Health Equity Impact Assessment: A Tool for Driving Equity Into Action May 18,2010

Bob Gardner Mt Sinai Hospital May 18, 2010 © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 1

1. health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy 2. 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, diabetes, etc. • building equity into ongoing performance and system management, and routine service delivery • investing in promising interventions, and pulling them together within a coherent overall strategy and an integrated and coordinated program • sharing and building on front-line and local initiatives, evaluation, and other enablers for innovation 3. 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 • will set out how to realize potential within hospital • will work through process with concrete example © The Wellesley Institute www.wellesleyinstitute.com 2

• 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 • plus major differences between women and men • in addition, there are systemic disparities in access to and quality of care within the healthcare system • not just unfair, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, 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 3

• Ministry: • new legislation/policy builds specific priorities into performance management • equity is among attributes of high-performing health system defined by Ontario Health Quality Council and in proposed legislation: • more generally, equity contributes to quality, sustainability and efficiency • can’t solve provincial priorities such as wait times or chronic conditions without addressing equity • Toronto Central LHIN: • also emphasizes building equity into performance management and core of planning – see analysis of first hospital equity plans • HEIA is being adopted seriously by TC LHIN • have to anticipate it will be required © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 4

• 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 5

• 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 • this requires sophisticated analyses of the bases of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of specific analyses within provider organizations and community-based research • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • and requires an array of effective and practical equity-focused planning tools © The Wellesley Institute www.wellesleyinstitute.com 6

1. quick check to ensure equity is 1. simple equity lens considered in all service delivery/planning 2. take account of disadvantaged populations, access barriers and 2. Health Equity Impact related equity issues in program Assessment planning and service delivery 3. assess current state of provider 3. equity audits and/or HEIA organization 4. determine needs of communities 4. equity-focused needs facing health disparities assessment 5. assess impact of programs/interventions on 5. equity-focused evaluation health disparities and disadvantaged populations © The Wellesley Institute 7 www.wellesleyinstitute.com

• 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 • piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI • refined template and developed a new workbook • 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 • increasing attention to potential – from WHO, through most European strategies, PHAC, to MOHLTC and LHINs © The Wellesley Institute www.wellesleyinstitute.com 8

1. template asks 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 health 2. planners assess potential positive and negative impacts of the initiative on the population(s) (and indicate where more information is needed) 3. develop strategies to build on positive and mitigate negative impacts 4. planners indicate how implementation of the initiative will be monitored to assess its impact 10

• generally designed for planning forward: • easy-to-use tool to ensure equity factors are taken into account in planning • more generally, can be a means to ensure equity is incorporated into routine planning throughout an organization • 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 © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 11

• much monitored and incorporated into performance mgmt and quality improvement • clear pressure to reduce re-admissions – ties to ALC, ER and other priorities • are there equity implications? • can assume people on operating table are treated equitably depending upon their immediate situation • but are there variations in outcomes – immediate success of operations, mortality, complications, re-admissions? • by gender • by social and economic situation • by ethno-cultural or immigration status • by comfort/facility with English © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 12

• whether there are inequitable variations in re-admissions is a research question: • hospitals don’t usually collect such data • so use proxy data from postal code = neighbourhood characteristics from census data • can use case studies and small-scale interview/chart review studies • highlights importance of project underway to collect better equity-relevant data • if evidence is yes – or if practitioners experience leads them to conclude that there are inequitable variations • then need to drill down using HEIA template to analyze why particular populations might have higher re-admissions – two examples to illustrate • patients from poor neighbourhoods • patients who do not speak or understand English well • and need to drill down to different stages of care process © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 13

•population health and •not much hospitals can do about epidemiological data indicate that social conditions? they may have poorer overall health → greater risk •can take poorer situations/higher + less capacity to cope well with risks into account: effects of surgery • at least, ensure no differential or inequitable treatment • equitable care = more intensive pre-admission planning and support • even broader = including child care, transportation and other assistance to support coming in for pre-surgery • nutritional and other support to help prepare © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 14

•population health and •can take poorer epidemiological data indicate situations/higher risks into that they may face: account • SES challenges as above reflecting more unequal or precarious position in labour •as previous + market • cultural competence lens • plus effects of immigration • interpretation at pre-surgery status, social exclusion and • translation of all material other social determinants • more intensive follow-up to shaping poorer overall health confirm/support – possibly → greater risk peer health ambassadors + less capacity to cope well with effects of surgery + might not understand pre-op instructions and prep © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 15

•poor living conditions, food, •can take poorer anxiety → less able to cope → situations/higher risks into poorer recovery account: •can’t take as much time off • at least, ensure no differential work or inequitable treatment in post-surgical (length of stay) •can’t afford dressings and or discharge planning other requirements • equitable care = more •can’t afford meds intensive case mgmt and assessment •don’t have equitable access • send home with more to home and community- supplies, meds, etc. based support • more intensive follow-up to • research question for CCAC those in greatest need – not • is access and utilization just medically defined equitable? © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 16

•social determinants •can take social conditions related challenges as into account as previous previous + cultural competence lens + may not understand how • interpretation for to take meds or follow-up discharge planning care • translation of all post- surgical materials may not be able to contact • more intensive follow up in professional for advice language/culture • potential of peer health ambassadors © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 17

• demonstrated value of equity lens on this issue – and most? • can identify inequitable constraints and barriers: • in this case, some seem outside of hospital’s control → but can take into account in care planning • can identify mediating actions that can be taken and make recommendations: • to senior mgmt team • to appropriate surgical, nursing and other care teams • then need to monitor impact: • indicators and stats • patient satisfaction – by these equity variables • can assess lessons learned → incorporate into ongoing quality improvement © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 18

• health disparities are pervasive and deep-seated – but can’t let that paralyze us • do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy • think big and think strategically – but get going • one part of this is equity-focused planning • more specifically, one promising and ready-to-go planning tool = Health Equity Impact Assessment • experiment and innovate with it © The Wellesley Institute www.wellesleyinstitute.com 19

Wellesley has developed a page on HEIA resources at http://www.wellesleyinstitute.com/health-equity-impact-assessment- heia-resources Other Health Equity Resources: • The Wellesley Institute http://wellesleyinstitute.com • Health Equity Council http://healthequitycouncil.ca • Rainbow Health Network http://www.rainbowhealthnetwork.ca • Ontario Women’s Health Network http://www.owhn.on.ca • Ethno-Racial People with Disabilities http://erdco.ca • Health Equity Toolkit – blog is at http://www.smallstepsbigdifference.blogspot.com 20

• 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 • 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 21

• 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 and developing data on health adjusted life expectancy = even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 22

POWER Study Gender and Equity Health Indicator Framework 23

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 24 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 25 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 26 www.wellesleyinstitute.com

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley Institute May 19, 2010 www.wellesleyinstitute.com 27

Health Equity Impact Assessment: A Tool for Driving Equity Into Action May 18,2010

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