We found that local government representatives in Victoria, Australia predominantly share the view that local government policy has a critical role to play in addressing health inequities. Whilst there was considerable variation in the perceived extent and nature of what constitutes equity in policy action, interviewees consistently reported that local governments can strengthen their current approach to achieve equitable health outcomes. Enabling factors for more equity-oriented local government policy action included factors internal to local governments: (i) having a clear conceptualisation of equity, (ii) fostering a strong equity-centric culture, (iii) developing organisational-wide competency in equity. External factors were related to key external stakeholder groups that support or influence local government action: (iv) the community, (v) State government and (vi) local partners, networks and NGO’s.
Our findings that local government health and wellbeing representatives perceive that they have a key role to play in addressing health inequities corresponds with international literature that suggests that local-level action has significant potential to influence the social determinants of health [
35‐
38]. As a major employer, community leader, designer of place-based initiatives and provider of health and well-being services, local governments have great opportunities to drive and support local-level action on health inequities. This also aligns with community views, with a recent study finding 91% of the Australian public surveyed believed local governments should deliver services that contribute to a healthier and fairer society [
39].
Previous studies exploring health equity in local- and national-level policies have found that while equity is often acknowledged in strategic documents, policy actions typically lacked an equity-orientation and rarely focused on upstream social determinants [
20‐
22,
40‐
44]. Our study is consistent with this, whereby we found that while some local governments oriented policy action towards addressing upstream determinants either across the whole population or targeted actions for specific priority groups, many actions either addressed more downstream determinants (e.g. supporting food relief efforts) or did not attempt to address health inequities at all. This may be partly due to the remits of the three levels of government, where federal and state government can have a greater influence on social determinants such as income, housing and education [
11]. Action on the broader social determinants of health is also generally less politically palatable or well understood than actions that target behaviour and lifestyle [
45]. This is despite the well accepted notion that reducing health inequities will require a commitment to addressing upstream determinants of health [
26,
36].
Several of the perceived enablers to equity-oriented policy action found in our study have also been reported in the international literature. For example, having clear equity-oriented strategic goals, adequate resourcing, access to equity-focused epidemiological and evaluation data and taking a whole-of-organisation approach [
23,
24]. Our results also echo previous studies on the influence of national and regional levels of governments and local partner organisations in facilitating improved action on equity at the local government level. Our study extends this prior work by demonstrating the inter-related nature of these enabling factors, which is highlighted in the following policy implications.
Implications for local governments
We found that equity is viewed as a complex issue, which risks action on health inequities being put in the ‘too hard basket’. Standard public sector responses to complexity have been viewed as inadequate, with leaders opting for ‘quick fixes’, instead of the multifaceted, inclusive responses required to address the ‘complex causes of complex problems’ [
46]. A paradigm shift that encourages local governments to
lean into the complexity of equity, avoiding both policy over-simplification and inaction is an important first step towards equity in local health policy action. Principles of ‘complexity leadership’ offer one approach to enabling such a paradigm shift [
47]. Complexity leadership challenges those with positional power to think about systems and multiple causal loops to problems, to let go of the notion of always ‘knowing what to do’, and focus on being adaptive rather than linear in developing and implementing solutions [
47]. Resources and frameworks can also be used to help make sense of the complexity to the broader organisation. United Nations (UN) Women is an example of an organisation that recognised that equity is complex and developed a resource guide to help work through the complexity using an intersectionality framework [
32]. Other frameworks such as the WHO’s
Commission on Social Determinants of Health conceptual framework [
26], VicHealth’s
Fair Foundations framework for health equity [
48] and more recently, the
Nutrition Equity Framework [
49], can also help unpack the complexity by helping local governments identify entry points for policy action across different levels and types of social determinants. Contemporary evidence and theory also suggests that to level-up the social gradient (rather than simply narrow the health gap), local governments should consider policy action that is universal (accessible to all) and implemented with a scale and intensity that is proportionate to the level of disadvantage (known as proportionate universalism) [
36]. For example, local government action to enhance usage and accessibility of local parks or community gardens for all, combined with specific outreach and engagement with those experiencing health and social inequities, to increase their use of the spaces.
Situating health equity as a
process and an
outcome can help to centre action towards shifting the ideologies, beliefs, structures, systems and processes, that contribute to the determinants of health inequities. Our study identified a number of enablers that support a process-centred approach for local governments, such as building equity-focused strategic principles, champions, tools and training, and listening to the community voice. Whilst previous studies have found that equity in strategic documents was largely rhetorical with little influence on actual policy action [
40,
41], we found that if supported by equity champions in leadership positions, equity-focused strategic goals and principles can act as a high-level mechanism for staff to apply an equity lens, even in the absence of an explicit equity-focused policy decision making tool.
There is evidence to suggest that pragmatic and inconsistent approaches to equity in health policy-making hinders the translation of equity-related policy objectives to effective policy action [
50]. We found that equity-focused tools fostered consistency and accountability in the way equity was considered in health policy action, while also providing an opportunity for ‘on the job’ professional development, especially when implementation of a tool is supported by equity champions or experts. The use of health equity tools is widely recommended by the WHO and other leading health promoting agencies [
26,
51‐
53]. While the international literature includes a substantial number of health equity tools, research has shown that for tools to be effective, they need to be practical, user-friendly, adaptable to diverse contexts, and help to build practitioner competency within the setting [
54]. As such, equity tools are often tailored for specific contexts or organisations [
55‐
59]. Our study highlighted different stages of the policy development process where equity tools and frameworks could be used to ensure a strong equity lens is applied when prioritising and implementing local government health policies. These include during the (i) prioritisation of health policy actions, (ii) development of specific health policies, programs and services (e.g. using an equity impact assessment), and (iii) reviews of implementation plans (e.g. annual review of local government action plans). In Victoria, the Gender Equality Act (2020) requires all local governments to conduct a Gender Impact Assessments (GIA) of all policies, programs and services that are new or up for review and have a direct and significant impact on the public [
60]. Given this tool is already mandated, State and/or local government could explore expanding the tool to include broader conceptions of equity. This may first require an evaluation of the acceptability, feasibility and impact of current equity-focused tools for local governments. Finally, inclusion of equity-related criteria in local government grant applications may also support a stronger equity focus within proposed health programs that are implemented by local partner organisations. The Health Research Council of New Zealand is one example of an organisation with strong equity criteria, requiring all grant applicants to demonstrate how their proposal is likely to advance Maori health [
61] .
Our findings further highlighted the role that ongoing equity training can play in helping teams outside the health directorate understand equity and their potential roles in addressing health inequities. There is evidence that training on the social determinants of health helps to develop knowledge about the root causes of health inequities and emphasises the importance of addressing them at the community level [
62,
63]. Equity-related skills and attitudes are also essential for public health and policy professionals to be advocates for change [
64]. We also found equity-competency and capacity needed to be developed across the whole organisation, which is also consistent with evidence that action on the social determinants cannot be limited to those working in health, with all departments having a role to play to address inequities [
65].
We found that measuring and monitoring health equity outcomes is also essential for achieving health equity. National census-based data was readily accessible to local governments, and used to help plan and prioritise strategies, policies and programs. However, few local governments had the resources to measure and monitor health inequities or the social determinants that cause them at a local-level, representing an important research and policy gap. Likewise, the lack of equity-focused policy and program evaluations found in our study has also been reported as a key barrier to enabling equity-oriented policy action in the literature [
23]. A range of tools and frameworks are available to inform equity in data collection and evaluation activities [
66,
67]. In particular, measures that recognise equity as both a process and an outcome will be important, including measuring changes to staff knowledge and skills, changes to internal processes and structures, as well as changes in health and social outcomes.
Conceptualisations of health equity as a
process to build widespread community capacity to identify and tackle causes of health inequities, highlights the need for strong, equitable community engagement and participation in policy decisions. Our study found that community voice was a key component of equity-oriented policy action, but required strong governance processes to contain the influence of the “loudest” and often more resourced voices. A core tenet of effective health and social policy design to address equity at the local level is authentic and ongoing participation of community with lived experience of the barriers to health equity [
68]. Yet, the lived experiences of many core equity groups remain unheard, with policy-makers often determining what is best for communities, while minimising their self-determination and agency [
69]. This may be due to inadequate understanding of the definitions and methods that support good community participation, a lack of cultural safety and allyship, and existing long-standing institutional tensions with policies and processes that are underpinned by colonial neoliberal ideologies [
70]. For governments to disrupt this status quo and commit to equity-oriented policies and processes, power and resources will need to be redistributed towards those who are most affected by health inequities. Greater investment in participatory platforms that enable diverse communities to prioritise and address their health needs is one way local governments can redistribute power and foster meaningful community participation in decision-making [
71].