Driving Health Equity into Action: The Potential of Health Equity Impact Assessment

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Driving Health Equity Into Action: The Potential of Health Equity Impact Assessment

Bob GardnerDiversity and Equity in Mental Health

ConferenceMay 27, 2011

2© The Wellesley Institute

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Starting Points1. health disparities in Ontario and Canada are pervasive and damaging2. but these disparities can be addressed through comprehensive health equity

strategy3. 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 learning4. focus today is on a key setting for implementing this overall strategy --

equity-focused planning and delivery of community-based mental health – using HEIA



Outline

1. set the scene: • challenge of systemic health inequities • potential of health equity strategy to address them

2. one pre-condition of an effective strategy is equity-focused planning

• and one useful tool is Health Equity Impact Assessment3. will sketch out background and potential of HEIA4. will work through several concrete planning

scenarios


The Challenge: Systemic Health Disparities

• there is a clear gradient in health in which people with lower income or socio-economic status, or facing discrimination, racism or other lines of social 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 and unjust, but health disparities make it more difficult

to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs

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

• that’s why we need strategies, tools and best practices to build equity into effective system and service planning

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Social Gradient of Health: Depression

• lowest-income neighbourhoods had a significantly higher prevalence of probable depression than highest-income neighbourhoods

• + 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




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

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Foundations of Health Disparities Roots Lie in Social Determinants of Health

• 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



Canadians With Chronic Conditions Who Also Report Food Insecurity



SDoH As a Complex Problem•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 StudyGender andEquityHealth IndicatorFramework

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Three Cumulative and Inter-Dependent Levels Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health →

2. also because of broader social and economic inequality and exclusion→

3. along very similar lines, disadvantaged and vulnerable populations face systemic barriers within the health and other systems →

1. gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. some communities and populations are more vulnerable and have fewer capacities, resources and resilience to cope with the impact of health inequities

3. these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

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Health Equity = Reducing Unfair Differences

• 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• Equity is a broad goal, including diversity in background, culture, race and

identity


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Think Big, But Get Going• health disparities can seem so overwhelming and their underlying

social determinants so intractable → can be paralyzing

• think big and think strategically, but get going• make 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

• need to start somewhere – and focus here is on building equity into best mental health promotion and care



even though roots of health disparities lie in far wider social and economic inequality

1. it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care

• equitable healthcare and proactive health promotion can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities

2. in addition, there are systemic disparities in access and quality of healthcare that need to be addressed

• people lower down the social hierarchy tend to have poorer access to health services, even though they may have more complex needs and require more care

• 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 position

Equity Into Health System: Why


• goal is to ensure equitable access to high quality healthcare regardless of social position

• through a multi-pronged strategy:1. 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

2. aligning equity with system drivers and priorities3. embedding equity in provider organizations’ deliverables, incentives and

performance management 4. 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

5. while thinking up-stream to health promotion and addressing the underlying determinants of health

Equity Into Health System: How

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Equity Into Health System: How IIwhile health disparities are pervasive and deep-rooted, they can be changed through policy and program actioncomprehensive strategy developed in 2008 for Toronto Central LHINmany recommendations have been acted onother LHINs are also prioritizing and moving to address health disparities


Start From The Community• goal is to reduce health disparities and speak to needs of most

vulnerable communities – who will define?• can’t just be ‘experts’, planners or professionals

• have to build community into core planning and priority setting• not as occasional community engagement• but to identify equity needs and priorities• and to evaluate how we are doing

• how:• many hospital have community advisory panels• CHCs and many other providers have community members on their boards • innovative methods of engagement – e.g. citizens’ assemblies or juries in

many countries• community-based research, needs assessment and evaluation

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Align with System Drivers and Trends: ECFA Act and Quality Agenda

• Quality Improvement Plans• hospitals just developed first generation and will be reporting every year • opportunity = equity can be built in as one of dimensions to report on• other provider institutions will be reporting in future

• quality and patient-centred care:• taking lived conditions/experience into account – meaning equity and

diversity → essential to high quality patient-centred care for all• chronic disease prevention and management is major prov priority

• context for you – many clients will have concurrent challenges?

• equity as contributing to cost-effectiveness and safety:• e.g. reducing language barriers to good care through better interpretation can

reduce mis-diagnoses and over-prescriptions → enhanced quality and cost effectiveness


Into Practice Through Equity-Focused Planning

• addressing health disparities in service delivery 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

• need to understand roots 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 community-based research• involvement of local communities and stakeholders in planning and priority

setting is critical to understanding the real local problems• requires an array of effective and practical equity-focused planning

tools

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Equity-Focused Planning Tools1. quick check to ensure equity is

considered in all service delivery/planning

2. take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery

3. assess current state of provider organization

4. determine needs of communities facing health disparities

5. assess impact of programs/interventions on health disparities and disadvantaged populations

1. simple equity lens

2. Health Equity Impact Assessment

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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Health Equity Impact Assessment• 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 experience here and in 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 this potential – from WHO, through

most European strategies, PHAC, to Ontario

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HEIA In Ontario• first piloted and refined in Toronto in 2009 by MOHTLC, Toronto Central LHIN and

WI, and in several LHINs afterwards• 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 • growing use within health:

• HEIA is being used in Toronto Central and other LHINs • by many hospitals and other providers across Toronto• Toronto Central has required HEIA within recent funding application processes

for Aging at Home, and refreshing hospital equity plans• primers on HEIA and a variant Mental Health Wellbeing Impact Assessment,

many Wellesley workshops and other resources can be found on page at http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment

• Equity Assessment Framework being developed and piloted by the Ontario Agency for Health Protection and Promotion

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http://www.health.gov.on.ca/en/pro/programs/heia/background.aspx

http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment

http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment

April 8, 2023 25© The Wellesley Institute


HEIA Into Practice: Lessons Learned

• from implementation so far and many workshops – can’t be prescriptive in using tool• 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• another lesson learned is that effective implementation odes require

capacities• easier in large organizations with planning resources• but, even with limited resources and correspondingly more limited scope –

can still be very useful exercise• need to realize that HEIA will serve different purposes in different

organization depending upon their experience with equity planning and implementation



Lessons Learned II: Adjust Purposes and Use to Context

• for LHINs and Province, HEIA is one lever to help:• ensure equity is routinely taken into account in health care planning and

delivery• equity gets embedded in providers’ organizational planning and practice• especially important for health service providers who are not experienced

with equity• but for HSPs who are experienced and committed to equity or who work with

disadvantaged populations, HEIA can help to:• ensure the full complexities of community challenges and capacities are

considered• identify sub-populations, specific barriers or other issues that can easily be

missed• can help clarify assumptions – what is exactly is meant by community? what

are the success conditions for the particular program in that particular community context?

HEIA Into Practice: Five Stagespreliminary stage = scoping

• could the policy or initiative have a differential or inequitable impact on different groups?

• if yes, consider HEIA

1. 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

2. assess potential positive and negative impacts of the initiative on the population(s)

3. develop strategies to build on positive and mitigate negative impacts4. plan how implementation of the initiative will be monitored to assess its

impact

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MOHLTC 2011 HEIA Template

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Scoping the Issue Through an Equity Lens

• simple equity lens that can be broadly applied =

• could the policy, program or initiative have a differential or inequitable impact on different groups?

• use this for scoping stage = whether there are inequitable differences is a research question:

• so, first action item from HEIA scoping = if we don’t know → find out• highlights importance of collecting better equity-relevant data across the system

and by every provider as a priority• can use proxy data from postal code = neighbourhood characteristics from

census data• can use case studies and small-scale interview/chart review studies• can rely on provider experience and community perceptions at this scoping stage

• if evidence is yes → then can drill down using HEIA template



Workshop Scenarios• We are establishing a new mental health promotion

program in an immigrant community. How can we ensure it has the greatest equity impact?

• 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?

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



Scenario I: Developing a Community-Based Mental Health Promotion Program in an Immigrant Community

•drill down = what specific make-up of this immigrant community?

• legal status • some without OHIP?• history -- both of particular

immigrant community and of individuals

• specific contexts from which people came – war, conflict

• what languages•what current socio-economic position?

• SDoH differences within community•what cultural differences/dynamics

• inter-generational differences?

•translate material into appropriate languages•take SDoH into account in service planning•needs assessment and gap analysis → prioritize services/outreach•thinking about reach as well – who isn’t signing up or getting the services they need? •innovative options such as peer ambassadors•train partners, provide resources for capacity building



Scenario II: Developing a Drop-in Service in a Poor Neighbourhood

•what make-up of this community?• are all poor• what kinds of jobs?• diversity along ethno-cultural ,

language and immigration lines• what languages are spoken and

preferred?• asset and strength-based, not just

challenges and barriers•what SDoH differences within community•what physical, environmental and other issues need to be considered – e.g. few parks, rail line or highways?•what mental health and related health and social services currently exist?

•needs assessment and gap analysis → prioritize mix of services→outreach to build on existing services and respected organizations→where to base the new service that is most convenient and effective

•translate material into appropriate languages•take SDoH into account in service planning/delivery•thinking about reach as well – who isn’t signing up or getting the services they need? •innovative options such as peer ambassadors/navigators



Scenario III: Post-Treatment Psychiatric Re-Admission Rates

Hospitals have found that there is a higher rate of re-admissions for their psychiatric patients who live in Parkdale and other poor neighbourhoods. What can be done?

• wider context = considerable attention to re-admissions:• quality issue• clear pressure to reduce re-admissions – ties to ALC, ER and

other priorities



Coming Into Hospital for Psychiatric Treatment: Patients From Poor Neighbourhoods

•population health and epidemiological data indicate that they may have poorer overall health → greater risk → greater prevalence

+ less capacity to cope well with effects of mental illness

•does this vary within the neighbourhood?• by race, immigrant status, etc.

•what community-based services are available in neighbourhood?

• are there access barriers to them – language, cost, accessibility?

•can take poorer situations/higher risks into account:

• at least, ensure no differential or inequitable treatment

• equitable care = more intensive pre-admission planning and support for those most in need

• more intensive preventative and support programs in community

•even broader = taking SDoH into account• including child care, transportation and

other assistance to support coming in for appointments

• nutritional and other support•partner with community providers to ensure better support for people

• to promote mental health and reduce need for treatment

• to enhance outcomes from treatments



Post-Psychiatric Treatment: Patients From Poor Neighbourhoods

•poor living conditions, food, anxiety → less able to cope → poorer recovery•can’t take as much time off work•can’t afford meds•don’t have equitable access to home and community-based support

• research question = is access and utilization equitable?

•can take poorer situations/higher risks into account:

• at least, ensure no differential or inequitable treatment in (length of stay, intensity, etc)

• equitable care = more intensive discharge planning, case mgmt and assessment

• send home with more supplies, meds, etc.

• more intensive follow-up to those in greatest need – socially as well as medically defined

•partner with community-based providers and groups



HEIA Into Action• demonstrated value of equity lens on this issue – and most?• can identify inequitable constraints and barriers:

• in many cases, some seem outside of provider’s control → but can take into account in care planning→ develop strategic partnerships

• can identify mediating actions that can be taken and make recommendations:• to senior mgmt and appropriate care teams

• then need to monitor impact:• indicators and stats• patient satisfaction – by these equity variables

• assess lessons learned → incorporate into ongoing quality improvement



Specific Variant: MWIA•potential =

• contribute to more efficient and comprehensive planning that embeds mental health

• can help build comprehensive view of mental well-being – dual continua approach

• demonstrate importance of mental health to so many service and policy spheres → transform working culture to take mental health into account

•interest in Canada – • PHAC has working group• will be exploring how to adapt MWIA

model to Cdn context

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Beyond Planning: Embed Equity in Performance Measurement and Management

• clear consensus from research and policy literature and consistent feature in comprehensive policies on health equity from other countries =• setting targets for reducing access barriers, improving

health outcomes of particular populations, etc• developing realistic and actionable indicators for service

delivery• closely monitoring progress against the targets and

indicators• disseminating the results widely for public scrutiny• tying funding and resource allocation to performance

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

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Beyond Healthcare System: SDoH Into Action

• have emphasized taking SDoH into account in service delivery and planning

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

• addressing wider SDoH is the glue for collaboration into action• public health departments and LHINs are pulling together or

participating in cross-sectoral planning tables• Local Immigration Partnerships , Social Planning Councils• comprehensive community initiatives to address poverty and other

complex local problems• the Ministry of Health Promotion and Sport is developing a healthy

communities strategic approach• cross-sectoral planning to ground health promotion • at best, this implies wider community development and capacity

building approaches

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Key Messages• 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• build equity into strategic priorities, align with quality agenda

and system priorities, embed in routine planning and performance management

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

• no magic blueprint -- experiment and innovate -- and build on learnings and success



Key Messages II• for both mental health – and health equity – we have solid evidence,

know the challenges, and know the levers and drivers for change• not perfect – but enough to act

• to drive action, we need comprehensive and innovative strategy, but we also need focused planning

• not just for effective implementation, but also to:• raise awareness of mental well-being and equity as vital issues• embed and operationalize them in organizational structures and

working cultures• build momentum for broad policy and social change

→where practical and actionable tools and processes come in • one promising and ready-to-go planning tool = Health Equity Impact

Assessment -- experiment and innovate with it



Appendices

• case study scenario: HEIA to a LHIN mental health strategy

• drilling down to theory of change underlying equity-focused planning

• Wellesley Health Equity Roadmap



Case Study: Using HEIA For TC LHIN Mental Health Strategy

• the goal:• ensure equity is adequately built into mental

health strategy• ensure strategy addresses systemic barriers to

access and quality care• ensure strategy will benefit most health

disadvantaged populations



1: Scoping Who Is Affected critical health disadvantaged pop’n equity issues all along life-course– racialized youth, poor seniorsdynamics of concurrent challenges

impact of racism and social exclusion, non-insured, need for customized servicesin TO? but newcomers, non -insuredabsolutelyabsolutely – and increasingly

critical importance of income inequality and poverty

place and isolation matters to mental health especially

gender – systemic differences and accesssexual orientation – well documented systemic discrimination and barriers



2: Drilling Down on Impact• for each of the vulnerable populations affected• did the strategy sufficiently identify?

• the specific needs of these specific disadvantaged populations• the access and quality barriers they face?

• unequal access to the social determinants of health and systemic barriers play out in people’s lives and in particular communities in cumulative, reinforcing and inter-dependent ways• clinical language of concurrent disorders or academic

language of inter-sectionality• was this complexity captured and built into strategy?



2: Drilling Down on Process• key goal = ensuring high-quality mental health services and

continuum of support for all• were those living with mental health challenges involved in

defining what quality means to them?• were they involved in indicator and measurement discussions?

• working backwards from ultimate goal = what would the best quality and continuum of care look like• through an equity lens?• to these different populations – from their different perspectives?

• were the voices of these different populations incorporated into planning process?



3: Addressing Needs and Barriers•Aboriginal populations

•homeless

•poor/economically vulnerable more generally

•newcomers and people facing language barriers

•were Aboriginal providers/networks built into planning process?•are specific Aboriginal-driven services being planned?•were existing resources – CAISI, providers, networks, successful programs – built on?•cross-sectoral collaborations – health, shelter, social services•linking to poverty reduction strategies and advocacy•interpretation and translation•cultural competence + resources and management•funding to specialized ethno-cultural community groups



4: Evaluation and Monitoring• evaluation goal = to figure out what works, in what contexts

and, most importantly, how and why • we break down our plan/strategy into stages to assess what happened• were key access barriers and service gaps identified and addressed?• were services planned and delivered effectively?

• full range of different service models and settings• coordinated into seamless continuum of care

• did service changes improve access and quality?• using clear quality and access indicators• and building in community voice – did identified populations think

these services made a difference to their well being?• ultimately, was mental health of identified populations improved and were

disparities reduced?


Challenges of Equity-Focused Evaluation

• Ministry, LHINs and research bodies need to fund and enable evaluation – not just as a tacked-on expectation in accountability regimes

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

• at a program as well as system level:• can’t just measure activity – number or % of pop’n that participated in

a program or received particular services• need to measure health outcomes – even when impact only shows up

in long-term• need to assess reach -- who isn’t signing up or getting the services

they need? • need to differentiate those with greatest need = who programs most

need to reach and keep to have an impact

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Drilling Down: Our ‘Theory of Change”

• ‘realist’ evaluation approach has great potential:• we break down our plan/strategy into stages to assess what happened• were key access barriers and service gaps identified and addressed?• were services planned and delivered effectively?

• full range of different service models and settings• coordinated into seamless continuum of care

• did service changes improve access and quality?• using clear quality and access indicators• and building in community voice – did identified populations think these services

made a difference to their well being?• ultimately, was mental health of identified populations improved and were disparities

reduced? • evaluation goal = to figure out what works, for whom, in what contexts• start from clear theory of how we think better planning will reduce health

inequities



taking account of

social constraints &

conditions

not just individual

programs but coordination,

partnerships & collaboration



enhanced access to primary care & health promotion

for most disadvantaged

up-stream heath conditions & opportunities

improve fastest for those in

greatest need



• 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 [email protected]• 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

Following Up

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mailto:[email protected]


Wellesley Roadmap for Action on the Social Determinants of Health

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;

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Wellesley Roadmap II6 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;

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Wellesley Roadmap III9 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.

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Driving Health Equity into Action: The Potential of Health Equity Impact Assessment