Selective Universalism and the Inverse Care Law: How Health Systems Overlook Neglected Tropical Diseases in Low-Income Settings

Neglected tropical diseases are often framed within universal health coverage, equity, and “leave no one behind” agendas, yet highly stigmatised chronic conditions remain unevenly incorporated into routine health systems. Drawing on Julian Tudor Hart’s Inverse Care Law, this study examines how national health policies and primary healthcare governance in Ethiopia shape access to care for podoconiosis, using a critical social policy approach combining policy analysis and qualitative evidence to examine how governance and finance arrangements translate equity commitments into everyday service delivery. The findings highlight that, despite formal recognition of podoconiosis in national strategies, its delivery remains poorly integrated into routine health information systems, financing mechanisms, and accountability frameworks, resulting in political invisibility, long-standing underinvestment, and reliance on intermittent NGO support, which in turn leads to fragmented and discretionary care. At the frontline, affected people face long travel distances, high self-care costs, stigma, and unpredictable service availability, creating an inverse relationship between need and provision. The inverse care arises not from policy absence but from selective integration within formally universal systems, where equity-oriented rhetoric coexists with governance structures privileging campaign-based over chronic care. Podoconiosis thus serves as a “tracer condition” to illustrate how symbolic policy inclusion can coexist with systematic institutional neglect, reproducing inequality through everyday administrative and fiscal practices. Addressing the inverse care law thus requires moving beyond rhetorical universalism toward governance arrangements that secure sustained, rights-based access for marginalised populations in practice.