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This chapter addresses inequalities in the United Kingdom through the lens of health inequalities. Driven by inequalities in income and power, health inequalities represent a microcosm of wider debates on inequalities. They also play a role as the more politically unacceptable face of inequalities – where other types of inequality are more blatantly argued as collateral damage of advanced neoliberalism including ‘inevitable’ austerity measures, politicians are more squeamish about discussing health inequalities in these terms.

The chapter starts by depicting health inequalities in Scotland and summarises health policy analyses of the causes of, and solutions to, health inequalities. It then describes the concept of ‘proportionate’ universalism’ and sets this within the context of debates around universal versus targeted welfare provision in times of fiscal austerity.

It then turns to a small empirical case-study which investigates these tensions within the Scottish National Health Service. The study asks those operating at policy and practice levels: how is proportionate universalism understood; and, is it a threat or ballast to universal welfare provision?

Findings are discussed within the political context of welfare retrenchment, and in terms of meso- and micro-practices. We conclude that there are three levels at which proportionate universalism needs to be critiqued as a means of mitigating the impacts of inequalities in the social determinants of health. These are within the political arenas, at a policy and planning level and at the practice level where individual practitioners are enabled or not to practice in ways that might mitigate existing inequalities.

This chapter considers how far political devolution has enabled the government in Wales to develop a distinctive approach to student funding. It examines in particular claims that policy choices in Wales on student funding reflect a commitment to ‘progressive universalism’, a term sometimes used by policy-makers in Wales and elsewhere to describe combining means-tested and non-means-tested benefits. The chapter also explores the growing use of income-contingent loans, arguing that such loans complicate debates about targeting and universalism.

Equity is an issue that pervades all aspects of primary care provision for children and as such is a recurring theme in the Models of Child Health Appraised project. All European Union member states agree to address inequalities in health outcomes and include policies to address the gradient of health across society and target particularly vulnerable population groups. The project sought to understand the contribution of primary care services to reducing inequity in health outcomes for children. We focused on some key features of inequity as they affect children, such as the importance of good health services in early childhood, and the effects of inequity on children, such as the higher health needs of underprivileged groups, but their generally lower access to health services. This indicates that health services have an important role in buffering the effects of social determinants of health by providing effective treatment that can improve the health and quality of life for children with chronic disorders. We identified common risk factors for inequity, such as gender, family situation, socio-economic status (SES), migrant or minority status and regional differences in healthcare provision, and attempted to measure inequity of service provision. We did this by analysing routine data of universal primary care procedures, such as vaccination, age at diagnosis of autism or emergency hospital admission for conditions that can be generally treated in primary care, against variables of inequity, such as indicators of SES, migrant/ethnicity or urban/rural residency. In addition, we focused on the experiences of child population groups particularly at risk of inequity of primary care provision: migrant children and children in the state care system.

Successive devolved governments have been attempting to address inequalities which are deeply rooted in Scotland, by adapting UK policies or by devising their own solutions. In addition, from 2007, Scottish National Party (SNP) governments have criticised the policies conducted at UK level – especially the austerity policies in response to the Recession from 2010. They have demanded further powers to be able to mitigate or reform them, thus adding a constitutional dimension which has been reignited after the referendum on Brexit. This chapter deals with some of the policies aiming at tackling inequalities related to incomes and capabilities in the fields of education and health. It sheds light on the ongoing debates in Scotland and on some of the results which have been achieved under SNP governments.

Objective – The first wave of experiences of exemptions policies suggested that poverty-based exemptions, using individual targeting, were not effective, for practical and political economic reasons. In response, many countries have changed their approach in recent years – while maintaining user fees as a necessary source of revenue for facilities, they have been switching to categorical targeting, offering exemptions based on high-priority services or population groups. This chapter aims to examine the impact and conditions for effectiveness of this recent health finance modality.

Methodology/approach – The chapter is based on a literature review and on data from two complex evaluations of national fee exemption policies for delivery care in West Africa (Ghana and Senegal). A conceptual framework for analysing the impact of exemption policies is developed and used. Although the analysis focuses on exemption for deliveries, the framework and findings are likely to be generalisable to other service- or population-based exemptions.

Findings – The chapter presents background information on the nature of delivery exemptions, the drivers for their use, their scale and common modalities in low-income countries. It then looks at evidence of their impact, on utilisation, quality of care and equity and investigates their cost-effectiveness. The final section presents lessons on implementation and implications for policy-makers, including the acceptability and sustainability of exemptions and how they compare to other possible mechanisms.

Implications for policy – The chapter concludes that funded service- or group-based exemptions offer a simple, potentially effective route to mitigating inequity and inefficiency in the health systems of low-income countries. However, there are a number of key constraints. One is the fungibility of resources at health facility level. The second is the difficulty of sustaining a separate funding stream over the medium to long term. The third is the arbitrary basis for selecting high-priority services for exemption. The chapter therefore concludes that this financing mode is unstable and is likely to be transitional.