The social determinants of health (SDOH) are the conditions in which people are born, grow, live, work and age. They include factors such as income, education, employment, housing, and access to healthcare. These determinants shape opportunities for good health and wellbeing and explain why some groups experience poorer outcomes than others.
Health inequalities arise when these determinants are distributed unfairly due to poverty, discrimination, or unequal access to resources such as safe environments, decent work, or quality education. These inequalities are not inevitable; they are avoidable and unjust.
The 2025 EuroHealthNet CHAIN report highlights that, while Europeans are living longer (average life expectancy 81 years), inequalities in health remain stark:
– A child born in Spain can expect to live 8 years longer than one born in Bulgaria.
– Only 10% of health differences are explained by healthcare access – the remaining 90% are shaped by social and economic conditions such as financial security, housing, and work.
– Commercial products and practices cause nearly one out of four deaths (24.5%) in the European region.
– People in the lowest education groups are twice as likely to report poor health as those with higher education.
– Mental health inequalities mirror this pattern: 18% of people in the lowest occupational group report poor mental health, compared to 8% in the highest.
– Financial hardship is the single strongest driver of both poor physical and mental health.
While some countries (e.g. Slovenia, Poland) have reduced both inequalities and improved health, others (e.g. Belgium, Norway, Lithuania) saw widening gaps. The report concludes that tackling inequalities requires a whole-of-government and whole-of-society approach, integrating health equity across all policy areas, from housing and employment to environment and economy.
In Belfast, local data mirrors these European patterns:
– The Belfast Agenda and City Health Development Plan show that people living in the most deprived wards can expect to live 10 years less than those in the least deprived.
– Life expectancy and healthy life expectancy are both strongly linked to deprivation, with higher rates of chronic disease, poor mental health, and premature mortality in lower-income communities.
– Factors such as poor-quality housing, fuel poverty, low educational attainment, and insecure work continue to drive inequalities across the city.
Belfast Healthy Cities, as part of the WHO European Healthy Cities Network, is leading cross-sectoral work to tackle the social determinants of health through a Health Equity in All Policies approach.
Key areas of focus include:
– Greening the City and Healthy Transport – integrating health equity into urban planning, sustainable transport, and green infrastructure – promoting design that supports active living, access to green space, and social connection.
– Health Equity and Health Literacy Training and Advocacy – supporting senior leaders to increase their knowledge and apply relevant tools.
– Maximizing learning and knowledge exchange – working with partners to strengthen local evidence and align with the WHO framework.
These initiatives contribute to addressing the root causes of health inequality by influencing city policy, empowering local communities, and aligning Belfast with the European movement towards a wellbeing economy.
But what is a Health Equity in All Policies Approach?
A Health Equity in All Policies (HEiAP) approach is a strategic framework for ensuring that decisions made across all sectors – not only within health – actively contribute to improving health outcomes and reducing health inequalities. It recognises that most determinants of health lie outside the health system, in areas such as housing, education, transport, the economy, and the environment. HEiAP aims to align policies, budgets, and programmes so that they work together to promote wellbeing and fairness.
The approach is rooted in the WHO Health in All Policies framework but places additional emphasis on equity – ensuring that all people, regardless of income or background, have fair opportunities to achieve good health. It encourages collaboration across government, shared accountability for outcomes, and the use of evidence and community engagement to assess how policies affect different population groups.
In practice, applying Health Equity in All Policies means that urban planning, transport, education, and economic strategies in Belfast are assessed for their health impacts, ensuring that they contribute to closing rather than widening the health gap. A current example of this in practice is the newly established Transport Poverty Group, established by Belfast Healthy Cities involving Regional and Local Government, academia and a range of community partners.
The evidence from Europe and Belfast aligns clearly: Health inequalities are avoidable and damaging to economic and social resilience negatively impacting our citizens and communities quality of life and outcomes.
Key recommendations for Belfast:
1. Embed health equity as a measurable outcome in all city and regional policies and investment frameworks.
2. Continue strengthening cross-sectoral governance through Belfast Healthy Cities’ coordination role.
3. Invest in local data and evaluation to track the social gradient in health and support equitable recovery and preparedness.
By sustaining leadership on the social determinants of health, Belfast can continue to model the WHO principle that “When nations talk, cities act.”
Email: Charlene Brooks, CEO at charlene@belfasthealthycities.com
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