Promoting action on structural drivers of health inequity: principles for policy evaluation

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  • 1 Australian National University, , Australia
  • | 2 Flinders University, , Australia
  • | 3 University of New South Wales, , Australia
  • | 4 University of Liverpool, , UK
  • | 5 Flinders University, , Australia
  • | 6 University of Adelaide, , Australia
  • | 7 Australian National University, , Australia
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Background:

Insufficient progress has been made towards reducing health inequities, due in part to a lack of action on the root causes of health inequities. At present, there is a limited evidence base to guide policy decision making in this space.

Key points for discussion:

This paper proposes new principles for researchers to conduct health equity policy evaluation. Four key principles are presented: (1) where to evaluate – shifting from familiar to unfamiliar terrain; (2) who to evaluate – shifting from structures of vulnerability to structures of privilege; (3) what to evaluate – shifting from simple figures to complex constructs; and (4) how to evaluate – shifting from ‘gold standard’ to more appropriate ‘fit-for-purpose’ designs. These four principles translate to modifying the policy domains investigated, the populations targeted, the indicators selected, and the methods employed during health equity policy evaluation. The development and implementation of these principles over a five-year programme of work is demonstrated through case studies which reflect the principles in practice.

Conclusions and implications:

The principles are shared to encourage other researchers to develop evaluation designs of sufficient complexity that they can advance the contribution of health equity policy evaluation to structural policy reforms. As a result, policies and actions on the social determinants of health might be better oriented to achieve the redistribution of power and resources needed to address the root causes of health inequities.

Abstract

Background:

Insufficient progress has been made towards reducing health inequities, due in part to a lack of action on the root causes of health inequities. At present, there is a limited evidence base to guide policy decision making in this space.

Key points for discussion:

This paper proposes new principles for researchers to conduct health equity policy evaluation. Four key principles are presented: (1) where to evaluate – shifting from familiar to unfamiliar terrain; (2) who to evaluate – shifting from structures of vulnerability to structures of privilege; (3) what to evaluate – shifting from simple figures to complex constructs; and (4) how to evaluate – shifting from ‘gold standard’ to more appropriate ‘fit-for-purpose’ designs. These four principles translate to modifying the policy domains investigated, the populations targeted, the indicators selected, and the methods employed during health equity policy evaluation. The development and implementation of these principles over a five-year programme of work is demonstrated through case studies which reflect the principles in practice.

Conclusions and implications:

The principles are shared to encourage other researchers to develop evaluation designs of sufficient complexity that they can advance the contribution of health equity policy evaluation to structural policy reforms. As a result, policies and actions on the social determinants of health might be better oriented to achieve the redistribution of power and resources needed to address the root causes of health inequities.

Key messages

  • Reducing health inequities requires policy reforms that redistribute power and resources.

  • Guidance on evaluating policy for health equity to shape structural policy reform is limited.

  • Four principles are offered to guide who and what is evaluated, and how and where evaluation occurs.

  • Use of these principles may enhance the impact of policy evaluation in reducing health inequities.

Background

Insufficient progress has been made towards reducing health inequities – differences in health which are considered unnecessary and avoidable as well as unfair and unjust (Whitehead, 1991). This can be explained in part by a failure to take action on the root causes of health inequities (Woolf, 2019) – the differential distribution of power and resources across dimensions of individual and group identity (for example, race, class, gender), also referred to as structural inequities (Baciu et al, 2017; Friel et al, 2021). At present there is a limited body of policy evaluation research to support evidence-based decision making on best practice policy design to rectify the structural inequities that drive health inequities (Lee et al, 2018). While guidance on how to conduct health equity policy evaluation has grown in the literature, it has not been targeted to the evaluation of structural inequities. Drawing on the findings from a five-year programme of health equity policy research in Australia, this paper presents a series of principles developed to support policy evaluation research design that generates knowledge and evidence regarding how structural policies shape structural inequities, to advance future policy action on the root causes of health inequities.

Individual vs societal perspectives in public health

Public health research and action is characterised by two competing views on the optimal site of intervention to improve health and reduce health inequities: the individual and the societal. The dominance of the individual perspective in public health has been explained in part due to its alignment with a biomedical approach to health; public discourse around lifestyle choices; the preference of many governments for reduced market intervention and welfare programming; and the lack of challenge it presents to power relations that have produced the prevailing social, economic and cultural inequities (Baum and Fisher, 2014). The focus on behavioural interventions and individual action and choice (such as physical activity) has proven most effective in economically advantaged groups (Link and Phelan, 2005), and has been shown to exacerbate inequity in health behaviours and health outcomes (Slama, 2010).

The societal-level perspective, on the other hand, emphasises the environmental, social, cultural, economic, and political conditions that shape health, such as access to food and clean water, quality of schooling, and social networks (Whitehead and Dahlgren, 2006; Kickbusch, 2009; Baum, 2016) (see Figure 1). Known as the social determinants of health (Commission on Social Determinants of Health, 2008), these conditions provide the mechanisms by which structural inequities produce health inequities (Baciu et al, 2017). For example, while poor health may be a result of reduced physical activity, one’s ability to be physically active may be limited by a requirement to hold multiple jobs to earn enough income to meet one’s material needs, which is influenced by conditions like inadequate minimum wage policies. In this instance, the societal perspective would suggest a greater gain in health and health equity could be made from introducing a socially acceptable minimum wage policy, rather than a campaign to educate the population on the importance of 30 minutes of activity a day. Much less is known about the impact of policies that aim to shape the wider socioeconomic and political conditions in which people live (that is, structural policies), relative to interventions aimed at modifying behavioural factors (Kunst, 2017).

Figure 1 provides a visual summary of the four principles for health equity policy evaluation introduced in this article.
Figure 1:

Principles for health equity policy evaluation

Citation: Evidence & Policy 2022; 10.1332/174426421X16420923635594

Guiding health equity policy evaluation

In the field of policy evaluation, the body of work from Carol Weiss has been highly influential (Alkin, 2013). Key for our purposes are her contributions to the evolution of programme evaluation into policy evaluation, the integration of the role of politics in evaluation, and the legitimacy of reshaping the evaluator from an impartial presenter of findings to an advocate for change (Weiss, 1999). Another important development is that of theory-based evaluation from scholars such as Ray Pawson and Nick Tilley, as well as Weiss (Pawson and Tilley, 1997; Weiss, 1997). This approach introduced a two-stage process for evaluation, first developing a theory of change, and then testing that theory of change, in order to go beyond describing what works, to explaining the mechanisms of why and how it works, and in what contexts. Contributions from these scholars can inform health equity evaluation of structural policies and structural inequities, including how to establish complex causal pathways between policies and outcomes, the importance of embedding the political context in the evaluation, and empowering the researcher to advocate for policy reform based on the evidence.

A key development in the health equity policy evaluation field more specifically is the European Union-funded DEMETRIQ study (Developing Methodologies for Reducing Inequalities in the Determinants of Health) (Whitehead et al, 2015). DEMETRIQ produced guidance for researchers and policymakers on how to design studies for the purpose of evaluating the impact of natural policy experiments on health inequities, including developing logic models to unpack pathways between the policy and health inequity outcomes; how to identify, characterise, and measure variation in exposure to a policy; and qualitative and quantitative analyses for detecting differential effects in a population. Another EU initiative, the SOPHIE project (Seas, Oceans and Public Health in Europe), accumulated evidence regarding the influence of structural policies on health inequities in Europe (Malmusi et al, 2018). DEMETRIQ and the SOPHIE project made important contributions to the evidence base and methods, but as yet have not developed guidance on designing health equity policy evaluation research targeted at structural policies and inequities.

Key points for discussion

The authors of this paper were involved in an Australian National Health and Medical Research Council (NHMRC) Centre for Research Excellence (CRE) in the Social Determinants of Health Equity, a five-year programme of work in Australia to advance understanding of how government policy can work more effectively to address the social determinants of health, to promote the fair distribution of health in society. The CRE evaluated the integration of health equity during the agenda-setting, formulation and implementation stages of policy, as well as the impacts of policy on outcomes relevant to health equity, across a range of macroeconomic, infrastructure, and social policy domains. This paper was developed across multiple team meetings, including two project workshops, and consultation with key policy stakeholders that advised the CRE over its lifespan. The principles are a result of extensive reflection on limited progress on the social determinants of health and the role of healthy equity policy evaluation in generating progress, as well as essential normative considerations and key contributions from the CRE programme of work in this space.

We identified that one of the CRE’s unique contributions had been the focus on evaluation of structural policies that shape structural inequities and thereby drive health inequities. Knowing limited guidance exists on this topic, principles were developed to guide the policy evaluation design process, namely, how to select the policy domains and populations that are investigated, and the indicators and methods that are used during evaluation to retain a structural focus.

In this section we describe four principles to guide researchers when conducting health equity policy evaluation (see Figure 1). We have organised the principles around four key research design questions: (1) who to evaluate? (2) where to evaluate? (3) what to evaluate? and (4) how to evaluate? Select case studies from this programme of work (see Box 1) will be used throughout to demonstrate these principles in practice.

Case studies from the NHMRC Centre for Research Excellence in Social Determinants of Health Equity

Macroeconomic policy: Comprehensive and Progressive Agreement for Trans-Pacific Partnership

A regional trade and investment agreement negotiated between Australia and ten other Pacific Rim countries which first entered into force on 20 December 2018. Analysis of the final text of the agreement raised public health concerns for potential impacts on employment and labour conditions, the liberalisation of health-harmful commodities, and constraints on government regulatory space.

Infrastructure policy: National Broadband Network

In 2009 the Australian government announced plans to develop a national fibre-to-the-premises (FttP) network – widely believed to be the gold standard of broadband infrastructure – to 93% of homes and businesses, and fixed wireless or satellite to the remaining premises in remote and rural Australia. It was framed as a nation-building investment that would help transform the Australian economy.

Employment and social policy: Paid Parental Leave

In 2009, the Australian government legislated its first national paid parental-leave scheme, which provides 18 weeks’ pay at the minimum wage for primary caregivers on the birth of a child. Australia was one of the last high-income countries to introduce paid parental leave.

Aboriginal affairs policy: Northern Territory Emergency Response

A 2007 government intervention into Aboriginal communities in the Northern Territory of Australia, involving the military, premised on allegations of child sexual abuse and violence in the communities. A suite of policies was introduced, including bans on alcohol and pornography, income management, and increased police presence, as well as the removal of customary law procedures in bail applications and criminal sentencing, and the revocation of Aboriginal control over access to land.

Where to evaluate?

Principle 1: shift from familiar to unfamiliar terrain

The first principle encourages researchers to focus on policy domains outside of sectors sympathetic to reducing health and social inequities (see Box 2). While health equity policy evaluation has long operated outside the healthcare sector, it has generally stayed within what have been referred to by former Director-General of the WHO, Margaret Chan, as sister sectors (Chan, 2013), such as social assistance, education, or housing policy (Lee et al, 2018). Although these areas do not have an explicit mandate to promote or protect population health, the policy goals are generally sympathetic to the aim of reducing social inequities and, by extension, health inequities.

Here, we argue that evaluations should target policy changes in domains that have significant capacity to shift structural inequities, such as taxation, financial regulation, and industrial relations, which shape the distribution of wealth and income. Additional emergent spaces for evaluating outcomes for health equity include policies and practices regulating corporate actors (Anaf et al, 2017; Knai et al, 2018), and those at the intersection of health, equity and climate (Swinburn et al, 2019; Ziegler et al, 2019).

Such a shift inherently requires evaluating a policy against objectives (for example, redistribution) that the policy may not have been designed to address. While some suggest that ‘examining the health impacts of an intervention intended primarily to achieve a policy goal in another sector’ may fail the test of evaluability (Ogilvie et al, 2011: 216), we suggest that such lateral movements are necessary to encourage evaluation research towards structural policies rather than interventions targeted at daily living conditions.

Where to evaluate? Shift from familiar to unfamiliar terrain

Evaluating health equity in policy sectors not traditionally committed to health and social welfare objectives is particularly evident in the CRE case studies investigating macroeconomic and infrastructure policy. Trade agreements like the Comprehensive and Progressive Agreement for Trans-Pacific Partnership are primarily intended to promote economic growth through the global exchange of goods, services and capital, and are assumed to enable conditions for good health, regardless of the validity of that assumption. A number of recent studies have highlighted the potential negative impacts for health and health equity introduced by trade and investment agreements (Thow et al, 2015; Ruckert et al, 2017; Baker et al, 2019). The CRE contributed to understandings of the ways that trade agreements can exacerbate health inequities (Schram et al, 2019; Townsend et al, 2020c; 2019), and observed that while select health issues have made it on to the trade agenda, issues of health equity have been limited to the role of intellectual property rights and access to medicines (Townsend et al, 2020b).

Inequities in access to digital technologies have also become increasingly problematic for health equity, as the internet has evolved into an essential determinant of health, required for full participation in economic, social, educational, political, and cultural life (Baum et al, 2012). Analysis of the National Broadband Network in Australia, showed that while the original framing of the policy stressed the role of high-quality broadband in creating greater equity in access to e-government, e-health, and e-education services; when a change in government led to a more compromised rollout, principles of equity dropped out of the national discourse (Fisher et al, 2020), and inferior digital infrastructure was introduced in communities of lower socioeconomic advantage (Schram et al, 2018).

Interestingly, although case studies on Paid Parental Leave and the Northern Territory Emergency Response were in ‘sister sectors’, this did not necessarily translate to support for equity objectives or required nuanced framing to bolster equity arguments. The Northern Territory Emergency Response was a deeply racist policy response which proved to be quite hostile to a health-equity approach; while in the case of Paid Parental Leave, health equity was an underlying rationale, but economic productivity and gender equality were used alongside health arguments to drive the policy agenda forward (Townsend et al, 2020a).

Who to evaluate?

Principle 2: shift from structures of vulnerability to structures of privilege

The second principle encourages researchers to balance evidence on structural sources of disadvantage with evidence on structural sources of privilege (for example, policies that enhance the concentration of power and resources among the advantaged). Research in the field of health equity has focused on closing the gap between the most disadvantaged segments of society and those better off (Deravin et al, 2018; Lloren et al, 2019), as well as reducing inequities along a socioeconomic gradient (Kelly et al, 2011; Wardle et al, 2016; Marmot, 2017). However, most evaluations have focused on the disadvantaged end of the spectrum. Privilege remains an understudied concept in public health research (Baum, 2005; Paradies, 2006; Stepanikova and Oates, 2017).

Addressing this shortcoming may be facilitated, in part, by the selection of the policy for evaluation. For example, evaluating the outcomes of a policy implementing a new child benefit, unemployment assistance, or disability scheme immediately casts the light on populations experiencing disadvantage. While investigating policies of this nature is essential, it is important that they are balanced with the evaluation of policies that support the continued concentration of power and resources among already affluent segments of society (see Box 3). This might include the introduction of, revisions to, or abolishment of estate taxes (that is, taxes on property transferred from a deceased person to their heirs, usually only applicable to multimillion dollar estates), or research on white privilege.

Who to evaluate? Shift from structures of vulnerability to structures of privilege

Case studies within the CRE provided examples of focusing on privilege over vulnerability. For example, evaluation of the implementation of the National Broadband Network rollout demonstrated that as the level of socioeconomic advantage of an area increased, the more likely it was to receive the highest quality infrastructure (Schram et al, 2018). The case study on international trade and investment had a clear focus on structures of privilege, demonstrating how structural and discursive power enabled private sector actors greater access and different forms of authority in the agenda-setting and policy formulation process, relative to public-interest actors (Townsend et al, 2019).

What to evaluate?

Principle 3: shift from simple figures to complex constructs

The third principle encourages researchers to measure multifaceted constructs that reflect the impact of the policy on the systemic distribution of power and resources across dimensions of individual and group identity (see Box 4). In a recent review of theories of power as related to policy design for health equity, the authors noted that ‘articulating the architecture of power within policy institutions is an important step in understanding the policy dynamics, actions and decisions that create or maintain health inequities’ (Harris et al, 2020: 548). Power in policy institutions is expressed in three fundamental and interacting ways: structure, agency, and ideas (Harris et al, 2020); and is exercised at every stage of the policy cycle (Lasswell and Kaplan, 2013). Accordingly, the redistribution of power can be investigated by unpacking how a policy contributes to structures being redesigned, agency being transformed, or dominant discourses being challenged, in ways that shape what gets on the agenda, how policies are formulated and implemented, and what does or does not get evaluated.

Focusing on structural inequities necessitates a shift from measuring health equity outcomes, to outcomes that matter for health equity. That is, rather than evaluating differential impacts of the policy on health outcomes (for example, morbidity and mortality indicators, physical and mental well-being), we focus on evaluating outcomes at each stage of the policy cycle that are likely to stratify health outcomes (for example, participation, distribution of resources, empowerment, social status). Evaluating changes in structural inequities as a means to reduce health inequities, for example, cannot be adequately measured by the number of children who receive hospital check-ups or a school lunch. Rather, this requires more complex constructs such as indicators of institutional violence and racial discrimination, and more structural outcomes such as child removal and incarceration rates among different groups; or, alternatively, indicators of structural advantage, such as public subsidies for private education.

This stage of identifying indicators could be informed by the theory-based evaluation literature as well as advice on building logic models from, for example, the DEMETRIQ study. When researchers are introducing equity objectives not embedded within the policy design or goals, this will require incorporating indicators of unintended consequences (positive and negative) for health equity into the model. This approach may retain a focus on the mechanisms for change encompassed in the policy, but expand the range and complexity of outcomes considered. Alternatively, researchers may include outcomes within the model that the policy has no mechanisms to address, with the express purpose of drawing attention to the types of mechanisms for tackling inequity omitted from the policy design. The nature and complexity of the construct would determine how much time would reasonably be required to detect a change; however, shifting from health inequities to structural inequities should reduce the number of intervening variables in the policy logic model, resulting in stronger claims regarding the contribution of the policy to the outcome.

What to evaluate? Shift from simple figures to complex constructs

The CRE evaluation of the National Broadband Network focused on structural outcomes for health equity, by associating the quality of digital telecommunication infrastructure received with neighbourhood levels of socioeconomic advantage (Schram et al, 2018). Areas receiving inferior digital infrastructure will experience long-term disadvantages, as they will receive lower broadband speeds, poorer reliability of connections, and reduced longevity of the infrastructure which may result in higher maintenance and upgrade costs in the future through a private rather than public scheme. This is critical as fast, reliable and affordable broadband connections enable access to, and participation in the economy, social inclusion, formal and informal education opportunities, as well as improved healthcare delivery. Thus, digital infrastructure indicators of the National Broadband Network rollout demonstrate deepening social stratification among neighbourhoods.

The examination of the Northern Territory Emergency Response illustrates an instance of policy agenda setting shaped by political motivations and inequities in power, including marginalisation of Aboriginal perspectives on imposed policy reforms, and the disempowering of and reduction of opportunities for self-determination for Aboriginal and Torres Strait Islander peoples. Although the initial Report of the Northern Territory Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse (Little Children are Sacred report) recommended addressing poverty, overcrowded housing, lack of educational and employment opportunities, and community-driven solutions, the policies introduced in response to the report included bans on alcohol and pornography, income management, and increased police presence. Government evaluations focused on indicators like school attendance (Partridge, 2013) and health outcomes of the intervention to date have been very poor (Gray, 2015), including psychological distress as a result of stigmatisation of community residents and the imposition of culturally inappropriate policies (National Aboriginal Community Controlled Health Organisation, 2017).

How to evaluate?

Principle 4: shift from ‘gold standard’ to ‘fit-for-purpose’

The fourth principle encourages researchers to use a plurality of methods to collect appropriate data, suitable to the policy issues and affected populations. The conceptualisation of evidence is often reserved for quantitative evidence, with policy actors preferencing notions of ‘objectivity’ and ‘hard data’ over ‘anecdote’, ‘lay knowledge’ and ‘intuition’ (Popay et al, 1998; Partridge, 2013). The evidence-based policy discourse, however, has been critiqued as being at best misleading, noting that government is influenced by many different forms of evidence, least of which has been formal research and evaluation; and itself selectively uses various forms of evidence to help sell particular policies (Partridge, 2013). At worst, it has been flagged as dangerous as it ‘depoliticizes what is inevitably a political and interpretive process in which values, power relations, vested interests, political agendas and ideologies influence the ways in which ‘evidence’ is interpreted and used, policy narratives constructed, arguments made and policy developed’ (Partridge, 2013: 403).

While quantitative data, and randomised controlled trials in particular, have long been the gold standard in clinical research design, the use of evidence in the policymaking process suggests that the terrain is, in fact, much more flexible in practice. In light of this, researchers conducting health-equity policy evaluations are likely to find that gold-standard research is not gold standard for most structural policy evaluation research designs. Instead a ‘fit-for-purpose’ approach is more valid (Kelly et al, 2007; Bowen et al, 2009). Such an approach would recognise the need for evaluation to produce more comprehensive evidence-informed policy narratives, which are grounded in a diversity of methodological approaches and a process of knowledge production that is representative of the plurality of ideas, values, norms and beliefs across society (see Box 5), and which can consider factors such as power distribution and its impact. Quality must continue to be a cornerstone of evaluation, and be based on the demonstration of construct validity, rigorous data collection, and the suitability of the questions, methods and indicators to the policy issues and populations.

Shift from ‘gold standard’ to ‘fit-for-purpose’

The CRE implemented a fit-for-purpose approach to the design of each case study, implementing a broad array of tailored qualitative and quantitative techniques, tackling complex constructs like the distribution of power and privilege in policy domains not commonly evaluated for the assessment of health equity. One of the elements proposed in fit-for-purpose research design is the representation of a plurality of ideas, values, norms and beliefs in the knowledge production process. It was critical for the CRE in Australia that Indigenous ways of knowing not be limited to work within Indigenous policy spaces only, but rather be normalised in inquiry across all policy spaces to enhance the quality and relevance of the findings. Indigenous ways of knowing, being and doing are based on the interconnectedness of all living things, and the reciprocal responsibilities and obligations generated from this connectivity. Indigenous knowledge is created and maintained across generations through embedding knowledge in art, song, story and language, that is, in oral forms. This is quite different to colonial constructs of knowledge which place value on what is written and what is ‘scientifically’ proven, and which position Indigenous peoples as inferior, uncivilised, and irrelevant (Author’s own, 2020). Integrating a plurality of ways of knowing across the CRE was supported by respectful and meaningful research interchange between an interdisciplinary team of Indigenous and non-Indigenous researchers, and the development of a framework to assess cultural safety in policy intended to reduce health inequities between Indigenous and non-Indigenous Australians (Mackean et al, 2020).

Conclusions and implications

This paper has introduced four principles to guide research design in policy evaluations of outcomes for health equity. Future evaluations designed on these principles would be consistent with existing equity-focused frameworks in public health, such as the social determinants of health framework (explained earlier) as well as a Health in All Policies (HiAP) approach. HiAP recognises that health is an outcome of a wide range of factors, many of which lie outside the health sector, and acknowledges the persistence of health inequities and the immediate need to rectify these (Baum et al, 2013). Our intention is that these principles will support other health equity researchers with complex evaluation designs that generate knowledge and evidence regarding how structural policies shape structural inequities, to advance future policy action on the root causes of health inequities.

By applying these principles in evaluation design, health equity researchers will construct a body of knowledge that unpacks power, and analyses how new and existing policies in all sectors contribute to its redistribution, or the entrenchment of the status quo. We will generate new understandings of policy sectors not traditionally aligned with health and social equity objectives, and identify opportunities to reduce policy incoherence or build policy coherence. We will redirect attention towards structures of privilege as much as structures of vulnerability. We will yield to the reality that what gets measured is what matters, and focus on evaluating more complex indicators of social stratification. Finally, we will tell compelling analytical policy stories, rooted in a plurality of evidence and values during the knowledge production process, to influence policy debate and reshape structural policy to reduce structural and health inequities.

Funding

This work was supported by the Australian National Health and Medical Research Council under Grant APP1078046.

Acknowledgements

We would like to acknowledge the many contributions of Dr Kathryn Browne Yung and Professor Dennis McDermott to the theoretical and empirical work that informed this manuscript.

Research ethics statement

Ethics approval for this study was received from Flinders University Social and Behavioural Research Ethics Committee (Project number 6786) and The Australia National University Human Research Ethics Committee (Protocol 2015/243). All informants gave informed consent.

Contributor statement

AS wrote the first and subsequent drafts of the manuscript, with comments from BT, TM, TF, MF, PH, MW, HVE, FB, and SF. AS, BT, TM, TF, MF, PH, MW, HVE, FB, and SF contributed to conceptual development. FB and SF conceived the study. AS, BT, TM, MF, and PH conducted data collection and analysis overseen by FB and SF.

Conflict of interest

The authors declare that there is no conflict of interest.

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  • Link, B. and Phelan, J. (2005) Fundamental sources of health inequalities, in L.B. Rogut, J.R. Knickman, D. Mechanic and D. Colby (eds) Policy Challenges in Modern Health Care, Chapel Hill, NC: Rutgers University Press.

    • Search Google Scholar
    • Export Citation
  • Lloren, A., Liu, S., Herrin, J., Lin, Z., Zhou, G., Wang, Y., Kuang, M., Zhou, S., Farietta, T. and McCole, K. (2019) Measuring Hospital-specific disparities by dual eligibility and race to reduce health inequities, Health Services Research, 54(Suppl 1): 24354. doi: 10.1111/1475-6773.13108

    • Search Google Scholar
    • Export Citation
  • Mackean, T., Fisher, M., Friel, S. and Baum, F. (2020) A framework to assess cultural safety in Australian public policy, Health Promotion International, 35(2): 34051. doi: 10.1093/heapro/daz011

    • Search Google Scholar
    • Export Citation
  • Malmusi, D., Muntaner, C., Borrell, C. and SOPHIE investigators, S. (2018) Social and economic policies matter for health equity: conclusions of the SOPHIE project, International Journal of Health Services, 48(3): 41734. doi: 10.1177/0020731418779954

    • Search Google Scholar
    • Export Citation
  • Marmot, M. (2017) Social justice, epidemiology and health inequalities, European Journal of Epidemiology, 32(7): 53746. doi: 10.1007/s10654-017-0286-3

    • Search Google Scholar
    • Export Citation
  • National Aboriginal Community Controlled Health Organisation (2017) #NTIntervention: ten years on and what has been achieved?, https://nacchocommunique.com/2017/06/23/naccho-aboriginal-health-ntintervention-ten-years-on-and-what-has-been-achieved/.

    • Search Google Scholar
    • Export Citation
  • Ogilvie, D., Cummins, S., Petticrew, M., White, M., Jones, A. and Wheeler, K. (2011) Assessing the evaluability of complex public health interventions: five questions for researchers, funders, and policymakers, Milbank Quarterly, 89(2): 20625. doi: 10.1111/j.1468-0009.2011.00626.x

    • Search Google Scholar
    • Export Citation
  • Paradies, Y.C. (2006) Defining, conceptualizing and characterizing racism in health research, Critical Public Health, 16(2): 14357, doi: 10.1080/09581590600828881.

    • Search Google Scholar
    • Export Citation
  • Partridge, E. (2013) Caught in the same frame? The language of evidence-based policy in debates about the Australian Government ‘intervention’ into Northern Territory Aboriginal Communities, Social Policy and Administration, 47(4): 399415. doi: 10.1111/spol.12026

    • Search Google Scholar
    • Export Citation
  • Pawson, R. and Tilley, N. (1997) Realistic Evaluation, London: Sage.

  • Popay, J., Williams, G., Thomas, C. and Gatrell, T. (1998) Theorising inequalities in health: the place of lay knowledge, Sociology of Health and Illness, 20(5): 61944, doi: 10.1111/1467–9566.00122.

    • Search Google Scholar
    • Export Citation
  • Ruckert, A., Schram, A., Labonté, R., Friel, S., Gleeson, D. and Thow, A.M. (2017) Policy coherence, health and the sustainable development goals: a health impact assessment of the Trans-Pacific Partnership, Critical Public Health, 27(1): 8696. doi: 10.1080/09581596.2016.1178379

    • Search Google Scholar
    • Export Citation
  • Schram, A., Aisbett, E., Townsend, B., Labonté, R., Baum, F. and Friel, S. (2019) Toxic trade: the impact of preferential trade agreements on alcohol imports from Australia in partner countries, Addiction, 115(7): 127784. doi: 10.1111/add.14925

    • Search Google Scholar
    • Export Citation
  • Schram, A., Friel, S., Freeman, T., Fisher, M., Baum, F. and Harris, P. (2018) Digital infrastructure as a determinant of health equity: an Australian case study of the implementation of the National Broadband Network, Australian Journal of Public Administration, 77(4): 82942. doi: 10.1111/1467-8500.12323

    • Search Google Scholar
    • Export Citation
  • Slama, K. (2010) Tobacco Control and Health Equality, London: Sage.

  • Stepanikova, I. and Oates, G.R. (2017) Perceived discrimination and privilege in health care: the role of socioeconomic status and race, American Journal of Preventive Medicine, 52(1S1): S8694, doi: 10.1016/j.amepre.2016.09.024.

    • Search Google Scholar
    • Export Citation
  • Swinburn, B.A. et al (2019) The global syndemic of obesity, undernutrition, and climate change: The Lancet commission report, The Lancet, 393(10173): 791846, doi: 10.1016/S0140-6736(18)32822–8.

    • Search Google Scholar
    • Export Citation
  • Thow, A.M., Snowdon, W., Labonté, R., Gleeson, D., Stuckler, D., Hattersley, L., Schram, A., Kay, A. and Friel, S. (2015) Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans-Pacific Partnership agreement, Health Policy, 119(1): 8896. doi: 10.1016/j.healthpol.2014.08.002

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Friel, S., Baker, P., Baum, F. and Strazdins, L. (2020a) How can multiple frames enable action on social determinants? Lessons from Australia’s paid parental leave, Health Promotion International, 35(5): 97383. doi: 10.1093/heapro/daz086

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Friel, S., Schram, A., Baum, F. and Labonté, R. (2020b) What generates attention to health in trade policymaking? Lessons from success in tobacco control and access to medicines: a qualitative study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership, International Journal of Health Policy and Management, 10(10): 61324. doi: 10.34172/IJHPM.2020.80.

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Schram, A., Baum, F., Labonté, R. and Friel, S. (2020c) How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas?, Critical Public Health, 30(1): 11526. doi: 10.1080/09581596.2018.1509059

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Schram, A., Labonté, R., Baum, F. and Friel, S. (2019) How do actors with asymmetrical power assert authority in policy agenda-setting? A study of authority claims by health actors in trade policy, Social Science and Medicine, 236: 19, doi: 10.1016/j.socscimed.2019.112430.

    • Search Google Scholar
    • Export Citation
  • Wardle, J., von Wagner, C., Kralj-Hans, I., Halloran, S.P., Smith, S.G., McGregor, L.M., Vart, G., Howe, R., Snowball, J. and Handley, G. (2016) Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials, The Lancet, 387(10020): 75159. doi: 10.1016/S0140-6736(15)01154-X

    • Search Google Scholar
    • Export Citation
  • Weiss, C.H. (1997) Theory-based evaluation: past, present, and future, New Directions for Evaluation, 76: 4155. doi: 10.1002/ev.1086

  • Weiss, C.H. (1999) The interface between evaluation and public policy, Evaluation, 5(4): 46886. doi: 10.1177/135638909900500408

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    • Export Citation
  • Whitehead, M. et al. (2015) Natural Policy Experiments and Their Impact On Health Inequalities: A Guide for Evaluation, Liverpool: University of Liverpool and Erasmus Medical Centre.

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    • Export Citation
  • Whitehead, M. and Dahlgren, G. (2006) Concepts and Principles for Tackling Social Inequities in Health: Levelling up Part 1, Geneva: World Health Organization.

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    • Export Citation
  • Woolf, S.H. (2019) Necessary but not sufficient: why health care alone cannot improve population health and reduce health inequities, Annals of Family Medicine, 17(3): 19699. doi: 10.1370/afm.2395

    • Search Google Scholar
    • Export Citation
  • Ziegler, T.B. et al. (2019) Shifting from ‘community-placed’ to ‘community-based’ research to advance health equity: a case study of the heatwaves, housing, and health: increasing climate resiliency in Detroit (HHH) Partnership, International Journal of Environmental Research and Public Health, 16(18): 3310. doi: 10.3390/ijerph16183310

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  • Lasswell, H.D. and Kaplan, A. (2013) Power and Society: A Framework for Political Inquiry, New Jersey: Transaction.

  • Lee, J., Schram, A., Riley, E., Harris, P., Baum, F., Fisher, M., Freeman, T. and Friel, S. (2018) Addressing health equity through action on the social determinants of health: a global review of policy outcome evaluation methods, International Journal of Health Policy and Management, 7(7): 58192. doi: 10.15171/ijhpm.2018.04

    • Search Google Scholar
    • Export Citation
  • Link, B. and Phelan, J. (2005) Fundamental sources of health inequalities, in L.B. Rogut, J.R. Knickman, D. Mechanic and D. Colby (eds) Policy Challenges in Modern Health Care, Chapel Hill, NC: Rutgers University Press.

    • Search Google Scholar
    • Export Citation
  • Lloren, A., Liu, S., Herrin, J., Lin, Z., Zhou, G., Wang, Y., Kuang, M., Zhou, S., Farietta, T. and McCole, K. (2019) Measuring Hospital-specific disparities by dual eligibility and race to reduce health inequities, Health Services Research, 54(Suppl 1): 24354. doi: 10.1111/1475-6773.13108

    • Search Google Scholar
    • Export Citation
  • Mackean, T., Fisher, M., Friel, S. and Baum, F. (2020) A framework to assess cultural safety in Australian public policy, Health Promotion International, 35(2): 34051. doi: 10.1093/heapro/daz011

    • Search Google Scholar
    • Export Citation
  • Malmusi, D., Muntaner, C., Borrell, C. and SOPHIE investigators, S. (2018) Social and economic policies matter for health equity: conclusions of the SOPHIE project, International Journal of Health Services, 48(3): 41734. doi: 10.1177/0020731418779954

    • Search Google Scholar
    • Export Citation
  • Marmot, M. (2017) Social justice, epidemiology and health inequalities, European Journal of Epidemiology, 32(7): 53746. doi: 10.1007/s10654-017-0286-3

    • Search Google Scholar
    • Export Citation
  • National Aboriginal Community Controlled Health Organisation (2017) #NTIntervention: ten years on and what has been achieved?, https://nacchocommunique.com/2017/06/23/naccho-aboriginal-health-ntintervention-ten-years-on-and-what-has-been-achieved/.

    • Search Google Scholar
    • Export Citation
  • Ogilvie, D., Cummins, S., Petticrew, M., White, M., Jones, A. and Wheeler, K. (2011) Assessing the evaluability of complex public health interventions: five questions for researchers, funders, and policymakers, Milbank Quarterly, 89(2): 20625. doi: 10.1111/j.1468-0009.2011.00626.x

    • Search Google Scholar
    • Export Citation
  • Paradies, Y.C. (2006) Defining, conceptualizing and characterizing racism in health research, Critical Public Health, 16(2): 14357, doi: 10.1080/09581590600828881.

    • Search Google Scholar
    • Export Citation
  • Partridge, E. (2013) Caught in the same frame? The language of evidence-based policy in debates about the Australian Government ‘intervention’ into Northern Territory Aboriginal Communities, Social Policy and Administration, 47(4): 399415. doi: 10.1111/spol.12026

    • Search Google Scholar
    • Export Citation
  • Pawson, R. and Tilley, N. (1997) Realistic Evaluation, London: Sage.

  • Popay, J., Williams, G., Thomas, C. and Gatrell, T. (1998) Theorising inequalities in health: the place of lay knowledge, Sociology of Health and Illness, 20(5): 61944, doi: 10.1111/1467–9566.00122.

    • Search Google Scholar
    • Export Citation
  • Ruckert, A., Schram, A., Labonté, R., Friel, S., Gleeson, D. and Thow, A.M. (2017) Policy coherence, health and the sustainable development goals: a health impact assessment of the Trans-Pacific Partnership, Critical Public Health, 27(1): 8696. doi: 10.1080/09581596.2016.1178379

    • Search Google Scholar
    • Export Citation
  • Schram, A., Aisbett, E., Townsend, B., Labonté, R., Baum, F. and Friel, S. (2019) Toxic trade: the impact of preferential trade agreements on alcohol imports from Australia in partner countries, Addiction, 115(7): 127784. doi: 10.1111/add.14925

    • Search Google Scholar
    • Export Citation
  • Schram, A., Friel, S., Freeman, T., Fisher, M., Baum, F. and Harris, P. (2018) Digital infrastructure as a determinant of health equity: an Australian case study of the implementation of the National Broadband Network, Australian Journal of Public Administration, 77(4): 82942. doi: 10.1111/1467-8500.12323

    • Search Google Scholar
    • Export Citation
  • Slama, K. (2010) Tobacco Control and Health Equality, London: Sage.

  • Stepanikova, I. and Oates, G.R. (2017) Perceived discrimination and privilege in health care: the role of socioeconomic status and race, American Journal of Preventive Medicine, 52(1S1): S8694, doi: 10.1016/j.amepre.2016.09.024.

    • Search Google Scholar
    • Export Citation
  • Swinburn, B.A. et al (2019) The global syndemic of obesity, undernutrition, and climate change: The Lancet commission report, The Lancet, 393(10173): 791846, doi: 10.1016/S0140-6736(18)32822–8.

    • Search Google Scholar
    • Export Citation
  • Thow, A.M., Snowdon, W., Labonté, R., Gleeson, D., Stuckler, D., Hattersley, L., Schram, A., Kay, A. and Friel, S. (2015) Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans-Pacific Partnership agreement, Health Policy, 119(1): 8896. doi: 10.1016/j.healthpol.2014.08.002

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Friel, S., Baker, P., Baum, F. and Strazdins, L. (2020a) How can multiple frames enable action on social determinants? Lessons from Australia’s paid parental leave, Health Promotion International, 35(5): 97383. doi: 10.1093/heapro/daz086

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Friel, S., Schram, A., Baum, F. and Labonté, R. (2020b) What generates attention to health in trade policymaking? Lessons from success in tobacco control and access to medicines: a qualitative study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership, International Journal of Health Policy and Management, 10(10): 61324. doi: 10.34172/IJHPM.2020.80.

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Schram, A., Baum, F., Labonté, R. and Friel, S. (2020c) How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas?, Critical Public Health, 30(1): 11526. doi: 10.1080/09581596.2018.1509059

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Schram, A., Labonté, R., Baum, F. and Friel, S. (2019) How do actors with asymmetrical power assert authority in policy agenda-setting? A study of authority claims by health actors in trade policy, Social Science and Medicine, 236: 19, doi: 10.1016/j.socscimed.2019.112430.

    • Search Google Scholar
    • Export Citation
  • Wardle, J., von Wagner, C., Kralj-Hans, I., Halloran, S.P., Smith, S.G., McGregor, L.M., Vart, G., Howe, R., Snowball, J. and Handley, G. (2016) Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials, The Lancet, 387(10020): 75159. doi: 10.1016/S0140-6736(15)01154-X

    • Search Google Scholar
    • Export Citation
  • Weiss, C.H. (1997) Theory-based evaluation: past, present, and future, New Directions for Evaluation, 76: 4155. doi: 10.1002/ev.1086

  • Weiss, C.H. (1999) The interface between evaluation and public policy, Evaluation, 5(4): 46886. doi: 10.1177/135638909900500408

  • Whitehead, M. (1991) The concepts and principles of equity and health, Health Promotion International, 6(3): 21728. doi: 10.1093/heapro/6.3.217

    • Search Google Scholar
    • Export Citation
  • Whitehead, M. et al. (2015) Natural Policy Experiments and Their Impact On Health Inequalities: A Guide for Evaluation, Liverpool: University of Liverpool and Erasmus Medical Centre.

    • Search Google Scholar
    • Export Citation
  • Whitehead, M. and Dahlgren, G. (2006) Concepts and Principles for Tackling Social Inequities in Health: Levelling up Part 1, Geneva: World Health Organization.

    • Search Google Scholar
    • Export Citation
  • Woolf, S.H. (2019) Necessary but not sufficient: why health care alone cannot improve population health and reduce health inequities, Annals of Family Medicine, 17(3): 19699. doi: 10.1370/afm.2395

    • Search Google Scholar
    • Export Citation
  • Ziegler, T.B. et al. (2019) Shifting from ‘community-placed’ to ‘community-based’ research to advance health equity: a case study of the heatwaves, housing, and health: increasing climate resiliency in Detroit (HHH) Partnership, International Journal of Environmental Research and Public Health, 16(18): 3310. doi: 10.3390/ijerph16183310

    • Search Google Scholar
    • Export Citation
  • 1 Australian National University, , Australia
  • | 2 Flinders University, , Australia
  • | 3 University of New South Wales, , Australia
  • | 4 University of Liverpool, , UK
  • | 5 Flinders University, , Australia
  • | 6 University of Adelaide, , Australia
  • | 7 Australian National University, , Australia

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