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Keeping it political and powerful: Defining the structural determinants of health

This  paper argues that the concept of social determinants of health has been depoliticized because it is commonly viewed as only including community conditions and is no longer connected to structural change.

To counter this, the authors identified the need for a refined, clear and practical definition of structural determinants of health. They developed such a definition based on a review of social and political theory.

Redefining structural determinants 

Their definition of structural determinants of health has two parts :

  1. the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health
  2. the manifestation of power relations in that people and groups with more power based on current social structures work—implicitly and explicitly—to maintain their advantage by reinforcing or modifying these rules (p. 1)

Identifying structural determinants

The authors also list and define key structural determinants of health, includ ing:

  • values, beliefs, world views, culture and norms
  • governance
  • laws, policies, regulations and budgets
  • institutional practices (p. 7)

They note that “the structural determinants of health enshrine and encode structural racism, White supremacy, neoliberal capitalism, cis-heteronormativity, and other forms of oppression and othering” (p. 7). Further, structural racism is another type of structural determinant of health that has been established by and can be seen in dominant world views, beliefs, laws, practices and more. 

The authors hope that “this  theoretically grounded definition of structural determinants can support a shared analysis of the root causes of health inequities and an embrace of public health’s role in shifting power relations and engaging politically” (p. 1).

Use this resource to

  • Deepen understanding of the structural determinants of health and their relation to power and health equity
  • Facilitate discussion about the structural determinants of health and how public health must engage politically in order to advance structural change and health equity


Related Resources:

Let's Talk: Redistributing power to advance health equity (2023)

Let’s Talk: Health equity (2023)

See other NCCDH resources on the social determinants of health and power.


Heller, J. C., Givens, M. L., Johnson, S. P., & Kindig, D. A. (2024). Keeping it political and powerful: Defining the structural determinants of health. The Milbank Quarterly. Advance online publication.

Tags: Structural determinants, Power, Assess and report, Academic Institution, Document, Journal Article