Tools

GEF (Gradient Evaluation Framework)

What is the Gradient Evaluation Form (GEF)?
Why do you need Gradient Evaluation Form (GEF)?
How was GEF developed?
When to use GEF
What GEF is not
Who can use GEF?
Key points about using GEF

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What is the Gradient Evaluation Framework (GEF)?

GEF is a European action-oriented policy tool that provides a framework for the evaluation of policy actions at each of the key stages of the policy cycle. It includes a set of principles, procedures and mechanisms that can be applied to:

  • Public health policies that comprise of a complex mix of actions, including programmes;
  • Specific health policy actions (e.g. nutrition programmes in schools);
  • Non-health policies that have a potential to impact on the social determinants of health inequalities (e.g. education, employment, and agriculture sectors).

A tool that can be applied to different policy contexts including upstream (targets the circumstances that produce adverse health behaviours such as the determinants of health that are ingrained in structural inequalities of society); mid-stream (affects working conditions or targeted lifestyle measures) and/or downstream (attempts to change adverse health behaviours and lifestyles directly).

However, GEF places more of a focus on up-stream actions which can have a greater impact on addressing the determinants of social inequalities in health, and thus levelling-up the gradient in health inequalities.

In addition to issues of evaluation, GEF also aims to support, advocate, and sensitise its users regarding the need for action to reduce health and social inequalities and make progress towards levelling-up the gradient in health among children, young people, and their families.

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Why do you need Gradient Evaluation Framework (GEF)?

The evidence base defining which policies and interventions are most effective in reducing health inequalities is extremely weak. This applies in particular to those policies and interventions that aim to level up the gradient. It is important therefore that policies and interventions that seek to influence the gradient need to be more adequately evaluated.

Yet this is by no means an easy and straightforward task. No single study can demonstrate which policies are the most effective and there is a need therefore to invest in evaluation to build up an aggregated body of evidence over time. However, our review of existing evaluation frameworks found no suitable framework that could be used to evaluate whether policies and/or interventions targeting children and families have the potential to reduce health inequalities and the gradient. Thus, a bespoke Gradient Evaluation Framework (GEF) has been developed as the first developmental step in addressing this gap.

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How was GEF developed?

GEF is a key output from the GRADIENT Project which has been funded between 2009-2012 by the EC’s Seventh Framework Programme (FP7). The Project is a research collaboration involving 12 institutions from all over Europe. The focus of the project is on children, young people and their families since the greatest impact on reducing the gradient in health inequalities can be achieved through effective early life policy interventions and by creating equal opportunities during childhood and adolescence.

GEF has been developed through a series of consensus-building workshops, involving experts from a wide range of European Member States, as well as consultations with experts in policy, evaluation, and health inequalities through individual meetings and a formal peer review process. GEF has also been informed by the results of an extensive literature review and a realist review of existing evaluation frameworks (see Davies & Sherriff, 2011). Finally, GEF has been developed in collaboration with EuroHealthNet, members of Work Package Two of the GRADIENT Project, the wider GRADIENT Consortium, and members of the GRADIENT Scientific Committee.

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When to use GEF

GEF can be used on any policy, action, programme, intervention or project that either affects, or is intended to affect (if not yet implemented), the health and equity of a given population. It is intended to guide those involved in the policy process (e.g. technical experts working in modern public health) by reducing their possibility of error having developed, or when developing, policies and related actions to increase the potential of levelling-up the gradient in health inequalities. GEF can be used retrospectively in terms of reviewing existing initiatives, and also prospectively when designing new ones.

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What GEF is not

Although GEF can optimise the chances of addressing the gradient in health inequalities, it is not a universal bullet that guarantees to inform the user whether or not a specific policy action has had an impact on the gradient. This is due (inter alia) to the complexity of attempting todemonstrate direct causal links, the effects of time lags, and current lack of appropriate measurements/indicators and measurement tools (such as when attempting to demonstrate inter-generational impacts). Moreover, GEF is not intended to be a comprehensive technical manual on how to conduct evaluation as there are already many technical resources readily available for this.

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Who can use GEF?

GEF is intended to be used by technical experts working at Member State (i.e. national) level. As stated earlier, specifically those individuals with a relatively high knowledge and understanding of the values, concepts, and principles of modern public health whom may (or may not) work in the health sector. However, GEF may also be of interest to other groups of stakeholders particularly policy-makers and/or decision-makers, researchers, evaluators, and practitioners working locally, nationally, or at European level.

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Key points about using GEF

GEF is designed to be flexible and adaptable to the needs of its (different) users. The ‘questions to consider’ and ‘example activities’ provided in GEF therefore, are meant to be indicative rather than exhaustive. They merely provide examples of the kinds of questions and activities that the users might want to consider. Consequently, some GEF questions and/or activities will be more relevant than others for different users, at different times, and for different policy actions. This will also be the case depending on what stage of the policy cycle GEF is being applied to. Users of GEF should thus feel free to address any additional relevant questions and/or areas to consider depending on their own particular context, policy action area and stage of policy development.

Given the above, users may want to consider exactly how they want to use GEF. For example, GEF can be used either for rapid assessment (e.g. using Dimension One only) or in a more in-depth way (Dimensions One and Two). Moreover, at times it may be more appropriate to work sequentially through GEF questions and examples when, for example, a policy action or programme is being developed from the beginning. Whereas, at other times, some questions or parts may be more relevant than others and users of GEF may therefore wish to ‘dip-in-and- out’ of Dimensions One and Two as and when required. The decision of how to use GEF is up to the user and their particular requirements and policy action in question. The process of using GEF to evaluate and/or design a policy action is as important as the outcome itself. So regardless of the actual questions addressed, or how GEF us used (e.g. rapid assessment vs. in-depth use of the full tool), the particular component, step, and/or dimension of GEF should be discussed and explored as widely as possible by the individual user or evaluation team. In doing so, users should be prepared to have their assumptions and their thinking challenged, either by others in the evaluation group or by the evidence that is presented, or of course both. This is because the process of completing GEF can help to sensitise users regarding the need for action to reduce social inequalities in the determinants of health in order to make progress towards levelling-up the gradient in health inequalities.

Given that the completion of GEF can be complex, it might be beneficial to record any discussions, key answers and comments, findings, action points and so on for each question for later reference (space is provided at the back of this document for user notes as well as at other points throughout GEF). This record will help make use of GEF as transparent and accountable as possible to stakeholders. It will also help to provide a rationale for decision-making. For this reason, such records can also be shared with others involved in applying GEF and with other key stakeholders.

GEF is designed to be used alongside other tools that seek to tackle a similar equity agenda such as health impact assessments (HIA), health equity assessments (HEA), as well as other evaluation tools that provide more detailed guidance on particular evaluation techniques and methods (e.g. Public Health Agency of Canada [PHAC], 2004).

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