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Bob Gardner
                HEIA Workshop
    Ontario Community Support Association
Great !deas Conference: New Recipes fo...
1.   health disparities in Ontario and Canada can be addressed through
     comprehensive health equity strategy
2.   equi...
1. a little background:
   •   nature and scale of health disparities
   •   overall health equity strategy – the recipe f...
• there is a clear gradient in health in which people with lower
  income, education or other indicators of social inequal...
© The Wellesley Institute
www.wellesleyinstitute.com   5
© The Wellesley Institute
www.wellesleyinstitute.com   6
© The Wellesley Institute
www.wellesleyinstitute.com   7
© The Wellesley Institute
www.wellesleyinstitute.com   8
inequality in how long people live
          • difference btwn life expectancy of top and bottom income
            decile...
•   clear research consensus that roots
    of health disparities lie in broader
    social and economic inequality and
  ...
© The Wellesley Institute
www.wellesleyinstitute.com   11
•Determinants interact and
intersect with each other
•In constantly changing and
dynamic system
•In fact, through multiple...
POWER Study
Gender and
Equity
Health Indicator
Framework




                   13
• the point of all this analysis is to be able to identify
  policy and program changes needed to reduce health
  disparit...
• Health disparities or inequities are differences in health outcomes
  that are avoidable, unfair and systematically rela...
• Ministry:
   • new legislation/policy emphasizes achieving specific
     priorities – and will build into system and per...
• goal is to ensure equitable access to high quality
  healthcare regardless of social position
• can do this through a tw...
while health disparities are
                pervasive and deep-rooted, they
                can be changed through policy...
• align equity with system drivers and priorities :
   • equity is pre-condition to quality and efficiency agendas
   • ca...
• addressing health disparities in service delivery and planning
  requires a solid understanding of:
    • key barriers t...
1.   quick check to ensure equity is            1.       simple equity lens
     considered in all service
     delivery/p...
• analyzes potential impact of program or policy change on health
  disparities and/or health disadvantaged populations
  ...
• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN
  and WI
   • refined template and developed a new workbook
 ...
24
1.   analyze how the planned program or initiative affects health equity for
     particular vulnerable populations
     •...
• diabetes prevention and management = a major
  provincial and LHIN priority, and key health issue for
  many
• new progr...
• this preliminary step is to see if there possibly could be inequitable
  effects of the planned initiative – to see if H...
• what is the current local demography of diabetes?
   • what areas/communities most affected/at risk?
   • isolated senio...
Three step analysis of inequality:
1. gradient of health outcomes:                     1.       highlights need to identif...
• need to drill down to identify most vulnerable sub-
  populations?
   •   recent immigrants with limited English
   •   ...
• need to always drill down to specific community or impact:
    • i.e. in diverse communities, ensure cultural competence...
• collect comprehensive health data – and differentiate by social
  determinants of health from the outset
• monitor how r...
• this hypothetical program obviously is ideal case
• in the real world, resource constraints, over-stretched staff
  and ...
• health disparities are pervasive and deep-seated –
  but can’t let that paralyze us
• do need a comprehensive and cohere...
Wellesley has developed a page on HEIA resources at
  http://www.wellesleyinstitute.com/health-equity-impact-assessment-
 ...
• these speaking notes and further resources on
  policy directions to enhance health equity, health
  reform and the soci...
1. look widely for ideas and inspiration from jurisdictions with comprehensive
   health equity policies, and adapt flexib...
6  rigorously evaluate the outcomes and potential of program initiatives and
   investments – to build on successes and sc...
9 act locally – through well-focussed regional, local or neighbourhood cross-
   sectoral collaborations and integrated in...
The Wellesley Institute advances urban health through rigorous research,
  pragmatic policy solutions, social innovation, ...
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Health Equity Impact Assessment: A Tool for Driving Equity into Action

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This presentation provides insight on how to drive equity into action.

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

Published in: Health & Medicine
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Health Equity Impact Assessment: A Tool for Driving Equity into Action

  1. 1. Bob Gardner HEIA Workshop Ontario Community Support Association Great !deas Conference: New Recipes for Success October 19, 2010 © The Wellesley Institute www.wellesleyinstitute.com
  2. 2. 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 through • equity-focused planning • aligning equity with key system drivers such as sustainability and quality, and priorities such as ER, ALC, diabetes, etc. • building equity into ongoing performance and system management, and routine service delivery • investing in promising interventions, and pulling them together within a coherent overall strategy and an integrated and coordinated program • enabling innovation through sharing and building on front-line and local initiatives, evaluation, and organizational learning 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 © The Wellesley Institute www.wellesleyinstitute.com 2
  3. 3. 1. a little background: • nature and scale of health disparities • overall health equity strategy – the recipe for success 2. all of which depends on solid equity-focused planning • pre-condition to getting the recipe right 3. introduction to health equity impact assessment • and working though one example together • adapting the recipe to local ingredients 4. working though HEIA in small group 5. back together on potential of HEIA to help drive equity strategy into action © The Wellesley Institute www.wellesleyinstitute.com 3
  4. 4. • there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health • plus major differences between women and men • in addition, there are systemic disparities in access to and quality of care within the healthcare system • not just unfair, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs • that’s why enhancing health equity has become a clear priority – from the Province to LHINs to many providers • and that’s why we need tools and approaches to build equity into effective system and service planning © The Wellesley Institute www.wellesleyinstitute.com 4
  5. 5. © The Wellesley Institute www.wellesleyinstitute.com 5
  6. 6. © The Wellesley Institute www.wellesleyinstitute.com 6
  7. 7. © The Wellesley Institute www.wellesleyinstitute.com 7
  8. 8. © The Wellesley Institute www.wellesleyinstitute.com 8
  9. 9. 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 © The Wellesley Institute www.wellesleyinstitute.com 9
  10. 10. • 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 www.welleseyinstitute.com 10
  11. 11. © The Wellesley Institute www.wellesleyinstitute.com 11
  12. 12. •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 © The Wellesley Institute www.wellesleyinstitute.com 12
  13. 13. POWER Study Gender and Equity Health Indicator Framework 13
  14. 14. • the point of all this analysis is to be able to identify policy and program changes needed to reduce health disparities • but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing • think big and think strategically, but get going • everything can’t be tackled at once --need to split strategy into actionable components and phase them in • make best judgment from evidence and experience • identify actionable and manageable initiatives that can make a difference • experiment and innovate • learn lessons and adjust • gradually build up coherent sets of policy and program actions – and keep evaluating and adapting © The Wellesley Institute 14 www.wellesleyinstitute.com
  15. 15. • 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 © The Wellesley Institute www.wellesleyinstitute.com 15
  16. 16. • Ministry: • new legislation/policy emphasizes achieving specific priorities – and will build into system and performance management • equity is among attributes of high-performing health system defined by Ontario Health Quality Council and in new legislation: • more generally, equity contributes to quality, sustainability and efficiency • key LHINs – especially Central and Toronto Central : • also emphasize building equity into performance management and planning © The Wellesley Institute www.wellesleyinstitute.com 16
  17. 17. • 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 17
  18. 18. 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 © The Wellesley Institute www.wellesleyinstitute.com 18
  19. 19. • align equity with system drivers and priorities : • equity is pre-condition to quality and efficiency agendas • can’t solve wait times or chronic conditions without addressing equity • build equity into strategic priorities: • all LHINs and providers to make explicit equity commitments • build equity into strategic and operational planning and service delivery • use levers to hand • e.g. LHINs can have providers develop equity plans • and/or ensure equity is vital part of quality plans that will be required under new legislation • build equity into routine into performance management: • explicit equity targets and incentives • cascading through the system -- Prov → LHINs, agencies, etc.→ providers © The Wellesley Institute www.wellesleyinstitute.com 19
  20. 20. • addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations • this requires sophisticated analyses of the bases of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of specific analyses within provider organizations and community-based research • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • and requires an array of effective and practical equity-focused planning tools © The Wellesley Institute www.wellesleyinstitute.com 20
  21. 21. 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 21 www.wellesleyinstitute.com
  22. 22. • 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 providers in pilot phases here – and experience from 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 potential – from WHO, through most European strategies, PHAC, to Ontario © The Wellesley Institute www.wellesleyinstitute.com 22
  23. 23. • piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI • refined template and developed a new workbook • HEIA is being used in Toronto Central and other LHINs • Toronto Central has required HEIA within recent funding application processes for Aging at Home, and hospital equity plans • HEIA is being incorporated into a “health in all policies’ framework by MOHLTC • Ministry is developing additional user resources and will be promoting HEIA • have to anticipate HEIA will be required for some purposes – so get out ahead and adapt for your own planning purposes © The Wellesley Institute www.wellesleyinstitute.com 23
  24. 24. 24
  25. 25. 1. analyze how the planned program or initiative affects health equity for particular vulnerable populations • list of health disadvantaged populations – not meant to be exhaustive • also, potential impact on social determinants of health 2. assess potential positive and negative impacts of the initiative on the population(s) • based upon best available information and evidence • and indicate where more information is needed 3. develop strategies to build on positive and mitigate negative impacts • international literature emphasizes that this step – in which concrete action recommendations are made – is crucial 4. plan how implementation of the initiative will be monitored to assess its impact 25
  26. 26. • diabetes prevention and management = a major provincial and LHIN priority, and key health issue for many • new program: • designed to help people self-manage diabetes – from their own homes • multi-disciplinary teams, including visiting nurses, dieticians • high-tech – I Pads, EHR and Internet connections for all participants • well resourced • links primary care and specialists, and builds on established local planning networks © The Wellesley Institute www.wellesleyinstitute.com 26
  27. 27. • this preliminary step is to see if there possibly could be inequitable effects of the planned initiative – to see if HEIA is necessary • evidence is clear on incidence and impact of diabetes: • systemic overall differences in incidence of diabetes • emerging evidence of differences by immigration status and ethno-cultural background • likely also differences in being able to cope with and manage diabetes? • diabetes is sensitive to social conditions in which people live • are there local and community variations? • by gender, age, etc. • by local social and economic situation – rural/urban, rich/poor neighbourhoods? • does access to services vary by comfort/facility with English? • speaks to need for local data and community research © The Wellesley Institute www.wellesleyinstitute.com 27
  28. 28. • what is the current local demography of diabetes? • what areas/communities most affected/at risk? • isolated seniors, poor, recent immigrants, First Nations? • who would benefit most from program? • sub-populations with highest incidence or worst/most complex conditions → to identify areas/communities to concentrate program in • are there populations that might have difficulty getting access to the program – poor English, homeless, rural? • how to design outreach to make sure most vulnerable get in? • any barriers in referral process? © The Wellesley Institute www.wellesleyinstitute.com 28
  29. 29. Three step analysis of inequality: 1. gradient of health outcomes: 1. highlights need to identify • inequitable incidence of diabetes where need is greatest → • the more vulnerable tend to be adjust and concentrate sicker and face more program complications 2. given wider social and 2. highlights need to take wider economic inequalities, some inequalities into account: have greater resources and • e.g. can’t design program based resilience to cope with diabetes upon good nutrition where so than others many face food insecurity 3. there is inequitable access to 3. build ensuring equitable access preventative, primary and and quality into fundamental specialist care for those at risk mandate of program of or with diabetes © The Wellesley Institute www.wellesleyinstitute.com 29
  30. 30. • need to drill down to identify most vulnerable sub- populations? • recent immigrants with limited English • immigrant seniors, even if long settled, who prefer service in their culture • First Nations people or communities • poor and poorly housed • homeless • also to identify possible barriers • any fees or other costs involved? • computer and health literacy? • universal material and program may not work effectively in diverse society • can anticipate crucial positive impacts: • proactive management will delay/prevent complications and lessen impact • holistic comprehensive care will be especially important to those with most complex needs – often most vulnerable populations © The Wellesley Institute www.wellesleyinstitute.com 30
  31. 31. • need to always drill down to specific community or impact: • i.e. in diverse communities, ensure cultural competence/anti- oppression training and support • and drill down to specific barriers: • if language, then ensure material is translated and interpretation/care in different languages is available • for accessibility, don’t just go to homes, but to community centres and other locations where the particular group community gathers • adapt innovative/proven ideas – ‘peer health ambassadors’ to deliver health promotion • recognize that most complex cases will need more care and take more time → adjust case mix and management © The Wellesley Institute www.wellesleyinstitute.com 31
  32. 32. • collect comprehensive health data – and differentiate by social determinants of health from the outset • monitor how recommendations from HEIA were acted upon by management and stakeholders • have explicit equity targets: • reduce differentials in complications by neighbourhood or language group • monitor progress on reducing inequitable differentials • assess reach -- were those from most disadvantaged communities brought into program? • and retention – did most vulnerable stick with program? • invest a significant proportion of program in evaluation from the start • involve participants and local community in defining success and setting objectives to be evaluated © The Wellesley Institute www.wellesleyinstitute.com 32
  33. 33. • this hypothetical program obviously is ideal case • in the real world, resource constraints, over-stretched staff and organizations, and competing priorities are norm • so try HEIA out in areas you know • each table to pick one new program being considered or an existing area being re-thought • go through the 4 steps quickly on that case study • will then come back together to discuss lessons learned • don’t worry about coming to substantive conclusions – really just trying out potential of HEIA © The Wellesley Institute www.wellesleyinstitute.com 33
  34. 34. • 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 • and one promising and ready-to-go equity planning tool = Health Equity Impact Assessment • experiment and innovate with it © The Wellesley Institute www.wellesleyinstitute.com 34
  35. 35. Wellesley has developed a page on HEIA resources at http://www.wellesleyinstitute.com/health-equity-impact-assessment- heia-resources Other Health Equity Resources: • The Wellesley Institute http://wellesleyinstitute.com • Health Equity Council http://healthequitycouncil.ca • Rainbow Health Network http://www.rainbowhealthnetwork.ca • Ontario Women’s Health Network http://www.owhn.on.ca • Ethno-Racial People with Disabilities http://erdco.ca • Health Equity Toolkit – blog is at http://www.smallstepsbigdifference.blogspot.com 35
  36. 36. • 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 36
  37. 37. 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 37 www.wellesleyinstitute.com
  38. 38. 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 38 www.wellesleyinstitute.com
  39. 39. 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 39 www.wellesleyinstitute.com
  40. 40. The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley Institute www.wellesleyinstitute.com 40

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