Background Ethnic inequalities in health status and healthcare remain substantial in Europe, and addressing them is becoming a priority. However, the best way to respond to such a challenge is, as yet, unclear. The research community is grappling with the contribution of socio-economic discrimination to ethnic inequalities.

Methods The authors present a new theoretical analysis, based on the landmark work of Charles Tilly on ‘Durable Inequality,’ and we apply it to the public-health goal of reducing ethnic health inequalities.

Results Tilly claims that, for organisational reasons, ethnic categories and socio-economic categories are tied together. The theory of Durable Inequality claims that the matching of ethnic categories with socio-economic categories helps to enforce exploitation, leading to durable inequalities. The authors present the theory, focus on its main components (categories, exploitation, opportunity hoarding, emulation and adaptation) and discuss the implications for health inequalities by ethnic group. In essence, the theory leads to four recommendations for the study of ethnic health inequalities: (1) to investigate organisational processes that create ethnic health inequalities; (2) to investigate the role of networks and ties on health behaviours, healthcare use and their psychological factors; (3) to define ethnicity through flexible, multidimensional binary categories, which should vary according to context; (4) to assess cumulative inequality within a domain, across domains and across generations.

Conclusions This paper, to our knowledge, is the first attempt to analyse Tilly's theory in relation to ethnicity and health, and opens up a debate on refining the implications of these ideas prior to empirical testing.