Beyond unequal access to pharmaceuticals, social and economic inequities hindered the effectiveness of public health and social measures at reducing the spread and impact of the COVID-19 pandemic. The pandemic’s impact in accelerating inequity has persisted beyond the initial crisis.
A global report published by the World Health Organization (WHO) highlights that the underlying causes of ill health often stem from factors beyond the health sector, such as lack of quality housing, education and job opportunities.
The new World report on social determinants of health equity shows that such determinants can be responsible for a dramatic reduction of healthy life expectancy – sometimes by decades – in high- and low-income countries alike. For example, people in the country with the lowest life expectancy will, on average, live 33 years shorter than those born in the country with the highest life expectancy. The social determinants of health equity can influence people’s health outcomes more than genetic influences or access to health care.
“Our world is an unequal one. Where we are born, grow, live, work and age significantly influences our health and well-being,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “But change for the better is possible. This world report illustrates the importance of addressing the interlinked social determinants and provides evidence-based strategies and policy recommendations to help countries improve health outcomes for all.”
The report underscores that inequities in health are closely linked to degrees of social disadvantage and levels of discrimination. Health follows a social gradient whereby the more deprived the area in which people live, the lower their incomes are and they have fewer years of education, poorer health, with less number of healthy years to live. These inequities are exacerbated in populations that face discrimination and marginalization. One of the vivid examples is the fact that Indigenous Peoples have lower life expectancy than non-Indigenous Peoples in high- or low-income countries alike.
Social Injustice Driving Inequities
The World report on social determinants of health equity is the first of its kind published since 2008 when the WHO Commission on Social Determinants of Health released its final report laying out targets for 2040 for reducing gaps between and within countries in life expectancy, childhood and maternal mortality. The 2025 world report, shows that these targets are likely to be missed.
Although data is scarce, there is sufficient evidence to show that health inequities within countries are often widening. WHO data cites that children born in poorer countries are 13 times more likely to die before the age of 5 than in wealthier countries. Modelling shows that the lives of 1.8 million children annually could be saved by closing the gap and enhancing equity between the poorest and wealthiest sectors of the population within low- and-middle-income countries.
The report shows that while there was a 40 per cent decline in maternal mortality globally between 2000 and 2023, low- and lower-middle-income countries still account for 94% of maternal deaths.
Women from disadvantaged groups are more likely to die from pregnancy-related causes. In many high-income countries, racial and ethnic inequities in maternal death rates persist, for example, in some areas Indigenous women were up to three times more likely to die during childbirth. There are also strong associations between higher levels of gender inequality, including child marriage, and higher maternal mortality rates.
Breaking the Cycle
WHO emphasizes that measures to address income inequality, structural discrimination, conflict and climate disruptions are key to overcoming deep-seated health inequities. Climate change, for example, is estimated to push an additional 68–135 million people into extreme poverty over the next 5 years.
Currently, 3.8 billion people worldwide are deprived of adequate social protection coverage, such as child/paid sick leave benefits, with direct and lasting impact on their health outcomes. High debt burdens have been crippling the capacity of governments to invest in these services, with the total value of interest payments made by the world’s 75 poorest countries increasing fourfold over the past decade.
WHO calls for collective action from national and local governments and leaders within health, academia, research, civil society, alongside the private sector to:
- address economic inequality and invest in social infrastructure and universal public services;
- overcome structural discrimination and the determinants and impacts of conflicts, emergencies and forced migration;
- manage the challenges and opportunities of climate action and the digital transformation to promote health equity co-benefits; and
- promote governance arrangements that prioritize action on the social determinants of health equity, including maintaining cross-government policy platforms and strategies, allocating money, power and resources to the most local level where it can have greatest impact, and empowering community engagement and civil society.
In resolution WHA74.16 (2021), the Seventy-fourth World Health Assembly requested the WHO Director-General to prepare an updated report on the social determinants of health, their impact on health and health equity, progress made so far in addressing them, and recommendations for further action. The World report on social determinants of health equity provides an update to the conclusion of the WHO Commission on the Social Determinants of Health in 2008 which stated that “social injustice kills on a grand scale”.
Inequitable Impacts of COVID-19
The report says that the COVID-19 pandemic is a profound global example of the inequitable health outcomes driven by upstream social determinants. From its outset, socio-economic inequality was a predictor of higher mortality. Between countries, inequity in COVID-19 outcomes was exacerbated by inequitable access to diagnostics, vaccines and other countermeasures.
At subnational level, higher COVID-19 incidence and mortality were associated with higher social and economic inequality, including alarming inequities due to race and ethnicity status in many countries. Beyond unequal access to pharmaceuticals, social and economic inequities hindered the effectiveness of public health and social measures at reducing the spread and impact of the pandemic. The pandemic’s impact in accelerating inequity has persisted beyond the initial crisis.
As the authors of the report say, “many low- and middle-income countries emerged with large amounts of sovereign debt, reducing the fiscal space for investment in necessary social and physical infrastructure to improve health, and resulting in large backlogs in health services.”
They say, “Global progress towards the Sustainable Development Goals (SDGs) was already faltering before the additional shock of the pandemic; now it is severely off-track. COVID-19 will not be the last pandemic with severe health and health equity impacts unless enhanced efforts are taken to address social and economic inequities as part of pandemic prevention, preparedness and response.”
