Health Equity Impact Assessment: Potential for LHINs

Health Equity Impact Assessment:
Potential for LHINs

Central Local Health Integration Network
Speaking Notes

Bob Gardner
Director, Healthcare Reform and Public Policy
October 19, 2009

Equity-Driven Planning

• 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

• and this requires an array of effective and practical
equity-focused planning tools

• HEIA is one part of this repertoire of equity-focused
planning tools
© The Wellesley Institute 2
www.wellesleyinstitute.com

Where HEIA Fits in
Repertoire of Equity-
Focused Planning Tools
1. ensure equity is taken into 1. simple equity lens
account in all service
delivery/planning
2. assess potential impact of 2. HEIA
service initiatives/policies on
disadvantaged populations,
access barriers and related
equity issues
3. determine needs of 3. equity-focused needs
communities facing health assessment
disparities
4. assess impact of 4. equity-focused evaluation
interventions on health
disparities and disadvantaged
populations © The Wellesley Institute 3

Health Equity Impact
Assessment
• planning tool that analyzes potential impact of service initiatives or
policy changes 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
– essentially prospective
• arose out of broader health impact assessments, which have been
increasingly used in many jurisdictions in last 15 years
– one key reason was increasing policy attention to SDoH and health
disparities → need explicit equity focus
– at same time, need for shorter and more focused processes –
sometimes called Rapid HIA -- had been recognized
– HEIA is seen to be relatively easy-to-use tool


Components of HEIA

1. screening – projects where • while HEIA is sometimes
HEIA would be useful promoted as easy-to-use „first-
2. scoping – which pop‟n and pass‟ planning tool
health effects to consider
3. assessing potential equity • does not mean it is only about
risks and benefits – 1–3
specifying particular pop‟n
4. developing recommendations • experts argue core of HEIA is
– to promote positive or in fact 4 – developing
mitigate negative effects recommendations to address
5. report results to decision equity implications
makers
6. monitoring and evaluation –
of effectiveness of
recommendations © The Wellesley Institute 5

Piloted In Toronto and
Ontario

• Ontario surveyed best practice jurisdictions:
– Wales and New Zealand were furthest advanced
– but increasing interest in other jurisdictions
• MOHLTC equity unit developed a one page tool and
accompanying „how-to‟ guide – first used in Aging at
Home initiatives in 2008
• partnership of MOHLTC, Toronto Central LHIN and
Wellesley Institute to consult, refine and pilot test in
spring-summer 09
• the hope was that HEIA may have potential in other
LHINs as well


Draft Ontario HEIA: 4 Step
Process
1. template asks how the planned program or initiative affects health
equity for particular disadvantaged populations
– setting out a list of health disadvantaged populations – although
list is not meant to be exhaustive
– also asking about potential impact on social determinants of
health
2. on the basis of the best available information and evidence,
planners assess potential positive and negative impacts of the
initiative on the population(s) (and indicate where more information
is needed)
3. and then develop strategies to build on positive and mitigate
negative impacts
4. and finally, planners indicate how implementation of the initiative
will be monitored to assess its impact

Toronto Consultations on
HEIA: Phase 1
• goals were to get reactions to basic idea, advice on developing most
effective tool and advice on designing pilot phase
– while tightly focused on HEIA, the sessions were also expected to yield
broader input on health equity strategy
– and to continue to lay foundations for ongoing dialogue on moving
health equity forward
– which they did
• Phase 1 consultations completed in March:
– seven sessions with 67 people
– full range of providers – hospitals, CHCs, multi-service agencies – and
sectors – mental health, seniors, acute, primary care – and specific
consumer table
– significant enthusiasm for idea and momentum for implementation
– report summarizing input to partners at end of March


Lessons from Consultations
I: Participants Defined
Success As …
• when operationalizing health equity becomes more than
the work of the “equity people”
• when a provider asks, “How can we include more people
in this program?” ”What barriers do we have to look for?”
“Are we as effective as we could be at supporting every
population?” -- i.e., providers have enough awareness of
health equity to ask these questions in their service
planning and evaluation
• when an organization embeds HEIA across its decision-
making models so that health equity becomes a core
value and one of the criteria to be weighed in all
decisions


II: Clarify Purpose and
Audience
• primary purpose for HSPs could be to:
• improve attention to equity within planning
• contribute to equity being solidly incorporated into program and
strategic planning
• raise awareness about health equity throughout the organization;
• primary purpose for MOHLTC and LHINs could be to:
• ensure equity impact is routinely considered in planning
• make HEIA part of resource allocation and program planning
and approval processes – e.g. a LHIN could:
• require providers to demonstrate they have used HEIA in funding
applications
• use data from filled out HEIAs in program and resource allocation
decisions


III: Design
• need to be aware of many audiences that could use tool, and
different purposes
• one-page tool would be great, but accessibility and clarity are more
important
• needs preamble with clear statement of principle and purpose
• shift language to more positive
• add prompts, definitions and case studies
• align language and concepts to show decision makers that tool
complements their strategic priorities and supports efficiencies
• use checklist of questions rather than form to fill out
• develop as electronic interactive tool with built-in prompts and online
resources: e.g., definitions, descriptions, case studies, links to web-
based resources, links to mentors who can provide direct support

Revised Tool

• in response to consultations:
– template was revised
– a new workbook was developed to support easy and consistent
use
• the workbook:
– provides definitions, examples, prompts and possible questions
– is set up to help users work through the HEIA process in a step-
by-step way
– users simply fill out the appropriate tables in workbook itself to
complete their HEIA
• the workbook was designed so it can be adapted to
become a Web-based interactive resource

Phase 2: Piloting HEIA

• Phase 2 pilot phase took place in July to test revised tool and new
workbook in practice
• three settings with varying planning cases/initiatives:
– hospital program in diverse urban setting
– support program for patients‟ families of specialized downtown
hospital
– community support services for seniors
• through flexible methods
– Wellesley introduced tool and goals of pilot
– participants either filled it out on their own or we undertook
facilitated planning exercises using the tool
– participants filled out evaluation survey on how process went
and advice on further changes to tool

Key Findings From Pilot

• significant support/momentum for using HEIA
• the tool was seen to be easy to use
• the workbook was an essential addition
• participants were able to effectively use the tool to
identify:
– barriers to access and appropriate care
– potential impacts of the planned program on particular
disadvantaged populations
• they felt it did or could build awareness of equity issues
within their organization, but needed to be widely
implemented to achieve this

Project Completed and
Report Delivered in August
• key message = while making some recommendations for revisions,
we felt it was „good enough to go‟ for widespread implementation
• recommendations included:
– intensive promotion and communication were going to be key to
widespread implementation
– Ministry and LHINs need to decide for what purposes HEIA will
be used, whether it will be mandatory, etc.
– a number of revisions to structure/focus of HEIA tool
– accompanying resources that would be needed – including
eventual on-line version
– organizing comprehensive implementation and roll out
– building systematic evaluation strategy in from the start


National Interest

• Senate Sub-Committee on Population Health
recommended HIA be used to ground government
decision-making and related equity data, research and
planning mechanisms in its recent report
• PHAC has commissioned a review of HEIA in other
jurisdictions
• PHAC is holding consultations in Oct
• parallel workshop on how HEIA and social determinants
and outcome indicators can be adapted for Aboriginal
health planning purposes


Moving Forward on HEIA:
Success Conditions and Key
Directions
• if a LHIN were to adopt HEIA, these are some success
conditions
– based on both piloting in Toronto and wider international
experience
• start from clear definition and strategy for health equity
– then specify where HEIA and equity-focused planning fits in
overall equity strategy
– develop clear definitions and data on potentially affected
populations and communities
– ensure clear focus/scope: which determinants of health, which
access barriers, etc.


Roll Out

• need systematic communications and roll-out plans:
– lesson of lack of uptake for Aging at Home is that providers can‟t
adopt new planning tool if they don‟t know about it, and won‟t if
they aren‟t encouraged/supported
– need to make goals and focus of HEIA very clear
– need to also indicate what resources will be available to support
providers in using HEIA
• decisions for Ministry:
– all LHINS, whichever want to, pilot in a few more?
– what centralized/common support to LHINs and providers?


Building Capacities to Use
HEIA

• need support from LHIN for effective use
– in pilot, participants received extensive orientation briefing and
had participated on initial consultations, and could call up
consultants
– with more widespread implementation, can anticipate questions
and need for advice/assistance from significant numbers
– many jurisdictions have workshops to support users
– even electronic tool will require technical back-up and assistance
• so LHINs need to build in internal capacities to support
providers – let alone to analyze and build on results


Where to Locate Capacity?

• debate in international circles on consultant vs. capacity
building models:
– if goal is widespread use by providers, then easy-to-use tool and
effective support -- i.e. capacity building model is best
• consensus among practitioners and experts that
significant methodological expertise in health impact
assessment is needed
• as always = resource question
– effective use and widespread roll-out will require devoted
resources from both LHINs and providers
– incremental and experimental roll-out could begin within existing
resources

Clarify LHIN Purposes

• a LHIN could use HEIA to:
– build awareness of health equity within and across HSPs
– ensure that HSPs take equity into account in their planning and
service delivery
– build up a fuller picture of equity challenges/opportunities and
needs of disadvantaged populations
– help LHINs set priorities and allocate resources for greatest
equity impact
• different goals → different HEIA strategy and techniques
– e.g. the latter two require more systematic processes to collate
and analyze results of many HEIAs


Context Is Everything

• need to be aware of context in which HEIA will be used:
– separate program or provider wide
– major hospital or small community-based provider
– specific barrier or disadvantaged population to which program is
directed
• and resources devoted to HEIA:
– both at provider level
– and by LHIN and/or Ministry
• understanding context is crucial for both effective
implementation and systematic evaluation


Decide How Seriously To
Drive Implementation

• decide whether use of HEIA is voluntary – and how
strongly encouraged – or mandatory – and how strongly
supported and enforced
– international lesson = explicit requirements – or at least
significant incentives – are key to widespread implementation
• then what kinds of incentives and levers to use to
encourage/drive use of HEIA
– special ear-marked funding or consultant support to begin to use
HEIA – especially at start
– requiring providers to demonstrate they have used HEIA in
planning out a potential project whenever they apply for funds
– requirements within Service Accountability Agreements that
providers use HEIA in appropriate circumstances

What About the Community?

• a premise of the draft Ontario HEIA – and many others – is that:
– assessing the potential impact of initiatives on particular
populations requires solid understanding of that population's
health situation, needs and context
– this can benefit from ongoing community engagement with the
population and/or specific needs assessment
• analyzing possible mitigation strategies will also benefit from
engaging the affected population in designing the necessary service
changes
• similarly, monitoring and assessing the impact of the initiative – and
how HEIA contributed -- also needs:
– research and input from the affected population on impact
– outcome data stratified by population and determinants


How Could LHINs Use HEIA
Results?
• LHINs could use results from HEIA in their planning and resource
allocation decisions
– using analysis of information in filled out HEIA forms as one
factor in resource allocation and program approval decisions
– using information to shape provider-specific performance
objectives and expectations
– as a source of intelligence and information on equity barriers,
disadvantaged populations and interesting and innovative
initiatives
• could also use HEIA for internal purposes
– apply it to major planning initiatives within the LHINs – e.g.
mental health or diabetes priorities
– starting internally is one option for staging implementation and
gradually building support

What’s Needed in Tool?

• depending upon the LHIN‟s purpose – i.e. building equity-focused
planning among HSPs and/or using HEIA within resource allocation
decision making – will want to ensure:
– results are easy to interpret
– results lend themselves to ranking and comparisons for
decisions
– HEIA yields useable information on current access barriers,
vulnerable populations and service innovations
• from user point of view, HEIA needs to be:
– easy to use – current form is good enough
– has to be accompanied by workbook
– need to take account of different IT and planning capacities, and
comfort of participants

Monitor and Evaluate

• whatever decisions are made about scope of
implementation, purposes and incentives, keep track of:
– which providers are using HEIA
– for what purposes and in what context
– with what results
• develop a systematic evaluation strategy from the outset:
– MOHLTC developed a Survey Monkey evaluation questionnaire
for pilot – could encourage all participants to use it
– supplement with more intensive interview-based evaluation
research with a smaller sample after a year of implementation
– define what „success‟– effective use of HEIA -- looks like
– evaluate progress against this goal


And a Note on Evaluating
Complex Interventions

• requires clear theory: use of HEIA → better equity-
focussed planning → better quality and more effectively
targeted services → reduced disparities
• goal is to understand how HEIA works in specific
circumstances → build up comprehensive understanding
of dynamics and potential of HEIA and equity-focused
planning
• recognize that simple tools won‟t suit all purposes
• if HEIA is seen as easy-to-use tool for service planning
• can‟t expect it to be useful for more complex or systemic
planning purposes


Building on Knowledge from
HEIA
• one broader hope is that HEIA will yield useful information on
existing system barriers and the needs of disadvantaged
populations, and on promising and successful programme
interventions
– LHINs will need to capture and share this information, and build
on these local front-line insights
– is there a potential to share the resulting knowledge among
LHINs and scale up across the province where appropriate?
– what resources do the LHINs and MOHLTC need to be able to
realize this potential?
• this knowledge management challenge applies in many other areas
– insights and case studies form hospital equity plans, experience of
equity-focused service innovations across the LHIN, etc.


Coordination

• at best, MOHLTC could:
– develop an HEIA tool and promote its use to all LHINs
– provide centralized support to encourage consistency of
approach and effective use
– move quickly to develop an on-line version
• if that doesn‟t prove possible -- or in the meantime -- individual
LHINs can implement HEIA in a coordinated fashion:
– could be interesting GTA LHIN coordinated project
– use same tool, record any adaptations to local contexts
– share experience on how it is working
– look for consistent purposes and approaches
– try to monitor and evaluate within consistent approaches


Follow-Up

• the implementation and impact of HEIA will continue to evolve and
we would be very interested in any further thoughts on
– how LHINs and Ministry can implement HEIA
– how you think it might fit in your area
– your experience with considering and using HEIA
• my email is bob@wellesleyinstitute.com
• we developed a page on HEIA resources at
http://www.wellesleyinstitute.com/health-equity-impact-assessment-
heia-resources
• further resources on health equity strategy, health reform and the
social determinants of health are available on our site at
http://wellesleyinstitute.com


Health Equity Impact Assessment: Potential for LHINs

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