How can WHO transform its approach to social determinants of health?

Five fundamental constraints to progress

The first two constraints are tied to WHO’s role as a specialised UN agency focused on health, which means that it primarily engages with and advises national ministries of health. Yet important policy changes that influence the social determinants and related health outcomes—for example, those pertaining to access to quality education, environmental protections, or decent working conditions—are designed and implemented outside the health sector. The health sector rarely has much influence over the formulation of such policies.192021 WHO’s first constraint is therefore that it has limited interaction with or influence over some of the key agencies and ministries that shape social determinants of health.

The second constraint is the apparent tension between WHO’s health mandate and the need to support other sectors’ leadership while stewarding the social determinants of health agenda. Intervening on the social determinants of health involves policies and interventions that affect health outcomes through complicated causal pathways that originate, for example, in laws that discriminate, tax systems that are regressive, or environmental degradation resulting from corporate activity that most affects people with the least resilience. However, the biomedical orientation that dominates within WHO22 and the health sector more generally21232425 diminishes the space for thinking about social determinants of health and fully appreciating their influence on health inequities. Those within the health sector might also be reluctant to acknowledge the influential role that policies in other sectors play in shaping health outcomes21242526 as it might be perceived as a call to divert resources and influence away from the health sector.

The sheer size and heterogeneity of the social determinants of health agenda is a third constraint. Conceptually, the agenda emphasises that numerous factors—including education, income, tax justice, environment and climate change, labour rights, gender inequality and discrimination and racism—act as determinants and reinforce each other in shaping health inequities. It has been hard for an overstretched WHO to mobilise global and national political attention to issues across this vast terrain of determinants,6 especially compared with solutions that revolve around the delivery of medical care, drugs, and vaccines.

A fourth constraint is a misalignment between the standard approaches WHO uses to produce evidence informed recommendations for clinical interventions and the approaches needed to construct an evidence base for policy choices to intervene on the complex causal pathways of social determinants of health.2728 WHO has recognised limitations to its conventional approach to guidance development and proposed ways to adapt it.293031

Finally, perhaps the most important constraint for WHO is that policies affecting social determinants of health are politically charged, shaped by ideology and values and influenced by powerful economic and commercial interests.2132333435 Climate change and environmental protection, gender equity, social housing, or a basic minimum wage and social protection are all areas where values and interests can diverge deeply across the political spectrum.

Each of these constraints is amenable to change. We suggest that these should motivate a strategic shift in how WHO approaches the social determinants of health and propose a five-point agenda for WHO to tackle the fundamental barriers to effective action on social determinants of health (table 1).

Use SDGs to foster leadership from other sectors

The sustainable development goals (SDGs) agreed by UN member states for 2030 highlight how actions in multiple sectors influence health. For example, SDG1 on poverty reduction, SDG5 on gender equality, and SDG8 on decent work are critical to achieving SDG3 on healthy lives and wellbeing. Other multilateral organisations such as the World Bank, the UN Development Programme (UNDP) on poverty reduction, Unicef on educational policy, or the International Labour Organization (ILO) on labour rights and social protection, hold greater responsibility for supporting countries and non-health sectors to achieve those goals. Ongoing, collaborative work on the SDGs is an opportunity for WHO to share ownership of the social determinants of health agenda and to advance work on social determinants with multilateral organisations with relevant sectoral mandates, expertise, and networks. In so doing, WHO can foster the leadership of these organisations in tackling social determinants of health and drive collective prioritisation of health equity.

The Global Action Plan for Healthy Lives and Wellbeing, which commits WHO and 12 other multilateral agencies to work together on the health-related targets of the SDGs represents a positive step in this direction.40 Together, these institutions can advocate for specific policies that countries should adopt, finance, and implement in each sector. For example, WHO and UNDP have come together to promote legislative and regulatory measures countries should consider to reduce risk factors for non-communicable diseases.36 Similarly, the UN Environmental Programme (UNEP) used air quality guidance developed by WHO as a starting point for a global assessment of air quality laws.41 WHO can also build on the various cross sectoral responses to covid-19, such as gender responsive social protection42 and interventions supporting early childhood development and educational services.43 These highlight the important contributions different sectors make to achieving public health goals and further strengthen intersectoral actions forged between health and other sectors. WHO should support health ministries in keeping these lines of communication open to promote health equity.

Build knowledge and capacity within WHO

A balance has to be struck between encouraging institutions in other sectors to act on social determinants of health and giving social determinants higher internal priority within WHO. Building and strengthening staff capacity will be crucial to ensure the social determinants of health cut across WHO’s work. Greater internal appreciation of the importance of social determinants of health can be generated through compelling examples of how health inequities have been reduced by working across sectors. For example, WHO has, through its work on health risks such as air pollution, engaged with other multilateral institutions and national policy makers on far reaching issues such as energy and transportation policy.44 Such experience could be used to motivate other areas of the organisation to more explicitly address the social determinants in their work.

Focus on intersectoral synergies and mitigating harms

In responding to the broad and multifaceted nature of the social determinants of health, WHO can tailor its approach to be more strategic in approaching other sectors and partners to advance work. For example, WHO may be able to use its work on specific diseases as an entry point to promote policies in other sectors that improve health equity, such as expanding social protection to reduce the burden of tuberculosis.45 However, reiterating the imperative to reduce health inequities alone is unlikely to compel other sectors to contribute to addressing social determinants of health, especially as they have their own core goals and outcomes.46 Appeals for collective action on social determinants of health must therefore highlight, when relevant, the advancement of mutual goals across sectors. For example, sectoral goals such as free and high-quality education, expansion of access to affordable and sustainable public transport, or conservation of natural resources can be advanced through policy options that also benefit health.

At the same time, drawing on evidence of harms to health, WHO can be more prominent in calling on governments to mitigate harmful determinants strongly driven by commercial interests (“commercial determinants”).47 Commercial determinants include exposure to harmful products (eg, processed foods or sugar sweetened beverages) and practices of transnational corporations (eg, environmental degradation or infringements on labour rights and working conditions).48 WHO has had some success advancing evidence informed policies and regulations that oppose powerful commercial interests that harm health, with a key example being its role in securing the Framework Convention on Tobacco Control. The recently established programme on commercial determinants is a timely and promising step in this direction.38

Embrace a broad evidence base

Recommendations from WHO on the social determinants of health must rely on a broader evidence base than is typically considered when assessing the effectiveness of clinical interventions.28 It should invest more in developing methodological approaches and a broader research programme to strengthen its guidance on social determinants. Crucially, different disciplinary and community based perspectives on evidence for action should be sought. Furthermore, the absence of strong evidence—as classified by the conventional evidence hierarchy—should not dissuade WHO from advocating for ambitious reforms and policies that can promote health equity.49

More fundamentally, WHO should accept that its legitimacy does not rest solely on its ability to synthesise scientific evidence but also in taking people’s concerns and values into account, especially considering the public’s willingness to support progressive policies in pursuit of health equity.50515253 Accordingly, evidence generation should also focus on what states should do to remove institutional and political constraints to addressing social determinants of health.

Articulate politically bold messages

Pursuing progressive approaches to reducing health inequities relies on developing evidence informed global norms, generating demands for policy makers to act, and implementing mechanisms for securing political accountability.212635 Growing health inequities are the result of poor policies, which are at times driven by a politics influenced by commercial organisations. WHO should be more explicit about these political drivers and use its authority on health to counter proposals and actions that go against health equity.

By being more politically forceful WHO can bolster and mobilise civil society, especially those representing the most vulnerable and marginalised groups, and generate political support for policies that are resisted by ideological and commercial forces. WHO’s principled stance on the waiver of intellectual property rights to accelerate technology transfer and access to covid-19 vaccines, which has given strength to the advocacy of civil society, is one example, although the policy is not yet adopted.54 WHO regional and country offices could also have an important role in this mission55—for example, by empowering health ministries to work across government.15

Crucial juncture in global health

The unequal distribution of vulnerabilities laid bare by the covid-19 pandemic is at the forefront of the public’s attention and, with it, considerations of how to ensure health equity as societies build back fairer.2 In the wake of the pandemic, WHO has the opportunity to pursue a more transformative agenda on social determinants of health, starting by tackling the five fundamental barriers to effective action discussed above.

It will also be important to hold countries to account for their progress. Systematic and continuous global monitoring is often lacking, and strengthening monitoring is one of the priority areas of the 2021 World Health Assembly resolution on social determinants of health.56 An opportunity exists to establish a monitoring system for action on social determinants of health that also considers contributions from relevant multilateral agencies and corresponding national ministries, thereby also spurring sectors outside health to act. More effective WHO leadership on social determinants of health that more systematically fosters greater involvement of other sectors will be critical if countries are going to deliver on their promise of healthy lives and wellbeing for all by 2030.