Abstract Labour migrants who travel overseas for employment can face deep health inequities driven in large part by upstream social and structural determinants of health. We sought to study the ‘labour migrant health ecosystem’ between one sending country (Pakistan) and one host country (Qatar), with a focus on how the ecosystem realizes the rights of labour migrants when addressing the social and structural determinants (e.g. housing, employment law, etc.) of health. Study objectives were to (1) undertake an in-depth review of policies addressing the structural and social determinants of the health of labour migrants in both Pakistan and Qatar, analysing the extent to which these policies align with global guidance, are equity-focused and have clear accountability mechanisms in place, and (2) explore national stakeholder perspectives on priority setting for labour migrant health. We used a mixed methods approach, combining policy content analysis and interviews with stakeholders in both countries. We found a wide range of guidance from the multilateral system on addressing structural determinants of the health of labour migrants. However, policy responses in Pakistan and Qatar contained a limited number of these recommended interventions and had low implementation potential and minimal reference to gender, equity and rights. Key national stakeholders had few political incentives to act and lacked inter-country coordination mechanisms required for an effective and cohesive response to labour migrant health issues. Effectively addressing such determinants to achieve health equity for labour migrants will depend on a shift in governments’ attitudes towards migrants—from a reserve army of transient, replaceable economic resources to rights-holding members of society deserving of equality, dignity and respect.