Realizing the Potential of Health Equity Impact Assessment

Realizing the Potential of Health Equity Impact Assessment

Ministry of Health and Long-Term Care HEIA Conference

Lessons Learned PanelBob GardnerMay 28, 2012

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Outline

lessons learned from my experience:• leading the first pilot testing of Ontario’s draft HEIA• workshops in many settings• working with LHINs, providers and networks to implement HEIA

will set out 4 things1. potential of HEIA2. enablers and success conditions to realize that potential3. barriers and challenges – and how to address them4. some ideas moving forward

but first: our common starting point – how to address pervasive and damaging health inequities

April 12, 2023 | www.wellesleyinstitute.com

Health Inequities = ‘Wicked’ Problem

• problem we are all trying to solve = pervasive and damaging health inequities

• health inequities and their underlying social determinants of health are classic ‘wicked’ policy problems:• shaped by many inter-related and inter-dependent factors • in constantly changing social, economic, community and policy

environments• action has to be taken at multiple levels -- by many levels of government,

service providers, other stakeholders and communities• solutions are not always clear and policy agreement can be difficult to

achieve• effects take years to show up – far beyond any electoral cycle

• have to be able to understand and navigate this complexity to develop solutions – need all the good tools we can get

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Key Directions to Build Equity Into the Health System

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 priorities• quality improvement, chronic disease prevention and management, wait

times• none of these directions can succeed without taking equity barriers, social

determinants of health and differential risks and needs into account• aligning with key priorities also enhances chance for success and

sustainability of equity focus3. identifying those levers that will have the greatest impact on reducing health

inequities and driving system change • enhanced primary care• integrated care networks

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Building Equity Into the Health System: How II

4. embedding equity in provider organizations’ deliverables, incentives and performance management • which means developing solid equity indicators and measurement

5. targeting some resources or programs specifically:• looking for investments and interventions that will have the highest impact on

reducing health disparities or improving the health of most disadvantaged, fastest• either addressing key access barriers – language, culture, availability• or disadvantaged populations – poor, isolated, racialized, homeless

6. while investing up-stream in health promotion and addressing the underlying determinants of health

7. and while building in innovation:• investing in pilot projects, intervention research and innovations• identifying what is working well – and in what contexts – through systematic

evaluation• sharing what works and lessons learned broadly and building cultures of learning

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Into Practice Through Equity-Focused Planning

• all of these directions need solid 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

• 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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Potential of HEIA

• HEIA is one lever to help ensure equity is routinely taken into account in health care planning and delivery

• can help us identify those key barriers to equitable access, specific needs of health-disadvantaged populations and service gaps

• it can also help ensure that projects not specifically about equity or a particular populations, will take equity into account• e.g. planning diabetes awareness and outreach – helps take

language, diversity, local community conditions, etc• can be seen as essential to success of programs

• especially important for health service providers (HSPs) who are not experienced with equity

• could also be important for non-health organizations to begin to take the population health impact of their policies into account


Potential of HEIA II• even 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 uncover unintended consequences or nuances easily 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?• e.g. really interesting work underway to develop quality standards for home care for

LGBTQ• what about people whose English is limited, from different cultures of origin,

refugees?• and more generally the tool can help facilitate wider conversations and analyses of

equity within organizations• these processes can help embed equity within organizations’ working culture – will

come back to how

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Realizing That Potential: Enablers

to facilitate effective use, organizations need:• training and resources – MOHLTC has been working hard – check

out their site• use concrete scenarios

• I develop specific scenarios for particular workshops and settings• e.g. a scenario of differences in post-surgery readmissions between

richer and poorer neighbourhoods sparked rich discussions at a major academic hospital

• make tool easy to use• workbook, examples, case studies, definitions• web-based + interactive as possible• goal moving forward = build virtual community of practitioners and

experience in using HEIA


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Realizing That Potential: Enablers II

• point = ensuring equity is systemically taken into account in policy and program devel and planning –

• but be flexible about how we get there -- can’t be prescriptive in how to use tool• I’ve learned its less about filling in table in a particular way• and it doesn't matter so much what kind of document results• real value is pulling people together to plan and analyze equity• key effect is facilitating conversations and analsysis on how to address

equity in specific policy, program or service initiative• one participant in initial pilot testing defined success as “when

operationalizing health equity becomes more than the work of the ‘equity people’”

• real impact comes from the way HEIA can help embed equity into the working culture of organizations


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Realizing That Potential: Enablers III

• do need ambitious but realistic expectations about results of process:• its about better planning, not so much about hard evidence of

impacts• nonetheless applying HEIA will yield very useful insight and

intelligence on local equity challenges and opportunities• moving forward = need to find ways to share this insight and local

information, and to learn from each other’s experience• also need to build on existing networks to champion and promote

HEIA:• Health Nexus, PHO/OPHA – its equity working group, local

networks like Toronto Hospitals Collaborative on Marginalized Populations


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Realizing That Potential: Enablers IV

• as with many other areas of complex change = need champions

• attach to incentives (mostly carrots so far, also deploy sticks)• MOHLTC and/or LHINs could require HEIA to be used for

certain purposes• here again, not in prescriptive way on how – just clear

expectations – and resources – so it will be used• could consider how to incorporate HEIA into emerging

patient or quality-based funding structures• here are a few Toronto examples


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Embedding HEIA and other equity-focussed planning

1.LHINs used levers to hand (which is a big lesson on driving equity into action)• Toronto Central and Central

required hospitals and other providers to do explicit equity plans

• Toronto Central required each hospital to use HEIA in refreshing its plan

2.Toronto Central required HEIA at short-list stage of funding applications

1. requirements ensured HEIA was used for particular purpose, but some of hospitals have gone much further:• one required all major

programs to apply HEIA• another used HEIA for all

significant policy or program shifts

2. this ensured equity was taken into account in proposal development and planning


Taking Account of Context

• but, of course, HEIA also had to prove useful for it to be generalized

• another lesson learned is that effective implementation does 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• theme in piloting of this and other tools:

• can do best equity plans• but could little impact without organizational resources and

commitment to implement results• success condition = senior management support

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Taking Account of Organizational Constraints, Implementation Barriers and Challenges

• understand organizational context:• competing priorities, time and resource pressures• can’t be seen as just one more tool

• back to making tool easy to use and supporting resources• also need to ensure HEIA is well aligned with existing planning

tools and processes• so it doesn't add to managers/planners’ work, but makes it more effective• integrate HEIA into continuous routine cycle of planning and innovation• e.g. what if HEIA was seen to be one of ways hospitals and other providers

could demonstrate their community engagement within accreditation• e.g. using HEIA becomes a standard part of strategic planning or when

considering major cuts or realignments


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Ideas Moving Forward• providers:

• every hospital has a bd-level quality committee• all could use HEIA for their planning• work with Health Quality Ontario to build this into Quality Improvement Plans

• Family Health Teams could apply to planning their service mix• LHINs

• use as lever to drive equity-focused planning into action• build on and adapt examples from leading LHINs

• requiring from providers for equity plans + other purposes• using for funding and resource allocation decisions

• apply to priority directions• e.g. each LHIN to apply HEIA to their initiatives to reduce diabetes, hospital

admissions, etc• potential of sharing and rolling these up across the prov


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Ideas Moving Forward II

• MOHLTC• back to big picture – for prov to act seriously on equity:

• require each LHIN to include equity (as a key ECFAA principle) in strategy plan/priorities

• apply HEIA against key provincial priorities – diabetes, avoidable hospital admissions

• linking up ideas – work with OHA and HQO to require HEIA in hospital QIPs

• provide resources and incentives so equity plans will be acted on:– X % of funds need to be addressing equity issues

• bigger picture again, HEIA can be encouraged/required in other Ministries/areas• can be part of driving integrated Health in All Policies approaches


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Conclusion

• loop back to where I started:• we need to align equity with key provincial and system priorities and

embed equity in LHIN and provider deliverables• HEIA can be a key tool to help planners and providers ensure this

alignment and meet these deliverables• e.g. carrying forward diabetes example -- if MOHLTC set up its

priorities and expectations to require LHINs to both:• reduce overall incidence of diabetes and reduce inequitable

differences by neighbourhood, income or other • would absolutely need to take account of inequitable burden and

risks to meet these deliverables• would absolutely need good equity-focused planning – and useful

tool such as HEIA


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Equation for action

HEIA has real potential= try it out

HEIA as one effective tool

Enablers

Incentives

Advancing

health equity


Realizing the Potential of Health Equity Impact Assessment

Health & Medicine

Transcript of Realizing the Potential of Health Equity Impact Assessment