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

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 messagesReducing 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.