Lessons from policy theories for the pursuit of equity in health, education and gender policy

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  • 1 University of Stirling, , UK
  • | 2 University of Copenhagen, , UK
  • | 3 University of Stirling, , UK
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We highlight practical lessons from policy theories on how to promote equity through transformational changes in policymaking. Health, education and gender are at the heart of such equity policy agendas. Their advocates seek transformational changes to: policy, to reject a ‘neoliberal’ paradigm and address the social and economic causes of unfair inequalities, and policymaking, to foster collaboration and holistic government. However, they also report a wide gap between aspirations and outcomes, and many seek insights from policy studies on how to close it. Our aim is to use their common engagement with policy theories to connect their agendas, foster intersectoral dialogue, and ensure that their contributions are greater than the sum of their parts. A common take-home message is to be cautious about any attempt to turn a provocative transformational political project into a technical process containing a ‘toolbox’ or ‘playbook’.

Abstract

We highlight practical lessons from policy theories on how to promote equity through transformational changes in policymaking. Health, education and gender are at the heart of such equity policy agendas. Their advocates seek transformational changes to: policy, to reject a ‘neoliberal’ paradigm and address the social and economic causes of unfair inequalities, and policymaking, to foster collaboration and holistic government. However, they also report a wide gap between aspirations and outcomes, and many seek insights from policy studies on how to close it. Our aim is to use their common engagement with policy theories to connect their agendas, foster intersectoral dialogue, and ensure that their contributions are greater than the sum of their parts. A common take-home message is to be cautious about any attempt to turn a provocative transformational political project into a technical process containing a ‘toolbox’ or ‘playbook’.

Introduction

Could policy theories help to understand and facilitate the pursuit of equity? Our ongoing series of qualitative systematic reviews of equity research – beginning with health, education, and gender – highlight that potential. In these fields, we find that equity scholars combine advocacy and academic research, seeking lessons on how to secure transformational changes to domestic and global policy and policymaking. While there is no single definition of equity, or vision of transformative change, Cairney et al (2022a) identify two common elements in these (and other) fields. First, policy change would involve rejecting a ‘neoliberal’ paradigm that prioritises economic growth and emphasises low state intervention, market forces, and individual responsibility. In its place would be a ‘social justice’ paradigm that prioritises equity and emphasises state responsibility to address the unequal distribution of resources that cause unfair inequalities. Second, transformative policymaking change would involve collaborative and participatory forms of governance and intersectoral action.

In that context, how could policy theories help equity scholars who seek transformations to policy and policy processes? One option is to address their disenchantment with limited progress, since our reviews find that they describe an unusually wide gap between their aspirations and actual outcomes. Many studies suggest that they possess more knowledge about what they need to do (or need from political systems) than the power or means to achieve it. For example, they need more effective intersectoral action because key causes of change are out of the control of a single sector, but express limited progress on such collaboration.

It is not, however, straightforward for policy theories to deliver these kinds of practical lessons. Advocates of transformational change may seek to use their understanding of policymaking to transform policymaking, but most theories were not designed for this purpose (Weible and Cairney, 2018). Further, the specific aims and approaches of each sector vary markedly. These issues suggest the need for careful consideration of the connections between policy theories and equity research across multiple sectors. Therefore, this article’s most general question – what is the role of policy theories in this transformational equity project? – reflects the need to immerse ourselves in each sector, and encourage cross-sectoral dialogue, to generate relevant insights.

We address this question via the following steps. First, establish what we mean when we describe practical lessons from policy theories: what relevant insights do they provide for our purposes? Second, explain the role of qualitative systematic reviews to identify the use of policy theories in multiple sectors. Third, summarise insights that emerge from each sector, including how scholars make sense of equity policy and policymaking, and what lessons they seek from policy theories. Fourth, encourage intersectoral and interdisciplinary dialogue and comparison, to draw transferable lessons across sectors and disciplines. In the conclusion, we reflect on a tension to emerge from these reviews: some scholars seek a ‘toolbox’ or ‘playbook’ to turn their political aims into straightforward technical steps; others reject any attempt to turn a necessarily challenging political project into a depoliticised strategy.

What are practical lessons from policy theories?

Most ‘mainstream’ policy theories suggest that minor policy change is common while major policy change is rare (Weible and Sabatier, 2018; Cairney, 2020: 233; see Durnova and Weible, 2020 on ‘mainstream’). The constraints and facilitators of policy change relate to two core concepts, which we interpret as follows.

First, bounded rationality suggests that policymakers do not possess unlimited cognitive and organisational resources to process all policy-relevant evidence then make clear and consistent choices (Simon, 1976). They can only pay attention to – and understand – a small number of issues, drawing on cognitive shortcuts to frame issues and organisational procedures to prioritise sources (Cairney and Kwiatkowski, 2017; Baumgartner et al, 2018).

Second, complex policymaking systems or environments suggests that policymakers do not fully understand or control policy processes. Policy theories conceptualise the relationship between:

  • many actors engaging in many levels and types of government (or authoritative venues);

  • institutions, or the formal and informal rules in each venue;

  • the networks that connect policymakers and influencers;

  • ideas, or the more or less dominant beliefs used to understand how the world works and should work (and therefore how to interpret problems and the feasibility of solutions);

  • the socioeconomic context and events that command policymaker attention (Cairney, 2020).

The overall message is that transformational policy change is rare and difficult to predict, which rules out straightforward advice on how to foster such change (Cairney, 2022). In that context, Weible and Cairney (2018: 189–91) highlight the kinds of lessons that policy theorists produce, such as to identify the limits to ‘evidence-based’ policy learning in political processes that exhibit disproportionate attention to policy problems and information (Koski and Workman, 2018; Dunlop and Radaelli, 2018). Consequently, actors search for effective ways to combine evidence with persuasion and storytelling, collaborate in networks or coalitions, and engage in multiple venues which exhibit their own modes of policymaking (Cairney, 2018; Crow and Jones, 2018; Heikkila and Andersson, 2018; Weible and Ingold, 2018; Swann and Kim, 2018).

A key aim of our reviews is to establish if scholars in other disciplines generate and use similar insights or interpret and use policy theories in other ways. For example, is there a common focus on what is required to improve policymaking, such as to foster collaboration inside and outside of government because key responsibilities are spread across policymaking systems? We might expect this common focus given this shared priority in each sector. The health equity strategy Health in All Policies (WHO, 2014) addresses the ‘social determinants’ of health that relate to factors – including income, employment, and access to safe homes and environments – that are not in the gift of health departments. Initiatives in education (UNESCO, 2021a; 2021b) identify the ‘out of school’ factors undermining social inclusion – such as poverty and marginalisation – that are more important than equal access to schools. Gender mainstreaming strategies avoid treating gender as a discrete sector since a ‘gender equality perspective’ is essential ‘in all policies at all levels and at all stages’ (Council of Europe, 1998).

We find, however, that they adopt sectoral approaches to intersectoral action – using different reference points, engaging with different meanings of equality and equity, and putting more or less emphasis on intersectoral action – to reflect how equity aims are contested in each sector (Cairney et al, 2021a). There are also differences regarding if, how and why they use policy theories. Only health equity advocates use theories instrumentally, identifying lessons to improve their advocacy skills and strategies. Education and gender scholars draw less on mainstream policy studies. Education equity advocates use critical policy analysis to challenge the ideational and systemic obstacles to policy change, while gender equality advocates find less value in mainstream policy theories since they pay low attention to gender. As described later in the article, we incorporated this possibility for variation into a flexible research design that makes few assumptions about the role of policy theories or the likelihood of themes to emerge from each review.

Method: the role of qualitative systematic reviews

The systematic review method allows scholars to synthesise and interpret insights from multiple studies to produce general conclusions on the state of the art in particular fields. Qualitative can refer to the emphasis on meaning rather than quantification of results, and/or the review of studies that use qualitative methods. Since there is high variation in the definition and design of qualitative reviews, the onus is on the designers to describe in detail their approach. To that end, we modify Kuckertz and Block’s (2021) criteria to guide designers and referees:

  1. Rationale. Equity researchers seek insights on the policy processes that constrain or facilitate policy change. However, it is not clear from whom and what they learn. We review the use of policy studies, identifying progress and gaps, and synthesising insights from policy process research (and each sector’s approach) to facilitate greater understanding across sectors.

  2. Research questions. Each review’s guiding question is: how does equity research use policy theory to understand policymaking? The question is deliberately general, to identify all references to policy theories in each field, before asking narrower questions for different purposes (for example, Cairney et al, 2021a; 2022a on inequalities policies across Europe).

  3. Engagement with previous reviews. We used comparable studies to highlight the lack of engagement with policy theories in sectoral studies (Embrett and Randall, 2014; Munro and Cairney, 2020) and guide our protocol (Such et al, 2019).

  4. Search terms. We combined a general focus on policy and policymaking with sectoral-specific terms – Health in All Policies, Healthy Public Policy, integrated health policy; education, equity, and policy; gender equality, mainstreaming, and policy – to maximise initial inclusion (for example, it would include studies addressing themes such as ‘intersectoral action’ or describing approaches such as ‘social justice’).

  5. Databases. We combined general and sector-specific databases. Health: Web of Science, Applied Social Science Index and Abstracts (ASSIA), Centre for Reviews and Dissemination (CRD), the Cochrane Library, Scopus, ProQuest, TRIP, and PROSPERO. Education: Institute of Education Services (ERIC) then snowballing for core references, then Cochrane/Social Systems Evidence database, Scopus, and Web of Science to explore gaps in coverage. Gender: Political Science Complete, Web of Science, Scopus, ProQuest, Science Direct, then Google Scholar to check for gaps.

  6. Timeliness. Searches ended in July 2020 (health), May 2021 (education), October 2021 (gender).

  7. Inclusion criteria. We sought discussion of the concepts described in the previous section. However, initially, we set a low bar for inclusion to foster immersion within each sector’s literature. It required a labour-intensive manual search within articles, identifying any study with at least one reference (with citation) to a policy cycle or stage, policy theory (such as multiple streams analysis), or relevant concept (such as path dependence, connected to historical institutionalism or complexity theory). We did not insist on engagement with mainstream policy theory (which would have made the education and gender searches too narrow). We used snowballing to identify key texts in each field, such as books by routinely-cited authors and essential ‘grey literature’ (including WHO and UNESCO reports). This approach yielded 113–40 articles per review, allowing us to foster interdisciplinary conversation. However, restricting inclusion to English-language articles biased the dataset towards a conversation in few countries (in health, 50% studied Australia or Nordic countries; in education, 40% were US; in gender, 40% were EU or EU countries).

  8. Aggregation and presentation method. We follow Sandelowski and Barroso’s (2007: xv) advice to foster respect for each author’s methods and aims. Further, we combined (a) a narrative review, using our policy theory-informed framework to interpret researcher engagement with policy concepts, and (b) an inductive approach to summarise each article and identify key themes in each field.

We produced individual reviews in sequence, beginning with 25,000-word articles on health (Cairney et al, 2021b) and education (Cairney and Kippin, 2021). The equivalent publication of the gender review is not yet on Open Research Europe, but we have completed and documented steps 1–8 (St. Denny, 2022) and published preliminary findings elsewhere (Cairney et al, 2022a) The flexible research design and continuous production of comparable studies (which will include additional sectors, as well as cross-cutting themes such as ‘co-production’) allows us to learn from the experience of each review while avoiding any tendency for one sector’s approach or insights to dominate.

Insights to emerge from each sector

The review of each sector allows us to ask how scholars make sense of equity policy and policymaking in multiple contexts. In other words, (1) what story do they tell of their field, and (2) what lessons do they seek from policy theories? Each review has equal status, but the order of reviews matters, since our first review was in health and we used the results to seek comparisons with education then gender.

Health in All Policies (HiAP): seek ‘upstream’ policies to challenge the ‘social determinants’ of unfair health inequalities

HiAP is a population health strategy that (a) seeks to mainstream health considerations into all aspects of policy and policymaking, and (b) tackle the health inequalities associated with the unequal spread of ‘non communicable diseases’ (NCDs) such as heart disease, diabetes and cancer (WHO, 2014; Cairney et al, 2021b: 6–8). In HiAP research, there is a consistent narrative that treats health as a human right, argues that most health inequalities are unfair, and challenges ‘neoliberal’ policies too-focused on unhealthy ‘lifestyles’ rather than social and structural factors. The general approach can be summarised in five steps:

1. Define the problem: the social determinants of unfair health inequalities

To promote equity, focus on the ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’ (Whitehead and Dahlgren, 2006: 4; WHO, 2021). Health inequalities are caused by inequalities in ‘social and economic factors, including employment opportunities, the law and the justice systems, education, housing, neighborhood environments, and transportation’ and are ‘too often associated with a person’s socioeconomic status, race, ethnicity, gender, religion, sexual identity, or disability’ (Bliss et al, 2016: S88).

2. Identify ‘upstream’ solutions: support state intervention and challenge ‘lifestyle drift’

Upstream describes whole-population policies to address social, economic and physical environments. It relates generally to ‘mechanisms for the redistribution of wealth, power, opportunities, decision‐making capacities, and other resources’ (Shankardass et al, 2011: 29) or specifically to ‘regulation, increasing access, or economic incentives’ (Brownson et al, 2010: 6; see also McMahon, 2021a; 2021b and Cairney et al, 2022b on the conceptual ambiguity of ‘upstream’). This focus challenges ‘lifestyle drift’, or the rhetorical commitment to HiAP followed by a renewed focus on individual choices (De Leeuw and Clavier, 2011: 237–40).

3. Deliver upstream solutions via cooperation across sectors and outside government

Upstream measures are not in the power of health sectors. Policies to reduce inequalities are led by many other sectors, and their fate depends on actors inside and outside of government. Effective health equity policies require meaningful collaboration across all sectors of government, and with stakeholders and citizens outside of government (Cairney et al, 2021: 8–10).

4. Seek high-level political support

Success requires political support, to: produce a formal intersectoral strategy that sets the national agenda, establishes roles and responsibilities for subnational governments, and minimises implementation problems; cut through ‘administrative silos’ (Carey and Crammond, 2015); and, boost support for health equity policy tools such Health Impact Assessments (HIAs).

5. Use the HiAP playbook

Cairney et al (2021b: 8–11) describe a ‘playbook’ to encourage the uptake of HiAP strategies: show how HiAP is essential to each government’s agendas and core business; build capacity in areas such as leadership and progress monitoring; focus on win–win solutions (mutual gains in each sector) to build trust and confidence; avoid the perception of ‘health imperialism’ when contributing to non-health sectors; identify the policy entrepreneurs who use their knowledge, networks, and skills to facilitate HiAP progress; promote HIAs to measure the contribution of non-health policies; and promote alternatives to cost–benefit analysis since health equity’s value of HiAP is not reflected in a narrowly-defined economic case.

This general narrative and approach is relatively uncontested in public health, and receives rhetorical support from most governments. However, most HiAP research identifies a lack of substantive support and progress, even in ‘best case’ examples. South Australia demonstrates high political commitment at a strategic level, but HiAP is overshadowed by healthcare spending and undermined by a neoliberal approach to policy. Finland’s political commitment, welfare state and political system is conducive to HiAP policies, but studies highlight limited local implementation (2021b: 13–16).

In that context, a small subset of HiAP articles draw on policy theories to improve two aspects. First, studies seek to improve the HiAP playbook by drawing general lessons from policy theories, including:

Such accounts come with some realism about their likely success. Kickbusch et al (2014) describe the ability of an entrepreneur to generate support-in-principle for HiAP, as a platform for further advocacy, not an end in itself. Van Eyk et al (2019: 1169) attach a warning to each piece of advice: seek a window of opportunity to adopt HiAP, but anticipate low commitment; connect HiAP to dominant agendas, but expect a neoliberal economic agenda to undermine HiAP; and, foster leadership but expect resistance to organisational change.

Second, some try to improve the HiAP ‘programme logic’ (known more generally as its ‘theory of change’) to guide action and evaluation: ‘Theory-based evaluation makes the causal assumptions behind policy interventions explicit, ie, it explains how and why a program or policy is thought to work, which forms the logic that underpins an initiative’ (Lawless et al, 2018: 512). The aim is to combine researcher experience, stakeholder feedback, and policy theory insights to guide advice, such as to develop ‘relational systems’, encourage ‘joint problem identification and problem-solving’, and facilitate ‘governance systems that connect HiAP work with senior decision-makers’ (2018: 513–14). The authors visualise how to engage in complex policymaking systems rather than study how actors engage (Cairney et al, 2022b).

Education equity: use critical policy analysis to challenge neoliberal approaches

Compared to HiAP research, education equity research highlights greater contestation to define and address the policy problem. First, while the UNESCO Salamanca statement on inclusion, plus Sustainable Development Goal 4 (‘Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all’), contain similar arguments (on social determinants) to HiAP, there are more international players with different ideas, including funders such as the World Bank and agenda-setters such as Organisation for Economic Co-operation and Development (OECD) (Cairney and Kippin, 2021). Second, the meaning of education equity is highly contested, focusing on: horizontal versus vertical equity (equal provision regardless of background, or unequal provision to address unequal backgrounds); the appropriate threshold that all students should be supported to reach; and the extent to which the state is responsible for solving inequalities (Gilead, 2019: 439). Third, fewer actors agree that all inequalities in education attainment are unfair since they relate partly to commitment and merit. Instead, there is more focus on equal access to schools. These debates inform two competing approaches to education equity:

  1. Social justice. Treating education as a human right and emancipatory experience. Seeking state intervention to address the social determinants of education inequalities, foster inclusion, and challenge marginalisation in relation to ‘sex, ethnic/social origin, language, religion, nationality, economic condition, ability’ (UNESCO, 2021a; 2021b; Cairney and Kippin, 2021: 7).

  2. Neoliberal. Treating education as an economic good, ‘to boost human capital and economic competitiveness in a global knowledge economy’, and promoting market and new public management measures to boost equal access to high-performing schools (such as school choice and voucher schemes, and league tables of school and country performance) (Faul, 2014; Klees and Qargha, 2014; Cairney et al, 2021a).

Most research describes the dominance of neoliberalism at the expense of social justice. Internationally, the dominant approach is to prioritise equal access to ‘high quality’ schools and teachers, and literacy and numeracy, using the latter to measure education system quality. Social justice approaches are backed rhetorically but not as substantively (Cairney and Kippin, 2021: 8). Domestically, the prioritisation of performance management and competition undermines social justice policies by equating equity with quality, reducing it to technical measures, and (in some countries) pretending that all students could attend the ‘best’ schools (2021: 11). There is little commitment to a ‘capabilities’ approach that asks how people with different resources could achieve the same outcomes, or policies focusing on racial inequity (most initiatives are ‘equality for all’) (2021: 13–15; 21–2).

Compared to HiAP, far fewer education studies use policy theories to improve advocacy or strategy (2021: 7). Instead, there is a far greater focus on critical policy analysis. Studies challenge a dominant neoliberal approach, highlight its ignorance of the impact of minoritisation, socioeconomic background, gender, unequal participation, and unequal resources on inequalities, and present an alternative social justice vision (2021: 24; Rizvi and Lingard, 2010: 2–3; 54–6; Felix and Fernandez Castro, 2018; Chu, 2019). Cairney and Kippin (2021: 26–7) describe most researchers in this field as ‘meta-narrators of cautionary tales of education inequity’, and use the Narrative Policy Framework’s four elements of narrative (Jones et al, 2014) to sum up their story:

Setting. Unfair inequalities endure despite global and domestic policy rhetoric. A small number of international organisations and countries influence a global neoliberal agenda, but there is some discretion to influence policy at local and school levels. Some studies relate limited progress to the influence of one or more levels, such as global and central government agendas undermining local change, or local actors disrupting central initiatives.

Plot. Many contrast an agency-focused narrative emphasising hopefulness (for example, among ‘change agents’) with systemic or structural narratives emphasising helplessness. Neoliberalism undermines equity by (1) equating it with equal access and test-based attainment, and (2) taking attention from social justice to focus on economic competitiveness. Some describe policymakers using equity as a facade, to ignore and reproduce inequalities in relation to minoritised populations. Others suggest that inequity defies simple solutions.

Characters. In global narratives, researchers challenge the story by international organisations that they are the heroes providing funding backed by conditions to make educations systems and economies competitive. Most articles portray neoliberal organisations and governments as the villains: narrowing equity to simplistic measures of performance at the expense of more meaningful outcomes. At national and local levels, they criticise dominant stories of equity within key countries, such as the US, that reproduce unequal outcomes while projecting progress.

Moral. The moral is to seek social justice alternatives to neoliberal approaches, focusing on social and structural factors, and addressing the association between inequalities and minoritised populations. Otherwise, policy reforms made in the name of equity will cause unequal, irreparable damage to students.

Gender equality: a transformative manifesto is more than a technical toolbox

Like education, gender equality policy exhibits high contestation to define and address the policy problem. Gender mainstreaming (GM) was adopted as the UN’s approach to reducing gender inequality across all policy sectors at the 1995 Fourth World Conference on Women in Beijing, and states and international organisations quickly followed suit. Nevertheless, the concept remains contested, to foster:

  1. A transformative strategy, with roots in radical feminism, requiring a fundamental rethink of democracy to ensure universal engagement with reducing gender inequalities.

  2. An integrationist strategy, to foster change from within by engaging with existing structures, and deliver better outcomes through concrete bureaucratic instruments (Jahan, 1995; Stratigaki, 2005).

These contrasting interpretations reflect disagreement over what in/equality means (does it concern opportunities, outcomes, or both?) and how it should be addressed (Beveridge and Nott, 2002). Gender equality can be based on: sameness, emphasising equal opportunities and equal treatment between men and women; difference, recommending special policies for women; or, transformation, to produce a fundamental renewal of social relations and structures to remove gendered hierarchies (Rees, 1998; Squires, 2005; Walby, 2005; Verloo, 2013). GM can be viewed as an approach combining policies based on one or all of these interpretations (Booth and Bennett, 2002).

GM researchers emphasise that plural meanings lead to plural policies, not all of which are effective, well-intentioned or coherent (Booth and Bennett, 2002; Daly, 2005). Most researchers espouse a preference for the transformative interpretation, while recognising the potential of working within existing structures as a site for important agenda-setting and norm-shifting work (for example, Mukhopadhyay, 2004; Verloo, 2005; 2001; Benschop and Verloo, 2006; Verge et al, 2018). Instead of privileging the transformative strategy to generate meaningful change at both levels, they describe GM’s real world application as a patchwork of activities aimed to secure equal rights (low bar) and, in some cases, distinctive policies and procedures – such as revised bureaucratic practices – to improve outcomes for women (higher bar) as long as they do not threaten the status quo (True and Mintrom, 2001; Beveridge and Nott, 2002: 310–11). The two strategies are not presented as mutually exclusive in theory, but as two interrelated levels at which change much be fostered. Nevertheless, a focus on bureaucratisation tends not to come with meaningful engagement with the political nature of technical processes such as implementation and evaluation (Lombardo and Mergaert, 2013; Mergaert and Lombardo, 2014).

Most research contrasts high international commitment to GM with a general failure to deliver, based on the following factors. First, there is limited agreement about what gender equality and GM means. This vagueness is unintentional (a failure to negotiate a clear definition) and/or strategic (intentionally vague framing). Second, there are translational challenges when policy-relevant ideas and norms are diffused and reformulated across different sectors, networks and territorial levels (True and Mintrom, 2001). Translation is necessary but risky, since elements may be (de)emphasised during their interpretation. Third, institutions and systems are deeply gendered and gendering, producing active political resistance to the gender equality agenda and/or the deprioritisation of gender in relation to competing issues (Beveridge and Nott, 2002; Bacchi, 2017; Lombardo et al, 2017). Fourth, gender equality is a cross-cutting issue that requires sectoral and multi-level coordination for policy coherence (Allwood, 2020). However, actors may not agree on the problem, their priorities change, and they do not have a panoptic view of the policy process and likely outcomes.

In that context, researchers describe two very different step-by-step solutions. The Best Practice Playbook seeks policy change within the existing policy process:

  1. Define gender mainstreaming. Conceptual ambiguity represents a failure of policymakers to agree on what is meant by gender, equality, and mainstream. Rather than assuming international norms will translate without loss or distortion (Acosta et al, 2019), a clear and uniform definition must be agreed and diffused territorially, sectorally, and organisationally (Krekula et al, 2017).

  2. Make policy translatable. Multi-level governance offers opportunities for policy learning and transfer (Alonso, 2017). One-size-fits-all lessons should not be imposed. They should be designed to be ‘localised’. Translatable norms and ideas allow for appropriate divergence while ensuring convergence across the most important aspects (Celis and Meier, 2011).

  3. Guide action with a specialised toolbox. Specialised GM tools and methods tackle different aspects of policymaking (Eden and Wagstaff, 2021). Gender impact assessments (Kim and Kang, 2016) and audits (Clancy and Mohlakoana, 2020) supply information to inform policy development. Gender budgeting ensures adequate and fair resourcing for gender-responsive implementation (Adeyeye and Akinbami, 2010). To avoid these instruments reproducing problematically fixed and binary conceptions of gender equality as a marginal ‘women’s issue’, develop and support specialist knowledge of gender roles and relations (Caglar, 2013: 339; Elomäki and Ylöstalo, 2021).

  4. Acknowledge trade-offs. Cumulative change can produce transformation. Incremental approaches that seek to integrate or layer GM onto existing structures and processes should not be dismissed, since they represent the critical capacity of actors to overcome institutional resistance (Eyben, 2010). Pragmatic considerations of feasibility and trade-offs are crucial for importing lessons from elsewhere (Cairney et al, 2021). Integrationist approaches may yield less rapid radical outcomes but are more likely to be embraced and implemented. Lessons from experience can be learned through the use of gender-sensitive or feminist policy evaluation (Hermoso and Sugawara, 2016; Bustelo, 2017).

The Transformative Manifesto is more prescriptive and draws on feminist theorising about how best to redeem gender mainstreaming as a radical strategy.

  1. Capitalise on vagueness. There appears to be international-level consensus about what GM broadly means even though different GM narratives emerge when international ideas are translated to other territorial levels. In other words, this high-level consensus is illusory yet potentially powerful (Pollack and Hafner-Burton, 2000; Booth and Bennett, 2002). Capitalise on it to politicise gender equality, sustain a strong and shared vision to guide leadership, and foster networks of state and civil society actors to ensure that it remains high on the agenda (True, 2003; Guenther, 2008) (compare with education strategies to ‘foreground equity’ and ‘own’ historic inequalities, Rorrer et al, 2008: 328).

  2. Co-produce locally. International ideas cannot guide concrete action in specific contexts (True and Mintrom, 2001). Encourage the co-production of GM policy with civic organisations and communities to ensure they are context-appropriate (Mukhopadhyay, 2014). Gendered hierarchies limit access to policy feed-in, so cast a wide net to engage actors beyond the ‘usual suspects’.

  3. Repoliticise gender in institutions and processes. Facilitate and incentivise learning and the socialisation of actors (for example, bureaucrats) to challenge biased norms, implicit gendered assumptions, and unconscious bias. Expert-bureaucratic tools are often (but not always) used as an empty gesture or tick-box exercise to depoliticise gender (van Eerdewijk, 2014; Lombardo et al, 2017). Repoliticise gender by explicitly interrogating power, tensions, and incompatibilities (Mazey, 2000; Mukhopadhyay 2004; Verloo 2005; 2001). Take seriously the potential of critical actors, and the alliances they form, to challenge institutional resistance (Verge, 2021).

  4. Transform to achieve coherence. GM efforts ‘tinkering’ at the edges of the system will fail to achieve radical equality (Rees, 1998; Allwood, 2013). Efforts to harmonise policy to reduce incoherence are wasted within this context. Rethink democracy to displace and diffuse power. This will help to mainstream gender and diversity, since a great many forms of discrimination need to be eradicated for policy to be made equitably (Squires, 2005). Adopt an ‘intersectional approach’ which considers multiple categories equally, sees these as mutually constitutive, and addresses the interaction between them (Hankivsky and Cormier, 2011). Gender inequality is interdependent and intersects with other inequalities, so it is impossible to achieve equality in this domain while other social inequalities persist.

Can policy theories facilitate intersectoral dialogue and practical lessons?

Our comparison of these three approaches highlights significant variation in the stories that equity scholars tell and their use of policy theories for practical lessons. We extend this comparison to derive distinctive lessons regarding each approach, then reflect on their more general implications.

Health: beware the superficial use of policy theories

HiAP research is the most likely to use policy theories instrumentally, to repurpose studies of policymaking to guide action. As such, we highlight two unresolved problems with this approach. First, few studies acknowledge the gap between (1) what HiAP advocates need and expect to happen versus (2) what actually happens. For example, there is a relatively high understanding of public administration insights to facilitate ‘joined up government’ and challenge ‘administrative silos’ (Greer and Lillvis, 2014: 14–15; Carey and Crammond, 2015: 1022–8). However, there is low engagement with public policy studies that explain why silo working makes sense to each ‘policy community’ (Cairney et al, 2021b: 24–5). Consequently, the expectation that the pursuit of intersectoral action – backed by an improved playbook – will ‘foster more collaborative policymaking, better policy, and health equity’ is a misguided ‘article of faith’ (de Leeuw, 2021: 1). Evidence from policy studies ‘does not back up these assumptions’ (De Leeuw, 2018: 765; Harris 2018: 875; Cairney et al, 2022b).

Second, most studies seek technical fixes to political problems, so few explore inherent trade-offs and dilemmas. For example, an ‘evidence-based policymaking’ dilemma arises when HiAP advocates seek to combine two general aims: (1) to generate evidence with reference to scientific rules and hierarchies regarding methods to determine quality, and (2) to foster collaborative forms of governance associated with a rejection of one-sided rules and knowledge-based hierarchies (Cairney, 2021). Further, a governance dilemma arises when HiAP describes the need for centralisation and the formalisation of a high-level strategy (to set the agenda and overcome silos) and decentralisation and informality (to encourage local actors to be creative when applying general principles to new contexts). These dilemmas will not be resolved with more evidence and technical fixes (Cairney et al, 2022b). Rather, HiAP studies would benefit from more engagement with studies of policymaking reality, to help distinguish – analytically – between (1) implementation gaps and unintended consequences of policymaking complexity, versus (2) the legitimate practices and outcomes that emerge from collaboration at local levels. These issues are explored more fully and frequently by policy theories and education and gender research.

Education: foster critical analysis, not blueprints for transformative action

Compared to HiAP, education research contains a far more realistic description of policymaking context. It draws on critical policy analysis to challenge ‘rationalist top-down accounts of policy design’ (Cairney and Kippin, 2021: 23). It shows that policy change is ‘more apparent on paper than practice’, with a tendency for policymakers to support social justice measures rhetorically and neoliberal approaches substantively (2021: 23). Social justice is lower down the policy agenda and its advocates are in less powerful advocacy coalitions (DeBray et al, 2014: 175; Kretchmar et al, 2016: 423). Neoliberal approaches are institutionalised and taken for granted, backed by a technical quantitative language of performance management (Grek, 2020).

One consequence of this approach is that scholars focus more on the obstacles to change than likely sources of transformation. For example, many studies suggest that strong direction from central government is necessary but not decisive, such as when challenging racism and racial inequalities. Several draw on Oakes et al (2005) to describe a ‘zone of mediation’ for policies challenging racism and marginalisation: new ideas supported by ‘change agents’ face well-established beliefs, cultures and practices, producing backlashes and demoralising experiences (2005: 284). If so, top-down mandates ‘may be necessary but insufficient to ensure major policy change’ (citing Oakes et al, 2005: 297; compare with Michener, 2019; Cairney and Kippin, 2021: 18). In many other discussions, ‘bottom up’ analysis and action may signal the potential for leadership-inspired change, but most articles ‘suggest that advocates for change are swimming against the tide’ (2021: 19). New leadership and policy initiatives seek to challenge minoritisation and marginalisation head-on, but they interact with local policy actors (including school leaders, teachers, and parents) more likely to defend the social constructions of target populations that reinforce inequalities (compare Schneider and Ingram, 1997; Evans, 2009: 85; Halverson and Plecki, 2015; Brezicha and Hopkins, 2016; with Bertrand et al, 2018).

In other words, greater engagement with policymaking reality does not necessarily provide a clear direction of travel for transformational change. Critical policy analysis helps to provide a valuable narrative on the ideological and institutional barriers to equity, and a rallying cry for action, but accompanied by warnings against unrealistic expectations. Like much policy theory, education equity research ‘allows academics and practitioners to reflect on the dilemmas that accompany equity policies’ rather than providing a blueprint for action (Cairney and Kippin, 2021: 27).

Gender: reject one-way lessons from policy theories to other disciplines

Gender mainstreaming research also engages sparingly with mainstream policy theories which are – at best – gender neutral and – at worst – too ignorant of gender. GM researchers have developed theories and concepts better attuned to grappling with the gendered nature of the policy process, and few fit into the dominant policy studies canon. Exceptions include attempts to complement existing policy theory paradigms to offer gender-sensitive variants, such as studies of feminist institutionalism (for example, Minto and Mergaert, 2018) and interpretive frameworks that unpick the discursive politics of sex and gender in policy (Bacchi and Eveline, 2010; Andersson, et al, 2018). More frequently, scholars turn to feminist political science, including constructivist international relations theories (Krook and True, 2010) and state feminism (Rai, 2003). It allows them to draw out the gendered nature of ‘neutral’ political processes, ranging from representation and democracy to interest group and state relations.

In that context, what exactly does the greater use of policy theories offer to a well-established gender literature? There are some possibilities. In the Best Practice Playbook, analytical descriptions may benefit from useful insights into the micro (for example, bounded rationality), meso (for example, organisational), and macro (for example, policymaking systems or environments) opportunities and constraints on policy change. Feminist philosophy of science would, however, suggest that the Transformative Manifesto, which aims to align transformative knowledge to radical action, is unlikely to be enhanced by mainstream policy theories (Tripp, 2010; Ackerly and True, 2018). Most of these theories grasp gender relations as a discrete area of politics and policymaking concerned with (the reductively labelled) ‘women’s policy issues’. They fail to grasp that, rather than a ‘special interest’ area, gender relations underpin and pervade all politics and policymaking. Indeed, these generic approaches produce knowledge that is not especially gender-aware and their own production and use is gendered.

By contrast, feminist policy analysis is continually refined to introduce a meaningful perspective to more aspects of the policy process (Mazey, 2000: 335), including implementation (Engeli and Mazur, 2018) and evaluation (Bustelo, 2017). The development and refinement of specialised concepts, such as intersectionality (see for example, Verloo, 2006), also expand feminist researchers’ analytical ability to critique mainstream policymaking (for example, Ciccia and Lombardo, 2019 on implementation and GM). These studies draw attention to the structural, systemic and mutually constitutive nature of intersecting inequalities. Feminist policy analysts highlight the many ways in which routine policymaking is characterised by sectoral, disjointed, and issue-by-issue approaches which are maladapted to achieving the holistic structural transformation required to eradicate pervasive social, political and economic inequity.

The scope for intersectoral and interdisciplinary learning

This comparison is crucial to a more general discussion of the role of policy theories in policy transformation. HiAP studies actively seek lessons to that end, while education research is open to lessons but in relation to a discrete frame of reference (often described as ‘policy sociology’), and they and feminist researchers represent an ill-tapped source of lessons. For example, education research engages more readily with tangible efforts to challenge minoritisation and marginalisation. Further, feminist researchers and practitioners have long-engaged with the dilemmas not fully explored in HiAP studies, and offer ways to challenge hierarchies to foster the meaningful co-production of knowledge and policy during a process of health equity mainstreaming (Godziewski, 2022).

Conclusion

What practical lessons do policy theories offer in the pursuit of transformational change in equity policy and policymaking? Our review of health equity research suggests that it is tempting to seek instrumental lessons to improve an advocacy playbook. However, our interpretation of policy theory insights, and reviews of education and gender research, highlight two very different conclusions. The first is to build practical lessons on policy processes that exist, not the processes that scholars would like to see. It allows scholars to compare what they need from governments with the low likelihood that governments can meet that need. While they seek coherent and transformational policy change, major policy change is rare and there is a strong rationale for incoherent (or at least uncoordinated) policymaking. Some outcomes result from political choice, such as when sharing power across multiple levels and sectors of government, and producing incommensurate policy and governance aims. Others result from necessity, such as the need to delegate power within and outside of government departments, and let go of the idea of centralised control of policy outcomes in such a decentralised system. Overall, these lessons encourage equity advocates to treat obstacles to transformational change as inherent features – not bugs – of policymaking systems.

The second is to treat transformational change as a political, not technical, project. Our reviews of equity research highlight two contrasting strategies available to equity scholars. One offers the attractive but misleading option of radical change through non-radical action, by mainstreaming equity initiatives into current arrangements and using a toolbox to make continuous progress. Yet, each review highlights a tendency for radical aims to be co-opted and often used to bolster the rules and practices that protect the status quo. Studies warn against the idea that we can turn a transformational political project into a simple playbook. The other offers a less attractive and more uncertain option of radical change through overtly political action, facing policy ambiguity and policymaking complexity head-on, while fostering continuous contestation. There is no clear step-by-step playbook for this option, since political action in complex policymaking systems is necessarily uncertain and often unrewarding. Still, insights from policy theories and equity research shows that grappling with these challenges is inescapable. Advocates of profound social transformation are wasting their (and each other’s) time if they seek short-cuts and technical fixes to political problems.

Acknowledgements

We thank the anonymous reviewers for their important points, which helped to improve the article.

This article forms part of a wider focus on ‘spatial justice’ in the EU (including the impact of public services on inequalities), funded by Horizon 2020/European Research Council [Grant Number REVINEQUAL-07-2016].

Conflict of interest

The authors declare that there is no conflict of interest.

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