Similar to other widespread economic crises (Navarro & Muntaner, 2016), the COVID-19 pandemic contributed to the creation and amplification of social and health inequities at a global level(International Labour Organization, 2020; International Labour Organization & United Nations Women, 2021; Kluge et al., 2020; Shadmi et al., 2020). Although governments around the world responded to the crisis with a range of economic, social, health, and safety policies and other measures to protect their citizens, the responses adopted by various countries, including Canada, generally lacked gender and other social identity considerations, resulting in inequitable and non-inclusive protections across individuals and groups (International Labour Organization & United Nations Women, 2021; Persaud et al., 2021; Public Health Agency of Canada, 2020; Scott, 2021; United Nations Women, 2021). For instance, in Canada, income-based support programs such as the Canada Emergency Response Benefit systematically excluded certain population groups due to strict eligibility criteria (e.g., type and length of employment, hours worked, minimum level of income) (Pin et al., 2023). Among the groups excluded from much needed income supports were low-income women who had a higher likelihood of being in part-time or informal work due to caregiving responsibilities and the unemployed or those in informal labour (Pin et al., 2023), with racialized populations being often overrepresented in these groups (Bernhardt, 2015; Colour of Poverty – Colour of Change, 2020). Women were at further disadvantage given that policies mandating the closing of childcare facilities or schools meant that, often, women had to choose between keeping their jobs or fulfilling caregiving responsibilities (Pin et al., 2023).

As a result, despite important progress made in efforts to address social and health inequities in recent decades, as illustrated next, limited attention to gender and other social identities in the design or implementation of public policies adopted during the COVID-19 pandemic negatively impacted individuals and population groups that are systematically excluded from access to resources or decision-making (International Labour Organization, 2020; International Labour Organization & United Nations Women, 2021; Kluge et al., 2020; Shadmi et al., 2020). For example, the concept of sex and gender-based analysis plus (SGBA+) is increasingly used in Canada, as briefly reviewed later in the Background section, as an analytical approach that ensures a rigorous method to assess systemic inequities, and examine how individuals or groups may experience policies, programs and initiatives in different ways (Women and Gender Equality Canada, 2021). Other examples of successful initiatives advancing action on social and health inequities include the adoption of Health in All Policies (HiAP) approaches (Kokkinen et al., 2017; World Health Organization, 2011), health (Harris et al., 2007), or equity-focused assessment frameworks (Mahoney et al., 2004), to ensure that health, well-being, and equity considerations are integrated into decision-making processes across all economic sectors, not only in health care. There has also been increased focus on examining the numerous links between health equity and various social determinants of health including migrant status (Abubakar et al., 2018; Labonté & Ruckert, 2019), Indigeneity (Anderson et al., 2016), gender (Manandhar et al., 2018), race (Clark et al., 2022; Kapadia & Borrell, 2023; Thompson, 2003), or their intersection (Bernhardt, 2015; Gunn et al., 2025; World Health Organization, 2008). Another example is the renewed attention to the importance of social protections in mitigating health and social inequities for the unemployed, precariously employed, or informal workers or other disadvantaged populations (International Labour Organization, 2020; International Labour Organization & United Nations Women, 2021; Kvart et al., 2025; Lavizzo-Mourey et al., 2021). Last, but not least, efforts to collect equity indicators have consistently increased (Ponce et al., 2023), despite setbacks and roadblocks. Engaging in policy analysis to assess the sex, gender, and overall equity-promoting character of COVID-19 public policies and developing relevant policy analysis instruments is thus an important responsibility. Such analysis could enable an understanding of policy limitations and the application of this knowledge towards the development of future public policies adopted in response to pandemics or other health, environmental, or economic crises. These considerations are well aligned with common aims of policy analysis, to enable informed decision-making and the creation of effective policies that benefit those affected by them through the “consideration of available evidence, coupled with well-reasoned inferences, to illuminate trade-offs among available choices for exercising government power” (Linquiti, 2022). However, despite a common aim to create policies that benefit those affected by them and a continued refining and increased sophistication of policy analysis tools (Linquiti, 2022), historically, policy analysis has tended to overlook sex and gender considerations (International Labour Organization & United Nations Women, 2021; McPhail, 2003), although this varies across countries or policy domains. A literature review of policy analysis instruments we conducted, as summarized later in this manuscript, revealed a scarcity of tools designed to assess or score a policy’s consideration for sex, gender, and other social identities, and thus, its overall potential to address issues of equity and inclusion related to the unique needs of groups who are systematically excluded from access to resources or decision-making. In response to this gap and driven by our intent to analyse the equity-promoting potential of COVID-19 public policies adopted in Canada, we conceptualized and developed a policy analysis and scoring tool to be used for this purpose. Specifically, this SGBA+ tool is meant for post-hoc use, to assess and score existing policies’ potential to promote equity and inclusion through considering and addressing sex, gender, and other social identities which, in combination with structures of discrimination and oppression, may impact some groups’ ability to benefit from public policies. This manuscript describes the rationale for, and the planning, creation, and refinement of the SGBA+ policy tool, being organized into several sections. First, we provide background information regarding the key role potentially played by public policies in the reduction of inequities and the importance of engaging in policy analysis and development of relevant tools to assess in concrete ways policies’ potential to fulfill such mandates. Within this section, we define several key terms used in the context of the SGBA+ and present linkages between social identities and systemic discrimination or oppression based on them. Second, we outline the approach used to conduct the literature review of existing policy analysis instruments that could be used to assess policies’ potential to promote equity and inclusion through consideration of sex, gender, and other social identities, and synthesize its key findings. Next, after summarizing the rationale and process of creating the SGBA+ tool, we introduce its various components, including its policy scoring process. Lastly, we discuss several practice, research, and policy implications.

Efforts to promote equity and inclusion in various social institutions and structures—including health (Gostin et al., 2023), education (Blau, 2022), employment (International Labour Organization & United Nations Women, 2021), resource allocation and policy-decision making (Kokkinen et al., 2017; Van Schalkwyk et al., 2021),—have intensified in recent decades (Persaud et al., 2021) in response to enduring social and health inequities (International Labour Organization & United Nations Women, 2021; Lavizzo-Mourey et al., 2021), often linked to various forms of systemic discrimination and oppression (Thompson, 2003), including racism (Clark et al., 2022; Kapadia & Borrell, 2023; Siddiqi et al., 2021). Because the concepts of ‘discrimination and oppression,’ ‘inclusion, equity, and diversity,’ ‘social identity,’ and ‘policy analysis’ were foundational to the development of this tool—and given their numerous, often inconsistent or conflicting definitions—we provide a detailed introduction to these concepts and their interconnections in Supplementary file 1.

Along with efforts to promote equity and inclusion, there is an increased preoccupation with studying the structural causes and manifestations of discrimination and oppression (Kapadia & Borrell, 2023; Torres et al., 2022; Venkateswaran et al., 2023) and understanding the ways in which population-level strategies (e.g., programs, services, policies) may affect population groups differently and thus, inadvertently, contribute to the creation of social and health inequities (International Labour Organization & United Nations Women, 2021; Persaud et al., 2021). For instance, the concept of SGBA+ is growing in use in Canada, as briefly reviewed next, as an analytical approach that considers the intersections among health determinants and their relationship to broader systems of power and discrimination, resulting in different groups experiencing policies, programs, and initiatives in unequal or distinct ways (Women and Gender Equality Canada, 2021). In addition to considering biological and gender differences, the inclusion of the word ‘plus’ in the SGBA+ concept builds on the concept of intersectionality, centered on Black women (Crenshaw, 2017). Alongside race, the use of the word plus (+) acknowledges social identities, such as sexual orientation, indigenous identity, ethnicity, age, income, class, and geography, among others, that intersect to influence an individual or group’s experiences with government programs, services, initiatives, or policies (Public Health Agency of Canada, 2024; Women and Gender Equality Canada, 2021).

It is important to note that guidance documents on the use of GBA+ consistently emphasize that, despite its name, GBA+ is not a ‘gender first’ analytical exercise (Women and Gender Equality Canada, 2021). Rather, it is an intersectional approach focused on understanding the interconnected processes through which power, privilege, and inequities are produced and reproduced (Women and Gender Equality Canada, 2021). Gender remains a key entry point, but the ‘plus’ highlights that meaningful analysis requires examining how gender interacts with other social identities and structural factors (Women and Gender Equality Canada, 2021). The Government of Canada expressed its commitment to integrate the practice of gender-based analysis plus (GBA+) (Women and Gender Equality Canada, 2021) or SGBA+ (Public Health Agency of Canada, 2024) in the development of all services, policies, and programs, collaborating with other governmental departments and agencies to support this process and incorporate it across all decision-making. As found through our literature review, despite this clear commitment to using GBA+ or SGBA+ as an intersectional approach to policy analysis, its implementation and operationalization in policy analysis is currently underdeveloped. Although this approach is sometimes referred to as an analytical tool, there is no concrete tool or instrument available to assess post-hoc if existing policies are considerate and inclusive of gender and other social identities. Examining public policies in the context of inequities is important since, given their wide reach, they have a considerable potential to decrease or eliminate inequities (Kim et al., 2022; Miyawaki et al., 2021; Ng & Muntaner, 2015) and facilitate just outcomes (Hankivsky, 2012). However, if insufficient attention is paid to the many ways in which systemic discrimination, oppression, and social identities intersect, an unintended consequence of public policies could be to worsen social and health inequities, instead of decreasing or eliminating them (Persaud et al., 2021). Yet, without an intentional assessment of the differential impact of public policies on population groups, as related to dimensions of oppression based on social identities, it is difficult to accurately diagnose and address policies that neglect issues of equity and inclusion.

Further, in the context of the COVID-19 pandemic, as well as other health, environmental, or economic crises, it is especially important to pay attention to the interactions between systemic discrimination and oppression, including structural racism, and the inequity creation potential of public policies adopted in response to crises (Persaud et al., 2021; Public Health Agency of Canada, 2020; Shim & Starks, 2021; Siddiqi et al., 2021) for several reasons. First, crises have a tendency to give prominence to and deepen persistent inequities and discrimination among certain population groups (Blundell et al., 2020; Gunn et al., 2022; Mawani et al., 2021; Persaud et al., 2021; United Nations, 2020). Second, while crises have the potential to trigger positive change (Scheidel, 2017), they could also hinder progress towards increased equity and inclusion (Shim & Starks, 2021). Worse, crises may lead to set-backs in existing achievements if other priorities take precedence during recovery efforts (Harper et al., 2020; Navarro & Muntaner, 2016) instead of equity and inclusion being thought of as integral to recovery (Mawani et al., 2021; Shim & Starks, 2021). Last, but not least, for a variety of reasons, survey response rates tend to decrease during periods of crisis, as confirmed during the COVID-19 pandemic, especially for those with lower formal education and lower income, which could mean that the inequities facing these groups could be more difficult to document and, consequently, more challenging to address and reduce (Krieger et al., 2023).

We conducted a mapping literature review (Booth, 2016; Grant & Booth, 2009) to identify existing policy analysis tools that could be used to assess public policies’ potential to promote equity and inclusion through consideration of sex, gender, and other social identities that may impact an individual or a group’s ability to benefit from them. Our second objective in conducting the review was to determine which policy analysis tools have been used to assess COVID-19 public policies’ gender and overall equity-promoting potential. The specific research questions guiding the review were:

We opted to conduct a mapping review, given that such reviews are suitable when the focus is on review questions instead of topics, the purpose is to identify gaps in the literature, and provide broad overviews (Booth, 2016; Grant & Booth, 2009). Our search covered three academic databases: Scopus, Web of Science, and PubMed, selected for their inclusion of interdisciplinary social, political, economic, and health studies. We also searched several sources of grey literature including three large international organizational websites, WHO (World Health Organization, 2011), CDC (Centers for Disease Control and Prevention, Office of the Associate Director for Policy, 2013), and the ILO (International Labour Organization, 2020), known for their coverage of social, economic, political, and health issues and especially their preoccupation with the impact of policies on populations groups who are systematically excluded from access to resources or decision-making. Given the Government of Canada’s commitment to integrate the practice of GBA+ or SGBA+ in the development of policies, and programs, and collaborate with other governmental departments and agencies to support this process (Public Health Agency of Canada, 2024; Women and Gender Equality Canada, 2021), we included the following five Government of Canada websites in our search: WAGE, Canadian Institute for Health System Research, Health Canada, PHAC, and National Collaborating Centres for Public Health. In light of the second research question, we also reviewed three Canadian-specific COVID-19 databases: CanCovid, COVID-END, and COVID-19 virtual library of health data and evidence (Government of Canada, 2021). We also hand-searched the reference lists of included studies. Searches were conducted June–August 2022 and repeated in May 2023. All studies published in English, on or after January 1, 2000 and up until May 2023, were considered.

The academic database search terms for Q1 were: (policy analysis tool OR policy analysis instrument OR policy grading tool OR policy analytical framework OR gender-based analysis OR GBA+ OR GBA plus OR SGBA+ OR SGBA plus) AND (sex OR gender OR age OR immigration status OR race OR ethnicity OR ability OR sexual orientation OR citizenship OR employment status OR experiences with the justice system OR identity factor OR identity). The search terms for Q2 combined the terms used for Q1 with (COVID-19 and synonyms). Our team tested and refined the search, to ensure it captures studies fitting the inclusion criteria. Given the less advanced search features of institutional website engines, the original academic search strategy was modified and simplified for use in the grey literature search.

Publications were considered for inclusion if they were focused on a policy analysis tool that assessed the ways in which sex, gender, and at least one other social identity impact the development, implementation, or outcomes of policies. The populations of interest included women, Indigenous communities, or other population groups historically or currently excluded from decision-making and access to resources such as LGBTQ+ minorities, immigrants or refugees, racialized individuals, persons with disabilities, informal or undocumented workers, non-standard or precariously employed workers, workers without formal credentials, unemployed individuals, or individuals who experienced the criminal justice system.

The Covidence platform was used for data management, and Zotero and EndNote were used for reference management. For each study, two reviewers completed both title and abstract, and full-text screening, and disagreement was solved through discussions among reviewers. A tailored data extraction tool was designed, piloted, and used. The information extracted covered the study design, purpose of the tool and intended users, tool development process, applications, country in which the tool was developed and used, guiding principles used to develop the tool, and key limitations. The information gathered from the literature was examined, analyzed, and synthesized, consistent with the aims of a mapping review. The findings were grouped by research question addressed and synthesized in both narrative and tabular formats.

We identified 445 potentially relevant records and, after removing 125 duplicates, screened the title and abstracts of 320 of them, and the full texts of 114. Five records met all our inclusion and none of the exclusion criteria for Q1 and no records met our inclusion criteria for Q2. The flow diagram displaying the identification, screening, and inclusion process is included in Supplementary file 2.

We identified five tools with a policy analysis focus used to assess the impact of sex, gender, and at least one other social identity: (i) Policy Scorecard for Gender Mainstreaming (Keleher, 2013), (ii) Feminist Policy Analysis Framework (McPhail, 2003), (iii) Intersectionality-Based Policy Analysis Framework (Hankivsky, 2012), (iv) EquiFrame (Amin et al., 2011), and (v) Health Equity Impact Assessment Tool (Ontario Ministry of Health and Long-Term Care, 2012), as summarized in Supplementary file 3. The first two tools, Policy Scorecard for Gender Mainstreaming and Feminist Policy Analysis Framework, are mainly focused on sex and gender, although they do consider other social identities, while the other tools, Intersectionality-Based Policy Analysis Framework , EquiFrame, and Health Impact Assessment Tools, are centred on social determinants of health approaches and do not give priority to any one factor, such as sex and gender, within their analysis.

Table 1 provides an overview of the five policy analysis tools, indicating the social identities and several types of inequities assessed, along with a few considerations related to tool development and application. With regard to types of social identities assessed, all five frameworks focus on gender and sex, four on disabilities and race, three on age, four on social class, and three on several other factors including sexual identity, religion, and national origin. Regarding types of inequities examined, four focus on health, two on gender (gender wage gap and distribution of unpaid responsibilities), one on systemic racism and structural poverty, and one on employment. We acknowledge that we considered only a limited range of inequities, focusing on those most frequently discussed in the pandemic context. Based on information provided about the groups consulted, it appears that four tools were created through a participatory process that included involved actor consultations and feedback opportunities, with most actors belonging to the communities whose identity factors were analyzed. Except for the Policy Scorecard for Gender Mainstreaming’ tool, all other tools adopted an intersectional perspective to the analysis of social locations.

Only one framework, the Feminist Policy Framework, had a less extensive development process, being created solely based on a review of feminist policy literature. While for three frameworks, the Policy Scorecard for Gender Mainstreaming, the Intersectionality-Based Policy Analysis Framework, and the EquiFrame, their actual application to assess specific policies is described, for the other two, only their possible applications are mentioned, without specific examples to show the ways in which they were previously used for policy analysis. Except for the Policy Scorecard for Gender Mainstreaming, EquiFrame, and Health Equity Impact Assessment Tool, which targeted health policies in particular, the other tools have a more general focus, being targeted to a diverse range of policies. In addition to their policy analysis application, several tools, including the Policy Scorecard for Gender Mainstreaming, Feminist Policy Framework, and Intersectionality-Based Policy Analysis Framework are meant to also raise awareness about the importance of using a gendered lens when examining policy.

Our search of Canadian government websites, including the (i) WAGE, the department leading the GBA+ project, and (ii) Health Canada, and PHAC, the departments using the SGBA+ tool, identified no concrete, practical analysis tool or instrument publicly available to assess if existing policies are considerate and inclusive of sex, gender, and other social identities. While the commitment to using GBA+ or SGBA+ as an intersectional approach to policy analysis is clear, its implementation and operationalization specifically towards policy analysis or scoring is currently underdeveloped.

We found, however, numerous relevant SGBA+ resources, as described next. Although these tools can impact policy in the long term, they are general in nature, without a specific focus on policy analysis. For instance, we learned about a sustainability framework (Women and Gender Equality Canada, 2021) and training kit that can be adapted by organizations interested in preparing their employees to incorporate SGBA+ considerations in their operational and planning activities (Women and Gender Equality Canada, 2021). Numerous resources are available to support online training on SGBA+ principles (Women and Gender Equality Canada, 2021; 2024). Additionally, relevant guiding questions and checklists have been developed to support the routine use of SGBA+ by organizations interested in (i) identifying inequity issues concerning organizational policies (e.g., hiring practices, anti-bullying policies, etc.), (ii) challenging assumptions and biases that could contribute to ignoring the possible unequal impacts of interventions on groups with diverse social identities and collecting evidence to assess differences, and (iii) consulting with target groups before proceeding to developing, implementing, and evaluating the impact of various operational strategies (Women and Gender Equality Canada, 2021). Other resources include specific guidelines and considerations for incorporating a SGBA+ lens in research activities (Women and Gender Equality Canada, 2021) and tools to help public servant employees promote inclusivity in government initiatives and service provision (Women and Gender Equality Canada, 2021). Overall, while these resources, questions, checklists, and considerations provide thoughtful and comprehensive guidance on applying diversity and inclusion perspectives across a wide range of activities, initiatives, or programs they do not appear to enable the scoring, or comparing of existing policies or programs on criteria of diversity and inclusion.

Our literature review did not identify any concrete, practical policy tools used to assess the gender, sex, and overall equity-promoting potential of COVID-19 public policies adopted in Canada. Instead, we located numerous studies and reports containing policy recommendations for equitable response and recovery strategies that take into consideration social identity factors (Bellefleur & Jacques, 2021; Colour of Poverty – Colour of Change, 2020; Persaud et al., 2021; Public Health Agency of Canada, 2020; Scott, 2021; Siddiqi et al., 2021; Sultana & Ravanera, 2020), although without providing specific direction for ways to assess if policies are meeting such mandates, or to score them based on relevant criteria.

We identified an intersectionality-based policy analytical framework used to examine the impact on poverty of major income support policies adopted in Ontario and federally in response to COVID-19 (Pin et al., 2023). This framework used nine questions to guide the analysis and considered the impact of gender but not sex on the equity-promoting potential of analysed policies. The analysis did not involve the scoring of policies, or policy components. We also found one study examining the impacts of COVID-19 policy measures implemented across Canadian provinces on the economy, which used an analysis tool consisting of a stringency index that measured the strictness of containment policies and public awareness campaigns. The focus of this tool was not on individuals or groups and only limited attention was paid to the role of gender or other social identities on policy development, implementation, or outcomes (Cheung et al., 2021).

The initial purpose of the SGBA+ policy tool we developed was to assess post-hoc if COVID-19 public policies adopted in Canada showed consideration for issues of equity, diversity, and inclusion in order to facilitate a fair and equitable response to the pandemic. However, this tool could be used to systematically review policy aspects to determine if various social identities—which, along with systems of discrimination and oppression, may impact the ways in which population groups are affected by public policies—are acknowledged and addressed. Specifically, the tool is relevant and applicable to other situations, including a range of public policies adopted following health, environmental, and economic crises because, except for several COVID-19-specific examples, all policy dimensions and key aspects covered are general in nature. Given the types of questions asked, we believe the tool could be adapted by public health professionals, researchers, advocacy groups, policymakers, and governments to proactively inform the assessment, refinement, or development of various public policies meant to promote just outcomes among population groups following natural or humanitarian crises.

In preparation for developing this SGBA+ tool, we reviewed the five policy analysis tools identified through our literature review. While none of these tools were sufficient for the purpose of our planned analysis and scoring of Canadian COVID-19 public policies, we used them to inform the development of the tool. In addition, we also studied several other policy analysis instruments and analytical frameworks located during our literature review, which although relevant, did not meet all inclusion criteria. The policy analysis instruments and approaches examined include the National Collaborating Centre for Healthy Public Policy’s Framework for Analyzing Public Policies (Morestin, 2013), CDC’s Policy Analytical Framework (Centers for Disease Control and Prevention, Office of the Associate Director for Policy, 2013), WHO’s Gender Assessment Tool and Gender Responsive Assessment Scale (World Health Organization, 2011), Pan American Health Organization’s Guide for Analysis and Monitoring of Gender Equity in Health Policies (Pan American Health Organization, 2009), European Training Foundation’s Guide to Policy Analysis (European Training Foundation, 2018), and a gender analysis approach for health systems research that pays attention to power relations (Morgan et al., 2016).

We structured the SGBA+ tool around six policy dimensions covering aspects relevant to our intended analysis: (i) policy coverage or jurisdiction, (ii) issue(s) addressed and policy objective(s), (iii) population(s) targeted, (iv) policy development or enactment, (v) policy implementation, and (vi) policy evaluation and monitoring. We then proceeded with drafting questions applicable to each dimension. Table 2 displays the six dimensions, number of corresponding questions by dimension, and several key aspects assessed for each dimension. Supplementary file 4 lists all questions, answer options, and instructions provided for tool users.

The tool consists of 81 mandatory questions across all six policy dimensions assessed, requiring a range of answers including (i) open-ended descriptive, (ii) closed-ended Yes/No, (iii) selection of applicable answers from pre-set entries, and (iv) a concluding open/ended comments/notes section. We created pre-set answer options for each question to ensure that the provision of answers, analysis, and interpretation of findings across policies is consistent. However, to acknowledge the diversity of public policies and facilitate broad applications of the tool, we also added free text boxes to the lists of options, to facilitate open-ended answers in case none of the pre-set entries were applicable. Given that the answers to several questions may require further interpretation, we included an accompanying note advising tool users to draw on their own perspectives when answering. For instance, if a reviewer believed, based on personal and professional experiences, that a policy may have negative implications for a certain population group and such acknowledgment was not made within the policy, the reviewer would indicate this in a note added directly to a given question or to the final comments section.

In addition, to ensure further consistency in answers and avoid double guessing the meaning of both, question, and answer options by tool users, we provided definitions and/or detailed explanations and examples alongside each question. To acknowledge that, in some cases, the information needed to answer a question could be missing, we included an option ‘not able to assess/info not available within the policy description.’ While having a majority of responses indicating that the information sought was not available is not helpful for determining the equity-potential of a given policy, this knowledge is indicative of a policy’s clarity, comprehensiveness, and transparency and is useful for informing recommendations for policy revisions.

When preparing answer options, we considered the population groups at higher risk of being negatively impacted by the pandemic and suffering worse health and social outcomes. We also thought of specific dimensions of oppression based upon social location that may prevent population groups from benefiting from blanket, non-tailored, COVID-19 policies given factors such as (i) increased risk of contracting the disease (e.g., due to economic sector they work in, housing, and transport arrangements), (ii) delays or difficulties in accessing healthcare (e.g., due to refugee status, non-standard worker lacking healthcare benefits to access non-essential health services), and (iii) lack of access to protective resources (e.g., paid sick days).

We decided to incorporate a screening step to be completed before proceeding with answering all questions to determine if one or more of the detailed questions on a certain topic can be skipped if the respective topic is not covered by the policy. The four screening questions utilized are: (i) Is gender mentioned? (ii) Are any historically or currently excluded population groups mentioned (referring to population groups facing marginalization and/or exclusion as related to social location and structures of discrimination and oppression)? (iii) Are any evaluation considerations mentioned? and (iv) Are the expected outcomes of the policy mentioned? The answer to each screening question determines if the more detailed questions on that respective topic need to be asked. Given that the tool is quite lengthy (81 questions that can take approximately 30-60 minutes to provide answers to), the inclusion of screening questions (that can take only about 5-10 minutes to provide answers to) and the possible streamlining of questions makes it more efficient and user-friendly. The tool was initially developed in Excel, then converted to a Zoho Form, and will eventually be transitioned to a more user-friendly, webpage platform.

We designed a scoring system to rate policies once assessed. The scoring is meant to enable comparisons across policies with regard to their potential to promote equity and inclusion among target populations. We assigned a score ranging from −1 to 3 to each Yes/No answer, building on several aspects of WHO’s Gender Assessment Tool and Gender Responsive Assessment Scale (World Health Organization, 2011). As shown in Table 3, each score indicates the level of responsiveness to gender and other aspects of social location of a given policy dimension, with the lowest score being assigned to aspects that may perpetuate gender and other social inequities and the highest to aspects that show not only responsiveness to gender and other social location considerations but potential to increase equity among population groups. Only questions assessing SGBA+ factors are scored, while general policy analysis questions (e.g., What is the policy lever? Are the policy objectives clearly specified?) are not. Although not scored, the more general questions provide valuable information, both subjective and objective, about the administration, implementation, and evaluation processes relevant to each policy, which could be used when providing recommendations for policy revisions.

In addition to assigning scores by question, each of the six policy dimensions is also rated, by adding up the scores afforded to Yes/No questions and dividing the total by the number of scored questions. To facilitate the interpretation of findings and comparisons among policy dimensions, the score obtained for each dimension is then used to determine the scoring range of a given dimension, as detailed in Table 3, with 5 possible ranges (< 0; 0; > 0 to 1; > 1 to 2; > 2). Further, to enable comparisons among policies, the same approach is used to calculate an overall score and a corresponding range for each policy.

The development of this tool was iterative and involved planning, brainstorming sessions with the research team members, consulting with community organizations, feedback incorporation, refining, and piloting. The first draft developed was piloted with two different pandemic-policies adopted in Ontario, Canada by members of the research team (the authors of this manuscript). This pilot involved a review of the policy dimensions covered by the tool and aspects assessed under each dimension to assess clarity and comprehensiveness, along with a review of question framing or priority. As a result, one more dimension was added (Policy coverage and jurisdiction), numerous questions were reformulated for brevity and increased clarity, new questions were added (e.g., questions assessing if policies mention targeted groups, goals, or potential negative impacts), while several questions identified as low priority were deleted. Next, the tool was piloted with four other pandemic policies adopted in Ontario, Canada by the research team members, who provided further suggestions for additions, changes, and clarifications. Specifically, following this round of feedback, the number of answer options were expanded considerably to list new population sub-groups, to differentiate between short- and long-term impacts, to provide examples that could help orient those using the tool, and add comment boxes. Another key change was to add four screening questions that would allow the skipping of subsequent questions related to uncovered topics.

Additionally, to broaden the perspectives used in the creation of this policy analysis instrument, the tool was shared with three community organizations working to advance the priorities and perspectives of population groups who are systematically excluded from access to resources or decision-making (e.g., racialized individuals, immigrants, migrant workers, persons with disabilities, workers in precarious employment, including healthcare workers) in a large metropolitan city in Canada. The community organizations were consulted regarding (i) population groups facing discrimination and oppression, (ii) social identities that, in combination with structures of discrimination and oppression, may prevent population groups from benefiting from COVID-19 policies, (iii) relevant policy dimensions to assess, (iv) screening questions, (v) use of inclusive language, (vi) considerations missing from the tool, and (vii) overall tool comprehensiveness. Because the tool was lengthy and required substantial time to complete, community organizations were not asked to apply it directly to policy analysis during the consultation. The consultation document shared with community members in the form of a Zoho survey is available as Supplementary file 5. The anonymous survey issued to community members did not entail the collection of private, personal, or personally identifiable information. The tool was further modified following this consultation. Additional questions were eliminated, new population sub-groups were added (e.g., youth, non-standard or precariously employed workers), and the list of economic sectors listed was expanded and standardized. Additionally, new possible inequities were listed (e.g., education inequities, unbalanced distribution of unpaid responsibilities among genders, crowded public transit), and the language was refined to make it more inclusive (e.g., using older adults instead of elderly/seniors). Following further revisions to integrate the additional feedback received and after holding a comprehensive training session, the updated tool was piloted with four other pandemic-policies adopted federally in Canada by several research team members and further refined. The additional changes included the inclusion of guidance on ways to find answers to the screening questions, specifications whether a question should be answered from the perspective of the reviewer or not, new ‘not applicable’ or ‘other’ text boxes, and larger comments boxes for some questions. The system to score questions assessing SGBA+ factors was also added at this point, to facilitate comparisons among policies. Given that the scoring feature of the tool was added as a last step, this aspect was not among the elements piloted or refined as a result of the pilot or consultation.

Given its nature, crisis‑driven policymaking takes place in contexts marked by urgency, ambiguity, and elevated political pressures, which, in turn, steer governments towards established administrative practices and prevailing policy paradigms. In such contexts, decision‑makers often portray policies as neutral responses to the emergency at hand, even as these measures perpetuate entrenched power asymmetries and the institutional blind spots that sustain them. Consequently, when crisis governance prioritizes speed over deliberation, individuals or groups already marginalized by existing systems of oppression are further sidelined in agenda‑setting and policy design. This situation creates a policymaking environment in which the status quo is reproduced and long‑standing inequities become built into the design of policy responses. For instance, the public health measures adopted during the COVID-19 pandemic largely assumed household structures, employment patterns, and access to resources that reflect dominant social groups rather than the lived realities of individuals or groups experiencing marginalization. Health care labour continued to be feminized and undervalued, despite it being deemed “essential”, and caregiving burdens intensified in ways that disproportionately positioned women as primary caregivers. These political conditions help clarify why policies framed as universal during the pandemic yielded uneven effects for individuals or groups, and why governments struggled to anticipate or mitigate these patterns of disadvantage, despite their foreseeability.

The SGBA+ policy tool described in this manuscript was developed for post-hoc use, to assess if COVID-19 policies considered issues of equity and inclusion to promote an equitable response to the pandemic. This work fits a larger trend calling for considerations for equity, diversity, and inclusion to be incorporated in various social institutions (Gostin et al., 2023; International Labour Organization & United Nations Women, 2021; Kokkinen et al., 2017; Venkateswaran et al., 2023) and for data collection, data use, and policy adjustments to enhance health equity and promote equitable health policy (Kaalund et al., 2022; Ponce et al., 2023). Most recently, the COVID-19 pandemic, and especially the enhanced focus on equity triggered by the pandemic, has prompted renewed calls for the adoption of transformative and redistributive policies that facilitate an equitable recovery and sustainable development (Gostin et al., 2023; Gunn et al., 2023; International Labour Organization & United Nations Women, 2021; Mawani et al., 2021; United Nations, 2020; 2023; United Nations Women, 2021; Van Schalkwyk et al., 2021).

A key strength of this SGBA+ tool is that it fills an existing gap regarding such policy analysis instruments, and it could be used to complement existing advocacy, research, and policy-making approaches meant to promote and enable equity and inclusion. Detailed information about the equity-promoting potential of policies and their ability to address the unique needs of population groups facing marginalization and/or exclusion could be used by health professionals, researchers, advocacy groups, policymakers, and governments for the development and/or revision of policies that facilitate equitable outcomes among population groups. Another strength of this tool is the thorough piloting it underwent, which contributed to strengthening the final version of the tool by improving its clarity, scope, and usability. Across multiple rounds of feedback—from researchers and community organizations—the tool was refined through the addition of a new policy coverage dimension, revised and streamlined questions, expanded response options, clearer guidance, and more inclusive language. Screening questions, additional population sub groups, new inequity considerations, and improved comment fields further enhanced usability. A final pilot led to further clarifications and the integration of an SGBA+ scoring system to support comparisons across policies. Together, these iterative refinements produced a more precise, practical, and equity-oriented analysis and scoring tool.

While the tool was developed to assess COVID-19 related policies adopted in Canada, given the type of questions it asks and policy dimensions assessed, we believe that with some adjustments, it could be applied to other public policies adopted in response to health, environmental, and economic crises, or other current or future policies in a range of country contexts.

A current limitation of the tool is that, although it underwent an extensive process of development, piloting, and refining, it has not yet been validated, and thus, in its current form it has a lower likelihood of adoption. In addition, while the tool is detailed and comprehensive, it could be time consuming to apply. The use of the screening questions to determine what parts of the tool need to be answered is meant to address this limitation. Additionally, depending on the purpose of policy analysis, type of policy, and context, a modular application of the tool could be considered, with only one or two policy dimensions being assessed or fewer questions asked. Another limitation is that, although very important, several dimensions of structural oppression, including classism or colonialism, were not covered. Further, because the individuals involved in piloting the tool were trained in using the tool by those involved in developing it, any biases introduced in the initial tool development process may have been missed during the piloting process. Another limitation is that, given limited resources, the mapping review conducted to identify existing policy analysis instruments that could be used to assess public policies’ potential to promote equity and inclusion covered only three academic databases and several sources of grey literature, and the search considered only English-language studies published before May 2023, thus potentially missing relevant publications included in other databases or government websites (e.g., wikis, intranets, etc.) or published since May 2023. Given that government analysts who use policy analysis tools do not always publish the tools they use, there may be unobserved omission bias in our literature search since the tools available on government websites may not be representative of all internal resources at the disposal of policy professionals. Our review would have been strengthened by interviews with key policy analysts to learn about internal, non-public resources. However, given the timing and purpose of our review, such interviews would not have been feasible.

We will continue to refine this tool, with several of the next steps including (i) the incorporation of questions/answer categories assessing other oppression dimensions or axes of inequity, (ii) more consultations, (iii) validity and reliability testing, and (iv) sharing of findings with those who would benefit from applying the tool including public health professionals, researchers, activists, advocacy groups, policy makers, and governments. In addition, we plan to transfer the tool to a web-based platform to increase the ease of application and facilitate its use by others outside our team. If successfully validated, the tool could be further adjusted and promoted as a universal analysis tool to ensure that practice, research, and policy in a range of economic sectors and social institutions address sex and gender alongside a range of intersecting social identities. The tool could support advocacy efforts that challenge systemic discrimination and oppression and call for just, transformative policies that facilitate social and health equity, and address power inequities resulting from sex, gender, and other social identities. Given that the tool reveals specific strengths and weaknesses of policies with regard to their potential to promote just outcomes among population groups, it could be used as an accountability mechanism for program and policy evaluation and monitoring. The ongoing use of the tool to systematically review public policies in Canada, and elsewhere, could allow for cross-country and longitudinal comparisons to assess progress towards increased equity and inclusion.

This policy analysis and scoring tool was created to help public health professionals, researchers, advocacy groups, policymakers, and governments systematically review specific policy aspects to determine post-hoc if social identities such as gender, sex. age, sexual orientation, race, ability, experiences with incarceration, migration, citizenship, or employment status were acknowledged and addressed by COVID-19 policies. Such considerations are important given that dimensions of oppression based upon social identity may impact the ways in which population groups gain access to or are affected by public policies, possibly preventing them from benefiting or even adversely affecting them. The information obtained from public policy analyses conducted using this SGBA+ tool is meant to inform the review or development of future public health or other emergency policies, to promote just health and social outcomes among population groups.

The tool was developed in response to a literature gap identified while searching for a policy analysis instrument that could be used to assess the gender and overall equity-promoting potential of policies adopted in response to the COVID-19 pandemic. However, the tool is relevant and applicable to other situations, including a range of public policies adopted following health, environmental, and economic crises because, except for several COVID-19-specific examples, all policy dimensions and key aspects covered are general in nature. The process of creating, piloting, and refining the tool was iterative and involved a literature review, a thorough planning, development, and testing process, and consultation with community organizations working with population groups facing marginalization and/or exclusion. The early dissemination and sharing of the tool development process are meant to inform and stimulate further iterations of this tool, and the creation of alternate tools with similar aims.

SGBA+ tools have the potential to make policymaking dynamics visible by systematically revealing how policy design is structured around normative assumptions about individuals, groups, households, work, health, or social risks. For example, instead of framing inequitable outcomes as incidental or unintended consequences, this policy analysis tool shows how inequities rooted in gender and other intersectional structures emerge from specific political choices—such as whose needs are prioritized, whose labour is valued, and whose vulnerabilities prompt action. By examining the assumptions shaping how policy measures allocate resources and risks, SGBA+ approaches reveal how claims of neutrality operate to conceal the values, interests, or power asymmetries shaping crisis responses. As a result, such tools provide policymakers, advocates, and researchers with a concrete means to interrogate policy design and decision‑making processes—clarifying when equity considerations have been sidelined, when particular groups have been rendered invisible, and where more equitable policy options were possible. This analytic clarity positions the applied use of SGBA+ not only as a tool for post-hoc policy evaluation, but also as a political instrument capable of steering future emergency governance toward enhanced accountability and equity.

Notes

List of abbreviations

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