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Driving Health Equity into Action: The Potential of Health Equity Impact Assessment
 

Driving Health Equity into Action: The Potential of Health Equity Impact Assessment

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This presentation provides a critical analysis of the potential of a health equity impact assessment. ...

This presentation provides a critical analysis of the potential of a health equity impact assessment.

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

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  • these damaging disparities = the problem we are trying to solvethese disparities + and their impact on people's ability to cope with health challenges = vital part of the context for all health, home and related service delivery
  • mental health is crucial component of overall well-being – also major provincial prioritysame social gradient of mental health
  • OHIP core services
  • Getting specific on concrete impact of health disparities on quality of livesactivities of ¼ of low income people are limited by pain = 2X than high income
  • In: that's impact on daily livesthat type of impact adds up over people's livesesp.. impt in this context – home and community services deal with the impact of chronic conditions and inequitable morbidity
  • reinforcing nature of social determinants on health disparities = complex problemsignificance for key priorities = crucial part of managing diabetes and other chronic conditions is good nutrition need to assess this and other facets of people’s living conditions and resources for case management and planning – what % of mw clients face food insecurityneed to customize services to meet complex and often more challenging needs of disadvantaged populations
  • this complexity is felt on the ground at program levelhighlights need to drill down to identify underlying basis of problems introduce term if needed to further illustrate complexity of landscape? inter-sectionality – reflecting the fact that personal identities, group dynamics and relations of power and opportunity do not reflect a single line of oppression/identity such as gender, race or class, but their reinforcing and interacting nature
  • another way of looking at this complexity and what to do about itcommunity resilience and capacities operates at key intersections herethis highlights that SDoH can be driven into action on the ground through:community-based development or capacity building e.g. community development workers in many CHCscross-sectoral collaborations – many local mh groups and networkscross-sectoral planning tables and processesto drive local coordinated action e..g comprehensive community initiatives such as Vibrant Communities or common pattern in European health equity strategies of concentrated/coordinated local investment/focusa central issue is how to build mental health into all that
  • Principle applies throughout system – at provider and often at program level as well
  • practical local example – esp. impt to UHN
  • In: start from solid strategic commitment – which you haveopenings: providers and LHINs are mandated to undertake community engagement
  • Sick Kids analysis of patients by neighbourhood income levelneed to match tools to purpose
  • need to match tools to purpose can adapt to particular care and disciplinary settings
  • tool --- better to think of as a process
  • where workbook comes in:provides definitions, examples, prompts and possible questionsis set up to help users work through the HEIA process in a step-by-step wayusers simply fill out the appropriate tables in workbook itself to complete their HEIAthe workbook was designed so it can be adapted to become a Web-based interactive resource
  • highlights looking for unintended consequences
  • which is equity-orientated by def’nthis is about need to drill down to complexities and specifics
  • which is equity-orientated by def’nthis is about need to drill down to complexities and specificsfor place-based = need to take account of built and social environment
  • variations would not just be unfair, but contribute to avoidable complications – quality issue – and costspart of bigger picture:here also would drill down at scoping stage to specify the problem:variations in treatment?are there variations in outcomes – immediate success of treatment, longer-term recovery, morbidity, re-admissions?
  • Step 2 – identifying possible impactsevidence tells us what does that meanStep 3 -- identifying possible mediating or remedial actionson the face of it, not much hospitals and other providers can do about social conditions?but drilling down, can actthese remedial actions seem beyond hospital mandatebut what if relatively modest costs and programs reduced re-admission and attendant costs?Sick Kids partnership with Law Society to provide landlord, legal and other support for poor families – assuming this will support children’s healthrole for LHINs in just this kind of experiment and innovation?
  • Step 2 – identifying possible impactsevidence indicates a fairly obvious implicationwhat else?any access barriers?Step 3 -- identifying possible mediating or remedial actionsbut drilling down, can act
  • many experts see recs for action as critical stage – no point in identifying inequitable impacts if nothing is going to be doneStep 4 -- monitoring impacts -- need to think about that as part of HEIA process and set up evaluation mechanisms from the start
  • recognizing that what gets measured, matters
  • if time is tight – end hereif not, skip
  • a few illustrative questions for eachwould need to drill down even deeper in working group

Driving Health Equity into Action: The Potential of Health Equity Impact Assessment Driving Health Equity into Action: The Potential of Health Equity Impact Assessment Presentation Transcript

  • Driving Health Equity Into Action: The Potential of Health Equity Impact Assessment
    Bob Gardner
    Diversity and Equity in Mental Health Conference
    May 27, 2011
  • Starting Points
    health disparities in Ontario and Canada are pervasive and damaging
    but these disparities can be addressed through comprehensive health equity strategy
    equity strategy can be driven into action within the health system through
    equity-focused planning
    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 management and service delivery
    investing in promising interventions, and pulling them together within a coherent and coordinated overall strategy
    enabling innovation through sharing and building on front-line and local initiatives, evaluation, and organizational learning
    focus today is on a key setting for implementing this overall strategy -- equity-focused planning and delivery of community-based mental health – using HEIA
    2
  • Outline
    set the scene:
    challenge of systemic health inequities
    potential of health equity strategy to address them
    one pre-condition of an effective strategy is equity-focused planning
    and one useful tool is Health Equity Impact Assessment
    will sketch out background and potential of HEIA
    will work through several concrete planning scenarios
    3
  • The Challenge: Systemic Health Disparities
    • there is a clear gradient in health in which people with lower income or socio-economic status, or facing discrimination, racism or other lines of social 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 and unjust, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs
    • enhancing health equity has become a clear priority – from the Province to LHINs to many providers
    • that’s why we need strategies, tools and best practices to build equity into effective system and service planning
    4
  • © The Wellesley Institute
    www.wellesleyinstitute.com
    5
  • Social Gradient of Health: Depression
    • lowest-income neighbourhoods had a significantly higher prevalence of probable depression than highest-income neighbourhoods
    • + inequitable service use:
    people living in the lowest-income neighbourhoods were somewhat more likely to use mental health services and to receive ECT
    much more likely to be hospitalized for depression
    however, individuals living in the lowest-income neighbourhoods accounted for lower mental health care costs, which suggests they either made fewer visits or received less expensive services than those living in the highest-income neighbourhoods.
    Source: POWER Study Vol 1 Exhibit 5a.9
    6
  • 7
  • Impact of Disparities
    inequality in how long people live
    difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women
    + inequality in how well people live:
    more sophisticated analyses add the pronounced gradient in morbidity to mortality -> taking account of 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
    Statistics Canada Health Reports Dec 09
    8
  • 9
    www.welleseyinstitute.com
    Foundations of Health Disparities Roots Lie in Social Determinants of Health
    • 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
  • Canadians With Chronic Conditions Who Also Report Food Insecurity
    10
  • SDoH As a Complex Problem
    • Determinants interact and intersect with each other
    • In constantly changing and dynamic system
    • In fact, through multiple interacting and inter-dependent economic, social and health systems
    • Determinants have a reinforcing and cumulative effect on individual and population health
    11
  • POWER Study
    Gender and
    Equity
    Health Indicator
    Framework
    12
  • Three Cumulative and Inter-Dependent Levels Shape Health Inequities
    because of inequitable access to wealth, income, education and other fundamental determinants of health ->
    also because of broader social and economic inequality and exclusion->
    along very similar lines, disadvantaged and vulnerable populations face systemic barriers within the health and other systems ->
    gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions
    some communities and populations are more vulnerable and have fewer capacities, resources and resilience to cope with the impact of health inequities
    these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need
    13
  • Health Equity = Reducing Unfair Differences
    • 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
    • Equity is a broad goal, including diversity in background, culture, race and identity
    14
  • 15
    Think Big, But Get Going
    • 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 focus here is on building equity into best mental health promotion and care
  • even though roots of health disparities lie in far wider social and economic inequality
    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 communities
    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
    Equity Into Health System: Why
    16
    • goal is to ensure equitable access to high quality healthcare regardless of social position
    • through a multi-pronged strategy:
    building health equity into all health care planning and delivery
    doesn’t mean all programs are all about equity
    but all take equity into account in planning their services and outreach
    aligning equity with system drivers and priorities
    embedding equity in provider organizations’ deliverables, incentives and performance management
    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
    while thinking up-stream to health promotion and addressing the underlying determinants of health
    Equity Into Health System: How
    17
  • Equity Into Health System: How II
    while health disparities are pervasive and deep-rooted, they can be changed through policy and program action
    comprehensive strategy developed in 2008 for Toronto Central LHIN
    many recommendations have been acted on
    other LHINs are also prioritizing and moving to address health disparities
    18
  • Start From The Community
    • goal is to reduce health disparities and speak to needs of most vulnerable communities – who will define?
    • can’t just be ‘experts’, planners or professionals
    • have to build community into core planning and priority setting
    • not as occasional community engagement
    • but to identify equity needs and priorities
    • and to evaluate how we are doing
    • how:
    • many hospital have community advisory panels
    • CHCs and many other providers have community members on their boards
    • innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries
    • community-based research, needs assessment and evaluation
    19
  • Align with System Drivers and Trends: ECFA Act and Quality Agenda
    • Quality Improvement Plans
    hospitals just developed first generation and will be reporting every year
    opportunity = equity can be built in as one of dimensions to report on
    other provider institutions will be reporting in future
    • quality and patient-centred care:
    taking lived conditions/experience into account – meaning equity and diversity -> essential to high quality patient-centred care for all
    • chronic disease prevention and management is major prov priority
    context for you – many clients will have concurrent challenges?
    • equity as contributing to cost-effectiveness and safety:
    e.g. reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over-prescriptions -> enhanced quality and cost effectiveness
    20
  • Into Practice Through Equity-Focused Planning
    • addressing health disparities in service delivery 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
    • need to understand roots 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 community-based research
    • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems
    • requires an array of effective and practical equity-focused planning tools
    21
  • Equity-Focused Planning Tools
    quick check to ensure equity is considered in all service delivery/planning
    take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery
    assess current state of provider organization
    determine needs of communities facing health disparities
    assess impact of programs/interventions on health disparities and disadvantaged populations
    simple equity lens
    Health Equity Impact Assessment
    equity audits and/or HEIA
    equity-focused needs assessment
    equity-focused evaluation
    22
  • Health Equity Impact Assessment
    • analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations
    generally designed for planning forward
    as easy-to-use tool to ensure equity factors are taken into account in planning new services, policy development or other initiatives
    • but experience here and in other jurisdictions identified other uses:
    for strategic and operational planning
    for assessing whether programs should be re-aligned or continued
    more generally, discussions around HEIA provide a way to ensure equity is incorporated into routine planning throughout an organization
    • increasing attention to this potential – from WHO, through most European strategies, PHAC, to Ontario
    23
  • HEIA In Ontario
    • first piloted and refined in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI, and in several LHINs afterwards
    • final version of template and workbook released by Ministry in 2011 see their page at http://www.health.gov.on.ca/en/pro/programs/heia/background.aspx
    • growing use within health:
    HEIA is being used in Toronto Central and other LHINs
    by many hospitals and other providers across Toronto
    Toronto Central has required HEIA within recent funding application processes for Aging at Home, and refreshing hospital equity plans
    primers on HEIA and a variant Mental Health Wellbeing Impact Assessment, many Wellesley workshops and other resources can be found on page at http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment
    • Equity Assessment Framework being developed and piloted by the Ontario Agency for Health Protection and Promotion
    24
  • HEIA Into Practice: Lessons Learned
    • from implementation so far and many workshops – can’t be prescriptive in using tool
    doesn't 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
    • another lesson learned is that effective implementation odes require capacities
    easier in large organizations with planning resources
    but, even with limited resources and correspondingly more limited scope – can still be very useful exercise
    • need to realize that HEIA will serve different purposes in different organization depending upon their experience with equity planning and implementation
    May 30, 2011
    25
  • Lessons Learned II: Adjust Purposes and Use to Context
    • for LHINs and Province, HEIA is one lever to help:
    ensure equity is routinely taken into account in health care planning and delivery
    equity gets embedded in providers’ organizational planning and practice
    especially important for health service providers who are not experienced with equity
    • but for HSPs who are experienced and committed to equity or who work with disadvantaged populations, HEIA can help to:
    ensure the full complexities of community challenges and capacities are considered
    identify sub-populations, specific barriers or other issues that can easily be missed
    can help clarify assumptions – what is exactly is meant by community? what are the success conditions for the particular program in that particular community context?
    26
  • HEIA Into Practice: Five Stages
    preliminary stage = scoping
    could the policy or initiative have a differential or inequitable impact on different groups?
    if yes, consider HEIA
    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 health
    assess potential positive and negative impacts of the initiative on the population(s)
    develop strategies to build on positive and mitigate negative impacts
    plan how implementation of the initiative will be monitored to assess its impact
    27
  • MOHLTC 2011 HEIA Template
    28
  • Scoping the Issue Through an Equity Lens
    • simple equity lens that can be broadly applied =
    could the policy, program or initiative have a differential or inequitable impact on different groups?
    • use this for scoping stage = whether there are inequitable differences is a research question:
    • so, first action item from HEIA scoping = if we don’t know -> find out
    highlights importance of collecting better equity-relevant data across the system and by every provider as a priority
    can use proxy data from postal code = neighbourhood characteristics from census data
    can use case studies and small-scale interview/chart review studies
    can rely on provider experience and community perceptions at this scoping stage
    • if evidence is yes -> then can drill down using HEIA template
    29
  • Workshop Scenarios
    • We are establishing a new mental health promotion program in an immigrant community. How can we ensure it has the greatest equity impact?
    • We are developing a drop-in counselling and support program for people with mental health needs in a poor neighbourhood. The whole point is to provide better services to a disadvantaged community. But are there other factors we need to take into account?
    • There are higher rates to re-admission for psychiatric patients from a poor neighbourhood. What can be done?
    30
  • Scenario I: Developing a Community-Based Mental Health Promotion Program in an Immigrant Community
    • drill down = what specific make-up of this immigrant community?
    legal status
    some without OHIP?
    history -- both of particular immigrant community and of individuals
    specific contexts from which people came – war, conflict
    what languages
    • what current socio-economic position?
    SDoH differences within community
    • what cultural differences/dynamics
    inter-generational differences?
    • translate material into appropriate languages
    take SDoH into account in service planning
    needs assessment and gap analysis -> prioritize services/outreach
    thinking about reach as well – who isn’t signing up or getting the services they need?
    • innovative options such as peer ambassadors
    • train partners, provide resources for capacity building
    31
  • Scenario II: Developing a Drop-in Service in a Poor Neighbourhood
    • what make-up of this community?
    are all poor
    what kinds of jobs?
    diversity along ethno-cultural , language and immigration lines
    what languages are spoken and preferred?
    asset and strength-based, not just challenges and barriers
    • what SDoH differences within community
    • what physical, environmental and other issues need to be considered – e.g. few parks, rail line or highways?
    • what mental health and related health and social services currently exist?
    needs assessment and gap analysis
    -> prioritize mix of services
    ->outreach to build on existing services and respected organizations
    ->where to base the new service that is most convenient and effective
    • translate material into appropriate languages
    take SDoH into account in service planning/delivery
    thinking about reach as well – who isn’t signing up or getting the services they need?
    • innovative options such as peer ambassadors/navigators
    32
  • Scenario III: Post-Treatment Psychiatric Re-Admission Rates
    Hospitals have found that there is a higher rate of re-admissions for their psychiatric patients who live in Parkdale and other poor neighbourhoods. What can be done?
    • wider context = considerable attention to re-admissions:
    quality issue
    clear pressure to reduce re-admissions – ties to ALC, ER and other priorities
    May 30, 2011
    33
  • Coming Into Hospital for Psychiatric Treatment: Patients From Poor Neighbourhoods
    • population health and epidemiological data indicate that they may have poorer overall health
    -> greater risk
    -> greater prevalence
    + less capacity to cope well with effects of mental illness
    • does this vary within the neighbourhood?
    by race, immigrant status, etc.
    • what community-based services are available in neighbourhood?
    are there access barriers to them – language, cost, accessibility?
    • can take poorer situations/higher risks into account:
    at least, ensure no differential or inequitable treatment
    equitable care = more intensive pre-admission planning and support for those most in need
    more intensive preventative and support programs in community
    • even broader = taking SDoH into account
    including child care, transportation and other assistance to support coming in for appointments
    nutritional and other support
    • partner with community providers to ensure better support for people
    to promote mental health and reduce need for treatment
    to enhance outcomes from treatments
    May 30, 2011
    34
  • Post-Psychiatric Treatment: Patients From Poor Neighbourhoods
    • poor living conditions, food, anxiety -> less able to cope -> poorer recovery
    • can’t take as much time off work
    • can’t afford meds
    • don’t have equitable access to home and community-based support
    research question = is access and utilization equitable?
    • can take poorer situations/higher risks into account:
    at least, ensure no differential or inequitable treatment in (length of stay, intensity, etc)
    equitable care = more intensive discharge planning, case mgmt and assessment
    send home with more supplies, meds, etc.
    more intensive follow-up to those in greatest need – socially as well as medically defined
    • partner with community-based providers and groups
    May 30, 2011
    35
  • HEIA Into Action
    • demonstrated value of equity lens on this issue – and most?
    • can identify inequitable constraints and barriers:
    in many cases, some seem outside of provider’s control
    -> but can take into account in care planning
    -> develop strategic partnerships
    can identify mediating actions that can be taken and make recommendations:
    to senior mgmt and appropriate care teams
    • then need to monitor impact:
    indicators and stats
    patient satisfaction – by these equity variables
    • assess lessons learned -> incorporate into ongoing quality improvement
    May 30, 2011
    36
  • Specific Variant: MWIA
    • potential =
    contribute to more efficient and comprehensive planning that embeds mental health
    can help build comprehensive view of mental well-being – dual continua approach
    demonstrate importance of mental health to so many service and policy 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
    May 30, 2011
    37
  • May 30, 2011
    38
  • Beyond Planning: Embed Equity in Performance Measurement and Management
    • clear consensus from research and policy literature and consistent feature in comprehensive policies on health equity from other countries =
    • setting targets for reducing access barriers, improving health outcomes of particular populations, etc
    • developing realistic and actionable indicators for service delivery
    • closely monitoring progress against the targets and indicators
    • disseminating the results widely for public scrutiny
    • tying funding and resource allocation to performance
    • what would equity-focused performance indicators, measurement and management look like for mental health?
    39
  • Beyond Healthcare System: SDoH Into Action
    • have emphasized taking SDoH into account in service delivery and planning
    • more broadly, cross-sectoral coordination and planning are much emphasized in public health and health policy circles
    • addressing wider SDoH is the glue for collaboration into action
    • public health departments and LHINs are pulling together or participating in cross-sectoral planning tables
    • Local Immigration Partnerships , Social Planning Councils
    • comprehensive community initiatives to address poverty and other complex local problems
    • the Ministry of Health Promotion and Sport is developing a healthy communities strategic approach
    • cross-sectoral planning to ground health promotion
    • at best, this implies wider community development and capacity building approaches
    40
  • Key Messages
    • 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
    • build equity into strategic priorities, align with quality agenda and system priorities, embed in routine planning and performance management
    • and build equity into front-line planning and delivery where you practice
    • no magic blueprint -- experiment and innovate -- and build on learnings and success
    41
  • Key Messages II
    • 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
    May 30, 2011
    42
  • Appendices
    • case study scenario: HEIA to a LHIN mental health strategy
    • drilling down to theory of change underlying equity-focused planning
    • Wellesley Health Equity Roadmap
    43
  • Case Study: Using HEIA For TC LHIN Mental Health Strategy
    • 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
    May 30, 2011
    44
  • 1: Scoping Who Is Affected
    • 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
    May 30, 2011
    45
  • 2: Drilling Down on Impact
    • 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?
    May 30, 2011
    46
  • 2: Drilling Down on Process
    • 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?
    May 30, 2011
    47
  • 3: Addressing Needs and Barriers
    • Aboriginal populations
    • homeless
    • poor/economically vulnerable more generally
    • newcomers and people facing language barriers
    • were Aboriginal providers/networks built into planning process?
    • are specific Aboriginal-driven services being planned?
    • were existing resources – CAISI, providers, networks, successful programs – built on?
    • cross-sectoral collaborations – health, shelter, social services
    • linking to poverty reduction strategies and advocacy
    • interpretation and translation
    • cultural competence + resources and management
    • funding to specialized ethno-cultural community groups
    May 30, 2011
    48
  • 4: Evaluation and Monitoring
    • 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?
    May 30, 2011
    49
  • Challenges of Equity-Focused Evaluation
    • Ministry, LHINs and research bodies need to fund and enable evaluation – not just as a tacked-on expectation in accountability regimes
    • need to figure our what interventions and approaches work, in what contexts and why
    • at a program as well as system level:
    • can’t just measure activity – number or % of pop’n that participated in a program or received particular services
    • need to measure health outcomes – even when impact only shows up in long-term
    • need to assess reach -- who isn’t signing up or getting the services they need?
    • need to differentiate those with greatest need = who programs most need to reach and keep to have an impact
    50
  • Drilling Down: Our ‘Theory of Change”
    • ‘realist’ evaluation approach has great potential:
    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?
    • evaluation goal = to figure out what works, for whom, in what contexts
    • start from clear theory of how we think better planning will reduce health inequities
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  • taking account of social constraints & conditions
    not just individual programs but coordination, partnerships & collaboration
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  • enhanced access to primary care & health promotion for most disadvantaged
    up-stream heath conditions & opportunities improve fastest for those in greatest need
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    • 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
    Following Up
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  • Wellesley Roadmap for Action on the Social Determinants of Health
    look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities;
    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;
    develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on;
    act across silos – inter-sectoral and cross-government collaboration and coordination are vital;
    set and monitor targets and incentives – cascading through all levels of government and program action;
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  • Wellesley Roadmap II
    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;
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  • Wellesley Roadmap III
    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.
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  • © The Wellesley Institute
    www.wellesleyinstitute.com
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