Power in Global Health: A Narrative Review, Relational Framework, and Systems-Based Analysis

Background: Power is routinely invoked to explain health inequities and governance failures in global health, yet existing work is conceptually fragmented, weakly connected to empirical analysis, and prone to what is referred to as the "power-as-resource fallacy": the conflation of power bases (what actors possess) with power relationships (how actors influence one another). This narrative review examines how power is conceptualized and operationalized in global health discourse, identifies systematic analytical gaps, and proposes a relational framework to address them. Methods: We conducted a narrative review of literature that explicitly engages with power in relation to global health, governance, or health systems. We synthesized the included texts thematically and, as a supplementary systems-thinking component, developed a causal loop diagram (CLD) based on a subset of quantitative studies to illustrate how different constellations of power interact with health outcomes over time. Results: In global health, power is pervasively invoked but rarely operationalized. We organized the reviewed texts into six thematic domains: (1) power as a determinant of health; (2) structural power (class, race, gender, geopolitical hierarchies); (3) power asymmetry; (4) power and governance for health; (5) power and health securitization; and (6) power constellations and health outcomes. Across these domains, we find that discussions of power remain largely qualitative and often stop short of clear operationalization. The CLD translates these insights into interacting feedback loops, illustrating how specific power constellations are associated with particular patterns of policy response and health outcomes, highlighting potential leverage points for governance reform. Conclusion: This review maps the existing knowledge on power in global health and provides an actionable framework for future research and governance design. It underscores that power is the fundamental thread connecting global political economy to local health inequities.