Keeping It Political and Powerful: Defining the Structural Determinants of Health

Early View Perspective
Global Health Population Health Social determinants of health
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Policy Points:

  • The structural determinants of health are 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, and 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.
  • 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, especially in its policy work.
  • Shifting the balance of power relations between socially constructed groups differentiates interventions in the structural determinants of health from those in the social determinants of health.

When the World Health Organization (WHO)’s Commission on the Social Determinants of Health (CSDH) published their framework for the social determinants of health (SDOH) in 2010, they intentionally included two distinct concepts in their definition, “distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result.”1 The WHO continues to include both “the conditions in which people are born, grow, live, and age” and “the wider set of forces and systems shaping the conditions of daily life” in their definition.2 Perhaps responding to prior criticism, the CSDH explicitly called out changing the distribution of power as central to addressing the forces and systems that maintain inequity and was clear that engaging in this work is a political endeavor.1, 3

Yet, almost immediately, many simplified the SDOH concept to include only the conditions of daily life. As part of Healthy People 2020, which was released in 2010, the US Centers for Disease Control and Prevention referenced the CSDH but defined the SDOH as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”4 As others have critiqued, this depoliticizes the concept of the SDOH5 and is perhaps a result of dominant neoliberal worldviews in the United States and elsewhere.6 Indigenous scholars and practitioners extend that critique, with a focus on the importance of decolonization, sovereignty, and self-determination as key social determinants of their health.7


  1. Solar O, Irwin A.A Conceptual Framework for Action on the Social Determinants ofHealth. World Health Organization Commission on the Social Determinants ofHealth; 2010. Accessed October 13, 2022.
  2. Social determinants of health. World Health Organization. Accessed April 25,2023.
  3. Navarro V. What we mean by social determinants of health. Int J Health Serv Plan Adm Eval. 2009;39(3):423-441.
  4. Social determinants of health. Healthy People 2020. Updated February 6, 2020. Accessed September 8, 2023.
  5. Geiger HJ. The political future of social medicine: reflections on physicians asactivists. Acad Med J Assoc Am Med Coll. 2017;92(3):282-284.
  6. Raphael D. Shaping public policy and population health in the United States:why is the public health community missing in action? Int J Health Serv Plan Adm Eval. 2008;38(1):63-94.
  7. Carroll SR, Suina M, Jäger MB, et al. Reclaiming indigenous health in the US:moving beyond the social determinants of health. Int J Environ Res Public Health.2022;19(12):7495.

Heller JC, Givens ML, Johnson SP, Kindig DA. Keeping It Political and Powerful: Defining the Structural Determinants of Health. Milbank Q. 2024;102(2):0227.