Skip to main content

The Role of Social Determinants in Tackling Health Objectives in a Context of Economic Crisis


The impact of the economic crisis on health through its social determinants has the greatest effect on disadvantaged, low income households as they are more vulnerable to falls in income and are more likely to suffer the employment effects of an economic crisis. They are subject to exclusionary processes that lead to worse health both in the short and long term.

The health impacts of an economic crisis include an increase in suicides, homicides and cardiovascular mortality, a fall in road traffic accidents, and worse infectious disease and mental health outcomes. Those who become unemployed have a greater risk of poor health than the employed, while employees may be affected by the rise in insecure and temporary work and a greater effort-reward imbalance. As the cost of living rises faster than incomes, more households fall below a minimum income necessary to live a healthy life. There are higher levels of poverty, greater income inequalities and more households with debt problems or other financial difficulties. Lower incomes lead to more homelessness and fuel poverty. All of these factors are associated with worse physical and mental health.

Health inequalities are likely to widen following an economic crisis, though policy responses can help to mitigate the impacts. Higher levels of social spending are associated with better health outcomes and reduced inequalities, whereas research suggests that austerity measures do not have positive health effects. Health equity impact assessments should be carried out on all policies. Specific policy areas covered in the recommendations include universal health coverage, active labour market programmes, a fairer tax system, homelessness prevention, housebuilding, debt relief and fuel poverty measures. Local interventions can also do much to improve daily living conditions, through improving public services and resilience to financial and other shocks.


  1. 1.

    Commission on Social Determinants of Health. CSDH Final Report: Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008.

    Google Scholar 

  2. 2.

    The Marmot Review Team. Fair society, healthy lives: strategic review of health inequalities in England post-2010 (The Marmot Review). London: The Marmot Review Team; 2010.

    Google Scholar 

  3. 3.

    Stuckler D, Basu S. The Body Economic: Why Austerity Kills. London: Allen Lane; 2013.

    Google Scholar 

  4. 4.

    Stuckler D, Basu S, McKee M. Public health in Europe: power, politics, and where next? Public Health Rev. 2010;32:213–42.

    Article  Google Scholar 

  5. 5.

    van den Berg GJ, Lindeboom M, Lopez M. Inequality in individual mortality and economic conditions earlier in life. Soc Sei Med. 2009;69:1360–7.

    Article  Google Scholar 

  6. 6.

    Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crisis and alternative policy responses in Europe: an empirical analysis. Lancet. 2009;374:315–23.

    Article  PubMed  Google Scholar 

  7. 7.

    Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet. 2011;378:124–5.

    Article  PubMed  Google Scholar 

  8. 8.

    Suhrcke M, Stuckler D, Suk JE, Desai M, Senek M, et al. The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence. PLoS One, 2011;6:e20724.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Stuckler D, Meissner CM, King LP. Can a bank crisis break your heart? Global Health. 2008;4:1.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Brenner MH. Mortality and the national economy: a review, and the experience of England and Wales, 1936–76. Lancet. 1979;314:568–73.

    Article  Google Scholar 

  11. 11.

    Davalso ME, French ML This recession is wearing me out! Health-related quality of life and economic downturns. J Ment Health Policy Econ. 2011; 14: 61–72.

    Google Scholar 

  12. 12.

    Gili M, Roca M, Basu S, McKee M, Stuckler D. The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010. Eur J Public Health. 2013;23:103–8.

    Article  PubMed  Google Scholar 

  13. 13.

    Evans-Lacko S, Knapp M, McCrone P, Thornicroft G, Mojtabai R. The mental health consequences of the recession: economic hardship and employment of people with mental health problems in 27 European countries. PLoS One. 2013;8:e69792.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    International Labour Office. Global employment trends: recovering from a second jobs dip. Geneva: ILO; 2013.

    Google Scholar 

  15. 15.

    Bethune A. Unemployment and mortality. In Drever F, Whitehead M (editors) Health Inequalities. London: Stationary Office; 1997. pp. 156–67.

    Google Scholar 

  16. 16.

    Bartley M, Sacker A, Clarke P. Employment status, employment conditions, and limiting illness: prospective evidence from the British household panel survey 1991–2001. J Epidemiol Community Health. 2004;58:501–6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Paul KI, Moser K. Unemployment impairs mental health: meta-analyses. J Vocat Behav. 2009;74:264–82.

    Article  Google Scholar 

  18. 18.

    Milner A, Page A, LaMontagne AD. Long-term unemployment and suicide: a systematic review and meta-analysis. PLoS One. 2013;8:e51333.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    European Commission Directorate-General Health and Consumers, Directorate-General for Communication. Attitudes of Europeans towards tobacco. Special Eurobarometer 385. European Commission: May 2010.

    Google Scholar 

  20. 20.

    Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med. 2012;172:1731–7.

    Article  PubMed  Google Scholar 

  21. 21.

    Gallo WT, Teng HM, Falba TA, Kasl SV, Krumholz HM, Bradley EH. The impact of late career job loss on myocardial infarction and stroke: a 10 year follow up using the health and retirement survey. Occup Environ Med. 2006; 63:683–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Sullivan D, von Wächter T. Job displacement and mortality: An analysis using administrative data. Quart J Econ. 2009;124:1265–306.

    Article  Google Scholar 

  23. 23.

    Eliason M, Storrie D. Job loss is bad for your health — Swedish evidence on cause-specific hospitalization following involuntary job loss. Soc Sei Med. 2009;68:1396–406.

    Article  Google Scholar 

  24. 24.

    International Labour Office. Global employment trends for youth 2013: a generation at risk. Geneva: ILO; 2013.

    Google Scholar 

  25. 25.

    Crawford C, Duckworth K, Vignoles A, Wyness G. Young people’s education and labour market choices aged 16/17 to 18/19. London: Department for Education; 2011.

    Google Scholar 

  26. 26.

    Zeytinogla IU, Seaton MB, Lillevik W, Moruz J. Working in the margins women’s experiences of stress and occupational health problems in part-time and casual retail jobs. Women Health. 2005;41:87–107.

    Article  PubMed  Google Scholar 

  27. 27.

    Natti J, Kinnunen U, Makikangas A, Mauno S. Type of employment relationship and mortality: prospective study among Finnish employees in 1984–2000. Eur J Public Health. 2009;19:150–6.

    Article  PubMed  Google Scholar 

  28. 28.

    Voss M, Nylen L, Floderus B. Unemployment and early cause-specific mortality: a study based on the Swedish twin registry. Am J Public Health. 2004;94: 2155–61.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Vahtera J, Kivimäki M, Pentti J, Linna A, Vistanen M, et al. Organisational downsizing, sickness absence and mortality: 10-town prospective cohort study. BMJ. 2004;328:555–60.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Quinlan M, Bohle P. Overstretched and unreciprocated commitment: reviewing research on the occupational health and safety effects of downsizing and job insecurity. Int J Health Serv. 2009;39:1–44.

    Article  PubMed  Google Scholar 

  31. 31.

    Brockner J, Greenberg J. The impact of layoffs on survivors: an organizational justice perspective. In: Carroll JS (editor) Applied Social Psychology and Organizational Settings. Hillsdale: Lawrence Erlbaum Associates; 1990. pp. 45–75.

    Google Scholar 

  32. 32.

    Artacoz L, Benach J, Borrell C, Cortes I. Social inequalities in the impact of flexible employment on different domains of psychosocial health. J Epidemiol Community Health. 2005;59:761–7.

    Article  Google Scholar 

  33. 33.

    OECD. Crisis squeezes income and puts pressure on inequality and poverty: new results from the OECD Income Distribution Database. OECD; 2013.

    Google Scholar 

  34. 34.

    Glennester H, Bradshaw J, Lister R, Lundberg O. Reducing the risks to health: the role of soical protecyion. Report of the Social Protection Task Gorce for the Strategic Review of Health Inequalities in England Post 2010. London: Centre for Analysis of Coial Exclusion, London School of Economics; June 2009.

    Google Scholar 

  35. 35.

    Dyson A, Hertzman C, Roberts H, Tunstill J, Vaghri Z. Childhood development, education and health inequalities. Report of task group. Submission to The Marmot Review; 2009.

    Google Scholar 

  36. 36.

    Hirsch D, Spencer N. Unhealthy lives: intergenerational links between child poverty and poor health in the UK. London: End Child Poverty; 2008.

    Google Scholar 

  37. 37.

    Solantaus T, Leinonen J, Punamaki RL. Children’s mental health in times of economic recession: replication and extension of the family economic stress model in Finland. Dev Psychol. 2004;40:412–29.

    Article  PubMed  Google Scholar 

  38. 38.

    Nagarajan S. Impact of global financial crisis on remittances flows to Africa. Development Research Department. Development Research Brief Number 4. Tunisia: African Development Bank; 2009. Available from URL: (Accessed 26 June 2013).

    Google Scholar 

  39. 39.

    O’Hara S, Ivlevs A, Gentile M. The impact of global economic crisis on remittances in the Commonwealth of Independent States. Eurasian Geography Econ. 2009;50:447–63.

    Article  Google Scholar 

  40. 40.

    Wilkinson R, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin books; 2009.

    Google Scholar 

  41. 41.

    Taylor MP, Pevalin DJ, Todd J. The psychological costs of unsustainable housing commitments. Psychol Med. 2007;37:1027–36.

    Article  PubMed  Google Scholar 

  42. 42.

    Consumer Credit Counselling Service. Survey reveals high human cost of debt problems — press release. CCCS; 21 July 2010. Available from URL: (Accessed 26 June 2013).

    Google Scholar 

  43. 43.

    Jenkins R, Bhugra D, Bebbington P, Brugha T, Farrell M, et al. Debt, income and mental disorder in the general population. Psychol Med. 2008;38:1485–93.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Meltzer H, Bebbington P, Brugha T, Farrell M, Jenkins R. The relationship between personal debt and specific common mental disorders. Eur J Public Health. 2012;23:108–13.

    Article  PubMed  Google Scholar 

  45. 45.

    Fondeville N, Ward T. Homelessness during the crisis. Research note 8/2011. Social Situation Observatory — Income distribution and living conditions 2011. European Commission, Employment, Social Affairs and Inclusion; November 2011.

    Google Scholar 

  46. 46.

    Burki T. Tackling tuberculosis in London’s homeless population. Lancet. 2010; 376:2055–6.

    Article  PubMed  Google Scholar 

  47. 47.

    Homeless Link. The health and wellbeing of people who are homeless: evidence from a national audit. London: Homeless Link; 2010.

    Google Scholar 

  48. 48.

    Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol. 2009;38:877–83.

    Article  PubMed  Google Scholar 

  49. 49.

    Geddes I, Bloomer E, Allen J, Goldblatt P. The health impacts of cold homes and fuel poverty. London: The Marmot Review, Team & Friends of the Earth; 2011.

    Google Scholar 

  50. 50.

    Edwards R. Who is hurt by procyclical mortality? Soc Sei Med. 2008;67:2051–8.

    Article  Google Scholar 

  51. 51.

    Dorling D, Thomas B. Geographical inequalities in health over the last century. In: Graham H (editor). Understanding Health Inequalities. 2nd edition. Buckingham: Open University Press; 2009.

    Google Scholar 

  52. 52.

    Kondo N, Subramanian SV, Kawachi I, Takeda Y, Yamagata Z. Economic recession and health inequalities in Japan: analysis with a national sample, 1986–2001. J Epidemiol Community Health. 2008;62:869–75.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Reinhart C, Rogoff K. Growth in a time of debt. Am Econ Rev: Papers Proceedings. 2010;100:573–8.

    Article  Google Scholar 

  54. 54.

    Blackstone B, Karnitschnig M, Thomson R. Europe’s banker talks tough. The Wall Street Journal. 24 February 2012. Available from URL: 10001424052970203960804577241221244896782 (Accessed 16 Januaruy 2014).

    Google Scholar 

  55. 55.

    Krugman P. End this Depression Now! New York and London: WW Norton & Company; 2013.

    Google Scholar 

  56. 56.

    Stiglitz JE. Freefall: America, Free Markets and the Sinking of the World Economy. New York and London: WW Norton & Company; 2010.

    Google Scholar 

  57. 57.

    Dahl E, van der Wei KA. Educational inequalities in health in European welfare states: a social expenditure approach. Soc Sei Med. 2013;81:60–9.

    Article  Google Scholar 

  58. 58.

    Stuckler D, Basu S, McKee M. Budget crises, health, and social welfare programmes. BMJ. 2010;340:3311.

    Article  Google Scholar 

  59. 59.

    Bambra C. Going beyond The three worlds of welfare capitalism: regime theory and public health research. J Epidemiol Community Health. 2007;61:1098–102.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social determinants of health and the health divide. Lancet. 2012;380:1011–29.

    Article  PubMed  Google Scholar 

  61. 61.

    Browne J, Hood A, Joyce R. Child and Working-Age Poverty in Northern Ireland from 2010 to 2020. IFS Repost R78. London: Institute for Fiscal Studies; 2013.

    Google Scholar 

  62. 62.

    Stevis M, Talley I. IMF concedes it made mistakes on Greece. The Wall Street Journal. 5 June 2013. Available from URL: (Accessed 26 June 2013).

    Google Scholar 

  63. 63.

    Shelter. Value for money in housing options and homelessness services. London: Shelter; 2010.

    Google Scholar 

  64. 64.

    Eurostat. Unemployment rates by education. 2010. Brussels: Eurostat; 17 August 2010.

    Google Scholar 

  65. 65.

    Bradshaw J. Social Exclusion, Vulnerability & Disadvantage Task Group background paper 3: child poverty in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2012.

    Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Michael Marmot FRCP.

Rights and permissions

Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.

The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

To view a copy of this licence, visit

The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Marmot, M., Bloomer, E. & Goldblatt, P. The Role of Social Determinants in Tackling Health Objectives in a Context of Economic Crisis. Public Health Rev 35, 9 (2013).

Download citation

Key Words

  • Economic recession
  • health
  • socioeconomic factors
  • employment
  • income
  • housing