How can the health equity impact of universal policies be evaluated?
Insights into approaches and next steps
Beth Milton, May Moonan, Margaret Whitehead, David Taylor-Robinson
WHO Collaborating Centre for Policy Research on Social Determinants of Health,
WHO Regional Office for
Available online PDF [67p.] at: http://bit.ly/slZJz1
"………Taking population level action on the wider social determinants of health in efforts to reduce health inequities is an international public health imperative. However, an important barrier to action is the perceived lack of evidence about what works to reduce health inequities. This is particularly evident in relation to universal welfare policies, which can have profound effects on health inequities, both positive and negative in nature.
Because universal policies are usually applied to whole populations, and are often complex in nature with long causal chains, this precludes a true experimental design, and other approaches to evaluation are required. This report presents arguments and case studies from an expert group meeting convened to clarify the importance and challenges of evaluating universal policies, and to outline potential approaches to assessing the impact of universal policies on health inequities.
The report also identifies key research and policy questions that need evaluating as a matter of priority, and sets the agenda for partnership working to develop these methods further….."
Section 1: Introduction
Section 2: Why is so important to evaluate universal policies" for their impact on health inequities?
2.1 Universal policies are potentially important determinants of health
2.3 The need for evidence to support efficient and effective use of scarce resources
2.4 Piecemeal learning at the local level
2.5 The current erosion of universal policies
2.6 Better evidence for policy--making
Section 3: What are the evaluation challenges and barriers in relation to such policies?
3.1 The issue of controls/comparison groups
3.2 Time--‐lags and long causal chains temporal issues for evaluators
3.3 Linking policy events to outcomes and indicators
3.4 Dealing with complexity
3.5 The transferability problem and the importance of context
3.6 The mismatch between research and policy time frames
3.7 The difficulty of engaging decision--‐makers from other sectors
3.8 The need to prioritize interventions for evaluation
3.9 The tension between robust and ood enough evidence
Section 4: Current promising approaches to evaluation and gaps/refinements needed
4.1 How might universal policies be evaluated?
Exploiting natural policy experiments
Retrospective analysis: the Inspector Morse/resilience approach
From randomization to case studies
Insights from Complexity Theory
Utilizing logic models and a systems approach
Cross--‐national comparative policy analyses
Assessing differential impacts
Using tracer groups or conditions
Section 5: Burning research questions and policies to evaluate as a matter of priority
5.1 What are the differential effects of national policies to deal with economic recession?
5.2 What are the effects of the Choice agenda on access to universal services?
5.3 What are the features of an equitable health care service?
5.4 What are the features of evaluations which have led to both reliable and misleading findings, and what are their effects on policy?
5.5 What are the essential elements of an evaluation methodology that capture the equity impact of a universal policy, including the historical context prior to policy implementation and the displacement effects of the implemented policy?
5.6 What lessons can we learn from collaborating with (for example) historians and archaeologists to systematically capture how the historical context of a place influences the impact (either positive or negative) of an implemented universal policy?
5.7 What lessons can we learn from economists in assessing the equity impact of a universal policy, factoring in the historical context of the place?
An opportunistic tracer group for evaluation children in low--‐income households
5.8 Researching knowledge exchange issues
Section 6: Establishing a longer term partnership
Section 7: Conclusion
Section 8: References and bibliography
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