Social Determinants of Health: the World Health Organisation's
Over the last several decades, there has been increasing recognition
that social determinants of health have an impact on human health, and that
they must be addressed if the overarching goals of health equality among all
people are to be achieved. At the 1978 International Conference on Primary
health Care in Alma Ata, governments from around the globe affirmed a holistic
view of health as more than the absence of illness, and that maintaining high
standards of health required action in the social and economic spheres,
The Conference strongly reaffirms that health, which is a
state of complete physical, mental and social wellbeing, and not merely the
absence of disease or infirmity, is a fundamental human right and that the
attainment of the highest possible level of health is a most important
world-wide social goal whose realisation requires the action of many other
social and economic sectors in addition to the health sector.
Almost a decade later in 1986, the first International Conference on
Health Promotion held in Ottawa, Canada, culminated in the 'Ottawa Charter for
Health Promotion' (Ottawa Charter). The Ottawa Charter highlighted a number of
prerequisites for health including peace, shelter, education, food, income, a
stable eco-system, sustainable resources, social justice and equity.
More recently, the 1997 WHO Global Conference
on Intersectoral Action for Health, the 2005 Bangkok Health Promotion conference
and the 2006 EU's Finnish presidency's theme of Health in All Policies each
recognised that political, economic, social, cultural, environmental,
behavioural, and biological factors can all favour health or be harmful to it,
and the need for all sectors of society to be involved in health policy.
These milestones demonstrate an appreciation in the international community
that the most effective means of tackling the social determinants of health is
through intersectoral action. As most of the determinants of health lie outside
of the health sector, the solutions will have to involve areas outside the
In 2008 the
World Health Organisation's (WHO) Commission on Social Determinants of Health
published a report titled 'Closing the gap in a generation: health equity
through action on the social determinants of health' (WHO Report).
This report refocused attention on the necessity of addressing the social
determinants of health. In the words of one of the report's authors, the WHO
...shone a global spotlight on the marked health inequalities
that exist between and within countries at the start of the 21st
century...the [WHO Report] in 2008 was a call to action to governments and
non-governmental agencies around the world to adapt the necessarily general
global recommendations into national and local socioeconomic and sociocultural
Australian perspective was actively represented on the Commission with one of
the 19 commissioners being Australian. During the preparation of the WHO Report
there was also a seminar in Adelaide which considered the social determinants
of indigenous health.
In May 2009,
following the publication of the WHO Report, WHO Resolution 62.14
urged member states:
To tackle the health inequities within and across countries
through political commitment on the main principles of 'closing the gap in a
generation' as a national concern, as is appropriate, and to coordinate and
manage intersectoral action for health in order to mainstream health equity in all
policies, where appropriate, by using health and health equity impact
assessment tools; [and]
To take into account health equity in all national policies
that address social determinants of health, and to consider developing and
strengthening universal comprehensive social protection policies, including
health promotion, disease prevention and health care, and promoting
availability of and access to goods and services essential to health and
In the wake
of the report a number of countries around the world and governments in
Australia began exploring options to address the social determinants of health
within their own populations.
social determinants of health vary between countries: developed and developing
countries necessarily face different challenges and will need to adopt
different solutions. In developed countries – such as Australia, a low
socioeconomic position means fewer education and employment opportunities, job
insecurity, poorer working conditions, a lack of amenities, and unsafe
neighbourhoods, with their consequent impact on family life.
Recommendations from the Commission on Social Determinants of Health
The WHO Report highlighted three broad key areas for action:
Improve daily living conditions including education, nutrition,
working conditions, and social protections;
- Address the inequitable distribution of power, money and
- Maintain accurate measurements of social determinants of health
and assess new policies' potential impact on health outcomes.
The WHO Report notes that although there are broad principles that can
be used to guide action in addressing the social determinants of health,
precise policy measures need to be devised by each individual nation depending
on their individual circumstances.
This chapter highlights the key policy areas nominated by the WHO Report for
action. The following chapters will discuss policy options for the Australian
Strengthening public sector
The Report notes the importance of public sector leadership in effective
national and international regulation of products, activities, and conditions
that damage health or lead to health inequalities.
As the report explains:
Underpinning action on the social determinants of health and
health equity is an empowered public sector, based on principles of justice,
participation, and intersectoral collaboration. This will require strengthening
of the core functions of government and public institutions, nationally and
sub-nationally, particularly in relation to policy coherence, participatory
governance, planning, regulation development and enforcement, and standard
A key proposal put forward in the WHO Report to improve the social
determinants of health is the inclusion of a health equity impact statement as
a component of public policy creation and administration to ensure that all
policies are assessed against their potential health impacts.
Policy coherence is highlighted as a key area of concern; ensuring that all
government policies complement each other in relation to promoting health
equity is an important step in addressing the social determinants of health.
This extends beyond the traditional domains of health: all policies should be
assessed for their health impact.
In the words of the WHO: 'The argument for a coherent approach to health equity
through action on the social determinants in all socioeconomic and
sociocultural contexts is unequivocal.'
The WHO Report argues that: 'Health equity impact assessment of policies and programmes
must happen as a matter of course – that is, it should be a routine procedure
in policy development.'
One recommendation in the WHO Report is that governments formally commit
to improving health equity through action on the social determinants of health
as a measure of government performance.
One mechanism to achieve this is through reporting mechanisms. This option is
discussed in more detail in Chapter 5 of this report.
Ensure universal social protection
The WHO report argues that universal social protections are important
for population health in general, and especially for disadvantaged groups, and
recommends that social protection systems are universal in scope and extend
across the life course. Universality in this context means that all citizens
have access to social protection as a social right. It is argued that:
Universal approaches are important for the dignity and
self-respect of those who need social protection the most. And because
everybody benefits, rather than just one group that is singled out, universal
social protection systems can enhance social cohesion and social inclusion, and
can be politically more acceptable. Including the middle classes by means of
universal programmes can enhance willingness of large parts of the population
to pay the taxes needed to sustain universal and generous policies.
The report goes on to note that universal benefits can improve the
social status and inclusion of older people who can no longer earn a living in
the market, and also decrease gender inequalities as women tend to live longer
and earn less than men making contributory pension schemes disadvantageous.
The WHO Report emphasizes the importance of ensuring universal access to
healthcare based on the principle of access rather than ability to pay. Out of
pocket expenses are argued to generate 'utilisation inequalities' and
potentially exclude vulnerable groups such as the aged and single parents.
The WHO Report highlights the importance of adequate funding to address
the social determinants of health. As the report explains:
Health equity relies on an adequate supply of and access to
material resources and services; safe, health-promoting living and working
conditions; and learning, working, and recreational opportunities. Supply of and
access to these, in turn, requires public investment and adequate levels of
public financing, and/or regulation of markets where private provision can be
an effective and efficient means of equitable access...Traditionally, governments
are expected to play an active role in providing public goods. Left solely to
the market, such goods are undersupplied.
Promoting gender equality
The WHO has pointed out that, globally, women control less capital,
receive lower wages, and carry more of the domestic burdens than their male
counterparts. This trend is as true in developed as developing countries. In
order to address the social determinants of health, there is a need to improve
the status and position of women in society; ensuring that they receive the
same remuneration as men for the same work, that their domestic contributions
are not overlooked, and that they are compensated for reduced earnings caused
by familial responsibilities such as child-birth and -rearing.
It was suggested that the provision of quality childcare facilities,
flexible working hours, and parental leave for men and for women would assist
in improving gender equality.
One of the serious consequences of women receiving lower wages than men
and spending more time out of the labour market as a consequence of acting as
primary caregivers is that they have lower accumulated retirement incomes.
Poverty and low pension benefits are strongly associated with worse health
Lesbian, Gay, Bisexual, Transgender
and Intersex people
During the inquiry the committee heard some criticism of the lack of
consideration of Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI)
people in the WHO Report.
Although the WHO report discusses the impacts of gender on the health of women
and girls, there is no mention of sexuality, nor its impacts on health.
The committee received evidence from a number of submissions that LGBTI
social determinants of health should also be considered in any government
Evidence provided to the committee highlighted that in Australia sexuality acts
a social determinant of health and needs to be recognised as such.
Fields such as education and access to healthcare were cited as key areas in
which the social determinants of health are acting on LGBTI people.
Improve understanding of the social
determinants of health
One of the key recommendations of the WHO Report – to improve the
measurement and understanding of the social determinants of health – is born
out of the acknowledgement that in many areas there is limited data available
on the impacts and causes of the social determinants of health. The standard
tools found in the researchers toolbox such as controlled trials and
benchmarking are difficult (and often unethical) to apply to a community.
Establishing chains of cause and effect for social determinants of health is
conceptually and empirically difficult as many determinants are distant –
spatially and temporally – from the individuals they impact.
Although the WHO Report recognises the limitations in the available
data, especially in relation to the most effective interventions to address the
social determinants of health, the available evidence appears to strongly
correlate with the theory of social determinants of health as discussed in the
previous chapter. Chapter five of this report provides a more fulsome
discussion of the importance of research and data to addressing the social
determinants of health.
Successfully tackling the social determinants of health will require
evidence-based policies. As the name implies, this will require good data on
the extent of the problem, and up-to-date evidence on determinants and on what
works to reduce health inequalities. It also requires that policy-makers and
other professions understand both the social determinants of health and the
evidence available in relation to them.
In order to successfully research the social determinants of health,
adequate research funding needs to be made available. The WHO Report argues
that although the largest health improvements come from addressing the social
determinants of health, the available research funding remains 'overwhelmingly'
In light of the large amount of work that needs to be done to adequately
understand the social determinants of health, the WHO Report highlights three
key areas of action:
First, research on determinants of health inequalities,
rather than determinants of average population health, need further study.
Second, more research is needed on what works to reduce health inequalities in
what circumstances, and how best to implement interventions such that they
contribute to a reduction of these inequalities...The third area for investment
is the development of methods for measuring and monitoring health inequities
and for evaluating the impact of population-level interventions.
The WHO Report advocates that governments collect data on the most
important social determinants of health ranging from daily living conditions to
more structural drivers of health inequality. The system, it is argued, should
be designed in such a way that it is possible to follow differences in gender
and social-strata outcomes over extended periods of time.
The theory and evidence for the social determinants of health having a
direct impact on the lives of individuals has been well documented by the WHO
and researchers from around the world. The WHO Report touches on almost all
areas of society and government responsibility. In response to the rising
awareness of the expansive nature of the social determinants of health, a
number of countries have begun taking a social determinant of health approach
to public policy making. There are also several initiatives in Australia which
are beginning to address the social determinants of health. The following
chapter discusses various social determinants of health and potential means to
addressing them in the Australian context.
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