A timely new report urges governments, the health sector and civil society to do more to address the underlying reasons why some groups of people are sicker and die younger than other groups – the social determinants of health equity.
Melissa Sweet writes:
As the Albanese Government looks to its next term, the World Health Organization has this week released a landmark report with strong calls for governments to reap the health, social and economic benefits of reducing health inequities.
The ‘World report on social determinants of health equity’ urges national and local governments to put health equity “at the highest governmental level and as a central purpose of government”, including in financial and social policies.
“The social, rather than solely biomedical or behavioural, roots of population health need to be recognised,” it says.
“Leaders should not confuse healthcare services with population health outcomes, nor make the assumption that healthcare can be delivered effectively and equitably without attention to its social context.”
The report says global progress in reducing health inequities has been “too slow” since a 2008 report from the WHO Commission on the Social Determinants of Health, ‘Closing the gap in a generation’, which concluded that “social injustice is killing people on a grand scale”.
“The available data shows that during the past two decades, the gap in life expectancy between the most and least advantaged groups within some countries has widened,” says the 2025 report.
“In the pursuit of prosperity, countries have too often failed to integrate equity and fairness into policies,” it says. “Globally, we have also failed to integrate an appreciation of intergenerational equity, further undermined by the existential threats of climate change, war and conflict.”
The report cites the combined impact of the COVID-19 pandemic, climate change, increasing levels of conflict, and a cost-of-living crisis.
Between countries, in 2021, the difference in life expectancy was as wide as 33 years, with inequalities of a similar magnitude seen within countries. These inequities are not explained only by a country’s income level: of the 34 countries that over the past 20 years have halved premature deaths (before age 70), some are high-income, some middle- and some low-income.
The report makes wide-ranging recommendations under four general strategies:
- Address economic inequality and investing in social infrastructure and universal public services
- Overcome structural discrimination
- Manage the challenges and opportunities posed by the mega-trends of climate change and the digital transformation in a way that systematically promotes health equity
- Put in place governance arrangements to maximise the coherence and impact of action.
When the WHO Commission on Social Determinants of Health handed down its report in 2008, a subsequent Senate Inquiry into Australia’s domestic response to the report produced recommendations urging action.
However, public health researcher Dr Miriam van den Berg told Croakey that these were not progressed. In September 2024, the Government quietly made a statement on its website that although the recommendations were noted, “given the passage of time since this report was tabled, in March 2013, a substantive Government response is no longer appropriate.”
Meantime, here are 12 takeaways from the latest report.
1. Peace is foundational
The report highlights the importance of addressing and protecting the social determinants of health equity in emergencies, migration and conflict.
It recognises peace as a fundamental determinant of health equity, and health as a bridge to peace.
2024 saw more conflicts globally than any since 1946, many with huge death tolls and widespread health consequences, such as in Gaza and Sudan.
Conflict has direct and indirect impacts on health. Approximately 80 percent of WHO’s humanitarian caseload and 70 percent of disease outbreaks that the WHO responds to take place in fragile and conflict-affected settings, as illustrated by the 2024 outbreak of polio in Gaza.
Countries that have avoided conflict have halved their poverty rates over the past decade, while in fragile and conflict affected states, poverty rates have been stuck at 40 percent or more .
Conversely, health equity and robust health systems can also foster social cohesion and trust. As such, sustaining peace and achieving equitable health care are mutually dependent and reinforce objectives critical to long-term violence prevention.
The report also highlights the importance of diplomacy in ensuring health-related concerns and the social determinants are kept to the fore in emergencies and conflict.
“Deepening the connections between health and foreign policy can contribute to a safer, more peaceful and healthier world,” the report says.
2. Positive change is happening
Threaded throughout the report are many examples of positive initiatives, at national and local levels.
Norway’s wealth tax helps to narrow the income gap between children from wealthy and less wealthy families, and contributes to long-term socioeconomic stability. Vietnam has made big gains in reducing poverty from about 60 percent of the population in the 1990s to closer to two percent now.
Intersectoral collaborations that promote civic participation and people-driven health care in the United Republic of Tanzania and Thailand explicitly moved beyond the medical model to include innovative governance models and intersectoral approaches to the social determinants of health.
During the COVID-19 pandemic, the government of Togo devised a fully digital emergency cash transfer programme via mobile phones, targeting informal workers and poor households, called Novissi, meaning “solidarity” in the Éwé language. Togo built the Novissi platform – a digital and contactless unconditional cash transfer programme, serving over 12 percent of the population – from scratch in just 10 days in response to COVID-19.
In Zimbabwe, the “Friendship Bench” used grandmothers as lay counsellors and had a significant impact on mental health symptoms among participants. The model has since spread to Malawi, Tanzania and New York City.
In Spain, the Ministry of Health has produced recommendations for regions (which are mostly responsible for health) to collect data on social determinants as part of the patient digital health record, including income, migratory status, social participation, social and family support, and area deprivation.
The report also highlights the role of Aboriginal Community Controlled Health Services in addressing racism, poor access to mainstream health services and low-quality care, and the impacts of ongoing colonisation, saying they are “the most successful and comprehensive model of primary healthcare” in Australia.
3. Address structural discrimination
The report urges governments to ensure restorative justice processes and reparations to those affected by discrimination embedded in policies, laws, institutions and social norms, and the negative impacts of colonisation.
Structural discrimination has multiple, widespread negative impacts on key social determinants of health, including increased poverty and reduced access to education, employment, healthcare and other services, and safe, good-quality living conditions and environments.
Racism, sexism, classism and ableism, for instance, often intersect and compound, acting across the life course and between generations to undermine health and people’s agency to lead flourishing lives.
Experiencing discrimination undermines trust and confidence in societies’ social, economic, political and cultural systems, which in turn affects individual and collective health. During the COVID-19 pandemic, it was notable that in many countries, vaccine hesitancy was higher among communities which were marginalized, excluded and discriminated against and was related to a lack of trust, which had been undermined by experiences of discrimination and associated trauma.
The increasing volume and precariousness of migration, together with unprecedented levels of conflict with widening impacts on civilian populations, are a form of structural violence which decimates health equity.
The report highlights the importance of practices which embed the principle of the right to health regardless of migrancy or citizenship status.
4. Indigenous Peoples’ rights
The report acknowledges Indigeneity as a determinant of health and health equity – shaped by discrimination and historical injustices, as well as protective factors.
It says there is a particular need to focus on the health legacies of colonialism on Indigenous Peoples. Although Indigenous Peoples make up just six percent of the global population, they account for about 19 percent of the extreme poor. Globally, Indigenous Peoples are subjected to discrimination, violence, impoverishment, cultural damage and, increasingly, the harmful impacts of climate change.
In turn, they experience higher rates of physical illness and disease, food insecurity, poor living standards and mental health conditions, that have been associated with the negative impacts of colonialism
The report highlights the importance of cultural practices, reparations, land rights, and truth-telling about colonialism, and says the revitalisation of Indigenous Peoples’ cultural identity is essential to tackle discrimination and promote health and well-being.
5. Childhood matters
The report highlights the importance of childhood in efforts to address the social determinants of health equity; both because they are especially at risk, and because successful interventions in childhood can bring lifelong benefits.
Children (those aged below 18) comprise a third of the global population and yet in 2023 accounted for more than half of those in extreme poverty, with poverty remaining one of the greatest risk factors for child morbidity and mortality.
The COVID-19 pandemic slowed progress, leaving 30 million fewer children being lifted out of extreme poverty than projected
The combination of nutrition, security and safety, responsive caregiving and good early development constitutes positive early childhood conditions that set the foundations for health throughout life.
Interventions to improve early childhood development have their greatest positive impacts on the most disadvantaged, including in relation to childcare, early childhood education, child protection, social welfare and community development.
While many countries have boosted equitable access to high-quality childhood education, at the global level, children from high-income families have seven times greater access than those from low-income families, the report says.
The report also says there is increasing body of evidence for the harmful impact of the digital transformation on child and adolescent health, with evidence from high-income Anglophone countries showing alarming increases in mental health conditions among adolescents and young adults over the past decade, and corresponding decreases in well-being in this age cohort.
6. Improve mental health
The report says there is an increasing appreciation of the social determinants as fundamental factors in determining population and individual mental health.
The relative neglect and exclusion of these factors from mental health discourse and practice can result in over-reliance on pharmacological treatments.
The use of broader psychological, social and economic interventions implemented collaboratively with communities and non-health sectors can help address the root causes of mental health conditions.
The report cites a 2024 statement by UN Special Rapporteur on extreme poverty and human rights:
“In order to address the social determinants of depression and anxiety, States should put the fight against poverty and inequality at the heart of national strategies to improve mental health, and they should combat the rise of income and wealth inequalities, the informalisation and destandardisation of work, the contractualisation of welfare, and housing segregation in urban areas.”
7. Tackle economic inequality
Absolute deprivation, such as poverty, worsens health inequities, but so economic inequality – that is, the unequal distribution of income across the population.
Economic inequality in a society is associated with worse overall population health outcomes, including life expectancy, infant mortality, obesity and mental health conditions, and with higher health inequities.
The report recommends progressive taxation and discusses the move towards wellbeing economies and budgets – something we’ve not heard much about in Australia in recent times.
8. Learn from COVID
Throughout the report are examples of the impacts of the COVID pandemic.
“The COVID-19 pandemic underscored the relationships between the economy, livelihoods, health, and social vulnerability, and uncovered and exacerbated social, economic and health inequities,” says the report.
“The pandemic amplified a feedback loop: social inequalities pre-pandemic made the pandemic worse, and in turn, the pandemic made health inequities worse, including through some of the control measures.”
Groups that experienced increased rates of COVID-19 morbidity and mortality include poorer people, marginalised ethnic minorities and Indigenous Peoples, low-paid essential workers, migrants, populations affected by emergencies and conflicts, incarcerated populations, homeless people and people with disabilities.
“The prevalence of deaths in older age groups has been dismissed as a biological inevitability, masking the reality of avoidable deaths among older people and the neglect of care systems,” says the report.
In the United Kingdom and the Republic of Korea, more than half of the COVID-19 related deaths in 2020 occurred among people with disabilities.
Maternal mortality rates have increased since the pandemic in several settings and sexual and reproductive health outcomes have deteriorated. Health services in lower-income countries were more heavily affected than those in wealthier ones, and their time to recovery has been longer.
The COVID-19 pandemic and subsequent shocks reversed these gains in reducing extreme poverty, increasing extreme poverty by nearly 90 million people.
Globally, economic inequalities between countries have declined since around 1980, as low- and middle-income economies have made gains, contributing to reductions in health inequities between countries. This trend went into reverse following the COVID-19 pandemic: 2022 saw an increase in inequality between countries for the first time in three decades.
9. Climate responses critical
The report calls for climate change mitigation and adaptation policies that maximise health equity benefits, and says climate action should be a core objective of health systems.
It highlights inequities in the climate burden, noting that the poorest 50 percent of the world’s population contributed 12 percent of global greenhouse gas emissions in 2019, while the top 10 percent accounted for 48 percent.
Climate change is also one of the drivers of forced displacement, affecting tens of millions of people annually.
10. Information environment
The report cites “an increasingly complex health information environment” and says misinformation, disinformation and the impact of AI are changing the information and political decision-making landscape, and have the potential to undermine trust in institutions, labour markets and social cohesion,
“The emergency context of disease outbreaks and pandemics shows clearly how crucial good health information is for rapid and effective responses, but also how these responses can be undermined by the malign influence of misinformation and disinformation,” says the report.
Much of the effort to manage health information, including misinformation and disinformation, has fallen to health institutions, which are often not equipped to deal with the contemporary information environment. Efforts focused only on better communication of accurate health information, including techniques such as fact checking, are not adequate to deal with the volume and diversity of misinformation and disinformation.”
It says new partnerships are needed between health authorities, the private sector (including platform owners) and civil society, to establish the governance frameworks that can systematically promote good information and call out bad information, in particular regarding its use to exacerbate health inequities
Algorithmic governance is an emerging area that requires particular attention, with specific efforts needed to combat the algorithmic bias that has contributed to health inequalities, it says.
Unfortunately the report does not address the role of public interest journalism in this space.
11. Civil society matters
As well as stressing the importance of local government in addressing the social determinants of health equity, the report highlights the importance of community engagement and civil society.
“Good governance for action on the social determinants of health requires the meaningful engagement of people, communities and civil society in decision-making – from priority setting to policy formulation, through to implementation and review,” says the report.
Civil society organisations are well positioned to represent and support the engagement of excluded communities, and can often deliver services at a lower cost, with greater efficacy, than other sectors, the report says.
12. Commercial determinants
The report also discusses the commercial determinants and says that just four industries – health-harming food and drinks, fossil fuels, alcohol and tobacco – account for at least a third of global preventable deaths, collectively in 2021 causing 19 million deaths annually.
These issues will be addressed in more detail in a forthcoming WHO Global Report on the Commercial Determinants of Health.
Next steps
Professor Sir Michael Marmot, who chaired the WHO Commission on the Social Determinants of Health, wrote in the BMJ this week, together with Dr Jessica Allen, that when the Commission launched in 2005, “understanding of social determinants of health was something of a guilty secret shared by a handful of academics”.
The Commission aimed to create a social movement on social determinants of health and health equity, and they said public awareness of the issues had since increased.
An internal literature review at the UCL Institute of Health Equity showed that between 2000 and 2022, there had been 17, 931 scientific publications on social determinants.
“Social determinants of health are now on the agenda. Pick up The New York Times and there will be discussions not just of inequities in health care, but of the social determinants of health.”
Marmot and Allen say the new report “is a timely and much needed reminder to the global community that to improve health equity we must improve society”.
“Health equity is not just for Ministries of Health. The WHO is calling for collective action from national and local governments and leaders within health, academic, research, civil society, alongside the private sector,” they wrote.
“It is time to make equity of health and wellbeing a central goal of society.”
Will the Albanese Government seize the opportunity? And what might help to enable this?
See Croakey’s extensive archives on the social determinants of health
