The WHO Social Determinants of Health (SDOH) framework is a conceptual model developed by the World Health Organization to explain how the conditions people are born into, live in, and work within shape their health outcomes and drive health inequities. Originally developed by Orielle Solar and Arvin Irwin, the framework emerged from the WHO Commission on Social Determinants of Health, established in 2005 to marshal evidence on what can be done to promote health equity globally. The Commission’s landmark 2008 report, “Closing the Gap in a Generation,” laid out the case that health disparities are not inevitable but are shaped by political choices, economic systems, and social policies.
The framework divides the forces that affect health into two layers: structural determinants (the root causes) and intermediary determinants (the everyday conditions those root causes create). Its primary output is not just better health, but health equity, which the framework argues governments have the responsibility to foster.
Structural Determinants: The Root Causes
Structural determinants sit at the top of the framework. They are the societal, economic, and political contexts a person is born into, and they dictate where someone lands on the social ladder. These include governance systems, economic policies, social policies affecting pay and working conditions, housing policy, and education systems. In practical terms, structural determinants answer questions like: How much does your country invest in public education? Are wages set at levels that allow families to afford healthy food? Does housing policy concentrate poverty in certain neighborhoods?
Critically, structural determinants shape whether resources necessary for health are distributed equally or unjustly divided along lines of race, gender, social class, geography, and sexual identity. A person’s socioeconomic position, meaning their income level, education, occupation, and social standing, is largely determined by these structural forces. That position then sets the stage for everything that follows in the framework. Two people living in the same city can have vastly different health trajectories not because of personal choices, but because structural forces placed them in different material realities from birth.
Intermediary Determinants: Where Inequality Becomes Illness
Once structural forces assign someone a socioeconomic position, intermediary determinants are the mechanisms through which that position translates into actual health differences. The framework identifies four categories of intermediary determinants.
- Material circumstances include the tangible conditions of daily life: housing quality, neighborhood safety, access to nutritious food, the physical conditions of your workplace, and whether you can afford heating in winter. These are the most visible ways that social position affects health.
- Psychosocial circumstances refer to the chronic stress, social isolation, lack of control, and emotional strain that come with disadvantage. Living with financial insecurity or in an unsafe environment triggers sustained stress responses that, over time, damage cardiovascular health, weaken immune function, and increase vulnerability to mental health conditions. Research from the Institute of Health Equity has mapped specific psychosocial pathways between social and economic conditions, psychological processes, and both mental and physical health outcomes.
- Behavioral and biological factors cover patterns like diet, physical activity, tobacco and alcohol use, which are themselves shaped by the material and psychosocial conditions people face. The framework treats these not as purely individual choices but as behaviors constrained by circumstance. Someone working two jobs with no safe place to exercise and limited access to fresh produce faces a fundamentally different set of options than someone with time and resources.
- The health system itself functions as an intermediary determinant. Access to care, quality of care, and the financial burden of seeking treatment all mediate how social position affects health. Research on children’s mental health has shown, for example, that parents struggling to pay medical bills and families relying on welfare provisions face barriers to accessing mental health services, creating an indirect but significant link between socioeconomic status and children’s emotional wellbeing.
How the Framework Guides Policy Action
The framework is not just descriptive. It identifies specific entry points where policy can interrupt the chain between social position and poor health. These draw on earlier work by Diderichsen and colleagues, which the WHO framework incorporated and expanded.
The first and most fundamental entry point is reducing social stratification itself. This means macroeconomic and social policies that redistribute wealth, power, and opportunity, narrowing the gap between social groups. Progressive taxation, universal education, and minimum wage laws fall into this category.
The second entry point targets differential exposure and vulnerability. Even when social stratification exists, policies can reduce the degree to which disadvantaged groups face harmful living conditions, workplace hazards, or environmental toxins. Affordable housing standards, workplace safety regulations, and neighborhood investment programs operate at this level.
The third entry point focuses on preventing unequal consequences once illness occurs. This is where most healthcare systems currently concentrate their efforts: ensuring that when people do get sick, the outcomes are not worse simply because of their social position. Universal health coverage and protections against catastrophic health spending work here. The framework emphasizes, though, that focusing only on this last entry point without addressing the upstream causes is insufficient.
Countries Putting the Framework Into Practice
Dozens of countries have formally adopted elements of the WHO SDOH framework into national health policy, though implementation varies widely. France launched a national health strategy in 2013 that included a social contract requiring every government department to be accountable for the impact of its policies on health inequalities. China’s Healthy China 2030 plan placed health at the center of the country’s entire policy-making apparatus, making “health in all policies” an official government position.
Canada has been at the forefront of SDOH research, with social determinants now firmly embedded in the public health agenda at both national and provincial levels. In the United States, the 2010 Affordable Care Act and the Healthy People 2020 initiative created an environment for addressing social determinants and health equity, though the U.S. approach has remained more fragmented. Wales took a distinctive legislative approach with its 2015 Wellbeing of Future Generations Act, which created a commissioner role and placed legal obligations on public bodies across areas aligned with social determinants.
The framework has also gained traction in lower- and middle-income countries. Brazil established a National Commission on Social Determinants of Health in 2006. Argentina and Chile created governance arrangements to promote social determinants work at high levels of government. The Union of South American Nations identified SDOH as one of five priorities in its 2010-2015 Plan of Action. In Africa, Zambia’s president established a ministry responsible for social determinants, and Zimbabwe, Kenya, Nigeria, and South Africa have pursued related initiatives. South Australia adopted a Health in All Policies approach specifically in response to rising healthcare costs driven by aging and chronic disease.
The 2024 Monitoring Framework
One longstanding challenge with the WHO SDOH framework has been measurement. Knowing that housing, income, and education shape health is one thing; tracking those relationships with consistent data across countries is another. In February 2024, the WHO released new guidance specifically designed to address this gap: an operational framework for monitoring social determinants of health equity.
This guidance grew out of a 2021 World Health Assembly resolution (WHA74.16) that encouraged member states to take action on social determinants and tasked the WHO with developing a standardized monitoring approach. The resulting framework offers a menu of indicators, a step-by-step process for technical monitoring, and guidance on how to use data to inform policy at national and subnational levels. The goal is to give governments the accurate, timely, and comparable data they need to develop evidence-based policies, allocate resources effectively, and prioritize interventions where health inequities are greatest.