Re-politicizing the WHO's social determinants of health framework.

Although the World Health Organization's (WHO's) framework on social and structural determinants of health and health inequities (SSDHHI) has done much to raise awareness of these determinants, it does not go far enough in considerations of politics and power. The framework has become more de-politicized since its publication, with the definition of social determinants shifting toward downstream and individualized factors. In the meantime, new research fields on legal, commercial and political determinants of health and health inequities have emerged; however, these have not become integrated adequately into broader SSDHHI frameworks. To address these challenges, we argue for a re-politicization and an expansion of the WHO's framework by including the agents who have power over shaping structural determinants and the ways they use power to shape these determinants. We also provide a more detailed conceptualization of structural determinants to facilitate research. We propose a guideline for evaluating studies according to the extent to which they point upstream versus downstream and incorporate agents and considerations of power. We then use this framework to encourage more research on associations among agents, mechanisms of power, and structural determinants; how changes in structural determinants affect power dynamics among agents; and a wider focus on structural determinants beyond laws and policies, such as broad economic and sociopolitical systems. We also urge researchers to consider societal and institutional forces shaping their research with respect to SSDHHI. Research based on this framework can be used to provide evidence for advocacy for structural changes and to build more just systems that respect the fundamental human right to a healthy life.