The Notion of Social Determinants of Health

The SDH approach provides a different perspective on what could be considered the causal factors of human illness: not the biological or the individual lifestyle, but the social conditions. This notion of social determinants of health derives from a long history of development, which could be dated back to Rudolf Virchow’s tradition in social medicine and the progressive social reform oriented tradition of public health in the nineteenth century.Reference Brown and Fee ⁵ This line of public health tradition focuses on the social and structural factors that contribute to people’s health or illnesses. The commissioned Black Report, published in 1980 in the United Kingdom, addressing the economic inequalities as a determinant of health, marked the beginning of the revival of this tradition of collective-level political and social interventions to improve the population’s health.Reference Macintyre ⁶ In the past few decades, the SDH approach attracted academic and policy attention,Reference Raphael ⁷ along with the development of social epidemiology, a subfield of epidemiology that combines social sciences theories and causal inferences to explain the mechanisms of the social determinants of health.Reference Berkman, Kawachi, Berkman, Kawachi and Glymour ⁸

The WHO’s Commission report published in 2008 was the height of this wave of revival of the SDH approach, summarizing considerable evidence of the distribution and the causal factors of illnesses and providing action recommendations. ⁹ The report explicitly states the ethical foundation underpinning the endeavor of this tradition, that health inequities — the “systematic differences in health are judged to be avoidable by reasonable action globally and within society they are, quite simply, unjust” ¹⁰ — should be eliminated as much as possible. The SDH approach generated a huge body of literature and policy attempts to tackle the causes of the causes from within a single country to a global scale.Reference Marmot ¹¹ International organizations, primarily the WHO, have published a series of policy papers and technical reports on how to address social determinants of health.Reference Solar and Irwin ¹² Throughout these years, the SDH approach acquired the moral imperative high ground and the status of a mainstream analytic lens to examine the health inequity issue.Reference Muntaner and Benach ¹³

Despite the SDH approach’s rich achievement in knowledge generation, in terms of public health policy and practice, there is a major limitation hindering the applicability of the knowledge, that is, the Health in All Policies strategy and the thorough cultural and social transformations implied by the findings of the SDH approach. These implications require whole-of-government and whole-of-society policies and governance. ¹⁴ In the next section, the article argues that under the current dominant public health policymaking paradigm — the rational decision-making model — the policies implied by the knowledge of the SDH approach would lead to an intrinsic contradiction with the logic of modern bureaucracy based on the legal authority (hereafter noted as Weberian bureaucracy) as suggested by Max Weber.Reference Weber, Henderson and Parsons ¹⁵

Health Policymaking Under the Rational Decision-Making Model

The use of knowledge from both the SDH approach and the traditional epidemiological studies applies the same logic in terms of the policymaking process: the rational decision-making model. This model presumes that the policy problem is clearly identified and that the policy’s purpose is to maximize the total welfare/utility with limited resources to solve that problem. ¹⁶ Public policy formation and implementation is a matter of linear function: You have your policy problems defined, you form several policy alternatives that could potentially address the problems, you get the optimal one legitimized, you implement it, and you evaluate your policy outcomes. This model has been adjusted by incrementalismReference Lindblom ¹⁷ and bounded rationality,Reference Forester ¹⁸ but it still remains the mainstream model for policymaking in public health.

How would policymakers respond to the SDH approach’s wisdom under this rational decision-making model? First, most would agree that the purpose of policy interventions is to maximize the population’s total health outcome and health equity. They would further agree that the problem is inequities, in terms of social classes, income, and early life environment, to name a few, based on whichever version of explanation or evidence on the social determinants of health they rely on. Hence, the target of policy interventions would be ameliorating these inequities, and the population’s health would then be enhanced. To address inequities, the SDH approach asks health policymakers to reorient their intervention strategies from the individual perspective to the structural perspective, aiming to address those “structural determinants of health” as suggested. ¹⁹

There are several challenges to the structural perspective. First, it might resonate poorly with the cultural context in some places. For instance, in North America, the market is the primary “arbiter of societal functioning.” ²⁰ People would have to interact as a community rather than a market to undertake “a collective obligation of concern and support, for each other’s health.” ²¹ Furthermore, as Wilkinson and Pickett have noted, for resolving public health problems from the structural perspective, “what is required amounts to a transformation of our societies, a transformation …which is unlikely to be achieved by tinkering with minor policy options.” ²² Indeed, a thorough transformation in any society would be difficult, and painful for some, and require solid and credible collective commitments.

Second, this structural perspective inevitably leads to the conclusion that to address the social determinants of health by policy interventions, all socially related policies should consider health issues while planning and implementing policies to solve their problems and accomplish their missions. This movement, which is asking for greater attention to health issues, has been identified as Health in All Policies.Reference Puska ²³ It also implies the whole-of-government principle — that all governmental agencies from national to municipal level should be involved — and the whole-of-society principle — that all governmental and non-governmental stakeholders should be involved. ²⁴ Health in All Policies seems to be appealing and attractive at first glance; nevertheless, it is not the case for most legislators or bureaucrats after a second thought because the logic of modern bureaucracy — the set of governmental agencies that implement public policies — complies with the rational-legal authority. ²⁵

Health Policy Implementation and the Weberian Bureaucracy

Under this legal authority, the legitimacy of a governmental agency is delegated by a specific law or regulation, which specifies the mission and competence of the agency and the corresponding responsibilities it has. With this delegated authority, the agency would have a “specified sphere of competence,” ²⁶ indicating the policy goals to achieve and to be evaluated and held accountable accordingly by the assembly of representatives of the people, such as Congress. Contrarily, outside the scope of its competence, the agency has no authority to take action, exercise its powers, or spend a penny on public issues. In addition, under this legal authority, the agencies’ missions are mutually exclusive. Each agency has its own “sphere of obligations to perform functions which have been marked off as part of a systematic division of labour.” ²⁷ Suppose the mission to solve a policy problem is delegated to one agency. It cannot be delegated to another agency; otherwise, two agencies would compete for authority over that policy problem. These are the general characteristics of the Weberian bureaucracy; each country’s political system and each policy sector within that system may have its own context.

For instance, achieving universal health coverage (ideally through a progressive financing mechanism) to improve equitable access to health services is one of the recommendations in the key action area 4 of “[b]ringing about change through new governance approaches” as noted in the WHO’s 2025 update report. ²⁸ In the United States, the Patient Protection and Affordable Care Act (PPACA) of 2010 is a significant attempt to achieve some kind of universal health coverage. The PPACA grants the Secretary of Health and Human Services (HHS) as the competent authority for a major part of its implementation. ²⁹ Within these health insurance affairs, only the HHS has the authority to create and manage the health insurance marketplace and enforce the prohibition of health plans’ denial of pre-existing conditions, to name a few. In addition, according to the PPACA, the Secretary of the Treasury is the competent authority in charge of enforcing the individual and employer mandates. ³⁰ In theory, under the legal authority of legitimacy, even under the same umbrella of a policy goal (e.g., pursuing some kind of universal health coverage in the case of PPACA), each governmental agency has its own competence as delegated by the law. The HHS and the Treasury Departments are both brought into the policy of pursuing universal health coverage under the PPACA, not because of their shared government goals, but more because of their functions under the unique US federalist political institutions.

Take the housing issue as another example. The conditions and costs of housing have been identified as social determinants of health.Reference Park ³¹ The WHO’s 2025 update report also recommends in the key action area 4 that the local government should “[e]nsure that urban, rural and territorial planning, transport and housing investments are underpinned by approaches that deliver healthy housing and built environments, and adopt universal design principles.” ³² It is beyond the competence of the health departments to intervene in the housing policy. However, it is also not in the interest of the housing departments to consider health equity. Even if the housing departments might be held accountable for ensuring the physical environment of housing, such as monitoring and prohibiting certain hazardous materials for house construction and renovation, ³³ it is also beyond its competence to intervene in the cost/price of housing, which traditionally has been considered falling under the competence of the private market.

Both examples ³⁴ demonstrate that, for the Weberian bureaucracy, the only agencies with missions regarding maximizing population health outcomes are generally the Department of Health (or the Ministry of Health or other institutes in different countries, hereafter noted as health departments) at different levels of the government. Other agencies that might have missions related to the social determinants of health, like departments of labor, business, internal affairs, housing, agriculture, and urban planning, are not responsible for health. However, as the whole-of-government principle requires, these other agencies should also play a role in the Health in All Policies initiative. As long as the maximization of total health outcomes is not part of an agency’s delegated missions, asking for Health in All Policies is an illegitimate and irrational request.

Unless health missions can diffuse to agencies other than the health departments, or unless the scope and missions of the health departments can be expanded to the extent that they can address all socially related policies, what the SDH approach could provide to policymakers is rather limited. However, both situations will contradict Weberian bureaucracy’s logic by creating competing authorities over the same policy problem. In the former situation, more than one agency is in charge of health issues; in the latter situation, the health departments intrude into issues other than health, such as labor, business, internal affairs, housing, agriculture, and urban planning, among others. In either case, the logic of Weberian bureaucracy will no longer stand. This conclusion seemed rather frustrating in comparison with the ideals the SDH approach promised, such as equity, fairness, and social justice. ³⁵ The policy interventions implied by knowledge of the SDH approach have an intrinsic contradiction with the logic of Weberian bureaucracy under the rational decision-making model.

A possible solution is to leave the government’s role in direct policymaking to civil society.Reference Blas ³⁶ By doing so, the governmental agencies would not necessarily have to satisfy the requirements of Health in All Policies, and what the health departments have to do is to provide a supportive environment from civil society organizations and voluntary associations to address the social determinants of health issues. Nonetheless, as the whole-of-society principle suggests, the government still plays an essential role in addressing the complex, multiple causes of health inequities. ³⁷ Conventional wisdom in public health also emphasizes the importance of government in setting agendas and investing public money to serve the public (health) interest.Reference Coggon and Gostin ³⁸

Another solution is to argue that it is precisely the point that it is imperative for legislators to put the Health in All Policies request into every governmental agency’s competence, so that the whole-of-government principle would be possible and the knowledge of the SDH approach would be better appreciated. ³⁹ As Marmot and colleagues claim, “inequalities that are preventable by reasonable means are unfair. Putting them right is a matter of social justice.” ⁴⁰ In the name of social justice, health, health equity, and their social determinants should be addressed in every policy proposal. This advocacy challenges the rational decision-making model of public policymaking and the legal authority that the Weberian bureaucracy complies with. Besides the rational decision-making model, how could we make public health policy? According to Stone’s proposal, another public policy paradigm that might be useful is the polis model.

An Alternative Paradigm in Health Policymaking: The Polis Model

In the polis model, the policymaking process happens in a polis, ⁴¹ which is a community where people with the same membership act collectively to pursue some common goals. The polis model sees public problems at the community level, consisting of groups and organizations that have different ideas, values, and loyalties, instead of an aggregate of self-interest-maximizing individuals. ⁴² In contrast to the “rational” calculation of benefits and risks in the rational decision-making model, the policymaking in the polis model is based on moral imagination, analogy, and persuasion between fellow community members; in the polis model, the primary motivations behind the policy are altruism and self-interest, while in the rational model it is all about self-interest; the goal of pursuing public interest would be for the shared interests — something common for the community, or common good — in the polis model, while in the rational model the goal is the maximization of aggregated self-interests; when engaging in social interactions, people tend to compete with each other in the rational model, and yet cooperate in the polis model. ⁴³

Most importantly, the legitimacy of a policy does not rely on the legal authority of a Weberian bureaucracy and whatever rights derived from it, but rather more on people’s recognition of and commitment to ideas. Policymaking is a “struggle over ideas”; the policy problem is not clearly identified and will never be solved. ⁴⁴ Policy problems are subject to a dynamic of political interaction, a framing effect, and collective actions between people. For policymakers, the policy problem should be as ambiguous as it needs to be so that political support can be mobilized in the appropriate conditions. This policymaking model could help us detour the legal authority required by the Weberian bureaucracy and better take advantage of the knowledge of the SDH approach and put Health in All Policies into practice.

Again, take the policy arrangements for universal health coverage, for example. We go back to the case of PPACA in the US. In the later years, the PPACA has grappled with political partisanship and polarized social values, and its goal of universal health coverage has been gradually undermined.Reference Béland, Rocco and Waddan ⁴⁵ The tactical success based on rational calculation in the enactment stage alone is not enough for the kind of whole-of-society and whole-of-government required for sustaining the endeavor to pursue the ideal policy goal. The rational decision-making model can hardly explain or guide the policymaking process with its presumptions on linear solutions and the mere aggregation of self-interest. However, health policymakers in a polis who want to pursue universal health coverage may address health inequities by addressing the value of loyalty and care towards fellow citizens and dwellers, as well as mutual assistance among them. They could, on the one hand, appeal to the conservative values of caring for families and mothers, interpreting universal health coverage as a form of loyalty abided by the virtuous members of society. On the other hand, they could appeal to liberal values of empowering individual autonomy through capabilities-building by providing access to essential health services to those whose life choices are limited because they cannot afford healthcare. Still, policymakers could appeal to the need to maintain political legitimacy or supply an adequate number of healthy workers and/or soldiers to build an economically and militarily strong nation-state.

In the polis model, the purpose of the policy arrangements for universal health coverage could be changed simultaneously in the policymakers’ discourses while persuading different audiences and forging a social consensus. Wilkinson and Pickett are right about the importance of the legitimacy of political authority, as they note that governments implement the egalitarian social health insurance (SHI) schemes, which could make the society more equal, not because the policymakers are benevolent, but because their political authority is facing a crisis of legitimacy of the whole government. ⁴⁶ Historically, the SHI in Prussia (Germany) (1883), Japan (1923), Taiwan (1950, integrated in 1995), and South Korea (1977, integrated in 2000), among others, were all established under this circumstance.Reference Bump ⁴⁷ The policymakers at that time did provide many stories, but the crisis of legitimacy was one. These crises at the national level would surpass the legal authority required by the Weberian bureaucracy and forge a broader social consensus that provides the legitimacy for the whole-of-government and whole-of-society policies implied by the knowledge of the SDH approach. The health departments, treasury departments, and even the labor departments would be involved in the pursuit of universal health coverage.

As for the housing issue example, the policymakers in the polis model may appeal to the shared interests that every fellow citizen ought to enjoy a decent quality of living environment, including having the ability to afford housing for such an environment. Therefore, housing policy is no longer about profiting from the private housing market (or whatever financial products derived from the housing market) only. It is also about investing in an environment for the future of the political community, where children and families could have the opportunities to love, play, grow, and flourish together. Who dares to say that this is not one of the common goals of the formation of a political community in the very first place? Without directly linking the goal of reducing health inequities to the housing issue, policymakers could still achieve that goal. The healthy housing knowledge from the SDH approach would be applicable in this way.

Furthermore, the implementation of a universal health coverage scheme or a healthy housing policy also transforms the Health in All Policies into Health for All Policies by producing the co-benefits for other sectors, such as healthier workers as accumulative human capital, healthier children and older people with less social care costs, and more consolidated democracy that better respects, protects, and fulfills human rights and the pursuit of sustainable development goals.Reference Greer ⁴⁸

Through this circuitous polis model, policymakers could detour around Weber’s snare of rational-legal authority and the logic of modern bureaucracy and better take advantage of the fruitful knowledge of the SDH approach to pursue structural policy interventions. In addition, this model’s assumptions of the common will and the possibility of collective actions for the common good also resonate with the ethics and practices of public health that emphasize the value of community.Reference Ortmann and Barrett ⁴⁹ This reorientation might be unimaginable for some. Nevertheless, the evidence-based, rational decision-making model of policymaking, as has been a prevalent discourse in the field of public health policy, has its limits.Reference Fafard ⁵⁰ It is not that politics infringe on evidence-based policymaking, nor that the rational decision-making model should be entirely abandoned. Nonetheless, it is necessary to admit that policymaking is itself political, and “value-free” evidence cannot provide normative guidance to policymakers.Reference Biller-Andorno, Lie and ter Meulen ⁵¹ How the hybrid of the two models should be done is an empirical question to be examined and identified in further policymaking practices. The best ways of combination would be subject to different political and administrative contexts. Notwithstanding how unimaginable and painful it might be, the polis model of policymaking may be necessary for the SDH approach to continue to thrive in the policy fields. ⁵²