Upstream Policy Changes to Improve Population Health and Health Equity: A Priority Agenda

Centennial Issue
Health Equity Population Health

Policy Points:

  • Upstream factors—social structures/systems, cultural factors, and public policy—are primary forces that drive downstream patterns and inequities in health that are observed across race and locations.
  • A public policy agenda that aims to address inequities related to the well-being of children, creation and perpetuation of residential segregation, and racial segregation can address upstream factors.
  • Past successes and failures provide a blueprint for addressing upstream health issues and inhibit health equity.

The upstream/downstream metaphor for understanding the root causes or fundamental upstream drivers of population health and how they produce downstream effects, consequences, and inequities is well understood in research, teaching, and public health practice circles. The upstream/downstream framework is visible in the World Health Organization’s (WHO’s) multilevel conceptual model of the social determinants of health and health inequities that posits that health and well-being are primarily determined by upstream social structural factors. These factors include socioeconomic, cultural, political, and public policy contexts that influence individuals’ socioeconomic position and experiences, as well as how racism and discrimination operate and function within the social structures.1 In turn, these macrostructural, or social structural, factors influence a broad set of intermediary social determinants of health at the mesolevels and microlevels (i.e., downstream levels), including what the WHO model refers to as the material conditions of living (housing, food, safety, etc.), health-related behaviors, biological factors, psychosocial processes, and personal health care services.

All of the factors in the WHO model work in multiple and sometimes bidirectional ways to influence both the expression of social needs and health at the individual level. Nonetheless, it is the upstream factors — social structures/systems, cultural factors, and public policy—that are the primary driving forces behind the stark downstream patterns and inequities in health that we observe across socioeconomic, racial, ethnic, gender, and place lines.2 As Williams and Sternthal have articulated: “[s]ocial structure refers to enduring patterns of social life that shape an individual’s attitudes and beliefs; behaviors and actions; and material and psychological resources.”3

Open Access


  1.  Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). World Health Organization. 2010.Accessed March 21, 2023.
  2. Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: definitions, examples, health damages, and approaches to dismantling. Health Aff (Millwood). 2022;41(2):171-178.
  3. Williams DR, Sternthal M. Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav. 2010;51(Suppl):S15-S27.

Ray R, Lantz PM, Williams D. Upstream Policy Changes to Improve Population Health and Health Equity: A Priority Agenda. Milbank Q. 2023;101(S1): 20-35.