WHO Commission’s Report Reveals Global Health Inequities

By Andrew Small

Concluding three years of initial work, the World Health Organization’s (WHO) Commission on Social Determinants of Health has recently submitted its final report, entitled “Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.” The report is the most comprehensive of its kind, and according to Commissioner Mirai Chatterjee, “has been eagerly awaited by policy makers, health officials, grassroots activists and their community-based organizations.”

The report seeks to address the underlying causes behind the alarming disparities in life expectancies and general health conditions between—and even within—different countries. The fact that, in Sweden, a woman’s risk of dying in pregnancy is 1 in 17,400, while in Afghanistan it is 1 in 8, or that a child born in a suburb of Glasgow, Scotland can expect to live 28 fewer years than one born only 13 kilometers away, cannot be explained by biological causes. Rather, the report finds that the “social determinants of health,” the differences in conditions where people are born and live, lie at the foundation of these inequities.

In the report, the commissioners claim that the “toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible. “

The commission found evidence of a strong correlation between socioeconomic standing and health inequality, stating that, in general, the poor are worse off than those less deprived—but they also found that the less deprived are in turn worse than those with average incomes, and so on. This relationship that links income and health defines the impact of a social gradient that appears in every country—not just in developing countries, but also the wealthiest nations. The resulting health inequalities may be more or less steep in different countries, but the phenomenon is universal.

However, the relationship of wealth to health equity is complex since increasing national wealth does not necessarily translate to a more robust national health system. Without equitable distribution of benefits, national growth can even exacerbate health inequities. In addition, some low-income countries such as Cuba, Costa Rica, China, and Sri Lanka have achieved levels of good health, even among their poorest citizens, despite relatively low incomes.

Nor can these problems be addressed by reforms in the health sector alone. The report claims that the social determinants of health are multifarious and interdependent, with domains that overlap with those of other economic and public policy concerns. Much of the work to redress health inequities lies beyond the health sector. According to the report, “water-borne diseases are not caused by a lack of antibiotics, but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units, but by the lives people lead which are shaped by the environments in which they live.” To further underscore this idea, Commissioner Anna Tibaijuka, who is also the Executive Director of UN-HABITAT, makes the point that “investment in basic services such as water and education will always remain constrained if not wasted, unless accompanied by requisite investment in decent housing with basic sanitation.”

While the report does show the need for reform in the health sector in order to extend access to quality care to those for who cannot afford it, local and global communities need to pursue reform with a view to address the broader causes of inequities in health care.

The Commission makes three overarching recommendations to tackle the “corrosive effects of inequality of life chances”:

Improve daily living conditions, including the circumstances in which people are born, grow, live, work, and age.
Tackle the inequitable distribution of power, money, and resources and the structural drivers of those conditions across global, national, and local channels.
Measure and understand the problem and assess the impact of action.

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