Cmha o jan 2011

Bob Gardner & Nimira Lalani Canadian Mental Health Association-Ontario January 24, 2011 © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 1

• how to ensure mental health is incorporated into: • health policy, planning and delivery in general • non-health spheres – from social services through justice to education • how to integrate and coordinate across policy fields/govt depts • sometimes called ‘joined up govt ‘or ‘whole of govt approaches’• huge challenge → need to address on many fronts• one front = potential of planning tools such as impact assessment in grounding and driving action © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 2

• we have been working on the similar challenge of ensuring that equity is embedded in healthcare planning and delivery, and that underlying social determinants of health are addressed • how to get beyond lip service commitment to equity • within health -- how to align with system drivers, performance management and quality improvement • beyond health – how to identify and mobilize for the necessary policy changes to reduce overall social and economic inequality and address the social determinants of health• some interesting parallels that can be drawn upon• and, of course, equity and mental health need to be integrated © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 3

• start with policy challenges around mental health• then explore some lessons learned in equity strategy: • focusing on the scope and value of equity-focused planning • esp. Health Equity Impact Assessment as it is being developed in Ont • we may explore one HEIA case study in which it was used in the development of LHIN mental health strategy• then back to mental health strategy into action: • will outline Mental well-being Impact Assessment as it has been developed in the UK • and interest in Canada • then small groups to assess potential here• back to draw together some conclusions and next steps © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 5

• clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion• impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally• real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities www.welleseyinstitute.com 6

•Determinants interact andintersect with each other•In constantly changing anddynamic system•In fact, through multipleinteracting and inter-dependent economic, socialand health systems•Determinants have areinforcing and cumulativeeffect on individual andpopulation health © The Wellesley Institute www.wellesleyinstitute.com 8

POWER StudyGender andEquityHealth IndicatorFramework 9

• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage• This concept: • is clear, understandable and actionable • identifies the problem that policies will try to solve • is also tied to widely accepted notions of fairness and social justice• The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes• A positive and forward-looking definition = equal opportunities for good health © The Wellesley Institute www.wellesleyinstitute.com 10

• the point of all this analysis is to be able to identify policy and program changes needed to reduce health disparities• but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing• think big and think strategically, but get going • make best judgment from evidence and experience • identify actionable and manageable initiatives that can make a difference • experiment and innovate • learn lessons and adjust – why evaluation is so crucial • gradually build up coherent sets of policy and program actions – and keep evaluating• need to start somewhere – and our common focus is on population health and our more specific focus is on driving equity through the health system © The Wellesley Institute 11 www.wellesleyinstitute.com

even though roots of health disparities lie in far wider social and economic inequality1. it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care • equitable healthcare and proactive health promotion can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities2. in addition, there are systemic disparities in access and quality of healthcare that need to be addressed • people lower down the social hierarchy tend to have poorer access to health services, even though they may have more complex needs and require more care • unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse • at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social position © The Wellesley Institute www.wellesleyinstitute.com 12

• goal is to ensure equitable access to high quality healthcare regardless of social position• can do this through a two pronged strategy: 1. building health equity into all health planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach 2. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers • looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable © The Wellesley Institute www.wellesleyinstitute.com 13

1. health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy2. equity strategy can be driven into action within the health system and in provider institutions through • equity-focused planning and aligning equity with key system drivers such as sustainability and quality, and priorities such as ER, ALC, mental health, etc. • building equity into ongoing performance and system management, and routine service delivery • investing in promising interventions to reduce barriers and enhance equitable care • sharing and building on front-line and local initiatives, evaluation, and other enablers for innovation3. focus today is on one facet of this overall strategy -- equity-focused planning – and more specifically on one promising planning tool -- Health Equity Impact Assessment © The Wellesley Institute www.wellesleyinstitute.com 14

• addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations• we need to analyze the contours and foundations of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, availability of services in particular neighbourhoods? • which requires good local research and detailed information – speaks to great potential of community-based research and specific equity plans within provider organizations • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems• this requires an array of effective and practical equity-focused planning tools © The Wellesley Institute www.wellesleyinstitute.com 15

1. quick check to ensure equity is 1. simple equity lens considered in all service delivery/planning2. take account of disadvantaged populations, access barriers and 2. Health Equity Impact related equity issues in program Assessment planning and service delivery3. assess current state of provider 3. equity audits and/or HEIA organization4. determine needs of communities 4. equity-focused needs facing health disparities assessment5. assess impact of programs/interventions on 5. equity-focused evaluation health disparities and disadvantaged populations © The Wellesley Institute 16 www.wellesleyinstitute.com

• increasing attention to potential – from WHO, through most European strategies, PHAC, to MOHLTC and LHINs• planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • can help to plan new services, policy development or other initiatives • can also be used to assess/realign existing programs • intended to be relatively easy-to-use tool • essentially prospective, helping plan forward• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI • HEIA is being used in Toronto Central and other LHINs and providers across the province • HEIA is being incorporated into a “health in all policies’ framework by MOHLTC © The Wellesley Institute www.wellesleyinstitute.com 17

• generally designed for planning forward: • easy-to-use tool to ensure equity factors are taken into account in planning• but providers in pilot phases – and experience from other jurisdictions -- identified other uses: • for strategic and operational planning • for assessing whether programs should be re-aligned or continued • to build principles into evaluation and quality improvement• another lesson from implementation so far and many workshops – can’t be prescriptive in using tool • doesnt matter so much what kind of document results • real value is pulling people together to plan and analyze equity • real impact comes from using HEIA to help embed equity into the working culture of organizations © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 18

preliminary stage = scoping • could the policy or initiative have a differential or inequitable impact on different groups?1. analyze how the planned program or initiative affects health equity for particular populations • list of health disadvantaged populations – not exhaustive • potential impact on social determinants of health2. assess potential positive and negative impacts of the initiative on the population(s)3. develop strategies to build on positive and mitigate negative impacts4. plan how implementation of the initiative will be monitored to assess its impact 20

• specific tool –or rather planning repertoire – to ensure mental health is built into policy development and service planning• developed because practitioners and advocates felt mental health was not being sufficiently emphasized in general HIA• developed in the UK with significant government support • the MWIA toolkit and other health impact resources are available at http://www.apho.org.uk/resource/item.aspx?RID=95836 © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 21

January 28, 2011 22

Aims to:• To provide a practical framework to:• Raise awareness and understanding of mental well-being.• Enable a range of stakeholders to begin to identify the impact a particular policy, service, programme or project is having on mental well-being.• Encourage stakeholders to explore ways to maximize potential positive impacts and minimize potential negative ones.• Enable stakeholders to explore and develop local indicators to monitor and evaluate progress on promoting mental well-being.The toolkit contains:• An introduction & overview• A screening toolkit• An assessment toolkit that could be used for rapid or comprehensive impact assessment• Determinants and protective factors for mental well-being• Guidance on developing indicators for mental well-being• Appendices to support the MWIA process © The Wellesley Institute www.wellesleyinstitute.com

• Lewisham & Lambeth developed first MWIA toolkit• NW NIMHE, University of Liverpool, Liverpool PCT and Capital of Culture saw opportunity to develop the work at policy level (2005)• Review of eight impact assessment tools demonstrated that mental well- being not being fully addressed within HIA (2005)• Revised toolkit to take on review of evidence base on mental well-being & tested out with public policy and others• Comprehensive MWIA on Liverpool Capital of Culture (2006/07)• Published toolkit as ‘A Living & Working document’ March 2007• National & international dissemination, ongoing evaluation and monitoring• MWIA central theme in Well London three year BIG Lottery project• Supported implementation - WM Champions, NW Pioneers 2nd stage, East Midlands, training development• Now established national steering group to inform national policy and direction on improving mental health and well-being and assessing impact of a wide range of government policies and guidance (2008). © The Wellesley Institute www.wellesleyinstitute.com

• potential = • contribute to more efficient and comprehensive planning that embeds mental health • can help build comprehensive view of mental well-being • demonstrate across policy spheres the need to build mental health in • demonstrate in service providers that importance of mental health to so many spheres → transform working culture to take mental health into account• interest in Canada – • PHAC has working group • will be exploring how to adapt MWIA model to Cdn context © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 25

• MWIA toolkit sets out various determinants & protective factors of mental health: • Population characteristics • Enhancing sense of control • Increasing resilience & community assets • Facilitating community participation • Promoting social inclusion• these are very similar to those in HEIA template © The Wellesley Institute www.wellesleyinstitute.com

• diabetes prevention and management = a major provincial and LHIN priority, and key health issue for many• LHINs have explicit diabetes strategies• but we know: • People living with a serious mental illness are at higher risk for a wide range of chronic physical conditions. • People living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population. • Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes.• how do we ensure mental health is solidly embedded into diabetes strategy – and into the programs and resources that drive the strategy into action• will work through MWIA to see © The Wellesley Institute www.wellesleyinstitute.com 27

Several options – one for each?1. explore how mental health would be integrated into a community-based diabetes prevention and treatment/maintenance program • go through the MWIA steps quickly to determine how mental health needs to be taken into account in developing such a program2. explore how mental health would be integrated into a LHIN diabetes strategy • use the MWIA toolkit to identify how mental health will need to be taken into account in the strategy• will then come back together to discuss lessons learned• don’t worry about coming to substantive conclusions – really just trying out potential of planning tools © The Wellesley Institute www.wellesleyinstitute.com 28

• we are facing key challenges: • getting – and keeping – mental health on the policy agenda across government • health disparities are pervasive and deep-seated – need comprehensive strategy and significant commitment• but can’t let that paralyze us• do need comprehensive and coherent health equity and mental health strategy (in fact, strategy that integrates both) – but don’t wait for perfect strategy• think big and think strategically – but get going © The Wellesley Institute www.wellesleyinstitute.com 29

• for both mental health – and health equity – we have solid evidence, know the challenges, and know the levers and drivers for change • not perfect – but enough to act• to drive action, we need comprehensive and innovative strategy, but we also need focused planning• not just for effective implementation, but also to: • raise awareness of mental well-being and equity as vital issues • embed and operationalize them in organizational structures and working cultures • build momentum for broad policy and social change• where practical and actionable tools and processes come in• one promising and ready-to-go planning tool = Health Equity Impact Assessment • experiment and innovate with it• another promising tool could be Mental Health well-being Assessment • get involved in adapting? © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 30

• what do you think? © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 31

• will governments commit to intensive HIAs? • unlikely, certainly not at first• let’s return to our initial goal: raise awareness of mental health and get it considered in policy development • while moving towards longer-term goals of implementing comprehensive ‘mental health in all policies’ approaches• could we start with simple actionable tool? • equivalent of health equity lens – which really just asks if differential or inequitable impact • must incorporate broader view of mental well-being Could this policy or program strengthen or weaken peoples’ ability to thrive and feel good about themselves and their lives?Other ideas? © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 32

• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com• Wellesley has developed a page on health impact and HEIA, including links to leading international sites and practitioners, at http://www.wellesleyinstitute.com/health- equity-impact-assessment-heia-resources• my email is bob@wellesleyinstitute.com• I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity © The Wellesley Institute www.wellesleyinstitute.com 33

• data on health disparities• case study: applying HEIA to TC LHIN mental health strategy• framework: planning to address complex problems in complex social and policy environments • breaking down our assumption and approaches • clarifying our theory of change• the big picture – roadmap for action on social determinants of health – and mental health © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 34

• there is a clear gradient in health in which people with lower income, education or other lines of social inequality and exclusion tend to have poorer health • over ¼ of low income people in Ontario – 3 X high income – report their health to be poor or only fair • 2-3 X as many low income as high income people have chronic conditions such as diabetes or heart problems • ¼ of low income people reported their daily activities were prevented by pain = 2X than high income • difference btwn life expectancy of top and bottom income decile in Canada = 7.4 years for men and 4.5 for women • more sophisticated analyses take account of the pronounced gradient in morbidity and quality of life → health adjusted life expectancy = even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 35

• there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health• in addition, there are systemic disparities in access to and quality of care within the healthcare system• plus major differences between women and men• not just unfair, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, mental health, diabetes, etc, and contribute to avoidable costs• that’s why enhancing health equity has become a clear priority – from the Province to LHINs to many providers• and that’s why we need tools and approaches to build equity into effective system and service planning © The Wellesley Institute www.wellesleyinstitute.com 36

• the goal: • ensure equity is adequately built into mental health strategy • ensure strategy addresses systemic barriers to access and quality care • ensure strategy will benefit most health disadvantaged populations © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 37

 critical health disadvantaged pop’n equity issues all along life-course– racialized youth, poor seniors dynamics of concurrent challenges impact of racism and social exclusion, non- insured, need for customized services in TO? but newcomers, non -insured absolutely absolutely – and increasingly critical importance of income inequality and poverty place and isolation matters to mental health especially gender – systemic differences and access sexual orientation – well documented systemic discrimination and barriers © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 38

• for each of the vulnerable populations affected• did the strategy sufficiently identify? • the specific needs of these specific disadvantaged populations • the access and quality barriers they face?• unequal access to the social determinants of health and systemic barriers play out in people’s lives and in particular communities in cumulative, reinforcing and inter-dependent ways • clinical language of concurrent disorders or academic language of inter-sectionality • was this complexity captured and built into strategy? © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 39

• key goal = ensuring high-quality mental health services and continuum of support for all • were those living with mental health challenges involved in defining what quality means to them? • were they involved in indicator and measurement discussions?• working backwards from ultimate goal = what would the best quality and continuum of care look like • through an equity lens? • to these different populations – from their different perspectives?• were the voices of these different populations incorporated into planning process? © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 40

•Aboriginal populations •were Aboriginal providers/networks built into planning process? •are specific Aboriginal-driven services being planned?•homeless •were existing resources – CAISI, providers, networks, successful programs – built on? •cross-sectoral collaborations – health,•poor/economically vulnerable more shelter, social servicesgenerally •linking to poverty reduction strategies and advocacy•newcomers and people facing language •interpretation and translationbarriers •cultural competence + resources and management •funding to specialized ethno-cultural community groups © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 41

• evaluation goal = to figure out what works, in what contexts and, most importantly, how and why • we break down our plan/strategy into stages to assess what happened • were key access barriers and service gaps identified and addressed? • were services planned and delivered effectively? • full range of different service models and settings • coordinated into seamless continuum of care • did service changes improve access and quality? • using clear quality and access indicators • and building in community voice – did identified populations think these services made a difference to their well being? • ultimately, was mental health of identified populations improved and were disparities reduced? © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 42

not just taking individual account of programs but social coordination,constraints & partnerships & conditions collaboration © The Wellesley Institutewww.wellesleyinstitute.com 44

enhanced access up-stream heathto primary care conditions & & health opportunities promotion for improve fastest most for those in disadvantaged greatest need © The Wellesley Institute www.wellesleyinstitute.com 45

1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities;2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long- term;3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on;4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital;5. set and monitor targets and incentives – cascading through all levels of government and program action; © The Wellesley Institute 46 www.wellesleyinstitute.com

6 rigorously evaluate the outcomes and potential of program initiatives and investments – to build on successes and scale up what is working;7 act on equity within the health system: • making equity a core objective and driver of health system reform – every bit as important as quality and sustainability; • eliminating unfair and inefficient barriers to access to the care people need; • targeting interventions and enhanced services to the most health disadvantaged populations;8 invest in those levers and spheres that have the most impact on health disparities such as: • enhanced primary care for the most under-served or disadvantaged populations; • integrated health, child development, language, settlement, employment, and other community-based social services; © The Wellesley Institute 47 www.wellesleyinstitute.com

9 act locally – through well-focussed regional, local or neighbourhood cross- sectoral collaborations and integrated initiatives;10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities;11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country;12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective program and policy instruments, and into a coherent and coordinated overall strategy for health equity. © The Wellesley Institute 48 www.wellesleyinstitute.com

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley InstituteJanuary 28, 2011 www.wellesleyinstitute.com 49

Cmha o jan 2011

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