Health Equity Impact Assessment: A Tool for Driving Equity Into Action May 18,2010

Bob Gardner
Mt Sinai Hospital
May 18, 2010

© The Wellesley Institute
May 19, 2010 www.wellesleyinstitute.com 1

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 and
in provider institutions through
• equity-focused planning and 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
• sharing and building on front-line and local initiatives, evaluation, and other
enablers for innovation
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
• will set out how to realize potential within hospital
• will work through process with concrete example

www.wellesleyinstitute.com 2

• 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


• Ministry:
• new legislation/policy builds specific priorities into performance
management
• equity is among attributes of high-performing health system defined
by Ontario Health Quality Council and in proposed legislation:
• more generally, equity contributes to quality, sustainability and
efficiency
• can’t solve provincial priorities such as wait times or chronic
conditions without addressing equity
• Toronto Central LHIN:
• also emphasizes building equity into performance management and
core of planning – see analysis of first hospital equity plans
• HEIA is being adopted seriously by TC LHIN
• have to anticipate it will be required


• 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


• 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


1. quick check to ensure equity is 1. simple equity lens
considered in all service
delivery/planning
2. take account of disadvantaged
populations, access barriers and 2. Health Equity Impact
related equity issues in program Assessment
planning and service delivery
3. assess current state of provider 3. equity audits and/or HEIA
organization
4. determine needs of communities 4. equity-focused needs
facing health disparities assessment
5. assess impact of
programs/interventions on 5. equity-focused evaluation
health disparities and
disadvantaged populations

© The Wellesley Institute 7
www.wellesleyinstitute.com

• planning tool that analyzes potential impact of program or policy change
on health disparities and/or health disadvantaged populations
• can help to plan new services, policy development or other initiatives
• can also be used to assess/realign existing programs
• intended to be relatively easy-to-use tool
• essentially prospective
• 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 and providers across the
province
• HEIA is being incorporated into a “health in all policies’ framework by MOHLTC
• increasing attention to potential – from WHO, through most European
strategies, PHAC, to MOHLTC and LHINs


1. template asks 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. planners assess potential positive and negative impacts of the
initiative on the population(s) (and indicate where more
information is needed)

3. develop strategies to build on positive and mitigate negative
impacts

4. planners indicate how implementation of the initiative will be
monitored to assess its impact

10

• generally designed for planning forward:
• easy-to-use tool to ensure equity factors are taken into
account in planning
• more generally, can be a means to ensure equity is
incorporated into routine planning throughout an
organization
• but providers in pilot phases – and experience from
other jurisdictions -- identified other uses:
• for strategic and operational planning
• for assessing whether programs should be re-aligned or
continued
• to build principles into evaluation and quality
improvement

• much monitored and incorporated into performance
mgmt and quality improvement
• clear pressure to reduce re-admissions – ties to ALC, ER and
other priorities
• are there equity implications?
• can assume people on operating table are treated equitably
depending upon their immediate situation
• but are there variations in outcomes – immediate success
of operations, mortality, complications, re-admissions?
• by gender
• by social and economic situation
• by ethno-cultural or immigration status
• by comfort/facility with English


• whether there are inequitable variations in re-admissions is a research
question:
• hospitals don’t usually collect such data
• so use proxy data from postal code = neighbourhood characteristics from
census data
• can use case studies and small-scale interview/chart review studies
• highlights importance of project underway to collect better equity-relevant
data
• if evidence is yes – or if practitioners experience leads them to conclude
that there are inequitable variations
• then need to drill down using HEIA template to analyze why particular
populations might have higher re-admissions – two examples to
illustrate
• patients from poor neighbourhoods
• patients who do not speak or understand English well
• and need to drill down to different stages of care process


•population health and •not much hospitals can do about
epidemiological data indicate that social conditions?
they may have poorer overall health
→ greater risk •can take poorer situations/higher
+ less capacity to cope well with risks into account:
effects of surgery • at least, ensure no differential or
inequitable treatment
• equitable care = more intensive
pre-admission planning and
support
• even broader = including child care,
transportation and other
assistance to support coming in for
pre-surgery
• nutritional and other support to
help prepare


•population health and •can take poorer
epidemiological data indicate situations/higher risks into
that they may face: account
• SES challenges as above
reflecting more unequal or
precarious position in labour •as previous +
market • cultural competence lens
• plus effects of immigration • interpretation at pre-surgery
status, social exclusion and • translation of all material
other social determinants • more intensive follow-up to
shaping poorer overall health confirm/support – possibly
→ greater risk peer health ambassadors
+ less capacity to cope well with
effects of surgery
+ might not understand pre-op
instructions and prep


•poor living conditions, food, •can take poorer
anxiety → less able to cope → situations/higher risks into
poorer recovery account:
•can’t take as much time off • at least, ensure no differential
work or inequitable treatment in
post-surgical (length of stay)
•can’t afford dressings and or discharge planning
other requirements • equitable care = more
•can’t afford meds intensive case mgmt and
assessment
•don’t have equitable access • send home with more
to home and community- supplies, meds, etc.
based support • more intensive follow-up to
• research question for CCAC those in greatest need – not
• is access and utilization just medically defined
equitable?


•social determinants •can take social conditions
related challenges as into account as previous
previous + cultural competence lens
+ may not understand how • interpretation for
to take meds or follow-up discharge planning
care • translation of all post-
surgical materials
may not be able to contact
• more intensive follow up in
professional for advice
language/culture
• potential of peer health
ambassadors


• demonstrated value of equity lens on this issue – and most?
• can identify inequitable constraints and barriers:
• in this case, some seem outside of hospital’s control → but can take
into account in care planning
• can identify mediating actions that can be taken and make
recommendations:
• to senior mgmt team
• to appropriate surgical, nursing and other care teams
• then need to monitor impact:
• indicators and stats
• patient satisfaction – by these equity variables
• can assess lessons learned → incorporate into ongoing
quality improvement


• 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
• more specifically, one promising and ready-to-go
planning tool = Health Equity Impact Assessment
• experiment and innovate with it

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

20

• 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 bob@wellesleyinstitute.com
• 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


• there is a clear gradient in health in which people with lower
income, education or other lines of social inequality and exclusion
tend to have poorer health
• over ¼ of low income people in Ontario – 3 X high income – report
their health to be poor or only fair
• 2-3 X as many low income as high income people have chronic
conditions such as diabetes or heart problems
• ¼ of low income people reported their daily activities were prevented
by pain = 2X than high income
• difference btwn life expectancy of top and bottom income decile in
Canada = 7.4 years for men and 4.5 for women
• more sophisticated analyses take account of the pronounced gradient
in morbidity and 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


POWER Study
Gender and
Equity
Health Indicator
Framework

23

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;


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;


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.


The Wellesley Institute advances urban health through rigorous research,
pragmatic policy solutions, social innovation, and community action.


Health Equity Impact Assessment: A Tool for Driving Equity Into Action May 18,2010

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