Health Equity Impact Assessment:
                       Potential for LHINs

  Central Local Health Integration Network
  ...
Equity-Driven Planning

• addressing health disparities in service delivery and
  planning requires a solid understanding ...
Where HEIA Fits in
                                           Repertoire of Equity-
                                      ...
Health Equity Impact
                                                          Assessment
• planning tool that analyzes po...
Components of HEIA

1.   screening – projects where             • while HEIA is sometimes
     HEIA would be useful       ...
Piloted In Toronto and
                                                        Ontario

• Ontario surveyed best practice j...
Draft Ontario HEIA: 4 Step
                                                    Process
1. template asks how the planned pr...
Toronto Consultations on
                                               HEIA: Phase 1
• goals were to get reactions to bas...
Lessons from Consultations
                            I: Participants Defined
                                     Succes...
Lessons from Consultations
                                  II: Clarify Purpose and
                                     ...
Lessons from Consultations
                                             III: Design
• need to be aware of many audiences t...
Revised Tool

• in response to consultations:
   – template was revised
   – a new workbook was developed to support easy ...
Phase 2: Piloting HEIA

• Phase 2 pilot phase took place in July to test revised tool and new
  workbook in practice
• thr...
Key Findings From Pilot

•   significant support/momentum for using HEIA
•   the tool was seen to be easy to use
•   the w...
Project Completed and
                              Report Delivered in August
• key message = while making some recommend...
National Interest

• Senate Sub-Committee on Population Health
  recommended HIA be used to ground government
  decision-m...
Moving Forward on HEIA:
                           Success Conditions and Key
                                            ...
Roll Out

• need systematic communications and roll-out plans:
   – lesson of lack of uptake for Aging at Home is that pro...
Building Capacities to Use
                                                      HEIA

• need support from LHIN for effect...
Where to Locate Capacity?

• debate in international circles on consultant vs. capacity
  building models:
   – if goal is...
Clarify LHIN Purposes

• a LHIN could use HEIA to:
   – build awareness of health equity within and across HSPs
   – ensur...
Context Is Everything

• need to be aware of context in which HEIA will be used:
   – separate program or provider wide
  ...
Decide How Seriously To
                                      Drive Implementation

• decide whether use of HEIA is volunt...
What About the Community?

• a premise of the draft Ontario HEIA – and many others – is that:
   – assessing the potential...
How Could LHINs Use HEIA
                                              Results?
• LHINs could use results from HEIA in the...
What’s Needed in Tool?

• depending upon the LHIN‟s purpose – i.e. building equity-focused
  planning among HSPs and/or us...
Monitor and Evaluate

• whatever decisions are made about scope of
  implementation, purposes and incentives, keep track o...
And a Note on Evaluating
                                  Complex Interventions

• requires clear theory: use of HEIA → b...
Building on Knowledge from
                                                 HEIA
• one broader hope is that HEIA will yiel...
Coordination

• at best, MOHLTC could:
    – develop an HEIA tool and promote its use to all LHINs
    – provide centraliz...
Follow-Up

• the implementation and impact of HEIA will continue to evolve and
  we would be very interested in any furthe...
© The Wellesley Institute   32
www.wellesleyinstitute.com
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Health Equity Impact Assessment: Potential for LHINs

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This presentation offers critical insight on the potential of LHINs.

Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI

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Health Equity Impact Assessment: Potential for LHINs

  1. 1. Health Equity Impact Assessment: Potential for LHINs Central Local Health Integration Network Speaking Notes Bob Gardner Director, Healthcare Reform and Public Policy October 19, 2009
  2. 2. Equity-Driven Planning • 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 • and this requires an array of effective and practical equity-focused planning tools • HEIA is one part of this repertoire of equity-focused planning tools © The Wellesley Institute 2 www.wellesleyinstitute.com
  3. 3. Where HEIA Fits in Repertoire of Equity- Focused Planning Tools 1. ensure equity is taken into 1. simple equity lens account in all service delivery/planning 2. assess potential impact of 2. HEIA service initiatives/policies on disadvantaged populations, access barriers and related equity issues 3. determine needs of 3. equity-focused needs communities facing health assessment disparities 4. assess impact of 4. equity-focused evaluation interventions on health disparities and disadvantaged populations © The Wellesley Institute 3 www.wellesleyinstitute.com
  4. 4. Health Equity Impact Assessment • planning tool that analyzes potential impact of service initiatives or policy changes 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 – essentially prospective • arose out of broader health impact assessments, which have been increasingly used in many jurisdictions in last 15 years – one key reason was increasing policy attention to SDoH and health disparities → need explicit equity focus – at same time, need for shorter and more focused processes – sometimes called Rapid HIA -- had been recognized – HEIA is seen to be relatively easy-to-use tool © The Wellesley Institute 4 www.wellesleyinstitute.com
  5. 5. Components of HEIA 1. screening – projects where • while HEIA is sometimes HEIA would be useful promoted as easy-to-use „first- 2. scoping – which pop‟n and pass‟ planning tool health effects to consider 3. assessing potential equity • does not mean it is only about risks and benefits – 1–3 specifying particular pop‟n 4. developing recommendations • experts argue core of HEIA is – to promote positive or in fact 4 – developing mitigate negative effects recommendations to address 5. report results to decision equity implications makers 6. monitoring and evaluation – of effectiveness of recommendations © The Wellesley Institute 5 www.wellesleyinstitute.com
  6. 6. Piloted In Toronto and Ontario • Ontario surveyed best practice jurisdictions: – Wales and New Zealand were furthest advanced – but increasing interest in other jurisdictions • MOHLTC equity unit developed a one page tool and accompanying „how-to‟ guide – first used in Aging at Home initiatives in 2008 • partnership of MOHLTC, Toronto Central LHIN and Wellesley Institute to consult, refine and pilot test in spring-summer 09 • the hope was that HEIA may have potential in other LHINs as well © The Wellesley Institute 6 www.wellesleyinstitute.com
  7. 7. Draft Ontario HEIA: 4 Step Process 1. template asks how the planned program or initiative affects health equity for particular disadvantaged populations – setting out a list of health disadvantaged populations – although list is not meant to be exhaustive – also asking about potential impact on social determinants of health 2. on the basis of the best available information and evidence, planners assess potential positive and negative impacts of the initiative on the population(s) (and indicate where more information is needed) 3. and then develop strategies to build on positive and mitigate negative impacts 4. and finally, planners indicate how implementation of the initiative will be monitored to assess its impact © The Wellesley Institute 7 www.wellesleyinstitute.com
  8. 8. Toronto Consultations on HEIA: Phase 1 • goals were to get reactions to basic idea, advice on developing most effective tool and advice on designing pilot phase – while tightly focused on HEIA, the sessions were also expected to yield broader input on health equity strategy – and to continue to lay foundations for ongoing dialogue on moving health equity forward – which they did • Phase 1 consultations completed in March: – seven sessions with 67 people – full range of providers – hospitals, CHCs, multi-service agencies – and sectors – mental health, seniors, acute, primary care – and specific consumer table – significant enthusiasm for idea and momentum for implementation – report summarizing input to partners at end of March © The Wellesley Institute 8 www.wellesleyinstitute.com
  9. 9. Lessons from Consultations I: Participants Defined Success As … • when operationalizing health equity becomes more than the work of the “equity people” • when a provider asks, “How can we include more people in this program?” ”What barriers do we have to look for?” “Are we as effective as we could be at supporting every population?” -- i.e., providers have enough awareness of health equity to ask these questions in their service planning and evaluation • when an organization embeds HEIA across its decision- making models so that health equity becomes a core value and one of the criteria to be weighed in all decisions © The Wellesley Institute 9 www.wellesleyinstitute.com
  10. 10. Lessons from Consultations II: Clarify Purpose and Audience • primary purpose for HSPs could be to: • improve attention to equity within planning • contribute to equity being solidly incorporated into program and strategic planning • raise awareness about health equity throughout the organization; • primary purpose for MOHLTC and LHINs could be to: • ensure equity impact is routinely considered in planning • make HEIA part of resource allocation and program planning and approval processes – e.g. a LHIN could: • require providers to demonstrate they have used HEIA in funding applications • use data from filled out HEIAs in program and resource allocation decisions © The Wellesley Institute 10 www.wellesleyinstitute.com
  11. 11. Lessons from Consultations III: Design • need to be aware of many audiences that could use tool, and different purposes • one-page tool would be great, but accessibility and clarity are more important • needs preamble with clear statement of principle and purpose • shift language to more positive • add prompts, definitions and case studies • align language and concepts to show decision makers that tool complements their strategic priorities and supports efficiencies • use checklist of questions rather than form to fill out • develop as electronic interactive tool with built-in prompts and online resources: e.g., definitions, descriptions, case studies, links to web- based resources, links to mentors who can provide direct support © The Wellesley Institute 11 www.wellesleyinstitute.com
  12. 12. Revised Tool • in response to consultations: – template was revised – a new workbook was developed to support easy and consistent use • the workbook: – provides definitions, examples, prompts and possible questions – is set up to help users work through the HEIA process in a step- by-step way – users simply fill out the appropriate tables in workbook itself to complete their HEIA • the workbook was designed so it can be adapted to become a Web-based interactive resource © The Wellesley Institute 12 www.wellesleyinstitute.com
  13. 13. Phase 2: Piloting HEIA • Phase 2 pilot phase took place in July to test revised tool and new workbook in practice • three settings with varying planning cases/initiatives: – hospital program in diverse urban setting – support program for patients‟ families of specialized downtown hospital – community support services for seniors • through flexible methods – Wellesley introduced tool and goals of pilot – participants either filled it out on their own or we undertook facilitated planning exercises using the tool – participants filled out evaluation survey on how process went and advice on further changes to tool © The Wellesley Institute 13 www.wellesleyinstitute.com
  14. 14. Key Findings From Pilot • significant support/momentum for using HEIA • the tool was seen to be easy to use • the workbook was an essential addition • participants were able to effectively use the tool to identify: – barriers to access and appropriate care – potential impacts of the planned program on particular disadvantaged populations • they felt it did or could build awareness of equity issues within their organization, but needed to be widely implemented to achieve this © The Wellesley Institute 14 www.wellesleyinstitute.com
  15. 15. Project Completed and Report Delivered in August • key message = while making some recommendations for revisions, we felt it was „good enough to go‟ for widespread implementation • recommendations included: – intensive promotion and communication were going to be key to widespread implementation – Ministry and LHINs need to decide for what purposes HEIA will be used, whether it will be mandatory, etc. – a number of revisions to structure/focus of HEIA tool – accompanying resources that would be needed – including eventual on-line version – organizing comprehensive implementation and roll out – building systematic evaluation strategy in from the start © The Wellesley Institute 15 www.wellesleyinstitute.com
  16. 16. National Interest • Senate Sub-Committee on Population Health recommended HIA be used to ground government decision-making and related equity data, research and planning mechanisms in its recent report • PHAC has commissioned a review of HEIA in other jurisdictions • PHAC is holding consultations in Oct • parallel workshop on how HEIA and social determinants and outcome indicators can be adapted for Aboriginal health planning purposes © The Wellesley Institute 16 www.wellesleyinstitute.com
  17. 17. Moving Forward on HEIA: Success Conditions and Key Directions • if a LHIN were to adopt HEIA, these are some success conditions – based on both piloting in Toronto and wider international experience • start from clear definition and strategy for health equity – then specify where HEIA and equity-focused planning fits in overall equity strategy – develop clear definitions and data on potentially affected populations and communities – ensure clear focus/scope: which determinants of health, which access barriers, etc. © The Wellesley Institute 17 www.wellesleyinstitute.com
  18. 18. Roll Out • need systematic communications and roll-out plans: – lesson of lack of uptake for Aging at Home is that providers can‟t adopt new planning tool if they don‟t know about it, and won‟t if they aren‟t encouraged/supported – need to make goals and focus of HEIA very clear – need to also indicate what resources will be available to support providers in using HEIA • decisions for Ministry: – all LHINS, whichever want to, pilot in a few more? – what centralized/common support to LHINs and providers? © The Wellesley Institute 18 www.wellesleyinstitute.com
  19. 19. Building Capacities to Use HEIA • need support from LHIN for effective use – in pilot, participants received extensive orientation briefing and had participated on initial consultations, and could call up consultants – with more widespread implementation, can anticipate questions and need for advice/assistance from significant numbers – many jurisdictions have workshops to support users – even electronic tool will require technical back-up and assistance • so LHINs need to build in internal capacities to support providers – let alone to analyze and build on results © The Wellesley Institute 19 www.wellesleyinstitute.com
  20. 20. Where to Locate Capacity? • debate in international circles on consultant vs. capacity building models: – if goal is widespread use by providers, then easy-to-use tool and effective support -- i.e. capacity building model is best • consensus among practitioners and experts that significant methodological expertise in health impact assessment is needed • as always = resource question – effective use and widespread roll-out will require devoted resources from both LHINs and providers – incremental and experimental roll-out could begin within existing resources © The Wellesley Institute 20 www.wellesleyinstitute.com
  21. 21. Clarify LHIN Purposes • a LHIN could use HEIA to: – build awareness of health equity within and across HSPs – ensure that HSPs take equity into account in their planning and service delivery – build up a fuller picture of equity challenges/opportunities and needs of disadvantaged populations – help LHINs set priorities and allocate resources for greatest equity impact • different goals → different HEIA strategy and techniques – e.g. the latter two require more systematic processes to collate and analyze results of many HEIAs © The Wellesley Institute 21 www.wellesleyinstitute.com
  22. 22. Context Is Everything • need to be aware of context in which HEIA will be used: – separate program or provider wide – major hospital or small community-based provider – specific barrier or disadvantaged population to which program is directed • and resources devoted to HEIA: – both at provider level – and by LHIN and/or Ministry • understanding context is crucial for both effective implementation and systematic evaluation © The Wellesley Institute 22 www.wellesleyinstitute.com
  23. 23. Decide How Seriously To Drive Implementation • decide whether use of HEIA is voluntary – and how strongly encouraged – or mandatory – and how strongly supported and enforced – international lesson = explicit requirements – or at least significant incentives – are key to widespread implementation • then what kinds of incentives and levers to use to encourage/drive use of HEIA – special ear-marked funding or consultant support to begin to use HEIA – especially at start – requiring providers to demonstrate they have used HEIA in planning out a potential project whenever they apply for funds – requirements within Service Accountability Agreements that providers use HEIA in appropriate circumstances © The Wellesley Institute 23 www.wellesleyinstitute.com
  24. 24. What About the Community? • a premise of the draft Ontario HEIA – and many others – is that: – assessing the potential impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context – this can benefit from ongoing community engagement with the population and/or specific needs assessment • analyzing possible mitigation strategies will also benefit from engaging the affected population in designing the necessary service changes • similarly, monitoring and assessing the impact of the initiative – and how HEIA contributed -- also needs: – research and input from the affected population on impact – outcome data stratified by population and determinants © The Wellesley Institute 24 www.wellesleyinstitute.com
  25. 25. How Could LHINs Use HEIA Results? • LHINs could use results from HEIA in their planning and resource allocation decisions – using analysis of information in filled out HEIA forms as one factor in resource allocation and program approval decisions – using information to shape provider-specific performance objectives and expectations – as a source of intelligence and information on equity barriers, disadvantaged populations and interesting and innovative initiatives • could also use HEIA for internal purposes – apply it to major planning initiatives within the LHINs – e.g. mental health or diabetes priorities – starting internally is one option for staging implementation and gradually building support © The Wellesley Institute 25 www.wellesleyinstitute.com
  26. 26. What’s Needed in Tool? • depending upon the LHIN‟s purpose – i.e. building equity-focused planning among HSPs and/or using HEIA within resource allocation decision making – will want to ensure: – results are easy to interpret – results lend themselves to ranking and comparisons for decisions – HEIA yields useable information on current access barriers, vulnerable populations and service innovations • from user point of view, HEIA needs to be: – easy to use – current form is good enough – has to be accompanied by workbook – need to take account of different IT and planning capacities, and comfort of participants © The Wellesley Institute 26 www.wellesleyinstitute.com
  27. 27. Monitor and Evaluate • whatever decisions are made about scope of implementation, purposes and incentives, keep track of: – which providers are using HEIA – for what purposes and in what context – with what results • develop a systematic evaluation strategy from the outset: – MOHLTC developed a Survey Monkey evaluation questionnaire for pilot – could encourage all participants to use it – supplement with more intensive interview-based evaluation research with a smaller sample after a year of implementation – define what „success‟– effective use of HEIA -- looks like – evaluate progress against this goal © The Wellesley Institute 27 www.wellesleyinstitute.com
  28. 28. And a Note on Evaluating Complex Interventions • requires clear theory: use of HEIA → better equity- focussed planning → better quality and more effectively targeted services → reduced disparities • goal is to understand how HEIA works in specific circumstances → build up comprehensive understanding of dynamics and potential of HEIA and equity-focused planning • recognize that simple tools won‟t suit all purposes • if HEIA is seen as easy-to-use tool for service planning • can‟t expect it to be useful for more complex or systemic planning purposes © The Wellesley Institute 28 www.wellesleyinstitute.com
  29. 29. Building on Knowledge from HEIA • one broader hope is that HEIA will yield useful information on existing system barriers and the needs of disadvantaged populations, and on promising and successful programme interventions – LHINs will need to capture and share this information, and build on these local front-line insights – is there a potential to share the resulting knowledge among LHINs and scale up across the province where appropriate? – what resources do the LHINs and MOHLTC need to be able to realize this potential? • this knowledge management challenge applies in many other areas – insights and case studies form hospital equity plans, experience of equity-focused service innovations across the LHIN, etc. © The Wellesley Institute 29 www.wellesleyinstitute.com
  30. 30. Coordination • at best, MOHLTC could: – develop an HEIA tool and promote its use to all LHINs – provide centralized support to encourage consistency of approach and effective use – move quickly to develop an on-line version • if that doesn‟t prove possible -- or in the meantime -- individual LHINs can implement HEIA in a coordinated fashion: – could be interesting GTA LHIN coordinated project – use same tool, record any adaptations to local contexts – share experience on how it is working – look for consistent purposes and approaches – try to monitor and evaluate within consistent approaches © The Wellesley Institute 30 www.wellesleyinstitute.com
  31. 31. Follow-Up • the implementation and impact of HEIA will continue to evolve and we would be very interested in any further thoughts on – how LHINs and Ministry can implement HEIA – how you think it might fit in your area – your experience with considering and using HEIA • my email is bob@wellesleyinstitute.com • we developed a page on HEIA resources at http://www.wellesleyinstitute.com/health-equity-impact-assessment- heia-resources • further resources on health equity strategy, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com © The Wellesley Institute 31 www.wellesleyinstitute.com
  32. 32. © The Wellesley Institute 32 www.wellesleyinstitute.com

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