EI-Haleon Report A4

The Health
Inclusivity Index
Measuring progress towards
good health for everyone
Supported by
The Health Inclusivity Index: measuring progress towards good health for everyone 2
Contents
3 About this report
5 Foreword
6 Preface
7 Executive Summary
13 Background
16 Introducing the Health Inclusivity Index
20 Theme 1: A focus on the social determinants of health leads to

more inclusivity
24 Theme 2: Health inclusivity requires the identification of vulnerable

populations
28 Theme 3: Universal health coverage is necessary, but not sufficient,

for health inclusivity
31 Theme 4: Money is not the only driver of inclusivity–in fact, better

inclusivity can drive economic growth
35 Theme 5: Community and individual empowerment is at the heart

of health inclusivity
40 Theme 6: Inclusivity is only part policy–without implementation,

policy is meaningless
46 Campaigning for an undefinable goal
49 Discussion: bringing it together
53 References
© The Economist Group 2022

About this report
“The Health Inclusivity Index: measuring progress London; Director, Science, Medicine, and Society
towards good health for everyone” is a white Network. He and his team acted as our principal
paper by Economist Impact, supported by expert adviser(s) as we created the Index.
Haleon. The white paper presents the Health
We would also like to thank our steering
Inclusivity Index, why it was created, a thematic
committee (in alphabetical order)
review of its main findings and what they reveal
about health inclusivity globally, and concludes
• Athia Yumna, Deputy Director of Research
with a series of actions that nations and other
and Outreach, The SMERU Research Institute
state and non-state actors can take to improve
(Indonesia)
health inclusivity, both for their citizens and for
other people and communities who turn to them • Brian C. Quinn, Associate Vice President,
for support. Robert Wood Johnson Foundation, (US)
Health inclusivity is a measure of whether • Charlotte Ersbøll, Founding partner of

national policies, systems and cultures give sustainable impact consultancy Hansen &
everyone in society the opportunity to optimise Ersbøll Agenda (Denmark)
their health. The Health Inclusivity Index, the
results of which are reported here, is the first • Christine Brown, Head, European Office
ever snapshot assessing the state of health for Investment for Health and Development,
inclusivity across 40 countries. World Health Organization (Italy)
Alongside the white paper is a methods and • Indrani Gupta, Professor and Head, Health
findings report, which describes in greater Policy Research Unit, Institute for Economic
detail how the Index was created, its domains, Growth (India)
subdomains and indicators, and our main
• Li-Wu Chen, Professor, Department of Health
findings.
Sciences, University of Missouri (US)
While the Index is an Economist Impact
• Professor Sir Michael Marmot, Professor of
index, we could not have created it without
Epidemiology at University College London,
the input and support of a variety of experts.
Director of the UCL Institute of Health Equity,
First among these is David Napier, Professor
and Past President of the World Medical
of Medical Anthropology, University College
Association (UK)

• Pastor Elías Murillo Martínez, Independent • Hoda Rashad, Professor and director of
Expert of the Permanent Forum on People of the Social Research Center, The American
African Descent, United Nations (Colombia) University in Cairo (Egypt)
• Rosemary Calder, Professor of Health Policy, • Indrani Gupta, Professor and Head, Health
Mitchell Institute, Victoria University (Australia) Policy Research Unit, Institute for Economic
Growth (India)
• Terry Huang, Professor and Director, CUNY
Graduate School of Public Health and Health • Kristine Sørensen, Founding Director, Global
Policy, Center for Systems and Community Health Literacy Academy (Denmark)
Design (US)
• Professor Sir Michael Marmot, Professor of
• William Hsiao, K.T. Li Professor of Economics, Epidemiology at University College London,
Emeritus, Harvard T.H. Chan School of Public Director of the UCL Institute of Health Equity,
Health (US/China) and Past President of the World Medical
Association (UK)
We would also like to thank our expert panel (in
alphabetical order) • Nima Asgari-Jirhandeh, Director, Asia Pacific
Observatory on Health Systems and Policies,
• Amanda Lenhardt, Teaching Fellow, SOAS
WHO (India)
University of London (UK)
• Rosemary Calder, Professor of Health Policy,
• Gayle Capozzalo, Professor and director of
Mitchell Institute, Victoria University (Australia)
the Social Research Center, The American
University in Cairo (Egypt) • Terry Huang, Professor and Director, CUNY
Graduate School of Public Health and Health
• Hoda Rashad, Professor and Director of
Policy, Center for Systems and Community
the Social Research Center, The American
Design (US)
University in Cairo (Egypt)
• Vera Schattan P. Coelho, Senior researcher,
• Regina Benjamin, 18th United States Surgeon
Brazilian Center of Analysis and Planning
General (US)
(Brazil)
• Vera Schattan P. Coelho, Senior researcher, Economist Impact bears sole responsibility for
Brazilian Center of Analysis and Planning the content of this report. The findings and views
(Brazil) expressed in the report do not necessarily reflect
We would also like to thank our interviewees (in the views of the sponsor or the experts who
alphabetical order) kindly gave their time to advise us.
The research was led by Emi Michael and Elly

• Abebe Shimeles, Director of Research,
Vaughan. Alan Lovell was the programme
African Economic Research Consortium
director. The research team consisted of Jad
(Kenya)
Baghdadi, Miranda Baxa, Anelia Boshnakova,
• David Napier, Professor of Medical Giulia Garcia and Murat Ozturk.
Anthropology, University College London;
Director, Science, Medicine, and Society
Network (UK)

Foreword
Health and health equity, the fair distribution of health, are issues for all countries. Action is needed
on the social determinants of health, as well as ensuring universal health coverage. There is ample
evidence on what that action should look like. It must involve the whole of government and civil
society. The problem, for too many countries, is lack of data – both to assess the nature of the
problem, and to monitor progress. For all countries, we need a set of measures that captures the key
determinants of health equity, and measures meaningful health outcomes. Researchers will want to
rank countries and perform analyses, rightly so, but countries themselves can base policy and practice
on measures that capture health equity.
This Health Inclusivity Index has the potential to fill this gap. It will still entail detailed data collection
by countries, but the Index provides a conceptual framework and a guide to the data that are needed.
There are several innovations in this Index that are worth highlighting. First, international organisations
commonly equate health and health care. When they give figures for spending on “health” they usually
mean spending on health care, not on poverty reduction, education, decent working conditions, social
protection, community enhancement and the like. This Index does indeed include a focus on access to
health care, but its main concern is population health. Second, and linked, there is a clear focus on the
social determinants of health. It makes little sense to aim to monitor health performance of countries
and exclude the key determinants of health.
Third, the Health Inclusivity Index emphasises empowerment of individuals and communities. The
Commission on Social Determinants of Health (which I chaired) emphasised empowerment as a key
step to achieving health equity. There is a danger that over-emphasis on individual agency may lead to
arguing that it is up to individuals to ensure their own health, and let governments off the hook. This
index makes explicit the need to engage communities and individuals, not to the exclusion of social
action – that is covered in other themes of the Index – but as a necessary complement to it.
Fourth, the Index makes explicit the need not only to have measures of appropriate policies but to
have means of assessing implementation.
The Health Inclusivity Index has the potential to make an important contribution to monitoring health
and health equity globally.
Professor Sir Michael Marmot

Professor of Epidemiology at University College London,
Director of the UCL Institute of Health Equity, and Past
President of the World Medical Association

Preface
It has been my great privilege and pleasure to lead the research deep dive for this exciting new
initiative. Examining equality and equity from the perspective of health inclusivity alters the horizons
of health policy. It draws attention to what health inclusion means—asking us to reflect on who
gets included, on who ‘we’ are and who ‘we’ aren’t. For equitable inclusion can be embedded in a
national system of care for citizens, while at the same time those without full health agency can find
themselves passively, or even overtly, excluded.
Because we cannot, therefore, talk about inclusion without examining exclusion, the Health Inclusivity
Index offers a new approach to health equity. By measuring the prevalence of policies and processes
that either equalise or unsettle a population’s health, it recognizes that risk factors cannot be isolated.
Rather, they compound one another in daily life, making behaviour change difficult, even at times
impossible, for those in the throes of abject calamity coping.
It is not only its attention to the dynamics of inclusion and exclusion that distinguish the Index. It is
also its ability to show that being health vulnerable is not a stigma. Rather, vulnerability is a signal
that compounding risks have limited a person’s ability to achieve a life fully realized. Hence, the usual
candidates we label ‘vulnerable’ (e.g., the homeless, or those dealing with substance abuse, or those
living with significant psychological stress) represent the consequences, not the causes, of exclusion.
Indeed, in considering illness from the standpoint of inclusion and exclusion, we acknowledge how
variously diverse but equally marginalised groups can be driven into isolation in times of crisis.
Shifting our focus from equity outcomes data to health inclusion and exclusion also allows for other
considerations. It requires us to consider how inclusion and exclusion function locally. Here, we must
not only ask how national health systems can serve communities, but also how that engagement
impacts the specific challenges to health that at-risk and vulnerable individuals face locally.
The purpose of this Index, therefore, is not just comparative. Even the highest scoring countries may
fall short when it comes to including populations easily marginalized in times of social stress. The
purpose of the Index is also to provide countries with an awareness of how health inclusivity can be
improved by addressing specific indicators or groups of indicators both at national and community
levels. For it is in the connections between the two where the Index stands not only to compare
countries and their policies, but to improve health inclusivity globally.
David Napier
Professor of Medical Anthropology,
University College London; Director, Science,
Medicine, and Society Network

Executive summary
Introducing the index: why it’s important and what it measures

Poor health–even of sections of society–is bad inclusion, and to show how they can be used
news for society overall. Poor health limits the effectively (see the associated technical report
social and economic participation of individuals, for more methodological details). We have
with consequent impacts on the social and clustered the indicators into three domains:
economic wellbeing of communities and
• Domain 1: Health in Society comprises
countries.
indicators designed to assess how highly a
We all know that widespread disparities in health nation values the health of its people, and
outcomes, both within and between countries, whether it considers health across all the
exist. But measuring disparities in outcome policies of its government
cannot explain why these disparities arise and
• Domain 2: Inclusive Health Systems
persist, or show us how to tackle them. Only by
includes indicators to measure the strength
understanding the barriers to good health for
and scope of the healthcare system, and
all people can we design a truly inclusive health
whether cost is a barrier to accessing services
system.
• Domain 3: People and Community
Enter the Health Inclusivity Index.
Empowerment measures efforts to ensure
The Index defines health inclusivity as the process that healthcare services are designed to be
of removing the personal, social, cultural and inclusive, accessible, and tailored to individuals
political barriers that prevent individuals and and their preferences, including those from
communities from experiencing good physical vulnerable groups
and mental health, and a life fully realised. Our The Index is intended to help governments
Index, the results of which are reported here, benchmark their progress and identify
is the first ever snapshot of how 40 selected opportunities for improvement. We hope it will
countries compare on this issue. encourage engagement and dialogue, and spur
action on health inclusivity.
The Index arose from a recognition that health
is a complex construct, and that providing This is the first year of an (initial) three-year
healthcare systems alone cannot guarantee programme. Years two and three will see the
good health for everyone. Inclusivity in health number of countries included in the Index rise
requires that a society value health so highly to 60 and then 80. This first iteration offers us
that it pervades all areas of national policy, an opportunity to stress-test the Index. This is a
strategy and programmes. The 37 indicators living, breathing, and, above all, inclusive project,
we developed are intended to demonstrate the so please do contact us (Emimichael@economist.
levers governments, policymakers and others com and [email protected]) with
can use to address health inequity and promote suggestions and observations.

Index findings and policy takeaways
Theme 1: A focus on social Theme 2: Health inclusivity requires

determinants of health leads to the identification of vulnerable
more inclusivity populations
Years of advocacy have elevated awareness It is concerning that 1 in 5 countries have
of the right to health and the importance of exclusionary policies or practices in place
the social determinants of health in improving that explicitly restrict access to healthcare for
health outcomes. According to our findings, certain groups or individuals. Six countries
93% of countries recognise health as a human say they recognise health as a human right—
right, and 75% of countries include policies yet exclude some people from healthcare
that address the social determinants of services. High-scoring countries have systems
health. Although evidence of “health in all to identify marginalised groups, although
policies” was skewed towards the high-scoring the prevalence of health exclusion policies
countries, 50% of the Index countries showed (indicator 1.1.5) is higher amongst the top 10
evidence that government departments scoring countries than the bottom 10.
worked together across sectors to promote
health, and of oversight to ensure cooperation.
The best performing countries emphasised a Implementing inclusivity: theme 2
“health in all policies” approach. • Exclusion from services could happen
from oversight or be deliberate.
Ask whether your “hard to reach”
Implementing inclusivity: theme 1 populations are simply underserved.
• Incorporate health as a human right, • Have processes to identify vulnerable
and definitions of wellness, into populations, and identify–and tackle–
strategic documents. While a “right to be social determinants of health that are
healthy” is impossible, a right to health especially pertinent for them.
emphasises the multifactorial actions
that are needed for inclusive health. • Identify, and remove, policies that
exclude some from accessing health.
• Inclusive health cannot be created
by focusing on healthcare alone.
Utilise what is known about the social
determinants of health, and ensure that
factors such as a patient’s education,
income level and environment are
considered when providing care.
• Emphasise a “health in all policies”

approach to government. Senior
leadership needs to use their influence
to align policies across ministries.

Theme 3: Universal health coverage Theme 4: Money is not the only

is necessary, but not sufficient, for driver of inclusivity–in fact, better
health inclusivity inclusivity can drive economic growth
Inclusive access to health care requires that Countries’ wealth and health spending do
health resources are accessible, easy to not guarantee greater inclusivity in health.
navigate, affordable and of decent quality. Inclusivity is only somewhat related to GDP
High-income countries have more doctors, per capita or current health expenditure.
nurses, pharmacists and dentistry personnel, There is also a moderate positive relationship
while middle-income countries have more between health inclusivity and a country’s
community health workers, environmental and current health expenditure, but there is a lot
occupational health workers, and traditional of scatter on either side of the line—meaning
medicine personnel. some countries score higher than expected
and others lower than expected. We found
a moderate positive relationship between
Implementing inclusivity: theme 3
healthy life expectancy and overall Index
• To engage with their health, people need scores. Of the 12 countries which scored 80 or
to be able to care for themselves and above for health inclusivity, nine scored in the
their families in a way that prioritises top group for healthy life expectancy.
health. Incorporate mechanisms to
safeguard individual agency alongside
community empowerment. Implementing inclusivity: theme 4
• Don’t just track crude outcomes data
• Stigma and prejudice remain a barrier such as life expectancy, but rather
to leading a healthy life. Systematise prioritise measures that capture quality,
cultural competency training and not just quantity, such as healthy life
person-centred approaches to service expectancy.
delivery.
• Recognise that health inclusion is
• Coordinate the provision of healthcare more complex than the money spent
services, ensuring that they are provided on health; empower communities by
in the community rather than in distant decentralising care and establish agency
healthcare facilities. This requires by removing societal barriers.
coordination across sectors –public
and private sector organisations must • Use out-of-pocket expenditure as a
recognise the critical role they play useful way of getting a “quick and dirty”
in driving health inclusivity and work assessment of health inclusivity in a
collaboratively to decentralise care. country.
• Utilise multidisciplinary teams, including • Low-income countries need to protect

nurses, dietitians, physiotherapists, themselves from “brain drain”, the
pharmacists, social workers and primary movement of expensively trained
care doctors to address the challenges healthcare professionals from poor to
that many people face when trying to rich countries. Similarly, high-income
manage their health at a community countries should not rely on immigration
level. to staff their healthcare services.

Theme 5: Community and individual Theme 6: Inclusivity is only part

empowerment is at the heart of policy–without implementation,
health inclusivity policy is meaningless
Countries with the highest overall scores provide Policies supporting inclusion require an
individuals and communities with the tools accompanying commitment to a whole-of-
to take charge of their own health. Domain 3: government implementation framework.
People and Community Empowerment has the Without this, the uncoordinated actions of
greatest range of scores, but also the strongest multiple ministries will inevitably lessen the
correlation with the overall health inclusivity impact of state interventions. Similarly, nations
score; it is also the highest scoring domain can’t manage what they don’t measure. It is
for 80% of the top 10 countries, together crucial that countries strengthen their efforts
indicating that it is the best predictor of a in data monitoring and reporting across all
country’s overall position in the Index. segments of the population.
Implementing inclusivity: theme 5 Implementing inclusivity: theme 6

• Community health workers can play a • The job of government is not completed
multidimensional role and should be by the passing of a (health inclusivity)
utilised in both high- and low-income policy.
countries to better engage communities,
• Ensure that policies have
debunk myths, and dismantle cultural
implementation and monitoring
barriers to care.
processes embedded in them, and dates
• Disseminate information for self-care in for post-implementation reviews.
relevant languages to target populations
• Track inclusivity by monitoring health
to ensure that all dimensions of health,
outcomes and service-user metrics for
physical, mental, and emotional, are
vulnerable populations. Equity does
considered and promoted.
not mean that all will have the same
• Support health literacy to increase outcomes, but only by measuring can
health knowledge, build population- you begin the process of identifying
level resilience, encourage positive where extra support is needed.
lifestyle changes, and empower people
to effectively manage long-term health
conditions.

An index, a toolkit and a conceptual framework

Although we have created an index of health If we were to offer a single takeaway, it would
inclusivity, it also functions as a conceptual be that while Domains 1 and 2 have, quite
framework and toolkit for policymakers rightly, long had their champions, the ideas
and other stakeholders. It’s a conceptual encapsulated in Domain 3–including cultural
framework because inclusivity is a term often competency, community empowerment and
used but rarely defined. Our hope is that by individual agency–are often missing from the
describing the domains and subdomains, we health inclusivity discourse. Un-championed,
offer a concrete, quantitative way to think unmeasured, and frequently unrecognised,
about inclusivity. It’s not perfect, and many the concepts in Domain 3 are, we believe,
will disagree with our approach, but we hope the components of the inclusivity landscape
that our transparency in defining inclusivity critical to future progress.
will encourage our critics to be similarly
transparent in their feedback.
The Index is like a toolkit because its focus on

policies, processes and institutions, rather than
outcomes, enables policymakers to identify
not only that action needs to be taken, but
what that action should be. The Index gives
governments a good starting point to see how
they stand compared to their peers, and where
action can be taken to improve their scores.

“Health does not begin in a hospital

or clinic. It begins in our homes
and communities, with the food
we eat and the water we drink, the
air we breathe, in our schools and
our workplaces.”
Dr Tedros Adhanom
Ghebreyesus, WHO
Director General1

Background
Why do we need an index of inclusivity in health?

Approaches to improving health for all have often focused on widening access to healthcare services.2
Yet, even countries with apparently universal access to healthcare services have wide disparities in
health outcomes within their populations.3 Typically, people with the highest incomes from dominant
groups enjoy the best health and the most years of life in good health, while people with lower
incomes from marginalised groups are most vulnerable to morbidity and mortality.4
We know that widespread disparities in health outcomes exist, both within and between countries.
But measuring disparities in outcome alone cannot explain why such disparities arise and persist,
or show us how to tackle them. These disparities could, for example, be evidence of inequity of
healthcare provision and social support, wider social determinants of health, or differences in people’s
ability to engage in a health-enhancing lifestyle.
The Health Inclusivity Index arose from a recognition that health is a complex construct, and that
healthcare systems alone cannot guarantee good health for everyone. The aim of the Index is to look
at the levers that policymakers and societies have at their disposal to improve health inclusivity–it is an
index of “inputs” rather than “outputs”. It does not measure disparities in outcome, but it does measure
the policy differences that have, at least in part, led to those disparities in outcome.
Good health goes beyond healthcare

Inclusivity in health requires a society to value health so highly that it pervades all areas of national
policy. We began the development of the Index by considering the many factors known to have an
impact on health.5 Good health rests on an ecosystem that spans many sectors. This ecosystem
includes good housing within a health-promoting environment, access to good education, economic
opportunities, opportunities to be physically active within an environment that facilitates this, and
access to a balanced and health-promoting diet. These factors, among others, are often collectively
referred to as the social determinants of health (SDH).6 WHO calculates that between 30% and 55% of
health outcomes can be attributed to the SDH.7

Inclusivity in health requires a society to

value health so highly that it pervades
all areas of national policy
We are therefore not just interested in healthcare services as health depends on far more than access
to medical care. This is not an access to healthcare index.
Furthermore, promotion of health happens primarily outside the healthcare system. People need
to know how to keep themselves well, and this means they need reliable advice, information and
education. Organisations, particularly those outside of the healthcare sector, should be aware of their
role in this regard. Keeping well is easier for some people than others, depending on whether they
are living within a health-promoting ecosystem and on their cultural approach to health. For Abebe
Shimeles, Director of Research, African Economic Research Consortium in Kenya, ‘’education is central
to this discussion. It creates awareness among people, and the more educated people are, the more
they seek modern healthcare services. When people are empowered and involved through actions
that improve agency, such as taxes, elections, etc., they press governments to take concrete actions’’.
Inclusive health is ambitious for everybody. Professor Sir Michael Marmot, Professor of Epidemiology
at University College London, Director of the UCL Institute of Health Equity in the UK, observes, “We
should be aiming for everybody to have the same level of good health as the best.” It is not enough to
see if we can improve access for the poorest or most vulnerable, he says, but for everyone in society to
reach “the level of good health that is potentially achievable”.
From vulnerability to resilience

Health-promoting ecosystems encourage resilience to ill health at an individual and societal level.
Both individuals and societies can adapt more quickly to shocks if their pre-existing environment
promotes optimal health. Resilience at an institutional or systemic level is not simply about resources.
We also have to consider the demographics, such as the age profile, of the country in addition to
understanding who can, and more importantly who can’t, access resources, how they are shared, and
whether national institutions and leaders are trusted.
It is unsurprising that people who were already vulnerable to ill health because of economic or social
factors were worst affected by Covid-19.8 In many geographies, these groups included older people
living in care homes, those with poor mental health or other long-term conditions, working people with
school-age children, ethnic minority populations, and people working in the service sector.9 However,
different countries, communities and geographical regions have varying demographics and levels and
types of vulnerability, and therefore, policies need to be considered and defined at a local level.

The complexity of a good health ecosystem, and people’s varying levels of resilience and vulnerability,
explain why we need an Index of Health Inclusivity. While a global index cannot explore within-country
dynamics, it can help identify whether each nation has a broad policy framework for inclusive health
in place. Unless vulnerable groups are properly understood and included, disparities and inequities will
persist and worsen with future health shocks.
What is inclusivity in health?

The greatest challenge may be to include and empower both the poor and vulnerable, and the
wealthy and healthy. For Indrani Gupta, Professor and Head, Health Policy Research Unit, Institute for
Economic Growth in India, inclusivity means exactly that: ‘inclusivity, to me, means to include the poor,
the have-nots and the vulnerable. To make [a health service] really inclusive in an economic sense, you
also need to bring in the people with high income, with lower risks of health, diseases, etc. Because
that will increase efficiency and lower costs. So a good health coverage approach would include
everybody,’ she says.
There are other ways of defining health inclusivity. For example, Rosemary Calder, Professor of Health
Policy, Mitchell Institute, Victoria University in Australia, defines health inclusivity as: ‘’all individuals
and communities are able to experience, have access to and opportunity for good physical and mental
health, regardless of personal, social, cultural and political circumstances.’’
David Napier, Professor of Medical Anthropology, University College London; Director, Science,
Medicine, and Society Network in the UK, who led the deep learning phase of our Index construction,
says: “We define health inclusivity as the process of removing the personal, social, cultural and political
barriers that prevent us from experiencing good physical and mental health, and lives fully realised.”
This is the definition we have used for this Index.
To create an inclusive approach to health, we therefore need policies that ensure that everyone
in society can reach their full potential of good health. This includes social support, the removal
of systemic barriers, community and personal empowerment, as well as access to health services.
Alongside this, is the importance of everyday health—the actions and routines that individuals can
engage in every day to help them live longer and healthier lives. For this to happen, people must be
empowered by access to knowledge and information for self-care, in a form that is meaningful and
accessible to them.*
“This is not just about the healthcare system. It’s not an inclusive healthcare system, it is inclusive
health,” insists Professor Sir Michael Marmot. “What’s needed is action across the whole of
government.”
*The self-care model, as described in the Foreword of the WHO Guideline on self-care interventions for health and wellbeing, describes as a complement to the
provider-to-client relationship, a model in which “people are enabled to make active, informed health decisions to promote health, prevent disease, maintain
health and cope with illness and disability with or without the support of a health worker. Many health issues can already be diagnosed and managed through self-
care interventions, and the list continues to grow.”

Introducing the Health

Inclusivity Index
The Health Inclusivity Index measures the details). An index is an exercise in the art of
degree of health inclusivity within a country, the possible—many dimensions of inclusivity
through a set of indicators that assess the exist, where data is not or cannot be captured.
country’s progress towards the provision of Other activities and attitudes, not captured by
good physical, mental and social health for the Index, will inevitably impact inclusivity at
all. The markers we developed are intended a subnational level. Therefore, while the Index
to demonstrate the levers governments can is indicative of health inclusivity at a national
use to address health inequity and promote policy and programme level, the perceived
inclusion, and to show how effective these experiences of individuals and communities
levers can be when used. The Index is intended may differ from the scores reported in this
to help governments benchmark their progress white paper.
and identify opportunities for improvement.
We further hope it encourages engagement The Health Inclusivity Index assesses policies
and dialogue between policymakers, and processes using 37 indicators, measured
healthcare professionals and actors across across three domains (Figure 1):
various sectors to spur immediate and
• Domain 1: Health in Society (15 indicators)
effective action on health inclusivity.
• Domain 2: Inclusive Health Systems (13
This report provides a brief introduction to
indicators)
the Index; the full methods and results can
be found in the accompanying methods and • Domain 3: People and Community
findings report. Empowerment (9 indicators)
Inclusive health is about culture and priorities. Each domain is composed of 3 subdomains.
We wanted to ensure that the Index captured One of these is the “spirit of implementation”
this idea so that it did not simply reflect a subdomain, a composite indicator. The “spirit
country’s economic situation. Inclusivity is of implementation” indicators do not directly
multi-faceted, differing across and within map onto implementation of the indicators
countries, and this Index objectively measures of our domains or subdomains, but they give
a subset of the dimensions of inclusive an idea of the likely spirit of implementation.
healthcare systems at a national level (see the We explain this idea in detail in the relevant
associated technical paper for methodological chapter on Theme 6.

Domain 1:
Health in Society comprises indicators designed to assess how highly a nation values
the health of its people, and whether it considers health across all the policies of its
government. A nation which does not believe that everyone has a right to health, or that
believes health policy can be considered separately from other policy decisions, is less likely
to support inclusive health.
Indicators include: whether the national health strategy is based on the principle of health
as a human right; whether policies address the impact of the SDH; progress towards
implementation of tobacco control measures; and strategies around food insecurity and
healthy eating. Domain 1 also looks at whether there is evidence of cross-department
cooperation on health.
Domain 2:
Inclusive Health Systems includes indicators to measure the strength and scope of the
healthcare system, and whether cost is a barrier to accessing services. High-quality services
are not inclusive if most people cannot afford them. Services that are free at the point-of-
use are not inclusive if they are under-resourced, low in quality, or insufficient to meet the
needs of everyone in the country.
Indicators include: the percentage of the population spending more than 10% of income
on health; migrant health coverage; the proportion of current health expenditure that
represents domestic government health expenditure; number of healthcare providers per
10,000 head of population; and existence of a national electronic health record system.
Data here are at times scarce, and we could not include indicators for psychologists,
community health workers etc. as the data were not available from the WHO dataset for
about half or more of the countries included in the Index.
Domain 3:
People and Community Empowerment measures efforts to ensure that healthcare services
are designed to be inclusive, accessible, and tailored to individuals and their preferences,
including those from vulnerable groups. It also looks more generally at whether people are
given the tools that empower them to make decisions and direct their own health, and—
through community engagement—have the opportunity to shape the healthcare services
available to them.
Indicators include: whether a healthcare service translates health information into multiple
languages and has translators available for those who need them; whether a country
has outreach programmes for marginalised and vulnerable populations; whether it is
committed to person-centred care; and whether communities and the public are involved in
the development of health policy.
We acknowledge that data to measure health off point for deeper engagement on these
inclusivity are nascent. We see this Index as issues with stakeholders and policy makers.
the start of a journey towards a new way of Our findings are detailed in the sections
measuring health inclusivity, and a jumping- that follow.

FIGURE 1
The Health
Inclusivity Index
The Health Inclusivity Index assesses policies and processes using 37 indicators, measured across three domains.
Domain 1: Health in Society (15 indicators); Domain 2: Inclusive Health Systems (13 indicators); Domain 3: People
and Community Empowerment (9 indicators). Each domain is weighted equally.
Human D
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FIGURE 1. The Health Inclusivity Index

The Health Inclusivity Index assesses policies and processes using 37 indicators, measured across three domains. Domain 1: Health in Society
(15 indicators); Domain 2: Inclusive Health Systems (13 indicators); Domain 3: People and Community Empowerment (9 indicators). Each
domain is weighted equally.
Domain 1 Domain 2 Domain 3

Health in Society (33.3%) Inclusive Health Systems (33.3%) People and Community
Empowerment (33.3%)
1.1 Health as a priority (40%) 2.1 Health spending and coverage 3.1 Cultures of practice (40%)
(40%)
1.1.1 Right to health 2.1.1 Government health 3.1.1 Person-centred health care
expenditure
1.1.2 Wellbeing promotion 2.1.2 Population spending more 3.1.2 Translation services
than 10% on health
1.1.3 Social determinants of 2.1.3 Impoverishment due to 3.1.3 Community companions
health in policy out-of-pocket spending
1.1.4 Vulnerable population 2.1.4 Migrant healthcare 3.1.4 Case management
groups coverage
1.1.5 Health exclusion
1.1.6 Health inequalities 2.2 Infrastructure and workforce 3.2 People empowerment (40%)
monitoring system (40%)
2.2.1 Physicians 3.2.1 Health literacy programmes
1.2 Health in All Policies (40%) 2.2.2 Nursing and midwifery 3.2.2 Health information for
personnel self-care
1.2.1 Intersectoral cooperation 2.2.3 Dentistry personnel 3.2.3 Health outreach
policy programmes
1.2.2 Tobacco control 2.2.4 Pharmacists 3.2.4 Public/community
participation in policy
1.2.3 Marketing of foods to 2.2.5 Healthcare provider
children training
1.2.4 Dietary guidelines for 2.2.6 Electronic health records 3.3 People and Community
healthy eating Empowerment: Spirit of
implementation (20%)
1.2.5 National policy on alcohol 2.2.7 Telehealth 3.3 Human Development Index
1.2.6 Taxes on alcohol and 2.2.8 Public and private sector
unhealthy foods coordination
1.2.7 Food insecurity policies
1.2.8 Oral health policy 2.3 Inclusive Health Systems: Spirit
of implementation (20%)
2.3 Universal Health Coverage
service index
1.3 Health in society: Spirit of
implementation (20%)
1.3 Implementation of SDGs
(% achieved)

Theme 1: A focus on the

social determinants of
health leads to more
inclusivity
Years of advocacy–since at least the mid- Egypt, Cuba and the UAE scored less than 50
1850s–have elevated the importance of points.
the social determinants of health (SDH).10,11
The ideas embedded in Domain 1 have a long
And indeed, Domain 1: Health in Society,
history. The right to health has been a pillar
comprising indicators on the SDH and the
of human rights doctrine since it was first
“health in all policies” approach, was the
introduced by the United Nations (UN) in the
domain with the highest average score (74.0).
post-World War II era,12 while the idea that
Sixteen countries scored 80 or above, with
health is a “fundamental human right”, as we
Thailand, Canada and South Korea leading
have defined in Domain 1, was encoded in
the way. Only Bangladesh, Russia, Algeria,
the 1978 Declaration of Alma-Ata.13
FIGURE 2. Domain 1:
Health in Society DOMAIN 1
summary Health in Society
Top 10 scoring countries
and descriptive statistics TOP 10 COUNTRIES
MINIMUM
for Domain 1: Health in
41.6
Society 1 Thailand 92.6
2 Canada 92.5
3 South Korea 90.7
MEAN 4 UK 89.3
74.0 5
6
France
Colombia
88.0
86.9
7 Australia 86.8
MAXIMUM 8 Poland 86.0
92.6 9
10
China
Philippines
85.7
84.6

Perhaps this is why most of the countries Most countries acknowledge the
in our Index recognise health as a human importance of social determinants
right; only Jordan, the UAE and the USA fail of health, but there are many gaps in
to do so. And all but seven countries also coverage
show evidence that this principle extends
beyond access to healthcare to include safe The Health in Society domain has many
drinking water, sanitation, food, housing, and indicators that refer to the SDH. As Prof Calder
other requirements for a health-promoting explains, “‘Social determinants of health are
environment. Terry Huang, Professor and intended to convey that a person’s financial,
Director, CUNY Graduate School of Public housing circumstances, racial, and geographical
Health and Health Policy, Center for Systems circumstances determine their access to
and Community Design in the US, remarks opportunity for optimal health or good health.’’
that this is important. “We should be looking We found that 75% of countries include policies
at food, agriculture, transportation, education, that address the SDH.
environmental protection, and urban and
Most countries have at least a few policies
housing development. These are all typical
aimed at smoking, alcohol, healthy eating
domains of government that have a bearing on
and the marketing of food to children, but
health outcomes.”
their priorities vary. Russia, for example, had
Furthermore, only Algeria, Bangladesh, no evidence of a policy on food marketed
Cuba and Egypt did not include the notion to children, but had adopted all six tobacco
of “well-being” in their national health control measures.
strategies. On paper, therefore, there is
Only half of the countries studied had a
widespread acceptance of the importance of
strategy, policy or action plan to promote oral
acknowledging the right to good health and
health. We will look at universal health coverage
the inclusion of well-being.
later, but oral health is often overlooked. Prof
Huang says, “As we push for universal health
coverage around the world, which is a main
feature in the global health agenda these days,
oral health needs to be part of that. We should
look at countries where oral health is more
comprehensively covered, what are the used
mechanics, and adopt similar measures.”
Brazil can show other countries how it’s done.

Its National Oral Health Policy is an example
of oral health assistance being offered through
the universal public health system–its policy
represents an innovative strategy that focuses
on oral healthcare access, which can both
increase the number of oral health teams in
primary care and expand the secondary level of
oral healthcare.14

FIGURE 3. Addressing the SDH through collaboration (top and bottom 10 countries)
Cluster analysis of indicators related to addressing the SDH through collaboration. Individual indicator scores are shown for the top- and
bottom-scoring countries overall.
Social determinants of health in policy (1.1.3) Public and private sector coordination (2.2.8)
Inter-sectoral cooperation policy (1.2.2) Public/Community participation in policy (3.2.4)
Addressing SDH through collaboration: Top 10 countries Addressing SDH through collaboration: Bottom 10 countries
France Egypt
ada ladesh
Can Ge B ang Ho
rm ndu
any ras
ia
ria
ral
e
st
Alg
Au
Israe
India
l
100% 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0%
rea
n
h Ko
Jorda
Sout
Vi
et
UK
n ria
na
de ge
m
e
Sw Ni
Tha Uga
ilan d nda
d an Russia
Switzerl
High-scoring countries show We found that half of the Index countries

evidence of a “health in all policies” (n=20) showed evidence of government
approach departments working together across
sectors to promote health, and of oversight
Understanding the impact of SDH is a to ensure cooperation. Five countries had no
prerequisite for understanding who and how evidence of cooperation, while the others
to engage (other sectors and communities) in had some evidence of cooperation but no
the development and delivery of healthcare oversight body. An important difference
services. For Nima Asgari-Jirhandeh, Director between the most and least health inclusive
of the Asia Pacific Observatory on Health countries is that the majority of countries
Systems and Policies in the World Health (60%) scoring in the bottom ten (for overall
Organization in India, ‘‘Social determinants health inclusivity score) do not incorporate
are fundamentally linked to the whole point the SDH into their national policies
of who gets the services that they need. That (indicator 1.1.3). It is therefore unsurprising
means policies on housing, education, income, that the elements that follow this (inter-
and social class all include interactions with sectoral cooperation, public-private sector
(health) service delivery, access to health care, coordination and public community
and the use of the health services.” participation) are also limited.

Professor Gupta highlights that “you don’t Hoda Rashad, Professor and Director of
usually achieve much” if government agencies the Social Research Center, The American
do not work together on health. [...] ‘It’s not University in Cairo in Egypt, agrees, and
[just] health financing that you have to be suggests that a particular focus needs to be on
bothered about, you have to look at water, monitoring and evaluation. She tells us that
you have to look at sanitation, you have to “The key modalities of pursuing Health in all
look at hygiene, but you have to also look at policies are the conduct of health equity impact
awareness, literacy rates,” she says. Agencies evaluation prior to implementation of policies,
should be unified in their efforts to create and monitoring and evaluation of impact on
health-focused policies. health equity during implementation.’”
• Incorporate health as a human right, and definitions of wellness, into strategic documents.
While a “right to be healthy” is impossible, a right to health approach emphasises the
multifactorial actions that are needed for inclusive health.
• Inclusive health cannot be created by focusing on healthcare alone. Utilise what is known
about the SDH, and ensure that factors such as a patient’s education, income level and
environment are considered when providing care.
• Emphasise a “health in all policies” approach to government. Senior leadership needs to use
their influence to align policies across ministries.

Theme 2: Health
inclusivity requires
the identification of
vulnerable populations
Some people have been excluded or are not tailored directly to, for example,
marginalised from society historically, and migrants, disabled, or elderly. I believe that
therefore face more barriers when trying they have to change to be more inclusive, but
to manage or improve their health. Often that may also require a change of mindset
described as “hard to reach”, these groups of in the political landscape. In very strong
people are typically underserved by healthcare communities, there are entities that can reach
services that have been designed without out, such as church communities, people’s
them in mind. People may be vulnerable to movements, and grassroots organisations to
ill health or exclusion for a host of reasons, help bridge those health literacy gaps.’’
including age, disability, ethnicity, gender,
geographical isolation, language, lifestyle, One in five of the countries exclude
migration status, religion, sexuality and people from accessing healthcare
socioeconomic status. systems
People in vulnerable and marginalised groups Beyond the factors elucidated above as
often have poor health. This may be a result of barriers to more inclusive health, sometimes,
SDH such as poverty, unemployment or poor people are deliberately excluded by policy.
housing. They may be excluded by precarious One in five of the countries in the Index
or difficult access to healthcare services, exclude people from accessing healthcare
including health promotion and oral health systems based on characteristics such as
services. They may lack the health literacy migration status. A country with inclusive
skills needed to engage in their own everyday health, on the other hand, actively seeks out
health choices. It may be a combination of people in vulnerable groups, investigates
these and more factors. their barriers to good health, and designs
and implements policies to overcome these
Health exclusion due to cultural and/or social
barriers.
barriers is also commonplace. For example,
Kristine Sørensen, Founding Director, Global For example, in Australia, the Department of
Health Literacy Academy in Denmark, says Health and Aged Care operates a Rural Health
that “Often, communications and campaigns Outreach Fund (RHOF) and the Medical

TABLE 1. Index countries with policies of exclusion

Table of countries with policies of exclusion
Country Excluded group

Israel Migrants and asylum-seekers, except when they are of Jewish origin
Jordan LGBTQ+, HIV-positive, non-nationals. Refugees living outside of
designated camps
Poland Limited access for immigrants†
Russia Migrants
Rwanda People with disabilities
Sweden Undocumented migrants and asylum-seekers
UAE LGBTQ+ individuals
UK Asylum-seekers whose applications have been rejected
Outreach Indigenous Chronic Diseases already needy populations, they do so at

Program, both of which target vulnerable their own peril. “What policymakers would
populations at the primary care level. The be advised to realise is that the last thing
RHOF targets Australians living in remote they should be doing in a crisis is making cuts
areas with insufficient access to health that radically impact vulnerable populations.
services,15 while the outreach program funds Pushing already vulnerable people into
general practitioners (GPs), specialists, health calamity coping not only makes it impossible
workers and multidisciplinary teams working to build levels of social trust amongst the
with Aboriginal and Torres Strait Islander disadvantaged; it also makes it impossible for
patients suffering from at least one chronic those already marginalised to address the very
condition.16 health challenges that must be addressed to
ameliorate that crisis.”
Prof Napier highlighted the importance of
maintaining a broad-lens view of the term
High scoring countries have systems
“we”. He notes that “It’s important to realise
to identify marginalised groups
that, when resources are scarce, who ‘we’
are can shrink dramatically. Exclusion, that We explored a group of indicators that show
is, leaves a lot of vulnerable people without efforts to support marginalised groups, from
services and assistance.” He pointed to the way recognising who they are to establishing
even high-income countries during Covid-19 mechanisms that reduce barriers to their
shifted from “we’re all in this together” to care. Most countries made some effort–
“fighting over toilet roll”, concluding that for example, only Russia and Algeria had
when governments cut out services for no policies at all to identify vulnerable
Immigrants only have limited access to healthcare and little targeted information about entitlements and health issues. Health services and policies have yet to
†
address immigrant patients’ specific access/health needs. In relation to the conflict in Ukraine, from where Poland has taken a significant portion of its refugees,
the government has set up a Ukrainian-language version of its website, which includes information on getting state medical care.

populations. However, we found that the with respect to health including refugees,
countries ranked in the top ten of the Index women, children and young persons, the
all score consistently well on policies that elderly, the disabled and the unemployed.17
include, for example, the identification of The goal of the act is to reduce health
vulnerabilities and the provision of translation inequalities caused by, amongst other things,
services. However, it is worth noting that the SDH and gender. In addition, the German
health exclusion policies (indicator 1.1.5) are Federal Act on Equal Treatment explicitly
also more prevalent among the top 10 scoring prohibits discrimination on grounds of “race
countries than the bottom 10. or ethnic origin, gender, religion or belief,
disability, age or sexual orientation” with
For example, in Germany, the Prevention Act
specific regard to social protection, including
identifies several vulnerable population groups
social security and healthcare.18
FIGURE 4. Support for marginalised groups (top and bottom 10 countries)

Cluster analysis of indicators related to the support for marginalised groups. Individual indicator scores are shown
for the top- and bottom-scoring countries overall.
Vulnerable population groups (1.1.4) Migrant healthcare coverage (2.1.4)
Health Exclusion (1.1.5) Translation services (3.1.2)
Support for marginalised groups: Top 10 countries Support for marginalised groups: Bottom 10 countries
France Egypt
sh
ada de
Can Ge Bangla Ho
rm ndu
any ras
ia
a
ral
eri
st
Alg
Au
Israe
India
l
100% 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0%
rea
n
h Ko
Jorda
Sout
Vi
et
UK
n ria
na
de ge
m
e
Sw Ni
Tha Uga
ilan nda
d and Russia
Switzerl

• Exclusion from healthcare services can happen from oversight, as well through deliberate
action. Ask whether your “hard to reach” populations are simply underserved.
• Have processes to identify vulnerable populations, and identify–and tackle–the SDH that
are especially pertinent for them.
• Identify, and remove, policies that exclude some from accessing health. Poor health–even of
sections of society–is bad news for society overall.

Theme 3: Universal health

coverage is necessary, but
not sufficient, for health
inclusivity
When ill health hits, prompt and inclusive provided in the community, rather than in
access to functional and effective health distant healthcare facilities, where possible.
services is required. While the SDH play a large Multidisciplinary teams– such as teams
role in deciding who will suffer poor health including nurses, dietitians, exercise therapists,
and who won’t, regardless of how vulnerable physiotherapists, pharmacists, social workers
(or not) you are–everyone at some point in life and primary care doctors–may be an effective
needs support from healthcare providers. Our way of addressing the multiple challenges
approach to inclusive health embraces the bio- that people face when trying to manage their
psycho-social model of healthcare19, rather health.22-24
than the biomedical model, but we all need
traditional “sick care” services on occasion. The role and extent of the
government in health systems
In September 1978, the declaration of
ranges widely
Alma-Ata was adopted at the International
Conference on Primary Health Care. The The Index’s Domain 2: Inclusive Health
Declaration was a major milestone for public Systems includes indicators to measure the
health, underlining the importance of primary strength and scope of the healthcare system,
care as the key to achieving “Health for All”.12 and whether cost is a barrier to accessing
Equitable access to healthcare requires health services. This domain presented challenges
resources to be accessible, easy to navigate, even for the countries which scored highest
affordable and of decent quality.20,21 However, overall in the Index. The average score for the
services which are free at the point-of-use are domain was 64.6. Seven countries scored 80 or
not inclusive if they are under-resourced, low above on this domain, with Australia, UK and
in quality, or hard to access distance-wise. Germany as the highest scorers. Bangladesh,
Uganda, Egypt and Honduras scored less than
It follows, therefore, that the provision of
40 points. Bangladesh was at the bottom of
healthcare services should be coordinated
the table.
and appropriate for the individual, and

FIGURE 5.
Domain 2: Inclusive DOMAIN 2
Health Systems Inclusive Health Systems
summary
Top 10 scoring countries TOP 10 COUNTRIES
MINIMUM
and descriptive statistics
28.1
=1 Australia 84.4
for Domain 2: Inclusive
Health Systems =1 UK 84.4
3 Germany 84.0
MEAN 4 Sweden 83.2
64.0 5
6
Israel
France
82.7
80.3
7 USA 80.0
MAXIMUM 8 UAE 77.8
84.4 9
10
Italy
Turkey
77.1
75.8
Government health expenditure is assessed The proportion of people spending more than
as the proportion of all health expenditure in 10% of their income on health did not seem
the country, which is funded from government strongly linked to the country’s income level,
sources, social health insurance and with household expenditure on health lowest
compulsory prepayment, indicating how much in the UAE, South Africa, Honduras, Rwanda
expenditure comes from public resources. This and Germany. Households from India, China,
indicator ranged widely, from 15% in Uganda Bangladesh and Egypt were most likely to
to 89% in Cuba. spend more than 10% of their income on
health. Half (20) of the Index countries showed
Expenditure from the state is important to
no evidence that people were impoverished
track because strong primary healthcare
because of out-of-pocket spending on health.
systems are likely to originate from the state.
According to Dr Asgari-Jirhandeh, “Many
There is a large variation between
developed countries, often have regulations
countries in workforce numbers
in place to allow coordinated collaboration
between. We are seeing that there is a need Domain 2 also includes indicators relating to
for something similar in the rest of the world countries’ health system infrastructure and
because it makes it a lot more cost-effective. workforce. We again find Cuba at the top
This means that you can pick up people who for one of our indicators, with the highest
may be excluded because they actually are number of doctors per 10,000 (84.2). Thirteen
suffering from social care as opposed to countries had fewer than 10 doctors per
health care.” While often underfunded and 10,000 people, with just 1.2 and 1.5 in Rwanda
overstretched, primary care structures are and Uganda, respectively. Furthermore, a
mostly likely to support inclusive health. wider pattern emerges when looking at the

health workforce as a whole. Broadly speaking, example of good practice is South Korea,
high-income countries have more doctors, which provides centralised education and
nurses, pharmacists and dentistry personnel. training for healthcare service providers
On the other hand, middle-income countries through the Korea Human Resource
have more community health workers, Development Institute for Health & Welfare.
environmental and occupational health The curriculum includes courses on specialised
workers, and traditional medicine personnel. care for people with developmental disabilities
However, these metrics were not used in and dementia patients, elderly support, public
the Index as the data from the WHO Global communication, dietary well-being, and
Health Observatory were not available for a handling of foreign patients.
significant proportion of the countries.
While most countries (32) showed evidence
This finding was no surprise to Dr Asgari- of active electronic health records, only 14 of
Jirhandeh. He reflects that ‘’In some countries, these had records integrated at the national
there is a push to increase the role of nurses level. Numbers were similar for the existence
and nurse practitioners in providing services as of telehealth policies or strategies, and
leaders, simply because there are not enough whether these had implementation plans and
doctors of a generalist nature. Countries are targets. Indicators like telehealth are critical
trying to balance the inequity of the healthcare for health inclusivity as they improve access
workforce.’’ to healthcare for marginalised groups that
face geographical or financial barriers, and
Regarding training of healthcare professionals,
they allow hospitals and clinics to prioritise
17 countries showed evidence of training
the most at-risk groups and urgent medical
curricula that included cultural competency,
cases.25
well-being and person-centred care. An
• To engage with their health, people need to be able to care for themselves and their
families in a way that prioritises health. Incorporate mechanisms to safeguard Individual
agency alongside community empowerment.
• Stigma and prejudice remain a barrier to leading a healthy life. Systematise the inclusion of
cultural competency training and person-centred approaches to service delivery.
• Coordinate the provision of healthcare services, ensuring that they are provided in the
community rather than in distant healthcare facilities. This requires coordination across
sectors –public and private sector organisations must recognise the critical role they play in
driving health inclusivity and work collaboratively to decentralise care.
• Utilise multidisciplinary teams including nurses, dietitians, physiotherapists, pharmacists,

social workers and primary care doctors to address the challenges that people face when
trying to manage their health at a community level.

Theme 4: Money is not the

only driver of inclusivity–in
fact, better inclusivity can
drive economic growth
Most policy-focused indices track GDP Index overall. The Philippines, a lower middle-
because higher-income countries tend to have income country, ranked among the top ten
better governance systems, which translates countries in Domain 1, while the UAE, a
into a greater likelihood of formally recognised high-income country, ranked in the bottom
policies. It is therefore unsurprising that the ten. The two lowest-income countries in the
overall Index score is correlated with GDP per Index (Uganda and Rwanda) ranked 26 and
capita. However, while there is a moderate 34, respectively–thereby ranking higher than
positive correlation, there is a lot of scatter many other, richer countries.
on either side of the line. Significant outliers
Out-of-pocket expenditure on health,
include countries like Thailand and South
suggests Professor Sir Michael Marmot, is a
Africa, which appear above the correlation
“key indicator” for understanding some of the
line (i.e., they score higher than expected,
patterns seen here. “When you’ve got high
given their GDP per capita), while others like
out-of-pocket expenditures, such as in India,
the USA, UAE and Egypt score lower than
you get great inequity of access. Because if
expected.
you’re poor, you can’t afford care. Whereas
in Thailand, with relatively low out-of-pocket
Index score is positively correlated
expenditure, it means that care is much more
with GDP per capita, but there is a
readily available. So that’s a key variable, which
lot of scatter
relates to access.”
There is a similar amount of scatter when
There is also a moderate positive relationship
we look at individual country domain scores,
between health inclusivity and a country’s
compared to GDP per capita. Thailand, for
current health expenditure as a proportion
example, an upper middle-income country,
of GDP. Countries that spend more on health
was the highest scoring country in Domain
tend to have better health inclusivity. However,
1: Health in Society, as well as ninth in the
again, there are exceptions. The USA, Cuba,

Algeria and Bangladesh scored lower than Better health inclusivity is associated
might be expected on health inclusivity, with better health outcomes and
given their level of spending on health; (probably!) higher productivity
other countries, including the UK, Israel and
Thailand, scored relatively higher. While life expectancy has improved globally,
healthy life expectancy has not–we are
Disparities between low- and high-income therefore living proportionally more years of
countries are clear when it comes to health our life in poor health.26 Supporting health
expenditure and the size of the healthcare inclusivity may be a way to close this gap
workforce–as tracked in the Index. Truly because we found a moderate positive
accessible health systems need investment relationship between healthy life expectancy
and a workforce–a situation that can be and overall Index scores.27 Of the 12 countries
worsened by the ongoing brain drain of which scored 80 or above for health inclusivity,
highly trained practitioners from poor to rich nine scored in the top group for healthy life
countries. Prof Gupta points out that “India’s expectancy. Of course, there were some
doctor per population, nurse per population outliers: the UK, which topped the Health
ratios are very low. And this would be so Inclusivity Index overall, Thailand and the
in many other countries, in many African USA did not make it into the top grouping for
countries, many other Asian countries, etc. So, healthy life expectancy. Conversely, Japan and
we export doctors to other countries, but we Italy scored in the top grouping for healthy life
somehow don’t have enough of them here.” expectancy, but not for health inclusivity.
FIGURE 6. Health inclusivity scores and current health expenditure

R2 = 0.3581
There is a moderate positive 100
relationship between the UK
Health Inclusivity Index 90
scores and Current Health Italy Germany USA
Thailand Israel
Expenditure.
80
Kazakhstan China
70
Health Inclusivity Index score
Indonesia Cuba
60
Nigeria
50
India Egypt
40
Bangladesh Algeria
30
20
10
0
0 2 4 6 8 10 12 14 16 18
% of GDP

FIGURE 7. Correlation between the Health Inclusivity Index scores and healthy life expectancy
There is a moderate positive 100

relationship between the Thailand UK Canada
Kazakhstan USA South Korea
scores and Health-Adjusted 80 Indonesia
Life Expectancy (HALE). South Africa Philippines Japan
Countries with better 70

Kenya Colombia
health inclusivity tend to Nigeria Cuba
have a longer healthy life 60 Rwanda
expectancy. Honduras
Uganda
50
India
Algeria
Africa
40
Americas Egypt
Eastern Mediterranean
30
SE Asia Bangladesh
Europe 20
Western Pacific
10
0
50 55 60 65 70 75 80
Years
When we compared the maternal mortality picture is less clear at the bottom. All
rate‡ with the Health Inclusivity Index, we countries that scored 80 or above on the
found a weak negative relationship with Index also scored 80 or above for having
maternal mortality ratio.28 While we can see the best maternal and infant mortality
a correlation at the top end of the table, the rates.
FIGURE 8. Correlation between the Health Inclusivity Index scores and change in
maternal mortality ratio from 2000 to 2017
R2 = 0.0316
There is a weak negative 100 Canada
relationship between the UK Mexico
Israel
scores and change in
80 Poland
maternal mortality ratio. Kazakhstan
Turkey
70
Rwanda
60 India Russia
50
Egypt
40
Algeria Bangladesh
30
20
10
0
0% 100% 200% 300% 400% 500% 600%
Change in Maternal Mortality Ratio
Maternal mortality is measured as maternal deaths per 100,000 live births. This measure shows wide disparities among the 40 countries in our index, ranging from
‡
single figures (less than 10 per 100,000) to 917 per 100,000.

• Don’t just track crude outcomes data such as life expectancy, but rather prioritise measures
that capture quality, not just quantity, such as healthy life expectancy.
• Recognise that health inclusion is more complex than the money spent on health; empower
communities by decentralising care and establish agency by removing societal barriers.
• Use out-of-pocket expenditure as a useful way of getting a “quick and dirty” assessment of
health inclusivity in a country.
• Low-income countries need to protect themselves from “brain drain”, the movement of
expensively trained healthcare professionals from poor to rich countries. Similarly, high-
income countries should not rely on immigration to staff their healthcare services.

Theme 5: Community and

individual empowerment
is at the heart of health
inclusivity
Barriers to health prevent individuals within We can only tackle these barriers if people
a population from accessing services, even with experience and knowledge of them are
when they exist and are available to them. included in the design and provision of health
Overcoming some of these barriers may services. Prof Huang believes that when
include ensuring that health information is patients are actively involved in decision-
provided in multiple languages, health services making, their health outcomes improve.
are available at a broad range of times, and “Patients will be less anxious about what is
that health promotion strategies are culturally to come if they can develop an improved
appropriate. It could also mean looking at understanding of their own health, and be able
geographical spread and provision of health to make more informed decisions. This is an
promotion services to those in remote or rural area that needs to be more developed.”
areas.
Countries with the highest overall
As we have mentioned previously, however,
scores provide individuals and
true inclusivity goes beyond the mere
communities with the tools to take
provision of services. People need the capacity
charge of their own health
to engage with and influence their own health.
Barriers to this engagement are varied and Community partnerships can be an effective
include: way to give marginalised communities a voice
in the design of culturally and contextually
• Time constraints, for example, lack of time appropriate services. Community health
to exercise or prepare healthy food workers and similar health paraprofessionals,
• Limited literacy, numeracy and ability to like community pharmacists, who often act as
understand health information the bridge between clinicians and individuals,
could also help people to navigate the
• Difficulty accessing services for reasons healthcare system.29
including eligibility, social exclusion,
geographical isolation, inability to pay, digital Inclusive health cannot be imposed, top-down.
exclusion from online services Individuals, and communities, need the tools
to take charge of their own health.

FIGURE 9.
Domain 3: People DOMAIN 3
and Community People and Community Empowerment
Empowerment
summary MINIMUM
TOP 10 COUNTRIES
22.6
Top 10 scoring countries =1 Australia 98.9
and descriptive statistics
=1 Sweden 98.9
for Domain 3: People
and Community 3 UK 98.6
Empowerment
MEAN 4 Switzerland 95.8
69.4 5
6
Germany
Israel
93.9
93.4
7 France 93.0
MAXIMUM =8 Japan 91.7
98.9 =8
10
South Korea
South Africa
91.7
89.2
Domain 3: People and Community information and e-services31, available 24

Empowerment measures efforts to ensure hours a day, both online and via phone.
that healthcare services are designed to be
The income level of a country was not directly
inclusive, accessible, and tailored to individuals
correlated with its performance in this domain.
and their preferences, including those from
While some high-income countries performed
vulnerable groups. It also looks more generally
consistently well in this domain, others, such
at whether people are given the tools that
as Italy, Poland, and in particular the UAE,
empower them to make decisions and direct
performed more poorly than expected,
their own health, and that of the healthcare
illustrating the dissociation between the ability
services available to them.
to empower individuals and communities and
The average score in Domain 3 was 69.4. extensive financial resources. Among middle-
Some countries scored high, such as Australia, income countries, South Africa, Thailand,
Sweden and the UK, all of whom scored Indonesia and Brazil performed best in this
above 98 points, and 14 countries scored domain. This may offer encouragement
80 or above. Australia has worked hard to to lower-income countries to look at how
build and support people and community community, culture and education can drive
empowerment. For example, health literacy health inclusivity, even when resources are
is included throughout mandatory basic limited.
education; children learn to compare product
Eight of the top ten scoring countries have a
labels on food items or nutritional information
higher score in Domain 3 than in the other
in recipes, and think about how to improve
two domains. Indeed, Domain 3 has the
the nutritional value of meals.30 Sweden, on
greatest range of scores, but also the strongest
the other hand, has implemented patient
correlation with overall scores, indicating that
information materials that support patient
it is the best predictor of a country’s overall
self-care through a national healthcare guide,
score.
which offers extensive healthcare advice,

We explored efforts aimed at helping Both health literacy and high-

individuals play an optimal role in their health. quality, accessible health
These indicators range from considering information are needed
whether health exists as a right to ensuring
that there are mechanisms in place to support Half of the Index countries had health
individual agency. Most countries that scored literacy programmes embedded in
in the top ten recognise health as a right, and national education curricula, while
most of their health systems at least attempt six had no evidence of health literacy
to have a person-centred focus. In comparison, programmes or policy. Only eight
while most countries that scored in the bottom countries had no evidence of information
ten recognise health as a human right, half materials for patients to support self-
do not have healthcare provider training on care, and only five countries (Algeria,
cultural competency or person-centred care. Egypt, Honduras, Kazakhstan and
Most countries in the bottom ten also do not Ukraine) had no evidence of outreach
have information available to support self-care. programmes for vulnerable populations.
FIGURE 10. Enabling individual agency (top and bottom 10 countries)

Cluster analysis of indicators related to enabling people to take control of their own health. Individual indicator
scores are shown for the top- and bottom-scoring countries overall.
Right to health (1.1.1) Person-centred healthcare (3.1.1)
Healthcare provider training (2.2.9) Health information for self-care (3.2.2)
Enabling people to take control of their own health: Enabling people to take control of their own health:
Top 10 countries Bottom 10 countries
France Egypt
a de sh
ad
Can Ge Bangla Ho
rm ndu
a ny ras
ia
ria
ral
e
st
Alg
Au
Israe
India
l
100% 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0%
rea
n
h Ko
Jorda
Sout
UK
Vi
et
ria
na
en ge
m
ed Ni
Sw
Tha Uga
ilan nda
d
Switzerland Russia

Dr Sørensen says that health literacy needs Inclusive health is led by the
to be recognised as a public health challenge community, for the community
that directly impacts people and community
empowerment. “We need to educate new It is often the case that inclusion is hyper-
generations through a much stronger focus on local: it is about working with, and being
health and well-being in primary and secondary supported and represented by, people from
care, because health literacy is developed your community. We found that 12 of the
throughout the life course,” she explains. 40 countries included in the Index had no
evidence of peer-support or community
Prof Huang adds that in order for patients companion involvement in healthcare
to fully exercise agency, they need to be encounters. This indicator is intended to show
accurately informed. He says that “The whether people can get support from their
problem is that there is a cacophony of health wider community, not just family or formal
information out there, many of which are carers.
false and inaccurate. So, how do we actually
manage information flow and make sure Community involvement is not just about
that there are trusted sources of medical one-to-one support, but rather the role
information that patients can access easily? of the community in decision-making. We
This is a huge public health challenge.” found some evidence of good practice here.
Just over half of the Index countries (21) had
We looked for evidence of healthcare systems national strategies or policies with detailed
providing patient information and translation guidelines on how communities could get
services in languages other than the country’s involved in policy, and evidence of forums
official language, and including accessible for citizens to engage with their wider
forms of communication, such as braille or sign community. A further 13 countries had either
language. We found 13 countries scored highly strategies or forums, while six countries
on translation and accessible communication, (Algeria, Bangladesh, India, Turkey, Uganda
while nine had no evidence of either service. and Vietnam) had neither.

Empowerment comes through economics and they have seen happen in the past. But if you
education first, says Prof Gupta, explaining, really want change, you need many more
“I think the two important pillars remain people from society to speak up,” she says.
income, or livelihood, and education.” Ensuring
Indeed, it was interesting to note the positive
that policymakers are representative of
association between the Index score and the
their constituents can help here, she adds.
EIU Democracy Index, which itself incorporates
Too often, policymakers represent only the
indicators around political participation—
powerful in society. “The so-called ‘change
suggesting that there is a strong argument for
agents’ are not really ‘change agents’, they’re
more deliberative democracy in healthcare.32
just bureaucrats who carry on policies that
• Community health workers can play a multidimensional role and should be utilised in both
high- and low-income countries to better engage their communities, debunk myths, and
dismantle cultural barriers to care.
• Disseminate information for self-care in relevant languages to target populations to

ensure that all dimensions of health, physical, mental, and emotional, are considered and
promoted.
• Support health literacy to increase health knowledge, build population-level resilience,

encourage positive lifestyle changes, and empower people to effectively manage long-term
health conditions.

Theme 6: Inclusivity is
only part policy–without
implementation, policy is
meaningless
In any policy-based index, there is the they do not directly map onto implementation
question of whether policies, processes and of the indicators of our domains or
other “inputs” described by the indicators are subdomains, they give an idea of the likely
translated into practice. We know that 11 spirit of implementation.
countries scored between 80 and 100 on the
Health Inclusivity Index–suggesting that, on For example, we can, to some extent, assume
paper, they have created an environment that that countries that score highly on the
supports and enables inclusive health. The implementation of SDGs take these goals
question remains, however, “are these policies seriously, and have both the capacity and
being fully implemented?” capability to effect change. It therefore seems
reasonable to assume that they will similarly
To bring an element of “outcomes” into the take some measures to implement the
Index, we included in each domain a “spirit of changes and policies captured in the indicators
implementation” indicator. These were: of Domain 1. On the other hand, countries
that score poorly on the implementation
• Domain 1: Implementation of the
of SDGs may also be similarly lax in the
Sustainable Development Goals (SDGs)
implementation of other policies related to
• Domain 2: Universal Health Coverage (UHC) health and health inclusivity
service coverage Iindex
We have added “spirit of implementation”
• Domain 3: Human Development Index indicators because there is so little evidence
(HDI) of policy outcomes in the world of health
The “spirit of implementation” indicators inclusivity. This is partly because such
are composite indicators in their own right. outcomes are hard to measure, for example,
Because they focus on outcomes, they due to confounding variables. But also, there is
represent (at least partially) the on-the-ground little agreement about how inclusivity should
reality in each country for each domain. While be measured, given its conceptual complexity.

How the “spirit of implementation” Index, while Nigeria had the lowest. As with
indicators changed, or did not Domain 1, countries that scored well in
change, domain scores Domain 2, tended to score well in the UHC
service coverage Index. But again, there were
Enabling health in society outliers, including some of the Index’s lowest
In choosing our “spirit of implementation” scoring countries (Uganda, Egypt, Bangladesh
indicator for Domain 1: Health in Society, we and India), which performed better in the
wanted to see whether the Index countries UHC service coverage Index than in the rest of
showed evidence of their commitment Domain 2.
to prioritise health in society through This might be partly explained by the nature of
implementation of the UN’s SDGs. The the workforce indicators in Domain 2, where
2030 Agenda for Sustainable Development, high-income countries will inevitably perform
adopted by the UN member states in 2015, much better than low-income countries. This
has 17 goals relevant to addressing some of relationship with income also holds true for
the SDH.33 Overall, the UAE had the lowest indicators on telehealth, electronic patient
score for the implementation of SDGs, while records, and healthcare provider training, and
Sweden had the highest. of course government health expenditure. Of
We found that, in general, countries that the three domains, Domain 2 is the one where
scored high in Domain 1 also had a high score high-income countries have the greatest
in the implementation of SDGs . However, advantage.
some outliers did emerge (see Figure 14). For Promoting people and community
example, Egypt’s Index score is not equally empowerment
matched by its implementation of SDGs score,
while Rwanda and Nigeria’s implementation The Human Development Index (HDI) is a
score is higher than their Index score. composite measure of average achievement
However, the biggest difference in scores is for citizens in terms of living a long and
seen with the UAE–its implementation score is healthy life, being knowledgeable, and having
much lower than its Index score. Such a finding a decent standard of living. We chose this as
suggests that in addition to the UAE’s low our “spirit of implementation” measure for
score in Domain 1, its level of implementation Domain 3 because we determined that the
may be even lower. HDI is a reasonable practical indication of how
empowered people and communities feel.
Creating inclusive health systems
For the most part, HDI scores are fairly well-
The UHC service coverage Index is the “spirit aligned with Domain 3 scores. However, we
of implementation” indicator for Domain 2: find that some countries with moderate scores
Inclusive Health Systems. The UHC Index on the HDI, such as Bangladesh, Algeria, the
assesses the extent to which a country’s UAE, Egypt and India, have not developed
population receives the health services they policies to empower or equip people to take
need without experiencing financial hardship. control of their own health.
Of our Index countries, Canada had the
highest score in the UHC service coverage

FIGURE 11. Policy v

Practice for Domain 1: Percent change
Health in Society -50% 0% 50% 100%

Policy > Practice →
Change in Domain 1 United Arab Emirates

scores after removing the
Egypt
“spirit of implementation”
indicator, i.e., Russia
Implementation of Jordan
UN’s Sustainable
India
Development Goals
(SDGs) indicator. Bangladesh
United Kingdom
France
Poland
Cuba
Brazil
Australia
USA
Canada
Israel
Vietnam
South Korea
Turkey
Thailand
Sweden
Italy
Philippines
Algeria
Japan
Mexico
Colombia
Ukraine
Uganda
China
Slovenia
Kazakhstan
Germany
Switzerland
South Africa
Kenya
Honduras
← Practice > Policy
Costa Rica
Indonesia
Nigeria
Rwanda

FIGURE 12. Policy vs

Practice for Domain Percent change
2: Inclusive Health -40% -35% -30% -25% -20% -15% -10% -5% 0%
Systems
Japan
Policy = Practice →
Change in Domain 2 Sweden

scores after removing the
“spirit of implementation” Cuba
indicator, i.e., Universal Germany
Health Coverage (UHC) Jordan
Index.
Poland
Italy
Australia
Costa Rica
Israel
USA
France
Slovenia
United Arab Emirates
Switzerland
United Kingdom
Kazakhstan
Canada
Turkey
Colombia
Philippines
South Africa
Mexico
Russia
Ukraine
Brazil
Indonesia
South Korea
Thailand
Rwanda
Algeria
Nigeria
Kenya
Vietnam
Honduras
China
India
Bangladesh
Egypt
Uganda

FIGURE 13. Policy

vs Practice for Percent change
Domain 3: People -50% -40% -30% -20% -10% 0% 10%

and Community Rwanda
Policy = Practice →
Empowerment South Africa
Change in Domain 3 Nigeria

scores after removing the Kenya
“spirit of implementation” Thailand
indicator, i.e., Human
Development Index United Kingdom
(HDI) scores. Australia
Sweden
France
Israel
Indonesia
Japan
South Korea
Switzerland
Uganda
Germany
Canada
China
Brazil
USA
Slovenia
Philippines
Mexico
Turkey
Colombia
Italy
Kazakhstan
Poland
Ukraine
Costa Rica
Russia
Cuba
Honduras
India
Jordan
Vietnam
Egypt
United Arab Emirates
Algeria
Bangladesh

• The job of government is not completed by the passing of a (health inclusivity) policy.
• Ensure that policies have implementation and monitoring processes embedded in them,
and dates for post-implementation reviews.
• Track inclusivity by monitoring health outcomes and service-user metrics for vulnerable
populations. Equity does not mean that all will have the same outcomes, but only by
measuring disparities can you begin the process of identifying where extra support is
needed.

Campaigning for an
undefinable goal
Making health more inclusive is what some SDGs. Many countries have made progress
might call a “wicked problem” – the causes in both areas, and even in instances where
are myriad, difficult to tease apart and implementation is lacking, the commitment
understand, and dynamic. It also involves is there, at least on paper. And for good
working with multiple stakeholders with reason; both UHC and the SDH are central
diverse values and priorities. There is little to inclusive health, and any effort to make
precedent to guide us, and no simple outcomes more equitable in a country needs
answers.34 to have these concepts at the core. It should
be noted also that the two are not unrelated.
The “implementing inclusivity” boxes of the
Healthcare systems should be actively
previous chapters are primarily targeted at
thinking about how they can improve the
policymakers, decision-makers in industry,
population’s SDH, while simultaneously
and other relevant stakeholders who
expanding access to healthcare.
influence countries’ policy formulation and
implementation. However, we recognise that • … but also champion the often overlooked
the Index may also appeal to an advocacy- elements of culture, empowerment and
oriented audience, including concerned agency. Similar impetus is required to boost
individuals, corporate institutions, NGOs, cultural competency, personal agency and
among others. What are some of the key community empowerment. Champions
takeaways from the Index that could prove are needed. Who will lead this campaign?
useful from a campaigning and advocacy There is much to do in the area of improving
perspective? cultural competency in provider training,
raising health literacy and supporting
• Don’t stop campaigning for universal health shared decision-making. Furthermore,
coverage and the social determinants of the importance of supporting community
health… As we’ve discussed in the report, health workers, who have repeatedly proven
these are not new ideas and they have their worth, in rich and poor countries
established champions. And it shows. In a alike, cannot be overstated. While these
classic example of death by acronym, both ideas and initiatives have their supporters,
UHC and the SDH are part of the UN’s they have not yet been brought together

under an overarching campaign. Our Index also be the first step in re-democratising
found that these factors were important healthcare. As Dr Rashad says, ‘‘The
to produce high scores in health inclusivity, importance of reducing exclusion can
and that they complement the UHC and be addressed with two self-reinforcing
SDH campaigns. The first step towards actions. The first is pushing fairness as
improvement in this area is simple: get out a pillar of good governance and social
there and listen. success. The second is giving visibility and
voice to excluded groups.’’
• Work from the outside in: by actively
supporting vulnerable groups, you will • Pull in the same direction: elevate
help improve health for all. A good place the importance of coordination to
to start listening is in the most vulnerable achieve common goals. Even if unable
sections of society, such as migrants, to fund or implement initiatives
refugees and asylum seekers, among others. themselves, governments can and
The Covid-19 pandemic has seen new or should play a crucial role in organising
reshaped infrastructure and partnerships and coordinating the work of others.
created to support mitigation measures Many initiatives arise from the local
including the vaccine roll-out; these can community or the private sector. The role
be adapted to form the backbone of of the state in these instances can be to
longer-term improvements in outreach support where possible, and help scale
and delivery of care. But exclusion of successful programmes. Government
marginalised communities is just as often a and civil service can coordinate between
matter of cultural competency, and as such, ministries, between the public and private
has lessons for all multicultural societies. sectors, between NGOs, and between
It is not only migrants and others that are the community and the state. Without
excluded through language and cultural an overarching strategy, and a dedicated
norms. Therefore, working with the most team to implement that strategy,
marginalised will help improve health the uncoordinated action of multiple
inclusivity for society at large, i.e., “work from ministries would inevitably dampen the
the outside in”. The listening exercise can impact of state interventions.
Working with the

most marginalised
will help improve
health inclusivity
for society at large

• Advocate for high-quality data collection, and Canada, alike. WHO workforce data
and “real-world evidence” for inclusivity. are collected from a variety of national and
Data limitations have minimised the broad regional sources.35 This lack of available
scale lens of inclusivity we had hoped to data on health workers suggests that
paint. For example, we spoke previously governments cannot ensure that they have
about the importance of community sufficient numbers, or oversee the quality
health workers. But the absence of reliable of their skills and training. We faced similar
data on the community health worker difficulties for many concepts, particularly
population meant that we were unable for indicators within Domain 3: People
to include these among our workforce and Community Empowerment. There
indicators. Indeed, comparable data was is a critical need for better indicators of
not available for several categories of health measurable progress for matters of culture,
workers, including environmental and individual and community empowerment.
occupational health workers, traditional In the same way that real-world evidence is
and complementary medicine personnel, currently revolutionising health technology
psychologists and community health assessment, so too can the better collection
workers. Data was missing for low-income of cultural and community-based evidence
countries like Rwanda, high and upper- improve the assessment of inclusivity.
middle income countries like Italy, Japan

Discussion:
bringing it together
Nations must tackle all three domains of The balance of results between the domains
the Health Inclusivity Index to achieve an of the Index suggests that most countries are
inclusive health system that allows everyone coming to grips with the elements of Domain 1:
in the country to reach their optimum state Health in Society, many countries are struggling
of health. Governments need to understand with elements of Domain 2: Inclusive Health
that health is affected by all areas of policy. Systems, and there is something of a divide
A requirement to take a “health in all between countries that have embraced Domain
policies” approach, and oversight to ensure 3: People and Community Empowerment and
implementation, is a preliminary step. those that have not.
FIGURE 14. Comparison of domain statistics

Descriptive statistics for each of the Health Inclusivity Index’s three domains: Domain 1: Health in Society, Domain 2: Inclusive Health Systems
and Domain 3: People and Community Empowerment
DOMAIN 1: SUMMARY STATISTICS DOMAIN 2: SUMMARY STATISTICS DOMAIN 3: SUMMARY STATISTICS
41.6 MIN 28.1 MIN 22.6 MIN
92.6 MAX 84.4 MAX 98.9 MAX
51.0 RANGE 56.3 RANGE 76.3 RANGE
78.0 MEDIAN 66.0 MEDIAN 67.9 MEDIAN
74.0 AVERAGE 64.0 AVERAGE 69.4 AVERAGE

Countries are unlikely to provide

accessible health services
if they do not believe that health
is a right and a priority
A history of campaigning shows its the most important part of the Index.” He says
worth that measuring levels of community health
engagement can allow even cash-strapped
Professor Sir Michael Marmot was encouraged countries to make progress at the level of
that Domain 1: Health in Society was the policy innovation; for empowering individuals
highest-scoring domain. “I’m pleased that and communities to manage better their own
Domain 1: Health in Society came out as health “provides people with options that are
important because I think that’s the key,” he real that they may not otherwise have thought
says. This view was backed by Prof Gupta, of or considered feasible.”
who highlighted that addressing poverty and
other SDH will “go a long way” to improve There is a historical context to consider
health inclusivity. However, she thinks that when comparing progress across the three
expenditure on health services–especially domains. For the last few decades, the first
primary care–must improve to provide access two domains in the Index can be mapped to
to everyone. progress towards international advocacy of
inclusive healthcare. For example, the idea
Professor Napier said he was “elated” that that health is a “fundamental human right”
the Index “recognised the fact that health as reflected in Domain 1: Health in Society,
is largely made or lost outside the formal was encoded in the 1978 Declaration of
health sector”, as doing so calls attention to Alma-Ata, at the International Conference on
the importance of the social determinants Primary Care.13 In addition, this declaration
of health, and to the health-in-all-policies deplored the “existing gross inequality” in the
approaches required to make health the health status of people globally, and said that
centre of our lived experiences”. He added: “I people had “the right and duty to participate
am really happy to see the Index taking on the individually and collectively in the planning
challenge of gathering critically important data and implementation of their healthcare”. In
in domains whose importance has been largely 2003, the WHO outlined its understanding of
undervalued because that data is hard to the SDH, including early life, social exclusion,
get.” He believes that Domain 3: People and employment, social gradient, stress, food and
Community Empowerment “could emerge as transport.36

It is a similar situation with Domain 2: 3 have been difficult to identify, as there is

Inclusive Health Systems, where in 2019, a lack of conceptualisation and consensus
world leaders adopted a high-level UN Political around these ideas, not to mention the distinct
Declaration on UHC. This declaration was lack of adequate datasets. Un-championed,
arguably the most comprehensive set of unmeasured, and frequently unrecognised,
health commitments ever adopted. Dr Tedros the concepts in Domain 3 are, we believe,
Adhanom Ghebreyesus, Director-General of the components of the inclusivity landscape
the WHO, commented that “this declaration critical to future progress. In support of this
represents a landmark for global health assertion, Domain 3: People and Community
and development”.37 Taking on-board the Empowerment had the greatest predictive
importance of health as a human right and the value for overall performance in the Health
need for inclusive health systems, a concept of Inclusivity Index.
“Inclusive Health” emerged around 2011. The
What is clear when considering progress in
paper encapsulated the ethos of “Health for
these domains is the extent to which they
All”, and called for a more proactive approach
overlap with one another. Countries are
to addressing the barriers to health inclusion.38
unlikely to provide accessible health services
if they do not believe that health is a right
Looking out for a hero
and a priority. Improving accessible services
However, while Domains 1 and 2 have long usually involves empowering people to use
had their champions—the ideas depicted them effectively. And empowering people
in Domain 3: People and Community to address their health often goes back to
Empowerment, cultural competency, making progress on the SDH. While the
community empowerment and individual three domains are a pragmatic framework to
agency are often missing from the discourse consider different aspects of inclusivity, they
on health inclusivity. Indicators in Domain are inextricably linked.

An index, a toolkit and a conceptual in health inclusivity without having to spend

framework infeasible amounts of money. Much can be
achieved by working together with diverse
Although we have created an index of health stakeholders to ensure that the government
inclusivity, it also functions as a conceptual acts in alignment, and making sure that
framework and a toolkit for policymakers. It’s decision-making, where possible, is devolved
a conceptual framework because inclusivity to empowered communities in a culturally
is a term often used but rarely defined. Our sensitive manner.
hope is that by describing the domains and
subdomains, we offer a concrete, quantitative We noted earlier the difference between a
way to think about inclusivity. It’s not perfect, “right to health” and a “right to be healthy”;
and many will disagree with our approach, the first being a useful campaigning tool, the
but we hope that our transparency in defining second being beyond the realm of any earthly
inclusivity will encourage our critics to be power to deliver. So it is with health inclusivity.
similarly transparent in their feedback. No government can guarantee everyone good
health or that everyone will experience the
The Index is like a toolkit because its focus on same level of health throughout their life. And
policies, processes and institutions, rather than yet the “Health for all” movement following
outcomes, enable policymakers to identify the Alma-Ata declaration remains a banner
not only that action needs to be taken, but around which we can rally. Its relevance was
what that action should be. The Index gives reiterated by the late WHO Director-General
governments a good starting point to see how Lee Jong-wook, in his foreward to the 2003
they stand compared to their peers, and where World Health Report:39 “It was not just an
action can be taken to improve their scores. ideal but an organising principle [...] Turning
While individual countries will have to look that vision into reality calls for clarity both
at their scores and discuss how local and on the possibilities and on the obstacles that
national improvements can be made, we have have slowed and, in some cases, reversed
described in the “implementing inclusivity” progress towards meeting the health needs of
boxes overarching actions and principles that all people.” We hope that the Health Inclusivity
we think policymakers should consider when Index can help countries and campaigners
looking to improve health inclusivity. Lower- identify, and remove, obstacles to good, and
income countries could make huge strides inclusive, health.

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The Health

16 Introducing the Health Inclusivity Index

20 Theme 1: A focus on the social determinants of health leads to

24 Theme 2: Health inclusivity requires the identification of vulnerable

28 Theme 3: Universal health coverage is necessary, but not sufficient,

31 Theme 4: Money is not the only driver of inclusivity–in fact, better

35 Theme 5: Community and individual empowerment is at the heart

40 Theme 6: Inclusivity is only part policy–without implementation,

46 Campaigning for an undefinable goal

49 Discussion: bringing it together

© The Economist Group 2022

About this report

Health inclusivity is a measure of whether • Charlotte Ersbøll, Founding partner of

© The Economist Group 2022

The research was led by Emi Michael and Elly

© The Economist Group 2022

Professor Sir Michael Marmot

© The Economist Group 2022

© The Economist Group 2022

Introducing the index: why it’s important and what it measures

© The Economist Group 2022

Index findings and policy takeaways

Theme 1: A focus on social Theme 2: Health inclusivity requires

• Emphasise a “health in all policies”

© The Economist Group 2022

Theme 3: Universal health coverage Theme 4: Money is not the only

• Utilise multidisciplinary teams, including • Low-income countries need to protect

© The Economist Group 2022

Theme 5: Community and individual Theme 6: Inclusivity is only part

Implementing inclusivity: theme 5 Implementing inclusivity: theme 6

© The Economist Group 2022

An index, a toolkit and a conceptual framework

The Index is like a toolkit because its focus on

© The Economist Group 2022

“Health does not begin in a hospital

© The Economist Group 2022

Why do we need an index of inclusivity in health?

Good health goes beyond healthcare

© The Economist Group 2022

Inclusivity in health requires a society to

From vulnerability to resilience

© The Economist Group 2022

What is inclusivity in health?

© The Economist Group 2022

Introducing the Health

© The Economist Group 2022

© The Economist Group 2022

sel rm Int era ol

© The Economist Group 2022

FIGURE 1. The Health Inclusivity Index

Domain 1 Domain 2 Domain 3

© The Economist Group 2022

Theme 1: A focus on the

3 South Korea 90.7

© The Economist Group 2022

Brazil can show other countries how it’s done.

© The Economist Group 2022

Inter-sectoral cooperation policy (1.2.2) Public/Community participation in policy (3.2.4)

3 South Korea 90.7

MEAN 4 Sweden 83.2