Social Determinants of Health

Discussions on the social, economic and political determinants of health are as old as the structures of international health governance. Even long before these were set up it was known that the conditions in which people are born, grow, live, work and age deeply influence their health and wellbeing.

The issue under discussion is not so much whether or not health is socially determined, but how we should take action to address the social determinants. One can take the view that it is a technical matter of improving sanitation and hygiene, child nutrition, a clean work environment etc. Or you could say that action should go far beyond the health sector, reforming economic structures, eliminating inequity and addressing power imbalances.

We strongly believe this second view is the right one. As stated in the preamble of the People’s Charter for Health: "Health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill‐health and the deaths of poor and marginalised people.Health for all means that powerful interests have to be challenged, that globalisation has to be opposed, and that political and economic priorities have to be drastically changed".


The League of Nations Health Organisation (LNHO), WHO’s predecessor, had a narrow area of work despite its responsibility for public health and social medicine within the League of Nations. As it tried to justify its demands for reforms under the name of science, it devolved initiatives to scientific experts, making health a question of standard-setting and gathering morbidity/mortality statistics. Health policy was “scientized” and a primacy of professionalized, increasingly technocratic solutions to public health evolved.

WHO followed the same course in the 1950s and ‘60s focusing on specific diseases, e.g. smallpox and malaria. As a reaction to WHO’s vertical approach, a broad-based philosophy of health that was more sensitive to local requirements and anchored around the provision of Primary Health-Care (PHC) gained ground at the WHO in the 1970s. This culminated in the International Conference on Primary Health Care in Alma Ata in 1978, out of which came the Alma Ata Declaration and the goal of “Health for All by the Year 2000”.

The Alma-Ata Declaration emphasized the fundamental importance of the economic and political context to PHC’s success and called for a New International Economic Order. Primary Health Care was understood as a comprehensive approach; integrating rehabilitative, therapeutic, preventive and promotive interventions, with an emphasis on the latter two. Equitable social and economic development, intersectoral collaboration and community participation were deemed essential aspects.

While we have seen substantial progress in global health in the thirty years since Alma Ata with an overall increase in life expectancy, gaps between and within countries are widening. The visionary policies in the Declaration were buried in the 1970s debt crisis, stagflation, and the dominance of the global economic policy by neoliberal thinking.

Commission on Social Determinants of Health

During the last ten years, attempts were made to revive Alma-Ata and the PHC-approach. The People’s Health Movement was founded in 2000 and adopted the People’s Charter for Health, which made a bold call for action to make Health for All a reality. At WHO, former Director General Lee Jong-Wook announced the creation of the Commission on Social Determinants of Health at the 57th World Health Assembly in 2004. It was designed to bring together the knowledge of experts, especially those with practical experience to provide guidance for all WHOs programmes.

The Commission was launched in March 2005 and it released its final report, called ‘Closing the Gap in a Generation’ in 2008. As an input to the work of the Commission, a group of Civil Society Organisations, led by the People’s Health Movement, released a Civil Society Report on the SDH. It explores why the promise of Alma Ata did not become reality and provides an alternative view on the determinants of health. It further describes the role of civil society and lists a number of case studies to illustrate civil society action on health.

The Commission’s final report has the following three overarching recommendations: (1) to improve daily living conditions; (2) to tackle the inequitable distribution of power, money and resources; and (3) to measure and understand the problem and assess the impact of action. A concern for equity is central to the Commission’s call to address social determinants. The report calls for action outside the health sector arguing that global health inequalities are “the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics”. In the same year the Commission released their final report, WHO devoted its World Health Report to Primary Health Care.

The results of the Commission were brought to the 62th World Health Assembly in 2009. The Assembly adopted resolution WHA62.14 on “Reducing health inequities through action on the social determinants of health”. The resolution notes the recommendations of the Commission’s report and links them with the PHC-approach. It is mindful of widening inequalities and calls for greater coordination with civil society and the private sector. It further points to the important role of global governance mechanisms in the regulation of goods and services with a major impact on health and the need for corporate responsibility.

The resolution called upon the international community to enhance health equity in all policies and to consider health equity in working towards achievement of the core global development goals. It urged member states to mainstream health equity in all policies and to enhance inter-sectoral and multi-stakeholder action. It called for the empowerment of marginalized groups.
It further requested the Director General to promote addressing social determinants of health as an objective of all areas of the Organization’s work and to provide support to Member States in implementing a health-in-all-policies approach. Finally it called for the convening of global event before the 65th WHA in order to “discuss renewed plans for addressing the alarming trends of health inequities through addressing social determinants of health” and to report on progress to the 65th WHA in May 2012.

World Conference on Social Determinants of Health

After the Health Assembly, the preparations for the requested ‘global event’ began. The World Conference on Social Determinants of Health (WCSDH), convened by WHO and the Government of Brazil, was to be held in Rio de Janeiro from 19 to 21 October 2011. The aim of the Conference was to bring Member States and other actors together to catalyze high level political support for national policies to address social determinants of health to reduce health inequities.

The WHO Secretariat prepared a Discussion Paper to inform proceedings at the Conference, about how countries could implement action on social determinants of health, including the recommendations of the WHO Commission on Social Determinants of Health. The final version of the Discussion Paper was developed following extensive consultation with Member States, academia, civil society, other UN agencies and within the WHO Conference Secretariat itself. A public web consultation was undertaken in May and June 2011, with almost 200 submissions.

A submission from PHM and other CSO highlighted five main weaknesses in the paper. During a Latin-American Civil Society consultation in August 2011 another Civil Society Consensus Statement was produced (in Spanish). The Rio Conference was attended by a strong network of public servants, public interest civil society, and academics committed to the principle of achieving a fairer world in which health is more equally distributed. See our event page [under construction] for more information, videos, blogs and official documents with our comments.

The Conference resulted in the Rio Political Declaration on Social Determinants of Health. An Alternative Declaration was produced by Civil Society, as well as a general civil society position.The results of the Rio Conference were brought to the 65th World Health Assembly through the 130th Executive Board in 2012. The Assembly adopted resolution WHA65.8, endorsing the Rio Political Declaration. In the resolution, member states expressed their political will to improve public health, and reduce health inequities through action on the social determinants of health. The focus is on addressing the challenges of eradicating hunger and poverty; ensuring food security; enabling access to healthcare and affordable medicines; and improving daily living conditions through provision of safe drinking-water and sanitation, employment opportunities and social protection; protecting environments and delivering equitable economic growth. See our reports on the EB and the WHA for a summary and analysis of the discussions and our statements to the Assembly.

A critical appraisal

The Global Health Watch 3 provides a critical appraisal of the ‘revitalisation’ of PHC and the Alma Ata Declaration in chapter B1. It argues that the concept of comprehensive PHC has been narrowed down to a technical, selective PHC-approach by a series of reform projects. Through its revival, PHC has become synonymous with first line or primary medical care provided by general doctors; or a cheap, low-technology option for poor people in low- and middle-income countries (LMICs). The spirit of PHC has been depoliticised, and the broader economic and political context of health neglected. The significance of an unfair global economic regime in reproducing the health disadvantage for poor people was clearly articulated in the Alma Ata Declaration and reaffirmed in the Commission’s Report. Unfortunately, these aspects are mostly absent in the relevant political declarations and WHA resolutions. These same concerns were voiced in the abovementioned alternative civil society documents and comments (Civil Society Report on the SDH, input to WHO Discussion paper, Alternative Civil Society Declaration for the World Conference on SDH).

Current issues

Discussions on the importance of the social determinants of health are now being held in the context of global goal setting; both for the broader development agenda post-2015 and for WHO in particular as part of the WHO reform. Resolution WHA65.8 requested the Director General to “continue to convey and advocate the importance of integrating social determinants of health perspectives into forthcoming United Nations and other high-level meetings related to health and/or social development”. The SDH were recognised in the outcome document titled ‘The Future We Want’ agreed by member states at the United Nations Conference on Sustainable Development (Rio+20) in June 2012. The document states: “We are convinced that action on the social and environmental determinants of health, both for the poor and the vulnerable and the entire population, is important to create inclusive, equitable, economically productive and healthy societies”. This Declaration is important in the post-MDG global goal setting process and thus also for the WHO reform. The next set of health-related MDG should closely match the priorities to be defined in the next General Program of Work (GPW).

Concerning priority setting within WHO, there was a quite heated debate at the 65th WHA in May 2012 over the treatment of SDH. The DG had originally proposed that SDH (along with the Right to Health, gender equity and PHC) would be treated as ‘cross-cutting’ issues or ‘mainstreamed’ which meant that they would not be treated as priorities in their own right but would be represented through a unit in the DG’s Office and she undertook to provide a personal guarantee that the principles of action on SDH would be expressed in all of the relevant priority areas, presumably through internal advocacy, capacity building and collaboration. There was a great deal of concern expressed by Member States, particularly from Latin America, to the effect that SDH would be buried under this strategy. Since the DG had not at that stage proffered any mechanisms for ensuring the full realisation of the ‘cross cutting’ principles there was some scepticism about the practicability of her assurances.

The draft Programme Budget for 2014-15 which has now been released for Regional Committee consultation has relocated SDH as a ‘priority’ within the ‘category’ of ‘promoting health through the life course’.  In this new document the concept of linkage has been given increased prominence, although the idea of cross-cutting still remains. ‘Linkage’ here means the complementarities and synergies between different categories and priorities, for example, between the two ‘categories’, NCDs and health systems. What is more worrying is that the Secretariat has all but acknowledged that it does not know how it is going to give effect to the ideas of linkage, cross-cutting and mainstreaming; not just across the silos in headquarters but also within the regional and country offices.

There are other questions to consider regarding WHO’s commitments for the biennium in relation to SDH. The five dot points offered as ‘outputs’ for the biennium are largely about standard setting, research, policy briefs, indicators and ‘support to member states’. This is a much more cautious agenda than that offered by the Commission on SDH or the CS Statement at the Rio Conference. For example, there is no explicit reference to trade and finance in the five dot points (for ‘outputs’) under SDH.   

To follow up the discussion on the WHO reform and priority setting see our topic page on WHO Reform.

Selected readings

The SDH were also discussed at:

World Conference on Social Determinants of Health, 130th EB, 65th WHA