From the Standpoint of Policymakers: An Institutional Ethnography Inquiry into the Policymaking Process to Address Health Equity and Social Determinants of Health in Canada

The health of a society’s population is determined by the way that society distributes its social and economic resources. This is because a high level of inequality and a wide gap in the socio-economic gradient corresponds with people’s experience of poor health. Despite available evidence of increasing socio-economic and health inequities in Canada, health equity (HE) considerations are not filtering through public policies, which may explain the skewing in the distribution of social determinants of health (SDH). Various governmental and non-state actors recognize these increasing social inequalities and have considered pursuing equity in public policies. Evidence shows that Canadian governments do not generally deliver on their pledges to implement HE-promoting policies. Inquiries about the incongruity between the stated institutional goal of pursuing HE in public policies and the persistent lack of it have pervaded public policy discourses. This study attempts to fill the knowledge gap in the public policy arena between the pluralist and institutionalist explanations of inequities to improve our understanding of “how” and “why” HE/SDH concepts are not filtering through into health policies. My original contribution to knowledge is an account of how policymakers’ work processes are drawn into and coordinated by a set of institutional relations of ruling. These institutional relations organize sequences of inter-related policymaking activities that link these activities to the work of others in producing or not producing policies with health equity outcomes. Using Institutional Ethnography as a method of inquiry, the study aims to highlight intrinsic institutional conceptual practices and explicate how “work” constituting policymaking is performed, influenced, and perceived in multiple institutional sites. Using mapping as an IE device, I map out institutional texts to illuminate the relations of ruling and social organization of policymaking as work. This study concludes that epistemologies rooted in hegemonic biomedical and neoliberal conceptual practices within the selected institutions dominate the ruling relations and the social organization of policymaking as work in these sites; and that, the gap between HE concepts and the government’s obligation to equity-driven health policy for actions on SDH demonstrates a lack of commitment to act in an increasingly market-oriented and politicized policymaking environment.