Social determinants of health

The Commission on Social Determinants of Health - what, why and how?

What is the Commission on Social Determinants of Health?

The Commission on Social Determinants of Health (CSDH) was a global network of policy makers, researchers and civil society organizations brought together by the World Health Organization (WHO) to give support in tackling the social causes of poor health and avoidable health inequalities (health inequities).

When and why was it created?

The CSDH was set up by Dr JW Lee, the former Director-General of WHO in March 2005 to bring together evidence on what can be done to achieve better and more fairly distributed health worldwide, and to promote a global movement to achieve this.

What was it expected to do?

The CSDH had a three year directive to gather and review evidence on what needs to be done to reduce health inequalities within and between countries and to report its recommendations for action to the Director-General of WHO. Building partnerships with countries committed to comprehensive, cross-government action to tackle health inequalities was integral to this. Experts were brought together to gather evidence, and civil society organizations also participated in the process.

Who were its members?

The CSDH was led by a remarkable group of Commissioners with wide experience in politics, academia and advocacy:

Michael Marmot, chaired the CSDH and is Director of the International Institute for Society and Health and Head of the Department of Epidemiology and Public Health at University College London. In 2000, he was knighted for services to epidemiology and understanding of health inequalities.

Frances Baum is Head of Department and Professor of Public Health at Flinders University and Foundation Director of the South Australian Community Health Research Unit. She is Co-Chair of the Global Coordinating Council of the People’s Health Movement.

Monique Bégin is Professor at the School of Management, University of Ottawa, Canada, and twice-appointed Minister of National Health and Welfare. She was the first woman from Quebec elected to the House of Commons.

Giovanni Berlinguer is a Member of the European Parliament. He has recently been a member of the International Bioethics Committee of UNESCO (2001–2007) and rapporteur of the project Universal Declaration on Bioethics.

Mirai Chatterjee is the Coordinator of Social Security for India’s Self-Employed Women’s Association, a trade union of over 900 000 self-employed women. She was recently appointed to the National Advisory Council and the National Commission for the Unorganized Sector

William H. Foege is Emeritus Presidential Distinguished Professor of International Health, Emory University. He was Director of the United States Centers for Disease Control and Prevention (CDC), Chief of the CDC Smallpox Eradication Program, and Executive Director of The Carter Center. He also served as Senior Medical Advisor for the Bill and Melinda Gates Foundation.

Yan Guo is a Professor of Public Health and Vice-President of the Peking University Health Science Centre. She is Vice-Chairman of the Chinese Rural Health Association and Vice-Director of the China Academy of Health Policy.

Kiyoshi Kurokawa is Professor at the National Graduate Institute for Policy Studies, Tokyo. He also serves as a Member of the Science and Technology Policy Committee of the Cabinet Office. Previously he was President of the Science Council of Japan and the Pacific Science Association.

Ricardo Lagos Escobar is the former President of Chile, and former Education Minister and Minister of Public Works. An economist and lawyer by qualification, he also worked as an economist for the United Nations.

Alireza Marandi is Professor of Pediatrics at Shaheed Beheshti University, Islamic Republic of Iran. He is former two-term Minister of Health (and Medical Education). In addition, he served as Deputy Minister and Advisor to the Minister. In 2008 he was elected to be a member of the Iranian Parliament.

Pascoal Mocumbi is the High Representative of the European and Developing Countries Clinical Trials Partnership and former Prime Minister of the Republic of Mozambique. Prior to that, he headed the Ministry of Foreign Affairs and the Ministry of Health.

Ndioro Ndiaye is the Deputy Director-General of the International Organization for Migration and was formerly Minister for Social Development and Minister for Women’s, Children’s and Family Affairs in Senegal.

Charity Kaluki Ngilu is Minister of Health of Kenya. Before taking office, she was a member of the National Assembly of Kenya representing the Democratic Party. Since 1989, she has been the leader of the Maenbeleo ya Wanawake organization, the national women’s movement.

Hoda Rashad is Director and Research Professor of the Social Research Center of the American University in Cairo. She is a member of the Senate, one of the two parliamentary bodies in Egypt. She serves on the National Council for Women, which reports to the President of Egypt.

Amartya Sen is Lamont University Professor and Professor of Economics and Philosophy at Harvard University. In 1998, he was awarded the Nobel Prize in Economics.

David Satcher is Director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute Initiative. He served as United States Surgeon General and Assistant Secretary for Health. He also served as Director of the U.S. Centers for Disease Control and Prevention.

Anna Tibaijuka is Executive Director of UN-HABITAT. She is also the founding Chairperson of the independent Tanzanian National Women’s Council.

Denny Vågerö is Professor of Medical Sociology and Director of CHESS (Centre for Health Equity Studies) in Sweden. He is a member of the Royal Swedish Academy of Sciences, and of its Standing Committee on Health.

Gail Wilensky is a senior fellow at Project HOPE, an international health education foundation. Previously she directed the Medicare and Medicaid programmes in the United States and also chaired two commissions that advise the United States Congress on Medicare.

How did it function?

The Commission was a truly global process, bringing together hundreds of researchers and practitioners from universities and research institutions, government ministries, and international and civil society organizations.

‘Knowledge networks’, including academics and practitioners from around the world, collected evidence on policies and interventions to improve health and reduce health inequities across a number of areas including: early child development, employment conditions, globalization, women and gender equity, urban settings, social exclusion, health systems, measurement, and priority public health conditions.

The Commission built further evidence-gathering partnerships through two regional networks (the Nordic and Asian networks) and with researchers in additional key areas, such as ageing, indigenous peoples, food and nutrition, violence and conflict, and the environment.

Partnerships with a number of countries committed to tackling health inequities were established. Brazil, Canada, Chile, Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the United Kingdom each became a Commission ‘country partner’, and made a commitment to progress on the social determinants of health to improve health equity. As the work of the Commission gained momentum, other supportive countries added both to the technical work on tackling social determinants for health equity (e.g. Norway) and to sharing experiences and advice on improving policy coherence in this field (e.g. Thailand).

Representatives of civil society groups in Africa, Asia, the Americas, and Europe contributed to the Commission’s work. Members of these groups were engaged in the Commission’s knowledge-gathering processes. They helped to shape the Commission’s thinking and will be active partners for change in the future.

The reports produced by the knowledge networks and all other background papers and reports, including reports from the country and civil society work streams, are available on the publications pages:

What was the thinking behind the Commission?

The Commission demonstrated that health inequities are the result of a complex system operating at global, national and local levels.

The global context affects how societies prosper through its impact on international relations and domestic norms and policies. These in turn shape the way society, at national and local level, organizes its affairs, giving rise to forms of social position and hierarchy. Where a person is in the social hierarchy affects the conditions in which they grow, learn, live, work and age, their vulnerability to ill health and the consequences of ill health.

To decrease the health inequality between and within countries, it is necessary to look beyond the immediate causes of disease. The Commission focused on the 'causes of the causes' - the social factors which determine how people grow, live, work and age. The underlying determinants of health inequities are interconnected and therefore, they must be addressed through comprehensive and integrated policies, responsive to the specific context of each country and region.

What was its approach to evidence?

Dedicated Knowledge Networks covering a number of themes reviewed the evidence and reported their findings to the Commission.

The Commission took a broad approach to evidence. Traditional hierarchies of evidence (which put randomised controlled trials and laboratory experiments at the top) generally do not work for research on the social determinants of health. The evidence needs to be judged on fitness for purpose - that is, does it convincingly answer the question asked? The Commission’s evidence comes from observational studies (including natural experiments and cross-country studies), case studies, and field visits, from expert and lay knowledge, and from community intervention trials where available.