SIECHI: A systems model of elite capture and structural inertia in health inequity

Persistent health inequities continue to shape population health outcomes across diverse political and economic contexts, despite sustained policy attention to the social determinants of health. Across countries with varying income levels and health system designs, disparities in housing stability, food security, access to care, and preventable morbidity remain resistant to reform. These enduring patterns suggest that barriers to health equity are not merely technical or programmatic, but are embedded within broader systems of governance, power, and institutional design. This editorial focuses primarily on the United States, not as an assertion of exceptionalism, but as a theoretically informative case for examining how elite capture and structural inertia operate within highly unequal, market-oriented democracies. The United States combines pronounced income inequality, fragmented governance, and extensive private sector involvement in social provision, creating conditions under which power concentration and institutional delay are particularly visible. Similar dynamics have been documented in other contexts with high inequality or constrained state capacity, including Brazil and the United Kingdom, where reform efforts have likewise been shaped by political contestation, administrative bottlenecks, and fiscal constraint. The mechanisms articulated here are therefore analytically transferable beyond the United States, even as their specific expressions vary across settings. This editorial introduces the SIECHI model, or Structural Inertia and Elite Capture in Health Inequity, as a conceptual framework for understanding how political economic forces and institutional resistance jointly suppress progress on the social determinants of health. Rather than treating stalled reform as evidence of policy failure alone, the model conceptualizes inequity as an emergent outcome of reinforcing structural dynamics that persist even when formal policy change occurs.