This presentation provides a critical analysis of the potential of a health equity impact assessment. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Driving Health Equity Into Action: The Potential of Health Equity Impact Assessment Bob Gardner Diversity and Equity in Mental Health Conference May 27, 2011

2. Starting Points health disparities in Ontario and Canada are pervasive and damaging but these disparities can be addressed through comprehensive health equity strategy 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, mental health, etc. building equity into ongoing performance management and service delivery investing in promising interventions, and pulling them together within a coherent and coordinated overall strategy enabling innovation through sharing and building on front-line and local initiatives, evaluation, and organizational learning focus today is on a key setting for implementing this overall strategy -- equity-focused planning and delivery of community-based mental health – using HEIA 2

3. Outline set the scene: challenge of systemic health inequities potential of health equity strategy to address them one pre-condition of an effective strategy is equity-focused planning and one useful tool is Health Equity Impact Assessment will sketch out background and potential of HEIA will work through several concrete planning scenarios 3

5. plus major differences between women and men

6. in addition, there are systemic disparities in access to and quality of care within the healthcare system

7. not just unfair and unjust, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs

8. enhancing health equity has become a clear priority – from the Province to LHINs to many providers

9. that’s why we need strategies, tools and best practices to build equity into effective system and service planning4

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12. + inequitable service use:people living in the lowest-income neighbourhoods were somewhat more likely to use mental health services and to receive ECT much more likely to be hospitalized for depression however, individuals living in the lowest-income neighbourhoods accounted for lower mental health care costs, which suggests they either made fewer visits or received less expensive services than those living in the highest-income neighbourhoods. Source: POWER Study Vol 1 Exhibit 5a.9 6

13. 7

14. Impact of Disparities 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 8

16. 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

19. In constantly changing and dynamic system

20. In fact, through multiple interacting and inter-dependent economic, social and health systems

21. Determinants have a reinforcing and cumulative effect on individual and population health11

22. POWER Study Gender and Equity Health Indicator Framework 12

23. Three Cumulative and Inter-Dependent Levels Shape Health Inequities because of inequitable access to wealth, income, education and other fundamental determinants of health -> also because of broader social and economic inequality and exclusion-> along very similar lines, disadvantaged and vulnerable populations face systemic barriers within the health and other systems -> gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions some communities and populations are more vulnerable and have fewer capacities, resources and resilience to cope with the impact of health inequities these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need 13

25. This concept:

26. is clear, understandable and actionable

27. identifies the problem that policies will try to solve

28. is also tied to widely accepted notions of fairness and social justice

29. The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes

30. A positive and forward-looking definition = equal opportunities for good health

31. Equity is a broad goal, including diversity in background, culture, race and identity14

34. unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse

35. 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 16

37. through a multi-pronged strategy:building health equity into all health care planning and delivery doesn’t mean all programs are all about equity but all take equity into account in planning their services and outreach aligning equity with system drivers and priorities embedding equity in provider organizations’ deliverables, incentives and performance management 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 thinking up-stream to health promotion and addressing the underlying determinants of health Equity Into Health System: How 17

38. Equity Into Health System: How II 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 18

40. can’t just be ‘experts’, planners or professionals

41. have to build community into core planning and priority setting

42. not as occasional community engagement

43. but to identify equity needs and priorities

44. and to evaluate how we are doing

45. how:

46. many hospital have community advisory panels

47. CHCs and many other providers have community members on their boards

48. innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries

49. community-based research, needs assessment and evaluation19

52. key barriers to equitable access to high quality care

53. the specific needs of health-disadvantaged populations

54. gaps in available services for these populations

55. need to understand roots of disparities:

56. i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc.

57. which requires good local research and detailed information – speaks to great potential of community-based research

58. involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems

59. requires an array of effective and practical equity-focused planning tools21

60. 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 22

63. final version of template and workbook released by Ministry in 2011 see their page at http://www.health.gov.on.ca/en/pro/programs/heia/background.aspx

67. HEIA Into Practice: Five Stages preliminary stage = scoping could the policy or initiative have a differential or inequitable impact on different groups? if yes, consider HEIA 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 27

68. MOHLTC 2011 HEIA Template 28

72. We are developing a drop-in counselling and support program for people with mental health needs in a poor neighbourhood. The whole point is to provide better services to a disadvantaged community. But are there other factors we need to take into account?

73. There are higher rates to re-admission for psychiatric patients from a poor neighbourhood. What can be done? 30

75. train partners, provide resources for capacity building31

77. what physical, environmental and other issues need to be considered – e.g. few parks, rail line or highways?

82. can’t take as much time off work

83. can’t afford meds

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90. setting targets for reducing access barriers, improving health outcomes of particular populations, etc

91. developing realistic and actionable indicators for service delivery

92. closely monitoring progress against the targets and indicators

93. disseminating the results widely for public scrutiny

94. tying funding and resource allocation to performance

95. what would equity-focused performance indicators, measurement and management look like for mental health?39

97. more broadly, cross-sectoral coordination and planning are much emphasized in public health and health policy circles

98. addressing wider SDoH is the glue for collaboration into action

99. public health departments and LHINs are pulling together or participating in cross-sectoral planning tables

100. Local Immigration Partnerships , Social Planning Councils

101. comprehensive community initiatives to address poverty and other complex local problems

102. the Ministry of Health Promotion and Sport is developing a healthy communities strategic approach

103. cross-sectoral planning to ground health promotion

104. at best, this implies wider community development and capacity building approaches40

106. do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy

107. think big and think strategically – but get going

108. build equity into strategic priorities, align with quality agenda and system priorities, embed in routine planning and performance management

109. and build equity into front-line planning and delivery where you practice

110. no magic blueprint -- experiment and innovate -- and build on learnings and success41

114. drilling down to theory of change underlying equity-focused planning

115. Wellesley Health Equity Roadmap43

118. equity issues all along life-course– racialized youth, poor seniors

119. dynamics of concurrent challenges

120. impact of racism and social exclusion, non-insured, need for customized services

121. in TO? but newcomers, non -insured

122. absolutely

123. absolutely – and increasingly

124. critical importance of income inequality and poverty

125. place and isolation matters to mental health especially

126. gender – systemic differences and access

127. sexual orientation – well documented systemic discrimination and barriersMay 30, 2011 45

132. homeless

133. poor/economically vulnerable more generally

134. newcomers and people facing language barriers

135. were Aboriginal providers/networks built into planning process?

136. are specific Aboriginal-driven services being planned?

137. were existing resources – CAISI, providers, networks, successful programs – built on?

138. cross-sectoral collaborations – health, shelter, social services

139. linking to poverty reduction strategies and advocacy

140. interpretation and translation

141. cultural competence + resources and management

142. funding to specialized ethno-cultural community groupsMay 30, 2011 48

145. need to figure our what interventions and approaches work, in what contexts and why

146. at a program as well as system level:

147. can’t just measure activity – number or % of pop’n that participated in a program or received particular services

148. need to measure health outcomes – even when impact only shows up in long-term

149. need to assess reach -- who isn’t signing up or getting the services they need?

150. need to differentiate those with greatest need = who programs most need to reach and keep to have an impact50

152. start from clear theory of how we think better planning will reduce health inequities51

153. taking account of social constraints & conditions not just individual programs but coordination, partnerships & collaboration 52

154. enhanced access to primary care & health promotion for most disadvantaged up-stream heath conditions & opportunities improve fastest for those in greatest need 53

156. my email is bob@wellesleyinstitute.com

157. 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 54

158. 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; 55

159. 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; 56

160. 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. 57

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