The social determinants of health (SDH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.
The SDH have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.
The following list provides examples of the social determinants of health, which can influence health equity in positive and negative ways:
- Income and social protection
- Unemployment and job insecurity
- Working life conditions
- Food insecurity
- Housing, basic amenities and the environment
- Early childhood development
- Social inclusion and non-discrimination
- Structural conflict
- Access to affordable health services of decent quality.
Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.
Addressing SDH appropriately is fundamental for improving health and reducing longstanding inequities in health, which requires action by all sectors and civil society.
There are challenges to overcome in implementing action to address health inequities through the social determinants of health. The social determinants of health equity is a complex and multifaceted field. It involves a wide range of stakeholders within and beyond the health sector and all levels of government. In addition, social determinants of health data can be difficult to collect and share.
While the evidence base on the social determinants of health has strengthened during the past decade, the evidence base on what works needs to be strengthened and good practices disseminated effectively.
Three areas for critical action identified in the report of the Global Commission on Social Determinants of Health reflect their importance in tackling inequities in health. These include:
- Improve daily living conditions:
The circumstances in which people are born, grow, live, work and age;
- Tackle the inequitable distribution of power, money and resources:
The structural drivers of those conditions of daily life (for example, macroeconomic and urbanization policies and governance);
- Measure and understand the problem and assess the impact of action:
Expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.
Scaled up and systematic action is required that is universal but proportionate to the disadvantage across the social gradient. This is necessary for effective delivery to addressing inequities in health and promoting healthier populations.
Life expectancy and healthy life expectancy have increased, but unequally. There remain persistent and widening gaps between those with the best and worst health and well-being.
Poorer populations systematically experience worse health than richer populations. For example:
- There is a difference of 18 years of life expectancy between high- and low- income countries;
- In 2016, the majority of the 15 million premature deaths due to non-communicable diseases (NCDs) occurred in low- and middle-income countries;
- Relative gaps within countries between poorer and richer subgroups for diseases like cancer have increased in all regions across the world;
- The under-5 mortality rate is more than eight times higher in Africa than the European region. Within countries, improvements in child health between poorest and richest subgroups have been impaired by slower improvements for poorer subgroups.
Such trends within and between countries are unfair, unjust and avoidable. Many of these health differences are caused by the decision-making processes, policies, social norms and structures which exist at all levels in society.
Inequities in health are socially determined, preventing poorer populations from moving up in society and making the most of their potential.
Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions.
Action requires not only equitable access to healthcare but also means working outside the healthcare system to address broader social well-being and development.
“Health equity is defined as the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically”.