What Really Drives Health Inequity in the Americas? A Landmark Review Maps the Engines of Power

When public health researchers talk about what shapes who gets sick and who stays well, they often reach for the word “driver.” It sounds dynamic, even mechanical, as if certain forces in society literally push health outcomes in one direction or another. But a sweeping new analysis suggests the term has been used so loosely for so long that it risks undermining the very field it was meant to energize. A team at the Pan American Health Organization, working with colleagues at the University of Ottawa and supported by the Robert Wood Johnson Foundation, has now completed one of the most ambitious attempts to bring order to this conceptual chaos, analyzing nearly three decades of literature on health equity across the Americas.

The study, published as a scoping review in the International Journal for Equity in Health, examined 286 documents published between 2008 and 2026. Following the PRISMA-ScR reporting guidelines, the researchers applied the Joanna Briggs Institute’s population, concept, and context framework to answer four questions: how the term “driver” is used globally and regionally, how it relates to the established concept of social determinants of health, what methodological strategies researchers deploy to study it, and where the glaring gaps in knowledge lie. The protocol was registered on the Open Science Framework, and the work was carried out as part of an effort to build a Health Equity Status Report for the Americas.

The headline finding is a conceptual one. The authors describe an evolution in the literature toward what they call Social Drivers of Equity in Health, a reframing that treats drivers not as passive background conditions but as operational engines of power. In other words, a driver is not simply a factor that correlates with poor health; it is a force that sets the social determinants of health in motion. This distinction matters because the social determinants framework, influential since the World Health Organization’s landmark commission on the subject, tends to describe the conditions in which people are born, grow, work, and age. Drivers, by contrast, imply agency and causation, the mechanisms that produce and reproduce those conditions in the first place.

The numbers reveal just how muddled the terminology remains. The review found that 36.4 percent of the analyzed literature uses “driver” and “determinant” interchangeably, treating them as synonyms despite their different analytical implications. Meanwhile, 38.5 percent of studies identify drivers as independent forces that put social determinants into motion, a more mechanistic reading. The remaining studies occupy various intermediate positions. This inconsistency, the authors argue, challenges theoretical coherence and makes it difficult to operationalize health equity in policy terms. If researchers cannot agree on what a driver is, they cannot agree on what should be driven, or by whom, or toward what end.

Methodologically, the field shows both strengths and limitations. About a third of the reviewed documents, 33.3 percent, were primary quantitative studies, and 46 of them employed multivariate modeling designed to isolate structural effects from individual-level confounders. That is a technically demanding undertaking. Structural forces such as racism, class, and gender hierarchy are not measured directly; they must be inferred through proxies, interactions, and hierarchical models that account for people nested within neighborhoods, institutions, and nations. The fact that only a minority of studies attempt this rigor suggests that much of the literature remains descriptive, cataloging inequities rather than explaining the machinery that produces them.

When the authors turned to the regional picture, the results were striking. Within the Americas, structural racism appeared as the predominant engine of health inequity, cited in 80.0 percent of the relevant regional literature, followed closely by socioeconomic status at 79.3 percent. These findings align with a growing body of evidence showing that racialized populations across the hemisphere face systematically worse outcomes, from maternal mortality to chronic disease burden, even after accounting for income and education. The review’s framing treats these not as isolated risk factors but as relational dimensions of inequality that structure social positions, analyzed across the PROGRESS-Plus axes, a taxonomy covering place of residence, race and ethnicity, occupation, gender, religion, education, social capital, socioeconomic status, age, disability, and sexual orientation.

Perhaps the most forward-looking element of the analysis is its identification of emerging axes of inequality that traditional frameworks have been slow to capture. The PROGRESS-Plus analysis surfaced digital and commercial dimensions as novel mediators of geographic inequity. The digital dimension reflects the reality that access to broadband, telehealth, and health information increasingly determines who can participate in modern health systems, a divide laid bare during the COVID-19 pandemic. The commercial dimension points to the growing influence of industries, from ultra-processed food to tobacco and alcohol, whose products and marketing practices shape health far beyond the clinic. Both axes cut across geography, deepening divides between urban and rural populations and between wealthy and impoverished regions.

Beneath these findings lies what the authors call a significant research inequity. A staggering 79.3 percent of the regional evidence base is concentrated in the United States, leaving Latin America and the Caribbean substantially underrepresented. This is not a trivial bibliometric curiosity. The structural drivers of health inequity in a high-income federal democracy with a fragmented insurance system may differ profoundly from those in middle-income countries with universal health systems, large Indigenous populations, histories of colonial extraction, and high levels of informal employment. Policies built on a US-centric evidence base risk misdiagnosing the levers of change elsewhere in the hemisphere, perpetuating a form of epistemic dependency that mirrors the material inequities the field seeks to dismantle.

To resolve the tension between the term “driver” and established social determinants models, the authors propose a pragmatic compromise: a hierarchy of drivers organized along the familiar upstream, midstream, and downstream gradient. Upstream drivers would encompass the structural forces, legal frameworks, and institutional arrangements that shape the distribution of power and resources, with legal reforms and social protection systems identified as precise levers of intervention. Midstream drivers would cover the conditions of daily life in communities, schools, and workplaces, while downstream drivers would address individual-level factors. This layered architecture allows policymakers to locate where in the causal chain an intervention is aimed, and to recognize that downstream programs, however well designed, cannot compensate indefinitely for upstream forces that continuously regenerate inequity.

The review’s conclusions come with a caution. The term “driver,” for all its rhetorical energy, should be used carefully and only in articulation with robust theoretical frameworks, lest it become another vague buzzword in a field already crowded with them. Used well, the authors suggest, it can serve as an operational catalyst for structural intervention, translating the descriptive language of determinants into the action language of policy. The study itself models a degree of transparency worth noting: the authors disclose that they used an AI tool during data synthesis to refine driver categorizations and cluster theoretical frameworks, with all outputs critically reviewed and verified by the team. Funded by the Pan American Health Organization and the Robert Wood Johnson Foundation, the review arrives at a moment when governments across the hemisphere are grappling with post-pandemic reversals in life expectancy and widening gaps between the richest and poorest. Its central message is deceptively simple: to make health equity more than an aspiration, the hemisphere must first agree on what is actually doing the driving, and then reach for the levers, especially legal and social protections, that can change direction.

Subject of Research: Social drivers of health equity in the Americas

Article Title: Drivers of health equity in the Americas: a scoping review

Article References: Chapman, E., Araujo, M., Maylen, R.-B., Pardo, J. P., & Mujica, O. J. (2026). Drivers of health equity in the Americas: a scoping review. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03031-6

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03031-6

Keywords: health equity, social determinants of health, scoping review, structural racism, socioeconomic status, PROGRESS-Plus, Pan American Health Organization, Latin America and the Caribbean, health policy, digital divide, commercial determinants, public health