'Knowing how the machine works': a novel framework for engaging with the political determinants of health

It is well established that social determinants influence people's health and well-being. Yet, limited attention is given to the fact that social determinants are, in turn, the result of political determinants. The political struggle between different ideas, interests and power over public policies, that is, how societies shall function, results in formal and informal structures that work as a 'sorting machine': they determine how societies (re)distribute material resources and opportunities among their members, creating societal classes that face disparate health outcomes. Their visible and measurable characteristics are then labelled 'social determinants'. Improving public health, therefore, needs engaging with the political determinants.We contribute to this broader vision with a process-oriented, interdisciplinary framework. It first operationalises the analysis of political determinants of health to understand how, in a specific public health concern, politics shapes policy processes and causes differential health outcomes. Building on these insights, the framework then supports strategic engagement with the politics of policy processes, using agile methods to identify and promote more equitable and politically feasible policy options.We illustrate our approach by reporting on an interdisciplinary 6-year research project in Burkina Faso, Ghana, Mozambique and Tanzania, examining how structural determinants contribute to unequal public health outcomes in industrial mining areas. Trade-offs between attracting mining firms and safeguarding public health have led to a patchwork of national legislation, global governance regimes and voluntary commitments, inviting an eclectic consideration of public health industrial mining. For instance, among over 560 mining projects across Africa, more than 90% of impact assessments were inaccessible. In the few that were, public health is only marginally considered, disproportionately harming vulnerable populations.To strengthen the 'structural competence' and policy relevance of the public health discipline, our results suggest an institutionalised cooperation with political science in curricula, training and applied research.