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‘Wicked’ Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health Equity Strategy Into Action Bob Gardner & Nimira Lalani Canadian Mental Health Association-Ontario January 24, 2011 January 24, 2011 1
Starting Points: Policy Challenges ,[object Object],health policy, planning and delivery in general non-health spheres – from social services through justice to education how to integrate and coordinate across policy fields/govt depts  sometimes called ‘joined up govt ‘or ‘whole of govt approaches’ ,[object Object]
one front = potential of planning tools such as impact assessment in grounding and driving actionJanuary 24, 2011 2
Starting Points II: Driving an Equity Agenda ,[object Object],how to get beyond lip service commitment to equity within health -- how to align with system drivers, performance management and quality improvement beyond health – how to identify and mobilize for the necessary policy changes to reduce overall social and economic inequality and address the social determinants of health ,[object Object]
and, of course, equity and mental health need to be integratedJanuary 24, 2011 3
© The Wellesley Institute www.wellesleyinstitute.com 4
Today ,[object Object]
then explore some lessons learned in equity strategy:focusing on the scope and value of equity-focused planning esp. Health Equity Impact Assessment as it is being developed in Ont we may explore one HEIA case study in which it was used in the development of LHIN mental health strategy ,[object Object],will outline Mental well-being Impact Assessment as it has been developed in the UK and interest in Canada then small groups to assess potential here ,[object Object],January 24, 2011 5
6 www.welleseyinstitute.com Foundations of Health Disparities Lie in Social Determinants of Health  ,[object Object]
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,[object Object]
SDoH As a Complex Problem ,[object Object]
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 health8
POWER Study Gender and Equity Health Indicator Framework 9
Health Equity = Reducing Unfair Differences ,[object Object]
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 health10
11 Think Big, But Get Going ,[object Object]
but health disparities can seem so overwhelming and their underlying social determinants so intractable -> can be paralyzing
think big and think strategically, but get goingmake 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 ,[object Object],[object Object]
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 positionEquity Into Health System: Why  12
[object Object]
can do this through a two pronged strategy: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 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 Equity Into Health System: How  13
Equity Into Health System How II: Strategy Into Action health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy 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 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 14
Equity-Focused Planning ,[object Object]
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 ,[object Object],15
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 16
Health Equity Impact Assessment ,[object Object]
planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populationscan 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 ,[object Object],HEIA is being used in Toronto Central and other LHINs and providers across the province  HEIA is being incorporated into a “health in all policies’ framework by MOHLTC 17
HEIA Into Practice ,[object Object],easy-to-use tool to ensure equity factors are taken into account in planning ,[object Object],for strategic and operational planning for assessing whether programs should be re-aligned or continued to build principles into evaluation and quality improvement  ,[object Object],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 January 24, 2011 18
HEIA Template 19
Ontario HEIA preliminary stage = scoping could the policy or initiative have a differential or inequitable impact on different groups? 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 20
Mental well-being Impact Assessment ,[object Object]
developed because practitioners and advocates felt mental health was not being sufficiently emphasized in general HIA
developed in the UK with significant government supportthe MWIA toolkit and other health impact resources are available at http://www.apho.org.uk/resource/item.aspx?RID=95836 January 24, 2011 21
January 24, 2011 22
The MWIA Toolkit Aims to: ,[object Object]
Raise awareness and understanding of mental well-being.
Enable a range of stakeholders to begin to identify the impact a particular policy, service, programme or project is having on mental well-being.

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'Wicked' Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health Equity Strategy into Action

  • 1. ‘Wicked’ Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health Equity Strategy Into Action Bob Gardner & Nimira Lalani Canadian Mental Health Association-Ontario January 24, 2011 January 24, 2011 1
  • 2.
  • 3. one front = potential of planning tools such as impact assessment in grounding and driving actionJanuary 24, 2011 2
  • 4.
  • 5. and, of course, equity and mental health need to be integratedJanuary 24, 2011 3
  • 6. © The Wellesley Institute www.wellesleyinstitute.com 4
  • 7.
  • 8.
  • 9.
  • 10. 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
  • 11.
  • 12.
  • 13. In constantly changing and dynamic system
  • 14. In fact, through multiple interacting and inter-dependent economic, social and health systems
  • 15. Determinants have a reinforcing and cumulative effect on individual and population health8
  • 16. POWER Study Gender and Equity Health Indicator Framework 9
  • 17.
  • 19. is clear, understandable and actionable
  • 20. identifies the problem that policies will try to solve
  • 21. is also tied to widely accepted notions of fairness and social justice
  • 22. The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes
  • 23. A positive and forward-looking definition = equal opportunities for good health10
  • 24.
  • 25. but health disparities can seem so overwhelming and their underlying social determinants so intractable -> can be paralyzing
  • 26.
  • 27. unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse
  • 28. at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social positionEquity Into Health System: Why 12
  • 29.
  • 30. can do this through a two pronged strategy: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 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 Equity Into Health System: How 13
  • 31. Equity Into Health System How II: Strategy Into Action health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy 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 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 14
  • 32.
  • 33. key barriers to equitable access to high quality care
  • 34. the specific needs of health-disadvantaged populations
  • 35. gaps in available services for these populations
  • 36.
  • 37. 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 16
  • 38.
  • 39.
  • 40.
  • 42. Ontario HEIA preliminary stage = scoping could the policy or initiative have a differential or inequitable impact on different groups? 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 20
  • 43.
  • 44. developed because practitioners and advocates felt mental health was not being sufficiently emphasized in general HIA
  • 45. developed in the UK with significant government supportthe MWIA toolkit and other health impact resources are available at http://www.apho.org.uk/resource/item.aspx?RID=95836 January 24, 2011 21
  • 47.
  • 48. Raise awareness and understanding of mental well-being.
  • 49. Enable a range of stakeholders to begin to identify the impact a particular policy, service, programme or project is having on mental well-being.
  • 50. Encourage stakeholders to explore ways to maximize potential positive impacts and minimize potential negative ones.
  • 51.
  • 53. An assessment toolkit that could be used for rapid or comprehensive impact assessment
  • 54. Determinants and protective factors for mental well-being
  • 55. Guidance on developing indicators for mental well-being
  • 56.
  • 57. NW NIMHE, University of Liverpool, Liverpool PCT and Capital of Culture saw opportunity to develop the work at policy level (2005)
  • 58. Review of eight impact assessment tools demonstrated that mental well-being not being fully addressed within HIA (2005)
  • 59. Revised toolkit to take on review of evidence base on mental well-being & tested out with public policy and others
  • 60. Comprehensive MWIA on Liverpool Capital of Culture (2006/07)
  • 61. Published toolkit as ‘A Living & Working document’ March 2007
  • 62. National & international dissemination, ongoing evaluation and monitoring
  • 63. MWIA central theme in Well London three year BIG Lottery project
  • 64. Supported implementation - WM Champions, NW Pioneers 2nd stage, East Midlands, training development
  • 65.
  • 66.
  • 67. LHINs have explicit diabetes strategies
  • 68.
  • 69. will work through MWIA to see27
  • 70.
  • 71. don’t worry about coming to substantive conclusions – really just trying out potential of planning tools28
  • 72.
  • 73. do need comprehensive and coherent health equity and mental health strategy (in fact, strategy that integrates both) – but don’t wait for perfect strategy
  • 74. think big and think strategically – but get going29
  • 75.
  • 76.
  • 77.
  • 78.
  • 79.
  • 80.
  • 81. Wellesley has developed a page on health impact and HEIA, including links to leading international sites and practitioners, at http://www.wellesleyinstitute.com/health-equity-impact-assessment-heia-resources
  • 82. my email is bob@wellesleyinstitute.com
  • 83. 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 equityFollowing Up 33
  • 84.
  • 85. case study: applying HEIA to TC LHIN mental health strategy
  • 86.
  • 87.
  • 88.
  • 89. in addition, there are systemic disparities in access to and quality of care within the healthcare system
  • 90. plus major differences between women and men
  • 91. not just unfair, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, mental health, diabetes, etc, and contribute to avoidable costs
  • 92. that’s why enhancing health equity has become a clear priority – from the Province to LHINs to many providers
  • 93. and that’s why we need tools and approaches to build equity into effective system and service planning36
  • 94.
  • 95.
  • 96. equity issues all along life-course– racialized youth, poor seniors
  • 98. impact of racism and social exclusion, non-insured, need for customized services
  • 99. in TO? but newcomers, non -insured
  • 101. absolutely – and increasingly
  • 102. critical importance of income inequality and poverty
  • 103. place and isolation matters to mental health especially
  • 104. gender – systemic differences and access
  • 105. sexual orientation – well documented systemic discrimination and barriersJanuary 24, 2011 38
  • 106.
  • 107.
  • 108.
  • 109.
  • 112. newcomers and people facing language barriers
  • 113. were Aboriginal providers/networks built into planning process?
  • 114. are specific Aboriginal-driven services being planned?
  • 115. were existing resources – CAISI, providers, networks, successful programs – built on?
  • 116. cross-sectoral collaborations – health, shelter, social services
  • 117. linking to poverty reduction strategies and advocacy
  • 119. cultural competence + resources and management
  • 120. funding to specialized ethno-cultural community groupsJanuary 24, 2011 41
  • 121.
  • 122. Theory of Change why and how to do equity-focused planning January 24, 2011 43
  • 123. taking account of social constraints & conditions not just individual programs but coordination, partnerships & collaboration 44
  • 124. enhanced access to primary care & health promotion for most disadvantaged up-stream heath conditions & opportunities improve fastest for those in greatest need 45
  • 125. 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; 46
  • 126. 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; 47
  • 127. 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. 48
  • 128. © The Wellesley Institute www.wellesleyinstitute.com January 24, 2011 49

Editor's Notes

  1. In: introduce each othercommon challenge = getting our issues high on policy agenda – in fact, integrating mh and equitywhat are key challenges you faceOut: our parallel experience re equity
  2. pervasive and systemic health disparities is the problem we focus on mental health is crucial component of overall well-being – also major provincial prioritysame social gradient of mental health
  3. reinforcing nature of social determinants on health disparitiessignificance for key priority = crucial part of managing chronic conditions -- diabetes esp. -- is good nutrition
  4. 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
  5. 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
  6. can explore in greater depth any of this -- planning, building equity intro performance management, investing in high equity impact directions, etc.don’t mean to be too prescriptive – isn’t a magic blueprint that works everywhere. But I do mean to be concretemore generally, have been broadly successful at getting equity on agenda at LHIN and prov levelsdo we want to explore how – as parallel to challenges for mh?
  7. need to match tools to purpose equity-focused as a specific angle is not consistently developed in all these levels
  8. 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
  9. just like HEIA, which arose to address weakness in addressing equity
  10. or would one be more generally, how to get mental health high on policy agenda?
  11. In: ask what they think?how to apply same to mh?mental health is often marginalized in health and overall public policy – although you have made major gains in some areas
  12. imagine potential if this – or a variant – was asked in all policy spheres
  13. In: different angles can help understand complex problems and how to mobilize to address themOut: there are profound human costs to poverty and inequality = stark indictment of an unfair society
  14. a few illustrative questions for eachwould need to drill down even deeper in working group
  15. summary again