Commercial Determinants of Health

Original Editor - Ewa Jaraczewska based on the course by Cornelia Barth

Top Contributors - Ewa Jaraczewska and Jess Bell  and Cornelia Barth

Introduction

Health is shaped by many interconnected factors, including the actions of the private sector. These influences, known as commercial determinants of health, can affect health outcomes both positively and negatively.

Understanding commercial determinants of health enables healthcare professionals to better identify the causes of health inequities, develop more effective interventions, and create more equitable healthcare systems that provide quality care and promote health for all. Addressing commercial determinants of health requires a multifaceted approach that includes policy change, healthcare delivery reform, and community empowerment. By acknowledging and addressing commercial determinants of health, rehabilitation professionals can build health systems that serve all members of society with dignity and respect.

Understanding Commercial Determinants of Health

"The concept of the ‘commercial determinants of health’ (CDOH) has been developed by public health researchers as a way to describe the political economy of corporations and the impact of their practices on health, social inequalities and climate change."

Industries, such as tobacco, alcohol, ultra-processed food, and fossil fuels, contribute significantly to the global burden of preventable disease. These four sectors are collectively responsible for at least one-third of annual preventable deaths worldwide (Figure 1). Much public health research focuses on the economic and political power of these industries. However, many other industries also play a role in shaping health-related behaviours and outcomes, including gambling, pharmaceuticals, automobiles, firearms, mining, big tech, and social media (Figure 2).

It is important to note that there is no health without commercial interests, and various industries play an essential role in keeping us healthy and driving healthy behaviour.

Figure 1. Industries that produce harmful products and their effect on preventable deaths worldwide.

Figure 2. Industries influencing health behaviours.

Key Definitions

Currently, there is no single, universally accepted definition of commercial determinants of health. Earlier definitions focused on the conflict between a company's profits and population health. For example, they were defined as: "factors that influence health which stem from the profit motive." However, this definition does not account for the full range of commercial activity - including businesses that promote healthy products or the wider impact companies have on policies, communities, and perceptions.

More recent definitions aim to capture the complexity of commercial determinants of health. They include:

"(....) private sector activities that affect people's health directly or indirectly, positively or negatively."

"(........) strategies and approaches used by the private sector to promote products and choices that are detrimental to health."

"Systems, practices, and pathways through which commercial actors drive health and equity."

"(........) social, political, and economic structures, norms, rules, and practices by which business activities designed to generate profits and increase market share influence patterns of health, disease, injury, disability, and death within and across populations."

Commercial Determinants of Health and Health Equity

Health equity is achieved when there are no unfair or avoidable differences in health status. Commercial determinants of health often contribute to these disparities. Commercial actors may direct marketing towards vulnerable populations, implement unfair pricing strategies or influence access to healthcare.

There is a long history of powerful industries influencing people's perception of what is fashionable, desirable or "cool". These industries routinely employ teams of psychologists and market analysts to shape consumers' behaviour.

Because of the far-reaching impact of many of these products on health, higher-income countries have introduced regulations restricting how these products are marketed. In response, many commercial actors then shifted their focus to low- and middle-income countries, or to vulnerable populations within high-income settings, where regulations may be weaker or less consistently enforced.

Global Impact of Commercial Determinants of Health

Globalisation has empowered large corporations through increased demand, wider markets, and international trade. This is evidenced by rising trade deals, market growth, and expansion into developing countries. Corporations exert influence via marketing, lobbying, corporate social responsibility, and extensive supply chains. This influence affects both policy and consumer choices, thereby amplifying the overall health impact of a product.

Marketing campaigns often associate unhealthy products with desired lifestyles, aesthetics, or experiences. Such messaging disproportionately targets people from lower socioeconomic backgrounds or minority groups. For instance, campaigns may be timed to align with the distribution schedule of food assistance benefits or aimed directly at children.

Corporations may engage in lobbying efforts to obstruct policy measures. This may include financing research to influence scientists or making donations to political parties to influence policymakers. In doing so, these corporations aim to manipulate policy at all levels. In relation to health, these lobbying activities can undermine public health regulations and taxation policies designed to reduce the consumption of harmful products. For example, major food companies might oppose public health measures, such as sugar taxes, warnings on packages or marketing restrictions aimed at reducing the consumption of unhealthy products.

Corporations may aim to boost their reputation through social responsibility initiatives or activities. For example, major soft drink companies frequently sponsor sports teams and events and fund children's physical activity programmes. These sponsorships help companies create a positive image as supporters of physical activity, countering criticism that their products contribute to the obesity epidemic.

Extensive, integrated supply chains expand a company's global influence and alter consumption patterns due to the surplus of unhealthy products, the relative lack of healthy products, and the difference in pricing and profit margins between unhealthy and healthy products. Vulnerable populations often become the target of these supply chains.

Burgess and colleagues identified seven domains of corporate influence on health in their Corporate Influences on Population Health (HEALTH-CORP) typology. These are: (1) political practices, (2) preference and perception shaping practices, (3) corporate social responsibility practices, (4) economic practices, (5) products and services, (6) employment practices, and (7) environmental practices. These domains can have direct (products and services, and environmental practices) or indirect (economic practices) impacts.

Local Impact of Commercial Determinants of Health

Commercial determinants of health contribute substantially to health challenges at a local level through several key mechanisms.

Urban communities often experience more intense exposure to unhealthy marketing, with a greater density of fast-food outlets, alcohol vendors, and tobacco retailers. In contrast, rural areas may have fewer regulatory protections and limited access to healthier alternatives.

Socioeconomic disparities are often exacerbated by corporations targeting harmful products at communities with lower income and education levels. This impact is compounded by reduced access to healthcare and support services in these communities.

Local cultural factors can influence the degree to which commercial activities impact health behaviours. For instance, traditional dietary patterns may provide some protection against the health impacts of ultra-processed foods. However, these cultural practices are increasingly being replaced due to the actions of global companies.

Impact of Commercial Determinants on Access to Health

Access to health depends on the availability, affordability, acceptability, and quality of health services and resources. Commercial determinants of health influence each of these dimensions.

Availability: commercial interests shape the distribution of health services across regions. Private hospital networks tend to focus on profitable urban centres, and health services may be absent from less profitable rural or underserved communities. Pharmaceutical research and development priorities are typically driven by market potential rather than disease burden. For example, pharmaceutical companies invest heavily in medications for conditions common in wealthy countries while neglecting diseases that predominantly affect lower-income regions.

Affordability: commercial pricing models often create significant barriers by generating out-of-pocket costs for essential medications, fee-for-service models that incentivise quantity over quality, and market-driven insurance premiums that exclude vulnerable populations.

Acceptability: the public's perception of acceptable healthcare can be altered by commercial marketing. Marketing can influence cultural norms around health and illness, create unrealistic expectations of healthcare services, and medicalise normal conditions to generate new markets.

Quality of health: market forces can both enhance and diminish the quality of health services. Competition-driven innovation can improve outcomes, yet cost-cutting to maximise profits can compromise safety. The growing digital health sector is creating new forms of health inequity. Telehealth services, health apps, and wearable technologies offer potential benefits but are often designed for and marketed to higher-income populations with existing technology access and literacy.

Commercial Determinants of Health and the Role of Rehabilitation Professionals

Commercial determinants of health contribute significantly to the global burden of non-communicable diseases, particularly in low- and middle-income countries. Rehabilitation professionals are central to managing non-communicable diseases and can actively address commercial influences through person-centred care, health education, interdisciplinary collaboration and advocacy.

By understanding both the global patterns and local manifestations of commercial determinants of health, rehabilitation professionals can design more targeted strategies to promote health equity and prevent non-communicable diseases. This integrated approach recognises that individual health behaviours occur within broader commercial contexts, which must be considered to achieve meaningful improvements in population health.

Health Promotion and Participation in Policy Discussions

Learn to Understand and Know Your Evidence

It is important to consider commercial determinants of health from a public health perspective. In 2021, non-communicable diseases caused at least 43 million deaths - this figure is equivalent to 75% of non-pandemic-related deaths globally. Of these 43 million deaths, 18 million were "premature", i.e. occurring in people aged under 70 years. The majority (82%) of these premature deaths occurred in low- and middle-income countries.

Cardiovascular diseases are the leading cause of death from non-communicable diseases, followed by cancers, chronic respiratory diseases, and diabetes. Factors like tobacco use, physical inactivity, harmful alcohol consumption, unhealthy diets, and air pollution elevate the risk of non-communicable disease-related death. This statistic highlights the urgent need for preventative measures to reduce exposure to harmful products.

Rehabilitation professionals are encouraged to remain informed about the latest evidence of how commercial determinants affect health and communicate this in accessible ways for patients, students, colleagues and communities.

Learn to Read and Understand Science

While commercial industries can negatively impact health, they can also play an important role in promoting and maintaining health. For instance, assistive products and health-tracking or coaching apps are vital to the health and functioning of many individuals.

To effectively promote health and prevent non-communicable diseases, rehabilitation professionals must focus more on health promotion and prevention. Understanding commercial determinants of health is essential to strengthening these roles and supporting behaviour change that prevents, mitigates or better manages non-communicable diseases.

Act on Individual Patient, Population and Policy Levels

Responding effectively to commercial determinants of health requires collaboration across health disciplines, social services, urban planning, and policy. Rehabilitation professionals are well-positioned to contribute to interprofessional teams addressing determinants of health.

Individual patient level: rehabilitation professionals often serve as the first contact person for patients and a trusted source of information on healthy behaviour. They provide patients and their families with accessible information and draw on behavioural research to support positive behaviour. When developing patient education materials and interventions, it is important to add information on how commercial forces shape health behaviours. This includes helping patients recognise and critically evaluate marketing tactics that promote harmful products.

Ethical practices within healthcare are essential to managing commercial influences. This includes maintaining transparency about conflicts of interest, critically evaluating industry-sponsored research, and prioritising patient needs over commercial relationships. Healthcare professionals must continuously reflect on how commercial partnerships may influence clinical decision-making.

Population level: rehabilitation professionals contribute to public health by launching, supporting and promoting initiatives on smoking cessation, weight control, physical activity, and mental health. Community-based rehabilitation initiatives play a role in addressing local commercial determinants of health by building resilience to harmful marketing and promoting sustainable, local alternatives. Community engagement strengthens resilience against harmful commercial influences by building health literacy. Empowered communities can better recognise and resist marketing tactics that promote unhealthy behaviours. Rehabilitation professionals can support culturally appropriate health promotion interventions. Innovations in care delivery that prioritise equity offer alternatives to purely market-driven approaches.

Policy level: as experts in movement and functioning, rehabilitation professionals offer valuable perspectives in advocacy efforts related to policy changes, work with journalists, and raise public awareness about commercial determinants of health. Within institutions, they can promote policies that limit the marketing of unhealthy products in healthcare facilities and encourage ethical partnerships with industry. Additionally, they may advocate for transparency in corporate political activities and promote health impact assessments for commercial policies. Healthcare professionals offer credible, evidence-based insights into how commercial activities affect patient outcomes.

Resources

• This podcast introduces the topic of the Commercial Determinants of Health: Commercial Determinants of Health: A Conversation With Anna Gilmore
• In this podcast, Prof Rob Moodie discusses commercial determinants of health and their powerful influence on society and health: Commercial Determinants: Powerful Influence on Society and Health
• This podcast explores how our health is influenced by commercial forces, wealth and power: Money Power Health with Nason Mani