Health Equity Impact Assessment: A Tool for Driving Equity into Action

Bob Gardner
HEIA Workshop
Ontario Community Support Association
Great !deas Conference: New Recipes for Success
October 19, 2010

© The Wellesley Institute
www.wellesleyinstitute.com

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

www.wellesleyinstitute.com 2

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


• 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


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


• 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

•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


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
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

• 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


• 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

• 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


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


• 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


• 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


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


• 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

• 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


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

• 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

• 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

• 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?


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


• 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


• 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


• 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


• 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


• 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

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

• 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


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;


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;


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 advances urban health through rigorous research,
pragmatic policy solutions, social innovation, and community action.


Health Equity Impact Assessment: A Tool for Driving Equity into Action

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