1.3 What are the social determinants of health?

What is your understanding of health?

When we talk about someone ‘who is in good health’, what do we mean? The answer can depend very much on the context. A 60-year-old man who is physically frail but mentally strong and alert may be described as in good health, whereas we would not describe a 20-year-old pregnant woman as being in ‘good health’ if she was physically frail yet mentally strong.

Health can be defined as: a state of complete physical, mental and social well-being, and not simply the absence of disease or illness.

If we asked people in a poor community for their definition of good health, how do you think that would differ to the response we would get asking the same question in a wealthy community?

The social determinants of health are the circumstances in which people are born, grow up, live, work and age:

  • Social determinants of health are risk factors found in a person’s living and working conditions (such as the distribution of income, wealth, influence, status and power), that influence the risk for a disease, or vulnerability to disease or injury. They are not in the individual (such as behavioural risk factors or genetics).
  • Social determinants of health include early childhood development, education, economic status, employment and work, housing environment, and effective prevention and treatment of health problems.

These circumstances are shaped by how money, power and resources are distributed at global, national and local levels. They can cause unfair and avoidable differences in health. These differences are known as health inequities between and within communities. For the majority of people, poor health arises from social and economic factors.

The World Health Organisation (WHO), a global body set up to promote the right to health, has published research to say that ‘this unequal distribution of health-damaging experiences is not in any sense a “natural” experience but is the result of a deadly combination of poor social policies, unfair economic arrangements [where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer], and bad politics.’

The WHO developed a Commission on Social Determinants of Health, which in 2008 published a report entitled ‘Closing the gap in a generation’. This report identified two broad areas of social determinants of health that needed to be addressed. The first area was daily living conditions, which included:

  • healthy physical environments
  • fair employment and decent work
  • social protection across the lifespan, and
  • access to health care.

The second major area was distribution of power, money and resources, including:

  • equity in health programs
  • public financing of action on the social determinants
  • economic inequalities
  • healthy working conditions, gender equity
  • political empowerment
  • a balance of power and prosperity of nations.

As a health worker, you need to understand how social determinants impact on the health and child rights issues in your community. In the activity below, you will take time to reflect and think of experiences that impact on children’s living conditions and thus their health in your community.

Activity 1.1: Your experience of the social determinants of health

Answer the following questions:

  1. Think about your own experience of growing up. Can you think of social determinants that have shaped your own health?
  2. Think about a specific situation in your community where you have observed poor living conditions for children. What are the poor living conditions that might impact on their health? Think about them under the following headings:
    • physical environment
    • employment and work opportunities (for parents/guardians)
    • social protection (for example access to education, a legal system, etc.)
    • access to health care.
  3. Who do you think is responsible for these conditions having developed?
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Your answers to these questions will be dependent on the circumstances that you are familiar with in your own community.

  1. Your answer to this will be personal.
  2. In a general sense, poor living conditions are likely to be found:
    • In a physical environment that is challenging, probably with little or no access to clean water, good food, sanitation, hygiene and reliable transport.
    • Where employment and work opportunities are restricted, and the available options are low status, poorly paid and potentially exploitative.
    • Where education is unavailable or is of low quality/value, and where people are unaware of their legal rights and/or unable and unsupported to claim them.
    • Where access to health care is unavailable or very limited, and/or of low quality/value, for example where a service is focused only on expensive treatment rather than low cost, widespread prevention of disease.
  3. You may have a very clear picture of how these conditions have developed in your own community, perhaps as a result of conflict, natural disaster or long-term policy decisions made by the local or national governing bodies – maybe even some combination of all three. You may just feel that the situation has been like this for so long that it is very difficult or impossible to describe how it came about. What is unlikely is that the people who live in poor living conditions have created them for themselves. Individuals are rarely able to exert direct control over the social determinants of their own health.

    Living in these circumstances is hard for any adult, and children raised in such communities are likely to have very low expectations of what life has to offer. They will have a limited understanding of human rights and no way of knowing what their own rights are or how to claim them.

Study note

For ease in reading the text, from hereon we will be referring to the UN Convention and the African Charter.

Activity 1.2: Relationship of social determinants to the right to health

In an earlier session in Module 2 you learned about the right to health. Here is a reminder of Article 24 on the UN Convention.

  1. States Parties recognise the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.
  2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures:
    • a.To diminish infant and child mortality.
    • b.To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care.
    • c.To combat disease and malnutrition, including within the framework of primary health care, through, inter alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking water, taking into consideration the dangers and risks of environmental pollution.
    • d.To ensure appropriate pre-natal and post-natal health care for mothers.
    • e.To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents.
    • f.To develop preventive health care, guidance for parents and family planning education and services.

How do you think the social determinants of health affect the rights of children in your community to the best possible health, as well as other rights?

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It will be clear to you that the social determinants in a child’s life will have a significant effect on their right to health. For example, if they are unable to access clean water or have a nutritious diet, they will not achieve the best possible health. They will be vulnerable to disease, blindness and stunting. Social determinants such as discrimination against girls, can lead to situations where they have less priority for food within the family, or may be less likely to have access to health care. This too will compromise their right to health. These social determinants may also lead to children not being able to realise their right to education or to optimum development. Poverty and lack of employment can lead to children being required to participate in work from a very young age. Girls may be forced into early marriage and other forms of sexual exploitation.

1.2 Learning outcomes

1.4 Understanding social justice and health inequities