{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T17:35:39Z","timestamp":1787333739079,"version":"build-2736575974"},"reference-count":50,"publisher":"BMJ","funder":[{"DOI":"10.13039\/100031401","name":"UK Prevention Research Partnership","doi-asserted-by":"crossref","award":["MR\/S037578\/1"],"award-info":[{"award-number":["MR\/S037578\/1"]}],"id":[{"id":"10.13039\/100031401","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["221266\/Z\/20\/Z"],"award-info":[{"award-number":["221266\/Z\/20\/Z"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009949","name":"University of Pennsylvania, School of Arts and Sciences","doi-asserted-by":"crossref","award":["n\/a"],"award-info":[{"award-number":["n\/a"]}],"id":[{"id":"10.13039\/100009949","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J Epidemiol Community Health"],"accepted":{"date-parts":[[2026,7,21]]},"abstract":"<jats:p>Public health scholarship is shaped by an evidence hierarchy that places systematic reviews of experimental and quasi-experimental studies at the top. This approach is invaluable for isolating the effects of discrete, often downstream interventions. However, it is less suited to evaluating upstream and programmatic efforts to reduce health inequalities at scale, since these methods rarely illuminate how combinations of policies shape inequalities or how such combinations achieve and sustain political and public support. These limitations are not merely technical. Many consequential upstream reforms, such as democratisation, welfare expansion, universal healthcare and fiscal transfers, do not lend themselves to clean treatment-control comparisons and are rarely introduced primarily to reduce health inequalities. In this essay, we outline a complementary comparative case study approach which enables the combined analysis of multiple policies\/levers and context-specific circumstances and so identifies the political and policy foundations of reduced health inequalities. We examine four historical episodes in which inequalities narrowed: the United States\u2019 Great Society, democratisation and social policy expansion in Brazil, German reunification and England\u2019s Health Inequalities Strategy. Across these cases, we identify four recurrent macro-policy packages associated with narrowing inequalities: welfare expansion, improved healthcare access, reductions in income inequality and democratisation. We also examine the political conditions that enabled these packages to be assembled and sustained and the factors that later stalled progress. We conclude by arguing for an evidence agenda that treats policy packages and politics as integral to efforts to improve health equity rather than as residual \u2018context\u2019.<\/jats:p>","DOI":"10.1136\/jech-2026-226182","type":"journal-article","created":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T17:20:17Z","timestamp":1787332817000},"page":"jech-2026-226182","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Realpolitik, real evidence: what comparative case study methodology teaches us about the policy mixes and political traction needed to reduce health inequalities"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1294-6851","authenticated-orcid":false,"given":"Clare","family":"Bambra","sequence":"first","affiliation":[{"name":"Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia","family":"Lynch","sequence":"additional","affiliation":[{"name":"Political Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1060-4102","authenticated-orcid":false,"given":"Katherine","family":"Smith","sequence":"additional","affiliation":[{"name":"Social Work and Social Policy, University of Strathclyde, Glasgow, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,21]]},"reference":[{"key":"2026082110201042000_jech-2026-226182v1.1","unstructured":"Higgins JPT , Thomas J , Chandler J . Cochrane Handbook for Systematic Reviews of Interventions Version 6.5. Cochrane, 2024. Available: www.cochrane.org\/handbook"},{"key":"2026082110201042000_jech-2026-226182v1.2","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1016\/S0140-6736(88)92833-4","article-title":"RANDOMISED TRIAL OF INTRAVENOUS STREPTOKINASE, ORAL ASPIRIN, BOTH, OR NEITHER AMONG 17 187 CASES OF SUSPECTED ACUTE MYOCARDIAL INFARCTION: ISIS-2","volume":"332","year":"1988","journal-title":"The Lancet"},{"key":"2026082110201042000_jech-2026-226182v1.3","doi-asserted-by":"crossref","first-page":"1246","DOI":"10.1016\/S1473-3099(19)30396-2","article-title":"Effect of measles vaccination in infants younger than 9 months on the immune response to subsequent measles vaccine doses: a systematic review and meta-analysis","volume":"19","author":"Nic Lochlainn","year":"2019","journal-title":"Lancet Infect Dis"},{"key":"2026082110201042000_jech-2026-226182v1.4","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyi088"},{"key":"2026082110201042000_jech-2026-226182v1.5","doi-asserted-by":"crossref","DOI":"10.1093\/ije\/dyw114","article-title":"The tale wagged by the DAG: broadening the scope of causal inference and explanation for epidemiology","volume":"45","author":"Krieger","year":"2016","journal-title":"Int J Epidemiol"},{"key":"2026082110201042000_jech-2026-226182v1.6","doi-asserted-by":"crossref","unstructured":"Gibson M , Thomson H , Banas K , et al . Welfare to work interventions and their effects on the health and well-being of lone parents and their children. 2018;2:CD009820. doi:10.1002\/14651858.CD009820.pub3","DOI":"10.1002\/14651858.CD009820.pub3"},{"key":"2026082110201042000_jech-2026-226182v1.7","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0251905","article-title":"Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review","volume":"16","author":"Besnier","year":"2021","journal-title":"PLoS ONE"},{"key":"2026082110201042000_jech-2026-226182v1.8","doi-asserted-by":"crossref","DOI":"10.1136\/bmj-2022-070872","article-title":"Making better use of natural experimental evaluation in population health","volume":"379","author":"Craig","year":"2022","journal-title":"BMJ"},{"key":"2026082110201042000_jech-2026-226182v1.9","doi-asserted-by":"crossref","DOI":"10.1093\/eurpub\/ckaa001","article-title":"Re-thinking health inequalities","volume":"30","author":"Mackenbach","year":"2020","journal-title":"Eur J Public Health"},{"key":"2026082110201042000_jech-2026-226182v1.10","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1111\/papa.12174","article-title":"Government Policy Experiments and the Ethics of Randomization","volume":"48","author":"MacKay","year":"2020","journal-title":"Philosophy & Public Affairs"},{"key":"2026082110201042000_jech-2026-226182v1.11","doi-asserted-by":"publisher","DOI":"10.1136\/jech-2019-213085"},{"key":"2026082110201042000_jech-2026-226182v1.12","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2016.303485"},{"key":"2026082110201042000_jech-2026-226182v1.13","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.h1258","article-title":"Process evaluation of complex interventions: Medical Research Council guidance","volume":"350","author":"Moore","year":"2015","journal-title":"BMJ"},{"key":"2026082110201042000_jech-2026-226182v1.14","doi-asserted-by":"crossref","unstructured":"Bartlett L , Vavrus F . Rethinking Case Study Research - A Comparative Approach. London: Routledge, 2017.","DOI":"10.4324\/9781315674889"},{"key":"2026082110201042000_jech-2026-226182v1.15","doi-asserted-by":"publisher","DOI":"10.1093\/epirev\/mxp002"},{"key":"2026082110201042000_jech-2026-226182v1.16","unstructured":"MP A . Landscapes of lifelong learning policies across europe: comparative case studies. In: Benasso S , Bouillet D , Neves T , eds. Comparative Case Studies: Methodological Discussion. Cham: Springer International Publishing, 2022."},{"key":"2026082110201042000_jech-2026-226182v1.17","doi-asserted-by":"crossref","unstructured":"Bambra C , Lynch J , Smith K . The Policies and Politics of Reducing Health Inequalities. Bristol: Policy Press, 2025.","DOI":"10.51952\/9781447372882.ch007"},{"key":"2026082110201042000_jech-2026-226182v1.18","doi-asserted-by":"crossref","unstructured":"Gerring J . Case Study Research: Principles and Practices. Cambridge University Press, 2007.","DOI":"10.1017\/CBO9780511803123"},{"key":"2026082110201042000_jech-2026-226182v1.19","doi-asserted-by":"crossref","unstructured":"Copi I , Cohen C , Rodych V . Introduction to Logic. Routledge, 2016.","DOI":"10.4324\/9781315510897"},{"key":"2026082110201042000_jech-2026-226182v1.20","doi-asserted-by":"crossref","unstructured":"Mills A , Durepos G , Wiebe E . Encyclopedia of Case Study Research Thousand Oaks. California: SAGE Publications, Inc, 2010.","DOI":"10.4135\/9781412957397"},{"key":"2026082110201042000_jech-2026-226182v1.21","doi-asserted-by":"crossref","first-page":"908","DOI":"10.1177\/14034948211022428","article-title":"Levelling up: Global examples of reducing health inequalities","volume":"50","author":"Bambra","year":"2022","journal-title":"Scand J Public Health"},{"key":"2026082110201042000_jech-2026-226182v1.22","doi-asserted-by":"crossref","unstructured":"Biggs R , Preiser R , de Vos A , et al . The routledge handbook of research methods for social-ecological systems . In: Biggs R , Vos A , Preiser R , eds. Comparative Case Study Analysis. London, 2021. Available: https:\/\/www.taylorfrancis.com\/books\/9781003021339","DOI":"10.4324\/9781003021339"},{"key":"2026082110201042000_jech-2026-226182v1.23","doi-asserted-by":"crossref","unstructured":"Beach D , Pedersen RB . Process-Tracing Methods: Foundations and Guidelines. University of Michigan Press, 2013.","DOI":"10.3998\/mpub.2556282"},{"key":"2026082110201042000_jech-2026-226182v1.24","doi-asserted-by":"publisher","DOI":"10.1257\/aer.90.2.326"},{"key":"2026082110201042000_jech-2026-226182v1.25","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2013.301350"},{"key":"2026082110201042000_jech-2026-226182v1.26","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyu047"},{"key":"2026082110201042000_jech-2026-226182v1.27","doi-asserted-by":"publisher","DOI":"10.1097\/EDE.0000000000000104"},{"key":"2026082110201042000_jech-2026-226182v1.28","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.0050046","article-title":"The fall and rise of US inequities in premature mortality: 1960-2002","volume":"5","author":"Krieger","year":"2008","journal-title":"PLoS Med"},{"key":"2026082110201042000_jech-2026-226182v1.29","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2007.127480"},{"key":"2026082110201042000_jech-2026-226182v1.30","doi-asserted-by":"crossref","unstructured":"Shei A , Costa F , Reis MG , et al . The impact of Brazil\u2019s Bolsa Fam\u00edlia conditional cash transfer program on children\u2019s health care utilization and health outcomes. BMC Int Health Hum Rights 2014;14. doi:10.1186\/1472-698X-14-10","DOI":"10.1186\/1472-698X-14-10"},{"key":"2026082110201042000_jech-2026-226182v1.31","doi-asserted-by":"crossref","first-page":"105957","DOI":"10.1016\/j.ypmed.2019.105957","article-title":"24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of Brazil","volume":"131","author":"Bandi","year":"2020","journal-title":"Prev Med"},{"key":"2026082110201042000_jech-2026-226182v1.32","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1000232","article-title":"Brazil and the framework convention on tobacco control: global health diplomacy as soft power","volume":"7","author":"Lee","year":"2010","journal-title":"PLoS Med"},{"key":"2026082110201042000_jech-2026-226182v1.33","doi-asserted-by":"crossref","DOI":"10.1186\/s12963-020-00208-1","article-title":"Inequalities in infant mortality in Brazil at subnational levels in Brazil, 1990 to 2015","volume":"18","author":"Szwarcwald","year":"2020","journal-title":"Popul Health Metr"},{"key":"2026082110201042000_jech-2026-226182v1.34","doi-asserted-by":"crossref","first-page":"117436","DOI":"10.1016\/j.socscimed.2024.117436","article-title":"Closing the life expectancy gap: An ecological study of the factors associated with smaller regional health inequalities in post-reunification Germany","volume":"362","author":"Simpson","year":"2024","journal-title":"Social Science & Medicine"},{"key":"2026082110201042000_jech-2026-226182v1.35","doi-asserted-by":"crossref","first-page":"1905","DOI":"10.1016\/S0277-9536(01)00320-3","article-title":"The contribution of medical care to changing life expectancy in Germany and Poland","volume":"55","author":"Nolte","year":"2002","journal-title":"Social Science & Medicine"},{"key":"2026082110201042000_jech-2026-226182v1.36","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s11577-015-0329-2","article-title":"Regional Mortality Disparities in Germany: Long-Term Dynamics and Possible Determinants","volume":"67","author":"Kibele","year":"2015","journal-title":"Kolner Z Soz Sozpsychol"},{"key":"2026082110201042000_jech-2026-226182v1.37","doi-asserted-by":"crossref","first-page":"486","DOI":"10.1093\/ije\/dyz265","article-title":"Declining regional disparities in mortality in the context of persisting large inequalities in economic conditions: the case of Germany","volume":"49","author":"van Raalte","year":"2020","journal-title":"Int J Epidemiol"},{"key":"2026082110201042000_jech-2026-226182v1.38","doi-asserted-by":"crossref","unstructured":"Gjonca A , Brockmann H , Maier H . Old-Age Mortality in Germany prior to and after Reunification. DemRes 2000;3. doi:10.4054\/DemRes.2000.3.1","DOI":"10.4054\/DemRes.2000.3.1"},{"key":"2026082110201042000_jech-2026-226182v1.39","doi-asserted-by":"publisher","DOI":"10.1136\/jech.54.2.84"},{"key":"2026082110201042000_jech-2026-226182v1.40","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.j3310","article-title":"Investigating the impact of the English health inequalities strategy: time trend analysis","volume":"358","author":"Barr","year":"2017","journal-title":"BMJ"},{"key":"2026082110201042000_jech-2026-226182v1.41","unstructured":"Bambra C . Targeting health inequalities: realising the potential of targets in reducing health inequalities. Health Equity North, and The Health Foundation; 2023. Available: https:\/\/www.health.org.uk\/publications\/reports\/targeting-health-inequalities-realising-the-potential-of-targets-in-addressing-health-inequalities"},{"key":"2026082110201042000_jech-2026-226182v1.42","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.g3231","article-title":"The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study","volume":"348","author":"Barr","year":"2014","journal-title":"BMJ"},{"key":"2026082110201042000_jech-2026-226182v1.43","doi-asserted-by":"publisher","DOI":"10.1136\/jech-2018-211679"},{"key":"2026082110201042000_jech-2026-226182v1.44","doi-asserted-by":"publisher","DOI":"10.1093\/eurpub\/ckae081"},{"key":"2026082110201042000_jech-2026-226182v1.45","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-063137","article-title":"Systematic review of the effectiveness of the health inequalities strategy in England between 1999 and 2010","volume":"12","author":"Holdroyd","year":"2022","journal-title":"BMJ Open"},{"key":"2026082110201042000_jech-2026-226182v1.46","doi-asserted-by":"publisher","DOI":"10.1177\/27551938251317472"},{"key":"2026082110201042000_jech-2026-226182v1.47","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthplace.2010.09.011"},{"key":"2026082110201042000_jech-2026-226182v1.48","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1080\/14631377.2010.498686","article-title":"What happened to the East German housing market? A historical perspective on the role of public funding","volume":"22","author":"Michelsen","year":"2010","journal-title":"Post-Communist Economies"},{"key":"2026082110201042000_jech-2026-226182v1.49","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1080\/19491247.2018.1540739","article-title":"Autogest\u00e3o in an era of mass social housing: the case of Brazil\u2019s Minha Casa Minha Vida-Entidades Programme","volume":"19","author":"Stiphany","year":"2019","journal-title":"International Journal of Housing Policy"},{"key":"2026082110201042000_jech-2026-226182v1.50","article-title":"Learning from the European experience of using targets to improve population health","volume":"7","author":"Smith","year":"2010","journal-title":"Prev Chronic Dis"}],"container-title":["Journal of Epidemiology and Community Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/jech-2026-226182","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T17:20:24Z","timestamp":1787332824000},"score":1,"resource":{"primary":{"URL":"https:\/\/jech.bmj.com\/lookup\/doi\/10.1136\/jech-2026-226182"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,21]]},"references-count":50,"alternative-id":["10.1136\/jech-2026-226182"],"URL":"https:\/\/doi.org\/10.1136\/jech-2026-226182","relation":{},"ISSN":["0143-005X","1470-2738"],"issn-type":[{"value":"0143-005X","type":"print"},{"value":"1470-2738","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,21]]}}}