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Driving Health Equity Into Action: The Potential of Health Equity Impact Assessment,[object Object],Bob Gardner,[object Object],Diversity and Equity in Mental Health Conference,[object Object],May 27, 2011,[object Object]
Starting Points,[object Object],health disparities in Ontario and Canada are pervasive and damaging,[object Object],but these disparities can be addressed through comprehensive health equity strategy,[object Object],equity strategy can be driven into action within the health system through,[object Object],equity-focused planning,[object Object],aligning equity with key system drivers such as sustainability and quality, and priorities such as ER, ALC, mental health, etc.,[object Object],building equity into ongoing performance management and service delivery,[object Object],investing in promising interventions, and pulling them together within a coherent and coordinated overall strategy,[object Object],enabling innovation through sharing and building on front-line and local initiatives, evaluation, and organizational learning,[object Object],focus today is on a key setting for implementing this overall strategy -- equity-focused planning and delivery of community-based mental health  – using HEIA,[object Object],2,[object Object]
Outline,[object Object],set the scene: ,[object Object],challenge of systemic health inequities ,[object Object],potential of health equity strategy to address them,[object Object],one pre-condition of an effective strategy is equity-focused planning,[object Object],and one useful tool is Health Equity Impact Assessment,[object Object],will sketch out background and potential of HEIA,[object Object],will work through several concrete planning scenarios,[object Object],3,[object Object]
The Challenge: Systemic Health Disparities,[object Object],[object Object]
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 planning4,[object Object]
© The Wellesley Institute,[object Object],www.wellesleyinstitute.com,[object Object],5,[object Object]
Social Gradient of Health: Depression,[object Object],[object Object]
+ inequitable service use:people living in the lowest-income neighbourhoods were somewhat more likely to use mental health services and to receive ECT,[object Object],much more likely to be hospitalized for depression,[object Object],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.,[object Object],Source: POWER Study Vol 1 Exhibit 5a.9,[object Object],6,[object Object]
7,[object Object]
Impact of Disparities,[object Object],inequality in how long people live,[object Object],difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women,[object Object],+ inequality in how well people live:,[object Object],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,[object Object],even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women ,[object Object],Statistics Canada Health Reports Dec 09,[object Object],8,[object Object]
9,[object Object],www.welleseyinstitute.com,[object Object],Foundations of Health Disparities Roots Lie in Social Determinants of Health ,[object Object],[object Object]
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,[object Object]
SDoH As a Complex Problem,[object Object],[object Object]
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 health11,[object Object]
POWER Study,[object Object],Gender and,[object Object],Equity,[object Object],Health Indicator,[object Object],Framework,[object Object],12,[object Object]
Three Cumulative and Inter-Dependent Levels Shape Health Inequities,[object Object],because of inequitable access to wealth, income, education and other fundamental determinants of health ->,[object Object],also because of broader social and economic inequality  and exclusion->,[object Object],along very similar lines, disadvantaged and vulnerable populations face systemic barriers within the health and other systems ->,[object Object],gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions,[object Object],some communities and populations are more vulnerable and have fewer capacities, resources and resilience to cope with the impact of health inequities,[object Object],these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need,[object Object],13,[object Object]
Health Equity = Reducing Unfair Differences,[object Object],[object Object]
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 identity14,[object Object]
15,[object Object],Think Big, But Get Going,[object Object],[object Object]
think big and think strategically, but get goingmake best judgment from evidence and experience,[object Object],identify actionable and manageable initiatives that can make a difference,[object Object],experiment and innovate ,[object Object],learn lessons and adjust – why evaluation is so crucial ,[object Object],gradually build up coherent sets of policy and program actions – and keep evaluating,[object Object],[object Object],[object Object]
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 positionEquity Into Health System: Why ,[object Object],16,[object Object]
[object Object]
through a multi-pronged strategy:building health equity into all health care planning and delivery,[object Object],doesn’t mean all programs are all about equity,[object Object],but all take equity into account in planning their services and outreach,[object Object],aligning equity with system drivers and priorities,[object Object],embedding equity in provider organizations’ deliverables, incentives  and performance management ,[object Object],targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers,[object Object],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,[object Object],while thinking up-stream to health promotion and addressing the underlying determinants of health,[object Object],Equity Into Health System: How,[object Object],17,[object Object]
Equity Into Health System: How II,[object Object],while health disparities are pervasive and deep-rooted, they can be changed through policy and program action,[object Object],comprehensive strategy developed in 2008 for Toronto Central LHIN,[object Object],many recommendations have been acted on,[object Object],other LHINs are also prioritizing and moving to address health disparities ,[object Object],18,[object Object]
Start From The Community,[object Object],[object Object]
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 evaluation19,[object Object]
Align with System Drivers and Trends: ECFA Act and Quality Agenda,[object Object],[object Object],hospitals just developed first generation and will be reporting every year ,[object Object],opportunity = equity can be built in as one of dimensions to report on,[object Object],other provider institutions will be reporting in future,[object Object],[object Object],taking lived conditions/experience into account – meaning equity and diversity -> essential to high quality patient-centred care  for all,[object Object],[object Object],context for you – many clients will have concurrent challenges?,[object Object],[object Object],e.g. reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over-prescriptions -> enhanced quality and cost effectiveness,[object Object],20,[object Object]
Into Practice Through Equity-Focused Planning,[object Object],[object Object]
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

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

Notes de l'éditeur

  1. these damaging disparities = the problem we are trying to solvethese disparities + and their impact on people's ability to cope with health challenges = vital part of the context for all health, home and related service delivery
  2. mental health is crucial component of overall well-being – also major provincial prioritysame social gradient of mental health
  3. OHIP core services
  4. Getting specific on concrete impact of health disparities on quality of livesactivities of ¼ of low income people are limited by pain = 2X than high income
  5. In: that's impact on daily livesthat type of impact adds up over people's livesesp.. impt in this context – home and community services deal with the impact of chronic conditions and inequitable morbidity
  6. reinforcing nature of social determinants on health disparities = complex problemsignificance for key priorities = crucial part of managing diabetes and other chronic conditions is good nutrition need to assess this and other facets of people’s living conditions and resources for case management and planning – what % of mw clients face food insecurityneed to customize services to meet complex and often more challenging needs of disadvantaged populations
  7. this complexity is felt on the ground at program levelhighlights need to drill down to identify underlying basis of problems introduce term if needed to further illustrate complexity of landscape? inter-sectionality – reflecting the fact that personal identities, group dynamics and relations of power and opportunity do not reflect a single line of oppression/identity such as gender, race or class, but their reinforcing and interacting nature
  8. another way of looking at this complexity and what to do about itcommunity resilience and capacities operates at key intersections herethis highlights that SDoH can be driven into action on the ground through:community-based development or capacity building e.g. community development workers in many CHCscross-sectoral collaborations – many local mh groups and networkscross-sectoral planning tables and processesto drive local coordinated action e..g comprehensive community initiatives such as Vibrant Communities or common pattern in European health equity strategies of concentrated/coordinated local investment/focusa central issue is how to build mental health into all that
  9. Principle applies throughout system – at provider and often at program level as well
  10. practical local example – esp. impt to UHN
  11. In: start from solid strategic commitment – which you haveopenings: providers and LHINs are mandated to undertake community engagement
  12. Sick Kids analysis of patients by neighbourhood income levelneed to match tools to purpose
  13. need to match tools to purpose can adapt to particular care and disciplinary settings
  14. tool --- better to think of as a process
  15. where workbook comes in:provides definitions, examples, prompts and possible questionsis set up to help users work through the HEIA process in a step-by-step wayusers simply fill out the appropriate tables in workbook itself to complete their HEIAthe workbook was designed so it can be adapted to become a Web-based interactive resource
  16. highlights looking for unintended consequences
  17. which is equity-orientated by def’nthis is about need to drill down to complexities and specifics
  18. which is equity-orientated by def’nthis is about need to drill down to complexities and specificsfor place-based = need to take account of built and social environment
  19. variations would not just be unfair, but contribute to avoidable complications – quality issue – and costspart of bigger picture:here also would drill down at scoping stage to specify the problem:variations in treatment?are there variations in outcomes – immediate success of treatment, longer-term recovery, morbidity, re-admissions?
  20. Step 2 – identifying possible impactsevidence tells us what does that meanStep 3 -- identifying possible mediating or remedial actionson the face of it, not much hospitals and other providers can do about social conditions?but drilling down, can actthese remedial actions seem beyond hospital mandatebut what if relatively modest costs and programs reduced re-admission and attendant costs?Sick Kids partnership with Law Society to provide landlord, legal and other support for poor families – assuming this will support children’s healthrole for LHINs in just this kind of experiment and innovation?
  21. Step 2 – identifying possible impactsevidence indicates a fairly obvious implicationwhat else?any access barriers?Step 3 -- identifying possible mediating or remedial actionsbut drilling down, can act
  22. many experts see recs for action as critical stage – no point in identifying inequitable impacts if nothing is going to be doneStep 4 -- monitoring impacts -- need to think about that as part of HEIA process and set up evaluation mechanisms from the start
  23. recognizing that what gets measured, matters
  24. if time is tight – end hereif not, skip
  25. a few illustrative questions for eachwould need to drill down even deeper in working group