Power, Politics, and Policy in the Making of Health Inequities: An Empirical Study of Equity-Oriented Policy Actors in Canada.

Structural health inequities in Canada remain entrenched-and in some areas have intensified-despite decades of commitments to equity. This study examines how power relations shape the conditions under which health equity policy reform is pursued and constrained. Grounded in critical political economy, the analysis draws on 23 semi-structured interviews with Canadian policy scholars, advocates, union leaders, and health professionals engaged in equity-oriented work. Thematic analysis identified four interrelated dynamics shaping health equity policymaking: institutional arrangements that privilege capital accumulation over redistribution; the institutionalization of corporate power within policymaking; neoliberal governance norms that narrow politically feasible policy responses; and fragmentation within civil society that weakens sustained collective pressure for redistributive change. Together, these dynamics illuminate how power is organized across economic, political, and institutional domains, contributing to persistent health inequities despite formal equity commitments. While participants referenced participation, consultation, and access to decision making, these mechanisms were experienced within policy environments characterized by structural power asymmetries. Rather than attributing inequities to evidence gaps or implementation failures, the analysis situates them as outcomes of political-economic arrangements shaping policy feasibility. Advancing health equity therefore requires confronting structural power relations and strengthening collective capacity for redistributive and democratic change beyond the health sector.