Tc lhin mental health strategy july 2010

Bob Gardner Toronto Central LHIN July 6, 2010 © The Wellesley Institute July 20, 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, 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 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 the potential of HEIA within mental health • will set out how to work through process in assessing your strategy © 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 • 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, 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

• roots of health disparities lie in far wider social and economic inequality → need macro policy changes to reduce inequalities → but how the health system is organized and how services and care are delivered is still crucial to tackling health disparities • 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 4

• 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 5

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 6 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 by providers across the province • HEIA is being incorporated into a “health in all policies’ framework by MOHLTC © The Wellesley Institute www.wellesleyinstitute.com 7

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 health 2. assess potential positive and negative impacts of the initiative on the population(s) 3. develop strategies to build on positive and mitigate negative impacts 4. plan how implementation of the initiative will be monitored to assess its impact 9

• 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 – can’t be prescriptive in using tool • real value is pulling people together to plan and analyze equity • your 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 Institute July 20, 2010 www.wellesleyinstitute.com 10

 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 Institute July 20, 2010 www.wellesleyinstitute.com 11

• 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 Institute July 20, 2010 www.wellesleyinstitute.com 12

• 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 Institute July 20, 2010 www.wellesleyinstitute.com 13

•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 services generally •linking to poverty reduction strategies and advocacy •newcomers and people facing language •interpretation and translation barriers •cultural competence + resources and management •funding to specialized ethno-cultural community groups © The Wellesley Institute July 20, 2010 www.wellesleyinstitute.com 14

• ‘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? • ultimate evaluation goal = to figure out what works, in what contexts and, most importantly, how and why © The Wellesley Institute July 20, 2010 www.wellesleyinstitute.com 15

not just taking individual account of programs but social coordination, constraints & partnerships & conditions collaboration © The Wellesley Institute www.wellesleyinstitute.com 16

enhanced access up-stream heath to primary care conditions & & health opportunities promotion for improve fastest most for those in disadvantaged greatest need © The Wellesley Institute www.wellesleyinstitute.com 17

• were key enablers for evaluation built into strategy? • clear indicators • consistent collection of required data to monitor progress on these indicators • community engagement to build consumer/survivor perspectives and input into evaluations • $ and resources so providers can actually do this data, measurement and evaluation work • moving forward: can potential of innovation and improved services be realized? • huge amount of front-line mental health innovation underway • need forums to share lessons learned – at best, not just LHIN, but city and province-wide • building evaluation into continuous learning and service improvement cycle within service providers © The Wellesley Institute July 20, 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 • 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, including links to leading international sites and practitioners, 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 → health adjusted life expectancy = even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women © The Wellesley Institute July 20, 2010 www.wellesleyinstitute.com 22

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 23 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 24 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 25 www.wellesleyinstitute.com

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley Institute July 20, 2010 www.wellesleyinstitute.com 26

Tc lhin mental health strategy july 2010

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