This presentations offers critical insight into the potential of an health equity impact assessment. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Realizing the Potential of Health Equity
Impact Assessment
Ministry of Health and Long-Term Care
HEIA Conference
Lessons Learned Panel
Bob Gardner
May 28, 2012

2. 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 things
1. potential of HEIA
2. enablers and success conditions to realize that potential
3. barriers and challenges – and how to address them
4. some ideas moving forward
but first: our common starting point – how to address
pervasive and damaging health inequities
September 5, 2012 |
2
www.wellesleyinstitute.com

3. 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
September 5, 2012 3

4. 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 focus
3. identifying those levers that will have the greatest impact on reducing health
inequities and driving system change
• enhanced primary care
• integrated care networks
September 5, 2012 4

5. 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
5

6. 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
6

7. 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
September 5, 2012 |
7
www.wellesleyinstitute.com

8. 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
8

9. 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
September 5, 2012 |
9
www.wellesleyinstitute.com

10. 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
September 5, 2012 |
10
www.wellesleyinstitute.com

11. 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
September 5, 2012 |
11
www.wellesleyinstitute.com

12. 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
September 5, 2012 |
12
www.wellesleyinstitute.com

13. Embedding HEIA and other equity-focussed
planning
1. LHINs used levers to hand 1. requirements ensured
(which is a big lesson on HEIA was used for
driving equity into action) particular purpose, but
• Toronto Central and Central some of hospitals have
required hospitals and other gone much further:
providers to do explicit • one required all major
equity plans programs to apply HEIA
• Toronto Central required • another used HEIA for
each hospital to use HEIA in all significant policy or
refreshing its plan program shifts
2. Toronto Central required 2. this ensured equity was
HEIA at short-list stage of taken into account in
funding applications proposal development
and planning
September 5, 2012 |
13
www.wellesleyinstitute.com

14. 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

15. 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
September 5, 2012 |
15
www.wellesleyinstitute.com

16. 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
September 5, 2012 |
16
www.wellesleyinstitute.com

17. 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
September 5, 2012 |
17
www.wellesleyinstitute.com

18. 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
September 5, 2012 |
18
www.wellesleyinstitute.com

19. Equation for action
HEIA has real potential= try it out
HEIA as Enablers Advancing
one
effective
Incentives health
equity
tool
September 5, 2012 |
19
www.wellesleyinstitute.com