Overview

The social determinants of health are the conditions in which people are born, grow, work, live, and age, the systems put in place to deal with illness, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Social determinants of health matter because addressing them not only helps prevents illness, but also promotes healthy lives and societal equity.

Commercial determinants of health are a key social determinant, and refer to the conditions, actions and omissions by commercial actors that affect health. Commercial determinants arise in the context of the provision of goods or services for payment and include commercial activities, as well as the environment in which commerce takes place. They can have beneficial or detrimental impacts on health.

Companies shape our physical and social environments

Commercial activities shape the physical and social environments in which people are born, grow, work, live and age – both positively and negatively. 

For example:

• Company choices in the production, price-setting and targeted marketing of products, such as breast-milk substitutes, ultra-processed foods, tobacco, sugar-sweetened beverages and alcohol lead to diseases such as cardiovascular disease, type 2 diabetes and certain cancers, as well as hypertension and obesity.
• Young people are especially at risk of being influenced by advertisements and celebrity promotion of material. For example, fast-food advertising to youth activates highly sensitive and still-developing pathways in teens’ brains.
• Mass removal of trees creates mosquito breeding sites, causing vector-borne disease outbreaks like malaria and chikungunya, with up to 20% of malaria risk in deforestation hotspots attributable to international trade of deforestation-implicated export commodities such as timber, tobacco, cocoa, coffee and cotton.
• Factories, which are disproportionately located in disadvantaged communities, pollute the air, causing and exacerbating respiratory diseases.
• Unsafe or toxic work environments can impact employee mental health, for example for women working in the ready-made garment industry.
• Commercial action in knowledge environments can foment groundless doubt and contribute to climate change denialism or vaccine hesitancy.
• Intensive animal agriculture is a leading cause of climate change, deforestation, antimicrobial resistance, and air, soil and water pollution. The consumption of animal-derived food products is linked to higher rates of noncommunicable diseases, including some cancers and diabetes. 
• Workers in slaughterhouses and meat packaging facilities, which are often located in disadvantaged communities, suffered high rates of injury and experienced high rates of infection from COVID-19.  
• Harmful use of intellectual property law can prevent some communities to access affordable medicines.

However, there are positive contributions by to public health, for example when companies implement the following health interventions:

• increasing the availability of essential medicines and health technologies, and supporting improved access to essential, high-quality, safe, effective and affordable medicines and medical products;
• reformulation of goods and products to reduce harm and injury, including the industry introduction of seat belts, efforts to reduce salt content in food production, and to eliminate trans fats from the global food supply;
• ensuring living wages, paid parental leave to improve child health outcomes, sick leave and access to health insurance; and
• financial decisions to divest from products and services harmful to health.
  

The workplace also functions as a setting of health promotion and protection against harm, allowing following:

• principles to guard against modern slavery, exploitation or indentured servitude;
• occupational health and safety standards and hygiene practices that reduce the risk of disease or work-related disability;
• health promotion activities aimed at the workforce, including use of stairs, healthy canteens, walkathons or sports events; and
• health literacy events, including awareness building about deadly ailments, blood donation or vaccination.

Commercial determinants drive inequities

Commercial determinants often disproportionately affect countries and populations that are not profiting from the product or service that causes harm to health or planet, but instead are faced with the burdens of these harms. As a result, they shape health equities, both within and between countries.

Commercial determinants also contribute to other factors that shape health and health equities through broader economic systems and economic determinants. This includes through economic development or trade policies, broader social, economic and political systems, and finance or investment flows. Examples include:income level

• educational opportunities
• occupation, employment status and workplace safety
• food insecurity and inaccessibility of nutritious food choices
• access to housing and utility services
• higher use of tobacco in some regions
• gender inequity
• racial segregation.

Countries with commodity-dependent economies are especially vulnerable, such as Small Island Developing States and least developed countries. They face greater pressure from industry due, for example, to greater employer status or multinational trading agreements.

Private sector influence on health policy

Recent decades have seen a transfer of resources to private enterprise, which now plays an increasing role in public health policy and regulation and outcomes. The emergence of non-State actors in the geopolitical arena, together with a shift in global governance, are fundamental to understanding the development of commercial determinants of health. Various authors have catalogued pathways of private sector health strategies and impact, including influencing the political environment, the knowledge environment and preference shaping.

There are multiple pathways that commercial actors influence health policy. Companies commonly influence public health through lobbying and party donations. This incentivizes politicians and political parties to align decisions with commercial agendas. Further, some commercial actors work to capture branches of government in order to prevent or weaken regulation of their products and services, leading to unregulated activity, limiting their liability and bypassing the threat of litigation and pre-emption.

More subtly, the private sector has been known to influence the direction and volume of research through funding medical education and research, where data may be skewed in favour of commercial interests.

To further shape preferences, some companies capture civil society by founding or funding front groups, consumer groups and think tanks, allowing them to manufacture doubt and promote their framings.

Addressing commercial determinants

Partnering with civil society, adopting so-called best buy strategies and conflict of interest policies and supporting safe spaces for discussions with industry are all examples of how countries can address the commercial determinants of health.

More research is needed on the health equity dimensions of commercial determinants of health as well as governance considerations, including transparency and accountability, in addition to state capabilities to avoid corruption and steer private sector engagements. 

There are clear opportunities to move forward on the commercial determinants, particularly in better understanding and addressing the conflicts of interest but also potential co-benefits of private sector action for better health, at global, national and local levels.

The role for transformative partnerships and approaches to achieve the ambitious global health goals was already recognized by the UN 2030 Agenda for Sustainable Development but has been brought to the forefront by COVID-19, with increasing attention on the role the private sector plays in health outcomes both within academia and from civil society. This has led to increased scrutiny on the role of the private sector in health and health equity, as well as increasing initiatives within the private sector itself to position itself as a partner.   

Examples of actions governments around the world are taking to address commercial determinants to improve public health include:

• At least 5 billion people are now covered by at least one of the live-saving MPOWER measures designed to address the worldwide tobacco epidemic, including twenty-nine countries with 832 million people (12% of the world's population) having passed a comprehensive ban on tobacco advertising.
• Approximately 50 countries, including Barbados, Brunei Darussalam, Chile, France, Hungary, India and Ireland, among others, have charged a tax on sugar-sweetened beverages. 
• Saudi Arabia imposed a tax on tobacco products, energy drinks and soft drinks in 2017. 
• In Bulgaria, companies give women over 58 weeks of maternity leave on average, which is one of the highest in the world. 

WHO Response

WHO addresses the wider economic factors impacting on health and health equity, including through workstreams on trade and health, as well as health and development. The WHO Council on the Economics of Health for All has elaborating several opportunities to rethink how value in health and wellbeing is measured, produced, and distributed across the economy. WHO also promotes the use fiscal instruments including taxation policies to invest in and improve health outcomes.

Private sector engagement is also addressed through different streams of work, including through the Advisory Group on the Governance of the Private Sector for Universal Health Coverage, as well as through programmatic and treaty approaches such as WHO Framework Convention on Tobacco Control.

WHO has initiated a new programme of action, the Economic and Commercial Determinants of Health, which has four goals: to strengthen the evidence base; develop tools and capacity to address the commercial determinants; convene partnerships and dialogue; and raise awareness and advocacy.