Call to action on social determinants of health

“Social injustice is killing people on a grand scale” was the rallying cry of the WHO Commission on Social Determinants of Health (CSDH), published in 2008.1 It remains appropriate to the World Health Organization’s (WHO) new World Report on Social Determinants of Health Equity, published on 6 May 2025.

The CSDH laid out ambitious health targets for reductions in health inequalities by 2040, underpinning its title, Closing the Gap in a Generation. The new report shows welcome progress, but with much still left to do. Ranking countries on life expectancy, the unhealthiest third experienced improvement in life expectancy from 59 years in 2000 to 66 in 2021. A smaller increase for the healthier third, meant that the gap between them narrowed from 18.2 to 12.5 years. After the financial crisis and covid, the improvement slowed.

Under five mortality rates in the fifth of countries with the lowest income went from just under 150 per thousand live births to 65. Though the gap with high income countries narrowed considerably, there is a long way to go to achieve their rate of 5 per 1000 live births. A similar picture is seen with maternal mortality ratios. Norway is the benchmark with a maternal mortality ratio of 2 per 100 000 live births. In more fragile countries it is still 500.

“Do something, do more, do better” was the mantra we adopted for the European Review of Social Determinants and the Health Divide.2 It applies well to the picture of between-country inequalities; even more so it applies to health inequalities within countries which, in many cases, have increased.34

The new WHO report builds on the WHO Commission on Social Determinants of Health (CSDH). When it was launched in 2005, understanding of social determinants of health was something of a guilty secret shared by a handful of academics.5 An aim of the CSDH—its report was published in 20081—was to create a social movement on social determinants of health and health equity. There is evidence that it happened. Not least, three of WHO’s regions conducted reviews of Social Determinants of Health: European, Americas (PAHO), and the Eastern Mediterranean.

The CSDH had three principles of action: improve the conditions of daily life; tackle inequities in power, money, and resources; measure the problem, evaluate action, expand the knowledge base, develop a workforce, and increase public awareness.

There has been definite progress on the third of these; a mixed picture on the first two. The evidence base has grown. 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. Starting at 50 a year in 2000, the publication rate grew steeply. By 2021, there were over 3,000 a year. 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.6 The interest in commercial determinants, in political determinants, in structural racism are all highly relevant.

The UK provides examples of action on the conditions of daily life. More than 50 local areas have adopted “Marmot Principles.”78 A similar network is being established in Italy.9

It is the second area focused on inequities in power, money, and resources, acting at global and national level that presents the most mixed picture and is the major theme of the new report.

According to the 2023 report of the Open Society Barometer, based on surveys in 30 countries, the major problems facing the world are poverty, inequality, and climate change, closely followed by corruption, food insecurity and hunger, and political instability and conflict.1011 The perception is that inequality is increasing. In 2025, so are instability and conflict.

There is a widespread view that neoliberalism has run its course.12 Yet the world faces great political and economic uncertainty and threats to peace. A mixed picture implies exactly that. There are numerous examples of slipping back, but many of progress. The report contains evidence of actions that can and have made a difference. Among the positive actions are: progressive taxation, public spending on social infrastructure, curbing the commercial determinants of health and supporting positive actors, spending on social protection, creating fiscal space for social action, debt relief, welfare benefits, community engagement and social participation. The damage to health and health equity of colonialism and structural racism has come under increasing focus. All that said, the challenges are still immense, and the new report makes recommendations, evidence-based, to meet these challenges.

This 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. It is time to make equity of health and wellbeing a central goal of society.