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

© The Wellesley Institutewww.wellesleyinstitute.com

Bob Gardner

HEIA Workshop

Ontario Community Support Association

Great !deas Conference: New Recipes for Success

October 19, 2010


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

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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 group5. back together on potential of HEIA to help drive equity

strategy into action

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• 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

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© The Wellesley Institutewww.wellesleyinstitute.com 5





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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• 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



•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

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POWER StudyGender andEquityHealth IndicatorFramework

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• 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


• 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

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• 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

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• 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

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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

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• 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

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• 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

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1. 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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• 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

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• 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

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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

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• 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

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• 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

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• 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?

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Three step analysis of inequality:1. gradient of health outcomes:

• inequitable incidence of diabetes• the more vulnerable tend to be

sicker and face more complications

2. given wider social and economic inequalities, some have greater resources and resilience to cope with diabetes than others

3. there is inequitable access to preventative, primary and specialist care for those at risk of or with diabetes

1. highlights need to identify where need is greatest → adjust and concentrate program

2. highlights need to take wider inequalities into account:• e.g. can’t design program based

upon good nutrition where so many face food insecurity

3. build ensuring equitable access and quality into fundamental mandate of program

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• 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

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• 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

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• 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

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• 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

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• 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

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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

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http://www.wellesleyinstitute.com/health-equity-impact-assessment-heia-resources











http://wellesleyinstitute.com/

http://healthequitycouncil.ca/

http://www.rainbowhealthnetwork.ca/

http://www.owhn.on.ca/

http://erdco.ca/

http://www.smallstepsbigdifference.blogspot.com/


• 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

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http://wellesleyinstitute.com/

mailto:[email protected]


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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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;

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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.

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The Wellesley Institute advances urban health through rigorous research,

pragmatic policy solutions, social innovation, and community action.



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

Health & Medicine