Health Equity for Immigrants and Refugees: Driving Policy Action


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This presentation discusses health equity for immigrants and refugees.

Bob Gardner, Director of Policy
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  • again = need sophisticated policy analysis and political strategy
  • in KE terms:tremendous research has identified the nature of the problem to be solvedthis = SO WHAT part of analysisbut NOW WHATwhat would success look like?how do we get therewhere research (and researchers) meets strategy, policy analysis/advocacy and political mobilizationwill illustrate through examples from Ont activism opposing cuts to IFH
  • equity is ‘wicked’ policy problem, but not all of it = predictable and avoidable results of bad policyeliminate the three month wait for OHIP for new immigrants
  • working with TC LHIN -- series of policy briefs and informal advice
  • strategists and activists identified necessary actions at all these levelsvarious products – policy briefs to govts and RHAstried to also ensure multi-level action were coordinated and pulled into coherent overall strategy
  • illustrate all this through recent history of campaigns in Onthave emphasized need to define what success looks likeneed to also know what is not failure:if we can’t rescind IFH = not failureif we didn’t build campaign and develop service responses = would be failureneed to take long viewwe had developed a series of policy briefsOur demands to Grondin and feds:Reverse the cuts to the Interim Federal Health program;Respond to the cases that have been reported by Canadian Doctors for Refugee Care and convene a roundtable to identify opportunities to collect data more systematically; andRespond to the concerns about cuts to the Interim Federal Health program raised by numerous professional health care associations.
  • demands to MOHLTC and Prov:Formally commit, as Quebec has done, to ensuring that refugees no longer supported by Interim Federal Health program are not denied care;Measure and report on the negative health outcomes caused by cuts to the Interim Federal Health program;Track financial price of the changes to the Interim Federal Health program through increases in preventable emergency room visits; andReview their existing policies on eligibility for provincial/territorial health coverage to ensure that they do not negatively impact immigrant and refugee health.sophisticated argument to Ont – risk of being embarrassed so rescind 3 month
  • demands on RHAsEnsure that refugees are not denied care;Endorse the documentation of impacts and adapt the Refugee HOMES documentation tool; andEnable or require health care providers to document cases and track additional costs incurred in serving refugee patients
  • demands we put forth:Ensure that refugees are not denied care; Endorse the documentation of impacts and adapt the Refugee HOMES documentation tool; andDevelop contingency plans and monitor the demand for services by refugees
  • back to taking the long view and remembering fundamental goals
  • building on realist evaluation/synthesis approach – nothing so practicalneed clear theory or framework for change
  • including collaborations well beyond the health care system to address the underlying determinants of health inequalities
  • Health Equity for Immigrants and Refugees: Driving Policy Action

    1. 1. Health Equity For Immigrantsand Refugees: Driving Policy Action Bob Gardner Migrant and Refugee Children: Entitlement and Access to Health Care in Canada National Seminar: Montreal March 26-7, 2013
    2. 2. Outline• inequitable health and access to care for immigrant and refugee communities is a complex problem – with huge unfair and avoidable human costs• we know what the problem is and what changes are needed to solve it• we need sophisticated policy analysis and political strategy to drive the needed changes • will set out what a strategy for change could look like • the policy cases that need to be made • effective and ways to make those cases • illustrate by sharing some experience/examples from OntarioApril 4, 2013 | 2
    3. 3. Systemic Health Inequities Faced by Immigrant Communities = ‘Wicked’ Problem• health inequities and their underlying social determinants of health are classic ‘wicked’ policy problems: • shaped by many inter-related and inter-dependent factors • in constantly changing social, economic, community and policy environments • action has to be taken at multiple levels -- by many levels of government, service providers, other stakeholders and communities • solutions are not always clear and policy agreement can be difficult to achieve • effects take years to show up – far beyond any electoral cycle• have to be able to gear solutions to specific needs, barriers and situations of specific populations – such as immigrants and refugeesApril 4, 2013 3
    4. 4. Think Big, But Get Going• the point of all this social determinants and policy analysis is to be able to identify the changes needed to reduce health disparities• but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing• have big goals and think strategically, but get going • make best judgment from evidence and experience • identify actionable and manageable initiatives • experiment and innovate • learn lessons and adjust • demonstrating success → build momentum for change• need to start somewhere – start where you are and where you can make a differenceApril 4, 2013 | 4
    5. 5. First, Clarify the Problem To Solve• emerging but clear evidence of health impacts: • inequitable access to health care and other services • inequitable treatment and quality • inequitable health outcomes • playing out differently in different populations → different needs and barriers to good care → different program and policy solutions• how people came to be uninsured – and their legal and social circumstances – is quite different → different policy solutionsApril 4, 2013 | 5
    6. 6. Then Develop Solid Strategy• have to be able to understand and navigate this complexity to develop solutions by identifying: • the key pathways to change that will make fundamental difference to population health overall or the particular problem/community • the crucial policy levers that will drive the needed changes• and need to understand the policy context or environment for achieving the needed changes • identifying the best opportunities: • being alive to policy windows as they emerge • knowing who controls the policy levels we want to change • and where needed changes will get the most traction• and making solid business case • actionable policy options • designed for particular level of government/decision makerApril 4, 2013 | 6
    7. 7. And Policy Analysis/Advocacy• research demonstrating inequitable access → delayed care and worse outcomes• analysis of federal cuts to refugee health care → predictable and avoidable adverse impact on particularly vulnerable people• building the policy case(s) e.g. IFH cuts → increased healthcare costs/demands at prov and provider levels • to demonstrate common interests • well designed policy briefs with actionable alternatives • and sustained interaction with policy makers • build alliances and coordination 7
    8. 8. And Innovative Advocacy• political activism • ‘white coat’ guerillas • clinicians effectively using their professional prestige and platforms • media work • coalitions, networks and direct action • lots of ‘insider’ work with policy makers+ with a service face • on-the-ground service innovations • plus enormous individual advocacy for refugees needing care • to mitigate adverse impact of cuts and deliver best care to vulnerable populations = constant demonstration that alternatives are possible+ multi-level strategy always needs a Plan B: • looking ahead – how to keep issue alive • continuing to document adverse consequences –Refugee HOMES documentation tool established by clinicians, revising HEIAApril 4, 2013 | 8
    9. 9. Need Action at Different System and Organizational Levels Need to Move Different Policy Levers Health Equity for Immigrants & Refugees Broad SDoH & Policy Environment Provincial Health Care Systems Regional Health Authorities Hospital, Community & Other Providers
    10. 10. Driving Action: Federal Level• key immediate challenge: • rescind the cuts to IFH • not much chance → advocacy to make impacts of cuts and operation of remaining insurance program a little less bad• key strategy has been building broad awareness and partnerships • powerful symbolism of so many national health organizations supporting demands• always make the connections – link IFH demands into need for more equitable immigration policy more generally • and better settlement strategy and resourcesApril 4, 2013 | 10
    11. 11. Driving Action: Provincial Level• the case to be made: • IFH cuts will adversely effect already health disadvantaged populations • will increase avoidable costs to be borne by prov• action needed: • clear commitment to make up difference and ensure access to care • clear directions to providers to serve refugees • ensure resources • monitor increased costs and adverse effects – encourage/require providers to use surveyApril 4, 2013 | 11
    12. 12. Driving Action: Local Level• Regional Health Authorities are key location for addressing problem • can establish coordinating or problem solving groups • can direct providers to ensure access • can direct providers to document health and cost impacts• Toronto Central led on refugee issue for LHINs: • it has long history of commitment to equity • providers and activists on this issue have been well connected to the LHIN and provided considerable input • have been addressing problems of uninsured – e.g. systematize referral and payment relationships between CHCs and hospitals• but also municipal govts – e.g. Toronto • Public Health and Board of Health highlighted adverse health situation of undocumented • Council adopted a ‘Sanctuary City’ type policy to provide services regardless of legal immigration statusApril 4, 2013 | 12
    13. 13. Driving Action: Provider Level• build on existing resources and networks: • CHCs have had provincial funding – now also midwives • Women’s College Hospital Network on Noninsured is forum for local coordination• what providers can do: • ensure no discrimination – right through their organization – and that refugees are never denied care • develop contingency plans to deal with effects of IFH cuts • add their voice opposing inequitable impacts – let alone increased pressure on their services • join with refugee doctors in systematically collecting info on patient consequencesApril 4, 2013 | 13
    14. 14. Looking Beyond IFHNever Just Equitable Access, But Quality For All• adverse social context and living conditions for many immigrants → can increase risk of mental and physical illness + fewer resources to cope (from supportive social networks, to good food and being able to afford medications)• for high quality person-centred care → providers and programs need to customize and adapt care to population needs and contexts → good communications and provider-patient relationship means taking the full range of people’s needs/situations into account • e.g.. more intensive case management, referral planning and post- discharge follow-up for health disadvantaged• in an increasingly diverse society, high quality care = culturally competent care: • requires organizational resources, commitment and operationalization 14
    15. 15. Back to Strategy/Back to the Front-Line• think big, but act where you are/where you can• providers and activists coming together to address a horrible problem: • innovative clinics and other ‘work-around’ solutions • community based services to provide comprehensive health, social and other support • improve equitable access to health care and opportunities for good health for immigrant and refugee communities• complex challenges need multi-level solutions• need to map out all the factors and forces that need to be shifted and coordinated to accomplish goalApril 4, 2013 | 15
    16. 16. Equitable Health Care for Immigrant Communities Mapping Enablers and Success Conditions Link Into Professional Ensure Funding, Training, Diversity Accountability, & Build Immigrant and Equity Other Incentives Care Into Explicit Policies Align with Broadly Based Equity Standards & Changes Needed Provider Coordinating Quality Networks & Cross- Improvement Sectoral Collaboration Enable Front-Line Service Delivery Political & Work-Arounds & Community Innovations Mobilization Broader PolicyBuild Awareness Environment:Across the Health More Equitable Opportunities to Care System Health Care for Shift Refugees Immigration Policy
    17. 17. Key Messages• health disparities are pervasive and deep-seated – but can’t let that paralyze us• do need a comprehensive and coherent immigrant/refugee health equity strategy – but don’t wait for perfect strategy• do need to immediately oppose damaging policies such as IFH cuts – but always keep long-term goals in mind• think big and think strategically – but get going• there is a solid base of evidence, provider experience, commitment and community connections to build on17
    18. 18. Key Messages II• key success conditions for enhancing health equity for immigrant and refugee communities: • solid research and policy analysis • demonstrate what success looks like through service innovations however/wherever you can • keep connected • make a solid case for reform – geared to different decision- makers and partners • all within a coherent strategy – well-focused, multi-level and long-term • use the platforms we have • build partnerships and coalitions to drive mobilization • try to shift the frame of public debate and discourseApril 4, 2013 | 18