The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, politics, and the commercial determinants of health. 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 the conditions, actions and omissions by corporate 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
Corporate activities shape the physical and social environments in which people live, work, play, learn and love – both positively and negatively.
- Company choices in the production, price-setting and aggressive marketing of products such as ultra-processed foods, tobacco, sugar-sweetened beverages and alcohol lead to non-communicable diseases such as hypertension, type 2 diabetes, certain cancers,
cardiovascular disease 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
- Factories emitting smoke pollute the air, causing and exacerbating respiratory diseases.
- Unsafe or toxic work environments can impact employee mental health.
- Commercial action in knowledge environments can foment inappropriate doubt and thus contribute to scientific denialism. During the COVID-19 pandemic some governments responded hastily with technologies and interventions that lack scientific evidence
of therapeutic effectiveness.
- Intensive animal agriculture is a leading cause of deforestation; antimicrobial resistance; and air, soil and water pollution. Animal-derived food products are themselves 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, suffer high rates of injury and, at the peak of the COVID-19 pandemic, experienced high rates of infection from the virus.
However, there are positive contributions by the private sector to public health, for example when companies implement the following health interventions:
- reformulation of goods and products to reduce harm and injury, including the industry introduction of seat belts, as well as more recently salt reformulation; and
- ensuring living wages, paid parental leave to improve child health outcomes, sick leave and access to health insurance;
The workplace also functions as a setting of health promotion and protection against harm, allowing the following:
- occupational health and safety standards and hygiene practices that reduce the risk of developing ill-health 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 also contribute to other factors that shape health and health equities or the lack thereof. These factors, which have an influence both within and between countries, have a direct impact as well as an indirect impact given that they influence broader economic systems and economic determinants. This includes through economic development or trade policies. 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 developing countries. They face greater pressure from industry due, for example, to greater employer status or multinational trading agreements.
Private sector influence
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.
Corporations commonly influence public health through lobbying and party donations. This incentivizes politicians and political parties to align decisions with commercial agendas. Further, corporations work to capture branches of government to shape their preferred regulatory regime, leading to unregulated activity, limiting their liability and bypassing the threat of litigation and pre-emption.
More subtly, corporations influence the direction, volume of research and understandings through funding medical education and research, where data may be skewed in favour of commercial interests.
To further shape preferences, they capture civil society through corporate 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.
Examples of actions governments around the world are taking to address commercial determinants to improve public health include:
- Twenty-nine countries with 832 million people (12% of the world’s population) have passed a comprehensive ban on tobacco advertising.
- The United Kingdom has banned junk food advertising online and before 9:00pm on television from 2023.
- Around 50 countries, including France, Brunei Darussalam, Chile, Hungary, India and Ireland, among others, have charged a tax on sugary soft drinks.
- Saudi Arabia imposed a so-called sin tax in 2017, which levied tax on tobacco products, energy drinks and soft drinks.
- In Bulgaria, companies give women over 58 weeks of maternity leave on average, which is one of the highest in the world.
The pandemic has had significant impacts on the global economy, industries, employment and poverty levels. The contribution of COVID-19 to economic inequality is emerging not only at the individual or population levels, but also with respect to national economies.
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.
WHO addresses the wider economic factors impacting on health and health equity through the WHO workstreams on trade and health, as well as health and development. It 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.