible initial inequalities in health among Canadian citizens ​(​Public Health Agency of
Canada, 2008). Unfortunately this is not often the case. Instead, those who know little french or
english are likely to feel that their access to health care is restricted due to language barriers and
sociocultural differences ​(Hart, 1971)​. A study conducted by the Public Health Agency of
Canada on health care found that immigrant women and Canadian­born women shared the belief
that health care and prevention were crucial in maintaining good levels of health yet health care
resources were much more accessible for the Canadian­born women. Researchers found that two
of the main causes for this difference in accessibility were “...​language difficulties experienced
by immigrants from countries of origin where French or English is not a primary language” and
“a lack of cultural sensitivity among health­care providers…” (​Public Health Agency of Canada,
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8. 2008). It is important to realize this issue in the Canadian health care system as it promotes the
growth of health inequities and uneven levels of health among populations of high and low
socioeconomic status’ (Raphael, 2000). On top of the linguistic barrier, feelings of being socially
isolated and misunderstood will effectively keep immigrants out of facilities. The limited
healthcare resources accessed by immigrant citizens leads to lower levels of health and higher
vulnerability; which will in turn make social and economic aspects of life much more difficult
such as maintaining a job and caring for children ​(​Public Health Agency of Canada, 2008). It
will also provide Canadian­born citizens with more resources as they are underused by others
who are likely to need it more (Hart, 1971) . To summarize, the the principals of the inverse care
law are shown to exist in the Canadian healthcare system in the management of health care
access to immigrant citizens.
The differences in lifestyle characteristics between populations of low and high
socioeconomic status is key factor that encourages the function of the inverse care law in the
Canadian health care system (​Whitelegg, 1982​). Those of low socioeconomic status are faced
with greater economic burdens and social barriers, which makes accessing health care
increasingly difficult. According to Raphael (2000), “status affects health by determining the
degree of control people have over life circumstances and, hence, their capacity to take action” in
terms of accessing health care and relative treatment. There are various lifestyle characteristics
that reveal the truth in Raphael (2000)’s statement on how little control over circumstances
makes accessing health care more challenging for deprived population. First, people of low
socioeconomic status have little control over their careers. They are obliged to work long hours
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9. to provide for themselves and their families. The entry­level jobs they have offer low salaries,
little flexibility and poor levels of job security. Taking time off work to visit a medical facility
puts their job at risk and and the hours of pay lost by seeking medical attention is an economic
burden (​Whitelegg, 1982​). The fears of being fired and losing money causes many people of low
status to neglect their medical concerns. In contrast, affluent populations have flexible and secure
jobs where they are not penalized for taking time off work for health reasons. They also tend to
work shorter hours and receive higher salaries which allows them to access health care resources
without the fear of losing their jobs or compromising their family’s well­being. Second,
(Raphael, 2000) mentions that low status populations in Canada have little control over their
health and ability to access health care resources because of poor social support and the lack
government assistance. Little time is free for those of low status populations as most of their time
is consumed by work and the rest is spent doing housework and caring for their children ​(​Public
Health Agency of Canada, 2008). While child care would be a simple solution to economize
time, most provinces in Canada do not subsidize care services which makes such services
unaffordable for people of low status. Also, little community support is offered as other families
in the community would have similar challenges (​Raphael, 2000)​. This weakens their ability to
access the medical care they need as their time off work is dominated by household duties;
leaving them with little control over life circumstances. Unlike populations of low status, those
of high status have much more time and capital which gives them control over life circumstances
and therefore facilitates health care access (​Raphael, 2000)​. Parents have jobs that consume less
of their time, child care is affordable and they have the means to offer their support to others in
the community. In short, health care is accessed less by the vulnerable populations who are more
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10. in need of it due to the economic and social barriers that limit them such as job insecurity and
limited childcare options.
The way in which private health insurance is exclusively possessed by two thirds of the
Canadian today threatens the idea of equal service and care accessibility relative to need and
therefore encourages the presence of the inverse care law among populations of high and low
SES status (Squires, 2010). Among the other challenges in accessibility of health care services
for vulnerable Canadians of low SES status, the lack of private insurance affordability stands in
the way of them accessing specialized services that would greatly benefit their health ​(Kasturi,
2003)​. Unlike populations of higher SES status, low SES populations suffer significantly more
from illness and disease as they are increasingly exposed to unhealthy environmental conditions
and stresses caused by factors such as community congestion, violence and poor job
opportunities; which indicates that low SES groups would benefit more from privately­insured
services (Céspedes et al., 2012). As private health care services are being used at higher rates
today than they were three decades ago and public services are being used less, more researchers
aim to determine the effectiveness, or rather the ineffectiveness of the Canadian universal health
care coverage system in ensuring equal health opportunities in terms of service accessibility
among high and low SES groups. According to the findings of P J Veugelers and A M Yip
(2002), the use of Medicare in Canada does not improve health inequalities and disparities as
much as they should because valuable private health care services remain inaccessible for many
Canadian citizens. Their results show that while the average number of clinic and hospital visits
per capita are similar among populations of high and low SES status, the major discrepancy lies
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11. within the rate of private care accessed per capita. The study concludes that private services need
to be available to low SES populations in order for a reduction in health inequality rates in
Canada, but until such changes are made the health gap between high and low SES groups will
continue to grow ​(Yip & Veugelers, 2002)​. To conclude, universal healthcare coverage in
Canada ensures that populations have free access to basic clinic and hospital care, yet the nature
of the inverse care law continues to exist as the most vulnerable populations of low SES groups
who are most in need of care cannot access private health care services that are uninsured by
medicare (Squires, 2010).
Low SES status and linguistic barriers make accessing health care a great challenge in
Canada. In low SES neighborhoods, clinics have been shown to be crowded with patients who
are in great need of medical care than clinics found in high SES neighborhoods ​(Watt, 2002)​. In
addition, many of the studies looked at in this essay have shown that low SES groups have
dramatically higher vulnerability to disease and illness. To ensure that low SES groups maintain
similar levels of health as the affluent portion of the Canadian population, they should have
access to more clinics and other health care services, yet such services are distributed
horizontally across populations of all SES groups, which makes accessibility difficult for people
of low SES status ​(Watt & Mercer, 2007)​. Also, low SES groups are faced with additional
challenges which that are often associated with their class. Factors such as linguistic barriers,
unhealthy working and living conditions and not being privately insured reduces their likelihood
of accessing health care (Raphael, 2000). The Canadian health care system does offer
taxed­funded insurance to all citizens in order to limit health inequalities between high and low
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12. SES populations but limits to this system causes the affluent to become increasingly healthy and
vulnerable populations to become increasingly unhealthy (Squires, 2010). When the Canadian
health care system is critically looked at in relation to the services and treatments different
classes have access to, it is evident that Hart’s inverse care law is still present in the Canadian
health care system today. A great next step for research regarding the relevance of the inverse
care law in Canada would be to compare the arguments of this essay with the recommendations
made in the 2002 Romanow report funded by the Commission on the Future of Healthcare in
Canada. This comparison would allow one to discover if the issues discussed in this essay are
being acknowledged by the Canadian government and if future plans have been established to
eradicate such health inequalities among different classes in Canadian society.
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