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Population with household expenditures on health > 10% of total household expenditure or income (%), 2015-2021: 2.36%
Population with household expenditures on health > 25% of total household expenditure or income (%), 2015-2021: 0.56%

Source: World health statistics 2025: monitoring health for the SDGs, Sustainable Development Goals. Tables of health statistics by country and area, WHO region and globally. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.

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Share of Household Income (2010-2019):
    Bottom %: NA; Top 20%: %; Bottom 20%: %
Gini Coefficient (2010-2019):
Palma Index of Income Inequality (2010-2019):

Note: Gini coefficient – Gini index measures the extent to which the distribution of income (or, in some cases, consumption expenditure) among individuals or households within an economy deviates from a perfectly equal distribution. A Gini index of 0 represents perfect equality, while an index of 100 implies perfect inequality.
Palma index of income inequality – Palma index is defined as the ratio of the richest 10% of the population’s share of gross national income divided by the poorest 40%’s share.

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“A widening treatment gap between the most and least deprived 20 % of the population in England occurred over the two decades to 2018/19 whilst hip and knee replacement rates doubled and trebled, respectively. In 2018/19, for every ten patients admitted for hip and knee surgery from the most deprived quintile, 19 and 15 were admitted from the least deprived, respectively, compared with 13 and 9 in 1997/98. Inequality increased in each of the three periods, accelerated from 2003/04 (period 2), and increased fastest between 2007/08 and 2018/19 (period 3) in the private sector when admissions to the NHS were falling.

“Inequality in admissions for hip surgery in England has been documented previously between 2001/02 and 2008/09 [13]. Our findings of increasing use of the private sector resulting in a pro-rich bias confirm earlier research findings of the least deprived patients having a substantially higher level of use of private providers between 2003/04 and 2012/13 and benefiting most from increasing private provision [17]. They also mirror findings from Scotland where outsourcing NHS funded hip replacements was associated with increasing age and socio-economic inequalities [16].”

Source: Kirkwood G, Pollock AM, Roderick P. Private sector expansion and the widening NHS treatment gap between rich and poor in England: Admissions for NHS-funded elective primary hip and knee replacements between 1997/98 and 2018/19. Health Policy. 2024;146:105118. doi:10.1016/j.healthpol.2024.105118

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“Julian Tudor Hart’s inverse care law states that the “availability of good medical care tends to vary inversely with the need for it in the population served” and “operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” [38]. The study’s findings support this and highlight the need for NHS England to revisit its policy of further outsourcing elective hip and knee replacements in the context of its inequality duties, and to rebuild in-house provision and capacity. Where contracts for these procedures have already been awarded or sub-contracted to the private sector, ICBs, NHS trusts and foundation trusts should assess, monitor and publish the impact of the contracts on admission inequalities.”

Source: Kirkwood G, Pollock AM, Roderick P. Private sector expansion and the widening NHS treatment gap between rich and poor in England: Admissions for NHS-funded elective primary hip and knee replacements between 1997/98 and 2018/19. Health Policy. 2024;146:105118. doi:10.1016/j.healthpol.2024.105118

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“In 2006, people living in more deprived areas were more likely to need a hip replacement than their counterparts in more affluent areas. These relative differences in need were sustained over the subsequent decade. But people living in deprived areas were less likely to receive an NHS-funded hip replacement than people living in other areas in 2006. This perfect illustration of the inverse care law confirms earlier research. Although the supply of NHS-funded hip replacements increased substantially between 2006 and 2016, the relative under-supply to people living in the most deprived areas did not improve. We note that ‘health inequalities’ and ‘healthcare inequities’ featured prominently in healthcare policies in both countries during this period, despite substantial differences in health policy.

“In fact, it was the least deprived areas that saw the greatest increase in supply of NHS-funded hip replacements over this period. These changes appear to be associated with NHS waiting times. When waiting times improve, the most affluent segments of the population opt for NHS-funded treatment and reduce their reliance on privately-funded care, switching back when waiting times deteriorate.”

Source: Wyatt S, Bailey R, Moore P, Revell M. Equity of access to NHS-funded hip replacements in England and Wales: Trends from 2006 to 2016. Lancet Reg Health Eur. 2022;21:100475. Published 2022 Jul 29. doi:10.1016/j.lanepe.2022.100475.

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“This study adds to the debate on how equitable improvements to primary care services for vulnerable populations can be promoted [49]. It explores the implementation of a new co-produced digital educational intervention to improve access, drawing in particular on NPT [Normalisation Process Theory] to understand how the intervention is enacted and embedded in practice. It also considers the impact of how the intervention and its implementation is experienced from the perspective of patients from the target population. Regarding the learning, pharmacists and their support staff reported several well documented barriers to learning. These were similar to those reported when undertaking continuing professional development (CPD) including not having time, lack of resources and interest [50]. Incorporating CPD as a form of in situ workplace learning has been suggested to improve engagement and professional practice [51]. However, our study suggests the perceived excessive workload within pharmacies, creates a barrier to undertaking new learning and constrains applying this knowledge in the workplace [52].

“The findings from the four constructs of NPT framework revealed the complexity and extent to which the outcomes from the learning became normalised in practice. Under the coherence theme, the findings revealed there were improvements in awareness and better understanding of health inequities including how they occurred. However, cognitive participation and collective action remained limited due to organisational barriers and work place constraints. This hindered effective practice change to occur and to be sustained. When appraising their work (reflexive monitoring), most success was seen when pharmacists took it upon themselves to effect change; when this occurred, there was real potential for this to overcome the barriers to implementation and to achieve and maintain normalization. It could be that pharmacists who had been proactive, had positive attitudes to innovation or were, ‘early adopters’ [53]. Others have described these pharmacists as engaging fully with training and learning activities, being receptive to innovative behaviours and welcoming greater autonomy [54]. Nevertheless, effective ways to address inequity should seek to involve staff from all levels with equal motivation to participate in ‘readiness for change’ where these could contribute to improving practice [55].

“Regarding the impact on patients, MURs ]Medicines Use Reviews] were welcomed and the extra help and support these afforded were appreciated. In terms of Levesque et al. [56] model of conceptualising access, the learning had promoted abilities to perceive, seek, reach and engage with several medically under-served groups. It is well reported that people from these groups are more likely to manage health as a series of minor and major crises, rather than treating diseases as requiring maintenance and prevention [57]. Where the intervention was successfully implemented and professional learning was successfully implemented, there was potential for patient benefit. In times where questions are being asked about whether MURs represent value for money, targeting MURs to marginalised or medically under-served groups could be a valuable step towards demonstrating their relevance within certain medically under-served groups. However, it is clear that further research is needed to address the structural inequities within the system.”

Source: Latif A, Waring J, Pollock K, et al. Towards equity: a qualitative exploration of the implementation and impact of a digital educational intervention for pharmacy professionals in England. Int J Equity Health. 2019;18(1):151. Published 2019 Oct 12. doi:10.1186/s12939-019-1069-0.

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World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other nations.

Page last updated August 6, 2025 by Doug McVay, Editor.