Models of the determinants of health have gained significant traction since the publication of the “rainbow model” of health inequalities (Dahlgren and Whitehead 1991). Researchers have developed conceptions of the social, economic, political, commercial, environmental, and behavioral determinants of health, and policy makers have enshrined elements of these in the strategies and agendas that guide health policy and wider policy activity. Some of the resulting approaches have become mainstream pillars of public health and health policy. Following a 2008 World Health Organization (WHO) commission and a wealth of research activity, the social determinants of health (SDoH) model, which encompasses economic, political, and environmental factors, is now well established (Marmot and Wilkinson 2006; Navarro 2009; WHO 2008). More recently, attention to the commercial determinants of health (CDoH) has increased markedly, and this field has become a frontier in global health research and practice (De Lacy-Vawdon and Livingstone 2020; Freudenberg et al. 2021; Gilmore et al. 2023; Maani, Petticrew, and Galea 2022; Mialon 2020). Although these models conform to a biomedical paradigm of “health determination,” which presents its own set of concerns when applied to social processes and phenomena, they have also contributed to a more holistic understanding of health in academic and policy circles.
In this context, embarking on a project to elaborate yet another health determinant, let alone one that is already implicit within existing models, might seem ill-advised. The term political determinants of health (PDoH) is not new. Moreover, the idea that it embodies—that health is political—is already embedded in the more structural aspects of the SDoH model, the CDoH model, and other health determinants models, and is widely recognized by researchers and practitioners. So why put this term at the center of analysis? In what follows, we make a case for the value of the PDoH as a unifying concept and label, and for its particular relevance to health in the European Union (EU), as the empirical focus of this special issue. We then draw from the issue's contributions and conceptualizations to explore how multilevel governance and power, as key themes permeating PDoH work, provide a distinct core of the field. They do this, we argue, by addressing two key challenges in the existing scholarship: the “black boxing” of politics and power, and the hierarchical conceptual structure of health determinism. We conclude by discussing some considerations when using the term PDoH, and we reflect on its (potential) value in elaborating a distinct subdiscipline with this label.
Why Pursue a PDoH Model?
The Limitations of “the Political” within Existing Determinants Models
While our understanding of political determinants has advanced via their inclusion within the related SDoH, CDoH, and legal determinants of health (LDoH) frameworks, politics is a peripheral concern of these fields. Politics is implicit but underdeveloped in other models and is often addressed simply as the context that might explain why other health determinants vary across time and space. As outlined elsewhere, too little SDoH scholarship addresses politics and power (Bambra, Fox, and Scott-Samuel 2005), while CDoH research is predisposed to black box the relationship between agency and structure, situating the behaviors and strategies of corporate actors within macrolevel structures of globalizing (neoliberal) capitalism without interrogating their interconnection (Ralston, Godziewski, and Brooks 2023). Therefore, despite the seeming consensus on the political nature of health, we argue that more targeted, explicit, and coherent PDoH research would enable us to better understand political determinants, not as another discrete category situated next to the other determinants, but as a cross-cutting dimension of any macrosocial driver of health. Since the discipline of public health currently lacks the appropriate toolbox—that is, established and contested theories of power—to conceptualize and address the determinants of health effectively, this will necessarily involve bridging insights from disciplines such as sociology, international relations, geography, science and technology studies, and numerous others.
Using PDoH to Bridge (Sub)Disciplines
From a research perspective, there remains a space for a label that might usefully link subfields, identify a collective endeavor, and raise this endeavor's profile within wider fields that we might not otherwise engage. At the most immediate level, the term PDoH connects those aspects of (critical) public health, health policy, global health governance, political epidemiology, sociology of health, and similar research fields that speak to political factors: public policy making, racism, and wealth inequity; taxation regimes, public-private partnerships, and trade agreements; regulation, government agencies, and legislative power. This research uses a wide variety of theories, methods, and approaches to explain interrelated phenomena, but the potential benefits of bringing together insights from these different theoretical and methodological orientations are underexploited. A label that makes explicit the shared political focus of this work provides it with an additional home and supports a supplementary scholarly community. We see this already with initiatives such as the Collective for the Political Determinants of Health, born out of The Lancet–University of Oslo Commission on Global Governance for Health, which mobilizes resources and raises awareness.
For example, the PDoH are understood to encompass different levels of governance, systems, institutions, and political decisions (Leimbigler et al. 2022); norms, policies, and practices (Ottersen et al. 2014); and power disparities, institutional environments, interests, political culture, and ideology (Kickbusch 2015). These conceptualizations direct public health research to the role that neoliberalism, globalization, geopolitics, commodification, and trade play in determining health (Barlow and Thow 2021; Blouin 2017; Goodman 2016; Kentikelenis and Rochford 2019; Schofield et al. 2021; Viens 2019). They also stimulate studies of “political epidemiology,” which are concerned with the impact of politics on population health (Barnish, Tørnes, and Nelson-Horne 2018; Mackenbach 2013; Muntaner et al. 2011). Existing work explores the link between government political party and infant mortality (Alexiou and Trachanas 2021), voting and health outcomes (Brown, Raza, and Pinto 2020), local political elites and child and infant mortality (Mershon 2020), political ideology in government and COVID-19 response (McKee et al. 2021), and regime type, participation, and conflict and progress toward the United Nations Millennium Development Goals for health (Atti and Gulis 2017). These clusters of work are rooted in different methodological traditions and offer complementary insights.
More broadly, such a community—identifiable by the PDoH label—provides a point of reference for those outside these immediate subfields of public health and epidemiology. It clearly signals shared interests with, for instance, those studying the role of party politics in shaping environmental outcomes, or the geopolitics of development assistance. This is important to support the development of understandings of power and politics, as noted above. Furthermore, in the face of complex, interrelated polycrises (e.g., environmental, socioeconomic, health), it is useful to develop common languages to study health (and its politics) in an interdisciplinary and epistemically inclusive way.
PDoH as a Way to Reach Policy and Practitioner Audiences
Finally, while acknowledging the shortcomings of the determinants model, we recognize its success and its value as a heuristic, particularly when engaging policy and practitioner audiences. Like all good models, it simplifies and makes visually compelling a series of complex relationships, facilitating the engagement of nonexpert audiences and the structuring of action. Similarly, terms like SDoH, CDoH, and LDoH are accessible and recognizable labels. In the context of extensive policy engagement with the existing determinants of health, use of the PDoH label immediately situates relevant work and makes it visible to those audiences.
The practitioner context is one in which the PDoH concept has been used frequently as part of a wider effort to engage public health actors in politics and advocacy. It appears alongside calls for greater application of political science theories and methods in public health research, and the embedding of better political science training for public health professionals (Bernier and Clavier 2011; Bekker et al. 2018; Kickbusch 2015). Because PDoH points to the impact of social injustice and inequality on population health, and the importance of public trust in government for the effective functioning of the health system, the term is used to argue for greater political engagement by public health professionals (McKee 2017, 2022; Peate 2022). As such, it provides a point of contact between research on the political drivers of health and practice committed not only to promoting public health but also to recognizing the inseparability of health and social justice.
While we acknowledge the risk of proliferating models of health determinants and “health siloing,” we argue that a more consistently utilized PDoH label could serve to cohere relevant research, support introspection, provide a reference point for dialogue with related disciplines, and position relevant research alongside the existing lenses being adopted by policy makers and advocates.
The PDoH and the EU
The aim of this special issue is not to propose a single analytical framework, nor is it to make an exhaustive census of specific PDoH. Rather, it is to explore the potential scope and value of the concept as a label for a common research and practice agenda. This project was designed to generate a bottom-up delineation; the call for papers invited scholars who consider their work to address the PDoH in the EU—regardless of their disciplinary home and how they might define this term—to propose contributions. No single definition or framework was supplied, and the editors did not evaluate submissions against any particular understanding of the PDoH. Instead, we sought to gather a group of articles focusing empirically on health at the national and supranational levels in the EU, covering both quantitative and qualitative methodologies and representing a broad range of disciplinary traditions. The only requirement was that authors demonstrate explicit engagement with how their article conceptualizes PDoH, and explain what they mean by “political.”
We chose to focus on the EU, in part, because our own work explores how the EU, as a political entity, shapes health. This work is part of a growing subfield that seeks to understand how an additional regional layer of health governance, particularly one with such circumscribed legal competence, has come to influence health so profoundly (de Ruijter 2019; Greer 2014; Mossialos et al. 2010; Steffen 2005). The EU's explicit health mandate is limited, but its wider powers—to regulate the internal market, set standards for occupational, consumer and environmental safety, and negotiate trade agreements, for instance—are strong. Its patchwork competence has forced it to use creative combinations of regulatory and discursive power and to foster policy networks that span the local, national, and supranational levels (for an overview, see Greer, Rozenblum, et al. 2022). As such, the EU is a unique site for studying power and multilevel governance—two core themes of PDoH work—and how these factors shape health systems and outcomes. The special issue's focus is framed as political determinants and (rather than in) the EU, so as to capture work across political levels and beyond the EU's borders, and the links between EU-focused PDoH and those in other empirical sites.
The result is a series of articles that address dynamics within member states, EU regions, and the EU as a whole. Individually, they adopt a wide range of approaches and explore a diverse set of research questions. Addressing questions familiar to studies of political epidemiology, Popic and Moise examine the link between reforms that privatize health care provision and inequality in population health outcomes, while Fox, Scruggs, and Reynolds study how policy decisions on redistribution, poverty reduction, and risk protection affect long-term population health. In a similar vein, Ceron explores associations between national austerity policies and responses to COVID-19, and the role of EU fiscal governance in promoting austerity and the consolidation of national health care spending. Fischer, Tille, and Mauer focus a little further up the causal pathway and develop an analytical framework for assessing how the European Health Union is shaping EU health policy and thus stands to influence health outcomes. Taking a more institutional approach, Riedel and Szyszkowska explore how party politics, legal-institutional structures, interest groups, and public opinion might explain poor performance in the Polish health care system. The articles by Ewert on the one hand and Perehudoff and Ippel on the other both focus on the EU's legislative process and how policy outputs—specifically nutritional labeling and pharmaceutical policy, respectively—are shaped by decision-making procedures and the relative power of political actors. Brooks and Lauber turn attention to the metaregulatory framework that underpins these procedures, and its wider effect on health policy making, while Guy examines how the principle of solidarity, as the foundational value underpinning European health systems, is framed and shaped at the EU level. Adopting a discursive approach, Roos examines how the EU is framed in national debates on access to health care for forced migrants, while Godziewski and Rushton show how the EU used a health security narrative to legitimize the creation of its latest health body, the Health Emergencies Preparedness and Response Authority.
Collectively, the articles raise a number of key points. Building on an understanding of how paradigms and frames shape (global) health policy outcomes, the articles highlight the role of institutions—and how they assign responsibility, power, and value—in determining the success of some frames over others. Perehudoff and Ippel show that the assignment of market-focused directorate-generals as the leads of pharmaceutical and biotechnology legislation, for instance, shaped the viability and effectiveness of an economic frame. Similarly, Godziewski and Ruston illustrate how strategies of discursive legitimation are shaped by legal competencies, pushing the EU to engage a security-based narrative to underpin further health integration. Reflecting the logic that underpins the Health in All Policies principle, the articles by Roos, Brooks and Lauber, Ceron, and Guy show the value of a PDoH lens in recognizing how adjacent fields—migration and asylum, regulatory governance, economic governance, and competition policy—shape health policy and outcomes. Explications of how corporate actors seek to shape the institutional context of health policy making (Brooks and Lauber) and to exploit prevailing structures to obstruct the adoption of public health legislation (Ewert) contribute to existing work in the CDoH field by highlighting the role of institutions. Explanations of how national governments make strategic use of EU action and respond to the EU's requirements (Roos) draw attention to politicization and dynamics of instrumentalization within multilevel governance systems.
The PDoH Contribution: Conceptualizing Power and Addressing Multilevel Governance
This section elaborates on two main points of contribution that speak to the core of PDoH research: a more nuanced conceptualization of power, and a more direct approach to multilevel governance.
Multifaceted Engagement with Power as an Alternative to Black-Boxing Politics
There are many ways to define “politics” and “the political.” While these terms are often used as a shorthand for government and other decision-making institutions and practices, they are also used to refer to power relations more broadly. Conceptualizing power and understanding how it operates are key drivers of the study of the political. Although public health increasingly recognizes the need to engage with power, this is generally done in ways that do not reflect the breadth, depth, and richness of ways to conceptualize power. Perhaps the most common conceptualization of the PDoH is one that understands political determinants to exist upstream of, or before, the social (and perhaps also other) determinants of health. Here the PDoH are understood as “the determinants of the determinants” (Dawes 2020) and the “causes of the causes of the causes” (Bambra 2016). They are the factors that determine the distribution of the SDoH—that is, of healthy environments for living, working, and aging—and of political and economic power. This conceptualization faces the same limitations outlined above and explained by Krieger (2008) regarding the assumption of linear causality and conflation of levels.
Other approaches focus on government decision-making, linking the PDoH to government efforts to address the SDoH (Hiam, Dorling, and McKee 2020; Lee 2017; McKee et al. 2021) via policies on education, unemployment, urban development, and other areas. The risk inherent in these approaches is that the concept of PDoH is used to invoke political will as the analytical end point, which in the process black boxes political will as something that cannot be explored or factored into analysis. Centering, refining, and opening up the term to a wider range of conceptualizations of power provides a language for characterizing and interrogating political (in)action as a driver of health and for interacting with health determinants that have been categorized under other headings (e.g., CDoH, SDoH, etc.).
This special issue includes articles putting forward different—and not necessarily reconcilable—conceptualizations of power. Perhaps even more importantly, they show how the study of PDoH can eschew a focus on population health and explore the relevance of “the political” to health systems (health care, public health systems) across different levels of governance. The contributions by Ceron, Popic and Moise, and Fox, Scruggs, and Reynolds analyze the health impacts of particular political processes or decisions, examining power dynamics playing out at both the national and EU levels. Others identify power as substantiated within institutions and rules, delving into the political structures and processes that determine the regulatory space for public health and/or health care (Ewert; Brooks and Lauber; Riedel and Szyszkowska). Other contributions (Godziewski and Rushton; Guy; Perehudoff and Ippel) use constructivist conceptualizations of power as relationally and/or discursively constructed, investigating social interactions and language as forms of power that shape how health issues and institutional actors become understood. Through this diversity, this special issue seeks to demonstrate how the PDoH approach might promote debate on different conceptualizations of power, with different philosophical underpinnings, to unpack the black box of politics.
Directly Addressing Multilevel Governance as an Alternative to Adding Layers to the Rainbow
PDoH research generally focuses on the transnational political dimension. This contrasts with SDoH frameworks, which tend to draw attention to national public policy (in the areas of education, welfare, transport and health care). The final report of the Commission on Global Governance for Health goes so far as to exclude national-level factors, defining the PDoH as “norms, policies, and practices that arise from transnational interaction” (Ottersen et al. 2014, emphasis added). A focus on the EU is helpful precisely to problematize the implication of linear causality between levels inherent to the rainbow model, encouraging us to explore the connections between levels in a way that better recognizes the “complex systemicity” of multilevel governance (Hooghe and Marks 2001). The contributions in this special issue analyze different governance levels, covering the EU (Brooks and Lauber; Godziewski and Rushton; Guy; Perehudoff and Ippel), specific comparisons across member states (Scruggs, Fox, and Reynolds; Moise and Popic; Riedel and Szyszkowska), and the dynamics between the two levels (Ceron; Ewert; Fischer, Tille, and Mauer; Roos).
When read together, they highlight the value—and necessity—of studying political determinants in a way that treats the relationships between levels as mutually reinforcing and producing effects greater than the sum of their parts. Guy, for instance, shows how the concept of solidarity is constructed at the EU level, framing a particular approach to redistribution and access to care. In studying how the health care arrangements that result from or reflect different conceptions of solidarity (i.e., the public-private mix in the health care system) are associated with population health outcomes, Popic and Moise illustrate implications of solidarity, as a PDoH, in the national sphere. Similarly, the instruments and practices of the Better Regulation agenda, as detailed by Brooks and Lauber and including provisions on stakeholder consultation, shape lobbying and interest-group pressure, as illustrated in Ewert's review of the nutritional labeling debate. Looking at these articles in conjunction illuminates the mutually reinforcing causal relations between national and supranational governance spaces that affect population health.
An important outcome of adopting a multilevel governance approach, and eschewing a specific definition of what governance level the PDoH are limited to (i.e., not limiting our analyses to transnational interactions), is that it provides conceptual freedom from hierarchizing causes and determinants of health. This approach thus avoids the tendency found within public health research to conceptualize health determinants in ascending/descending orders based on (flawed) conflations of time, space, and causal strength (Krieger 2008). The PDoH, rather than representing “the new top layer” in the famous Dahlgren-Whitehead (1991) rainbow model, is instead a promising conceptual tool to transcend “rainbow-style” thinking about the (politics of) drivers of health. In this sense, the PDoH might be developed in a way that intentionally resists being confined to a single governance level, and instead recognizes that power and politics pervade, collapse, and construct those very levels.
The Limits of a Determinants Model
One source of hesitation in advocating for a more substantiated PDoH subfield concerns the limitations of the health determinants model. While models of the structural forces shaping health seek to account for multiple, interconnected causes of health and disease, they generally fail to move beyond causal determinism. Such a paradigm encourages a sense that, all else being equal, an identified driver has a direct link to a health outcome, and that outcomes can be predicted if all information is known (Acolin and Fishman 2023). This paradigm has shaped approaches to social, commercial, and other risk factors, but it is not necessarily compatible with population health research, and it is certainly not compatible with a research enquiry that seeks to understand the politics of the drivers of health. In recent years, and predominantly outside of academia, the need to change the language used around health determinants—preferring terms like “social drivers of health”—has been highlighted (Lumpkin et al. 2021). On balance, the value of the PDoH concept—in drawing together relevant research, providing a reference point for other disciplines, and engaging policy and practitioner audiences—outweighs the potential cost; yet we are mindful of these limitations, and we argue for proceeding with caution in this regard.
One consideration raised is the choice of terminology. The PDoH is one option, but it is not the only label to have been suggested. Having made the case for health as a political issue, Bambra, Fox, and Scott-Samuel (2005), for instance, call for a political science of health (or health politics) field. Revisiting this issue, Mykhalovskiy and colleagues (2019) and Fafard, Cassola, and Weldon (2022) draw on earlier debates from the field of sociology to explore the epistemological and ontological challenges of bringing these disciplines together. Mykhalovskiy and colleagues (2019) identify the development of a “social science in public health,” wherein public health draws on social scientific ideas but in a way that remains superficial and instrumental, and they describe an alternative “social science of public health” that applies critical social scientific lenses to public health so as to highlight the limitations and problems of public health as a field of research and practice. They conclude that neither group engages with the other in a meaningful, Habermassian “communicative” sense, that is, with genuine openness and desire to learn. Drawing on Chantal Mouffe's concept of agonistic pluralism, the authors therefore call for critical social science with public health, a space for meaningful engagement across irreconcilable research paradigms that does not seek convergence or consensus but rather pursues mutual listening and learning. Whatever the terminology or label, the value of a PDoH approach, we argue, lies in its acceptance of the incompatibilities between different disciplinary theories, practices, and critiques, and its efforts to embed productive tensions.
Building a PDoH Bridge
When compared to the SDoH and CDoH models, it is clear that the PDoH has not developed in the same way. It does not have a distinct body of literature or specific typologies and models that map its dimensions. By contrast to policy interest in the SDoH and CDoH, the PDoH are not priorities of the WHO, and few civil society organizations use this term. Moreover, where there has been engagement with the term at an institutional level, the outcomes have been contested. The work and critique of The Lancet–University of Oslo Commission on Global Governance for Health is a case in point. This commission was established in 2014 to address “the political origins of health inequity,” and its final report examines a number of policy fields where improved global governance is necessary to promote health—including economic crises and austerity measures, knowledge and intellectual property, foreign investment treaties, food security, transnational corporate activity, irregular migration, and violent conflict (Ottersen et al. 2014). However, its recommendations—which included, inter alia, the creation of a UN multistakeholder platform and the use of health equity impact assessments—were criticized as “tame,” “old and tired,” and as reflecting a sense that, somewhat ironically, “the Commission wasn't prepared to ‘speak truth to power’” (McCoy 2014). Others found that it “failed to engage with questions about power or make recommendations that would challenge the ways [that] dominant neoliberalism restricts health governance options” (Smith 2020: 122; Gill and Benatar 2016). To some extent, these critiques reflect a challenge, found also in the CDoH sphere, of engaging in genuine political analysis that addresses agency as well as structure, and not only structure but also the political interests, institutions, and ideas that sustain it. Put bluntly, political determinants are politically sensitive, which both explains the patterns of use to date and makes them all the more important.
How do we see the PDoH unfolding, and where do we locate it within current scholarship in public health, political science, and beyond? As we have outlined above, the PDoH idea or label is not new. Its value is in bridging existing work that implicitly or explicitly address political factors in the context of health. Explicit use of the term is relatively rare, and where it is used, it is often mentioned in an introduction or even listed as a keyword but without explicit definition or conceptualization. More commonly, the specific term is not used, but the drivers or phenomena to which it might refer—political institutions, governance arrangements, structuring norms—are elaborated within existing models of the SDoH, the CDoH, and other determinants. Politics is, logically, a peripheral concern of these public health models; for this reason, the value of a PDoH label here is in making the political the direct object of analysis. For political science, the PDoH label might usefully link the large body of work that applies political science insights in health policy analysis with other work that explores how health policy change is shaped by agents’ responses to institutional structures (Greer, Fonseca, et al. 2022; Tuohy 2018), by policy learning and legacies (Popic 2023), and by the discursive construction of health policy instruments (Ralston, Godziewski, and Carters-White 2023). The PDoH label does not necessarily imply a new research agenda in political science, but it acknowledges the limitations of a focus on the policy process (Greer 2023; Harris 2023), and it encourages dialogue between those studying health from across the political and wider social science disciplines. Studies of the PDoH take the political nature of health—and the rejection of the individualized and biomedical paradigms—as a given, turning immediate attention to politics, ideology, and power. As a concept and as a platform for transdisciplinary agonistic dialogue, the PDoH thus provides a space where those addressing the underlying politics of the SDoH and the overarching structures of the CDoH can explore overlapping interests. As a bridge for agonistic engagement between critical social sciences (a family of social scientific approaches that produced rich debates and insights into how to conceptualize and study power, over decades and even centuries) with public health (a discipline that offers detailed, meticulously operationalized assessments of population health), without the need for one to subsume the other, we think that the PDoH offers important ways forward for studying power and public health.
While the concept of PDoH faces practical challenges and conceptual limitations, the contributions to this special issue highlight the breadth, depth, and value of work that speaks to “the political” in health. We are grateful to all of our authors, as well as the editorial team at JHPPL, for their stimulating and enthusiastic engagement with this project, and we hope that it underpins sustained development of PDoH research in the coming years.
