This presentation offers insight into the policy challenges that inhibit health equity. Bob Gardner, Director of Policy Steve Barnes, Policy Analyst www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. ‘Wicked’ Policy Challenges: Planning, Tools,
and Directions for Driving Health Equity
Strategy Into Action
Bob Gardner and Steve Barnes
CIHR Strategic Training Program in Public Health Policy
Theory to Action Forum
February 1, 2012

2. Key Messages
• health disparities are pervasive and damaging
• will set out how these disparities can be addressed through
comprehensive health equity strategy
• acting on health equity within the health system
• building equity into all planning and delivery
• targeting some programs and resources for equity impact
• aligning equity with key system drivers
• embedding equity in performance management and service delivery
• and well beyond healthcare -- tackling the underlying roots of
health inequality in the wider social determinants of health
• through community-based innovation, cross-sectoral collaborations and
fundamental social and policy change to reduce inequality
• community and political mobilization to demand and drive the necessary
policy changes
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3. The Problem to Solve = Health
Disparities in Ontario
•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
•+ major differences between
women and men
•the gap between the health of
the best off and most
disadvantaged can be huge – and
damaging
•impact and severity of these
inequities can be concentrated in
particular populations
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4. Impact of Health Inequities
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5. Impact of Health Inequities II
• not just a gradient of health and impact on quality
of life
• 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
• 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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6. Foundations of Health Disparities Roots Lie in
Social Determinants of Health
•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
•we need comprehensive strategy to
drive policy action and social change
across these determinants
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7. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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8. SDoH As a Complex Problem
Determinants interact and
intersect with each other in a
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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9. Three Cumulative and Inter-Connecting Levels
in Which SDoH Shape Health Inequities
1. because of inequitable access to 1. gradient of health in which more
wealth, income, education and disadvantaged communities have
other fundamental determinants poorer overall health and are at
of health → greater risk of many conditions
2. also because of broader social and 2. some communities and
economic inequality and populations have fewer capacities,
exclusion→ resources and resilience to cope
with the impact of poor health
3. because of all this, disadvantaged 3. these disadvantaged and
and vulnerable populations have vulnerable communities tend to
more complex needs, but face have inequitable access to services
systemic barriers within the health and support they need
and other systems →
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10. Health Inequities = ‘Wicked’ Problem
• 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
• we need to be able to:
• identify the connections and causal pathways between multiple factors
• articulate the mechanisms or leverage points that will drive change in these
pathways and in population health as a whole
• analyze the policy changes needed to act on these levers
• specify the short, intermediate and long-term outcomes expected and the
preconditions for achieving them.
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11. Think Big, But Get Going
• challenge = health inequities can seem so
overwhelming and their underlying social determinants
so intractable → can be paralyzing
• think big and think strategically, but get going
• make best judgment from evidence and experience
• identify actionable and manageable initiatives that can
make a difference
• experiment and innovate
• learn lessons and adjust – why evaluation is so crucial
• gradually build up coherent sets of policy and program
actions – and keep evaluating
• need to start somewhere:
• focus today is on public health policy
• good planning is one essential pre-condition for driving
action on health equity
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12. Health Equity = Reducing Unfair
Differences
• 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
• Equity is a broad goal, including diversity in background, culture, race
and identity

13. Planning For
Complexity of SDoH
Need to look at how
these other systems
shape the impact of
SDoH:
•access to health
services can mediate
harshest impact of
SDoH to some degree
•community resources
and resilience are impt
POWER Study: Gender and
Equity Health Indicator Framework
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14. Equity Into Health System: Why
even though roots of health disparities lie in far wider
social and economic inequality
1. it’s in the health system that the most disadvantaged
in SDoH terms end up sicker and needing care
• equitable healthcare and support can help to mediate the harshest
impact of the wider social determinants of health on health
disadvantaged populations and communities
2. in addition, there are systemic disparities in access
and quality of healthcare that need to be addressed
• people lower down the social hierarchy can have poorer access to
health services, even though they may have more complex needs
and require more care
• unless we address inequitable access and quality, healthcare and
community support services could make overall disparities even
worse
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15. Equity Into Health System: How
• goal is to ensure equitable health regardless of social
position
• can do this through a multi-pronged strategy:
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
3. embedding equity in provider organizations’ deliverables, incentives
and performance management
4. 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
5. while thinking up-stream to health promotion and addressing the
underlying determinants of health
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16. Into Practice Through Equity-Focused 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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17. 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
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18. Health Equity Impact Assessment
• 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 experience here and in 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 this potential – from WHO, through
most European strategies, PHAC, to Ontario
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19. HEIA In Ontario
• first piloted and refined in Toronto in 2009 by MOHTLC, Toronto Central LHIN and
WI, and in several LHINs afterwards
• final version of template and workbook released by Ministry in 2011 see their
page at http://www.health.gov.on.ca/en/pro/programs/heia/background.aspx
• growing use within health:
• HEIA is being used in Toronto Central and other LHINs
• by many hospitals and other providers across Toronto
• Toronto Central has required HEIA within recent funding application processes
for Aging at Home, and refreshing hospital equity plans
• primers on HEIA and a variant Mental Health Wellbeing Impact Assessment,
many Wellesley workshops and other resources can be found on page at
http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-
for-health-equity/heath-equity-impact-assessment
• Equity Assessment Framework being developed and piloted by Public Health
Ontario – geared to public health settings and standards
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20. Applying HEIA: First, Scope the Issue Through
an Equity Lens
• simple equity lens that can be broadly applied =
• could the policy, program or initiative have a differential or
inequitable impact on different groups?
• use this for scoping stage = whether there are inequitable differences is a
research and evidence question
• so, first action item from HEIA scoping = if we don’t know → find out
• highlights importance of collecting better equity-relevant data across
the system and by every provider
• can use proxy data from postal code = neighbourhood characteristics
from census data
• can use case studies and small-scale interview/chart review studies
• can rely on provider experience and community perceptions at this
scoping stage
• if evidence is yes → then drill down using HEIA template
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21. HEIA Analysis
1. analyze 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. assess potential positive and negative impacts of the
initiative on the population(s)
3. develop strategies to build on positive and mitigate negative
impacts
4. plan how implementation of the initiative will be monitored
to assess its impact
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22. MOHLTC 2011 HEIA Template
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23. HEIA Into Practice: Lessons Learned
• from implementation so far and many workshops – can’t be prescriptive
in using tool
• doesn't matter so much what kind of document results
• real value is pulling people together to plan and analyze equity
• real impact comes from using HEIA to help embed equity into the
working culture of organizations
• 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
• need to realize that HEIA will serve different purposes in different
organizations:
• different kinds of policies and policy contexts
• depends upon organizational experience with equity planning and implementation

24. Lessons Learned II: Adjust Purposes and Use to
Context
• for LHINs and Province, HEIA is one lever to help:
• ensure equity is routinely taken into account in health care planning and delivery
• equity gets embedded in providers’ organizational planning and practice
• especially important for health service providers who are not experienced with
equity
• could also be important for non-health organizations to begin to take population
health impact of their policies into account
• and 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 clarify assumptions – what is exactly is meant by community? what are
the success conditions for the particular program in that particular community
context?
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25. Scenario: Developing a Drop-in Program in a Poor
Neighbourhood
•what make-up of this community? •needs assessment and gap analysis
• are all poor? → prioritize mix of services
• what kinds of jobs? →outreach to build on existing services
• diversity along ethno-cultural , and respected organizations
language and immigration lines →where to base the new service that is
• what languages are spoken and most convenient and effective
preferred? •translate material into appropriate
• asset and strength-based, not just languages
challenges and barriers •take SDoH into account in service
•what SDoH differences within planning/delivery
community? •thinking about reach as well – who isn’t
•what physical, environmental and other signing up or getting the services they
issues need to be considered – e.g. few need?
parks, rail line or highways? •innovative options such as peer
•what mental health and related health ambassadors/navigators
and social services currently exist?
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26. Need Clear Theory of
not just
Change for Equity- taking individual
Focused Planning account of programs but
social coordination,
constraints & partnerships &
conditions collaboration
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27. enhanced access up-stream heath
to primary care conditions &
& health opportunities
promotion for improve fastest
most for those in
disadvantaged greatest need
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28. Beyond Planning: Embed Equity in System
Performance Management
• clear consensus from research and policy literature, and
consistent feature in comprehensive policies on health equity
from other countries:
• setting targets for reducing access barriers, improving health
outcomes of particular populations, etc
• developing realistic and actionable indicators for service delivery
and health outcomes
• tying funding and resource allocation to performance
• closely monitoring progress against the targets and indicators
• disseminating the results widely for public scrutiny
• need comprehensive performance measurement and
management strategy
• then choose appropriate equity targets, indicators and incentives
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29. Beyond Planning II: Into Overall
Strategy
1. building health equity into all health care planning and delivery
• so all take equity into account in planning their services and outreach
2. embedding equity in provider organizations’ deliverables, incentives
and performance management
3. aligning equity with system drivers and priorities – chronic
conditions, emergency wait times, ALCs, quality improvement
4. targeting some resources or programs specifically to addressing
disadvantaged populations or key access barriers
• planning and impact assessment is key to identifying interventions that will
have the highest impact on reducing health disparities or enhancing health
of the most vulnerable
• and public health focus on priority populations
5. while thinking up-stream to health promotion and addressing the
underlying determinants of health
• HEIA can help build understanding of SDoH into healthcare planning
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30. Case Study: City of Toronto Budget
• Applied a policy-orientated HEIA to three key
policy and program changes proposed by the
city:
• reducing child care funding and subsidies;
• eliminating the Hardship Fund; and
• limiting the development of affordable housing to
completing only what has already been approved
and funded.
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32. Child Care
• High-quality child care is a strong determinant of
school-readiness and of overall child
development.
• Reducing access affects people in low wage jobs,
people on social assistance, women, and recent
immigrants
• Building on the positive:
• Equity targets (age and location) already exist in child
care planning
• Equity targets should be extended to include those
disadvantaged within the current system
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33. Child Care cont…
• Mitigating the negative:
• Confirm provincial funding before reducing municipal
funding
• Equity objectives:
• Reducing number of children on waitlist for subsidized
spaces
• Reduce differential between children from vulnerable
populations and the most advantaged populations by
50% over 5 years
• Reduce differential in school readiness between
children from vulnerable populations and the most
advantaged populations by 50% over 5 years
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34. Were we successful?
• City council voted to restore funding in a range of
areas, and the Mayor and Budget Committee took
some cuts off the table
• But we cannot know whether our HEIA influenced
these decisions
• huge number of other community and policy organizations
were working to influence this process
• This is the challenge of evaluating HEIA
• We can easily look back at the process, but evaluating
impact is more complex
• e.g. health impact of program changes takes years to show
up + how to separate effect of particular program changes
and other factors
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35. Key Messages
• 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
• build equity into health system:
• into strategic priorities, align with quality agenda and system
priorities, embed in routine planning and performance management
• into front-line planning and delivery where you practice
• no magic blueprint -- experiment and innovate -- and build on
learnings and success
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36. Key Messages II: Equity-Focused Planning
• to drive action, we need comprehensive and innovative strategy, but we
also need focused planning
• not just for effective implementation, but also to:
• raise awareness of equity as vital issue
• embed and operationalize equity in organizational structures and
working cultures
• build momentum for broad policy and social change
→where practical and actionable tools and processes come in
• one promising and ready-to-go planning tool = Health Equity Impact
Assessment -- experiment and innovate with it

37. Appendix
• indicators, data and other success conditions
• Wellesley Health Equity Roadmap
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38. Success Condition: Effective Equity Targets
• innovative work underway to develop equity indicators – but don’t need
to wait
• build equity into existing targets:
• reducing diabetes incidence is prov and LHIN priority
→ equity target = reduce differences in incidence, complications and rates of
hospitalization between populations or areas
• a good service target has been proposed for diabetes = high/increasing % of
people who get best standard care
→ reduce differences by gender, income, ethno-cultural background
• need to drill down in specific areas that have high equity impact:
→ ensuring access and use of primary health care does not vary inequitably by
income level, immigration status, neigbourhood, gender, race, etc.
• many programs assess their services through client satisfaction surveys
and look for high and improving satisfaction
→ reduce any differences in satisfaction by gender, income, ethno-cultural
background, etc.
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39. Challenges: Equity Targets That Work
• can’t just measure activity:
• number or % of priority pop’n that participated in program
• need to measure health outcomes – even when impact only shows up in long-
term
• so if theory of change for health program begins with enabling more exercise
or healthier eating – then we measure that initial step
• need to assess reach
• who isn’t signing up? who needs program/support most?
• who stuck with program and what impact it had on their health – and how this
varies within the pop’n
• and assess impact through equity lens
• need to differentiate those with greatest need = who programs most need to
support and keep to have an impact
• then adapt incentives and drivers
• develop weighting that recognizes more complex needs and challenges of
most disadvantaged, and builds this into incentive system
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40. Success Condition = Better Data
•looking abroad for promising practices =
Public Health Observatories in UK
• consistent and coherent collection and
analysis of pop’n health data
• specialization among the Observatories
– London focuses on equity issues
•interest/development in Western Canada
•national project to develop health
disparity indicators and data
•Toronto PH is addressing complexities of
collecting and using race-based data
•key direction = explore potential of
equity/SDoH data for Ontario
•pilot project in 3 Toronto academic
hospitals to collect equity data
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41. Wellesley Roadmap for Action on the
Social Determinants of Health
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 programme action;
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42. Wellesley Roadmap II
6 rigorously evaluate the outcomes and potential of programme 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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43. Wellesley Roadmap III
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 programme and policy instruments, and into a
coherent and coordinated overall strategy for health equity.
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44. Following Up
• 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
• email is bob@wellesleyinstitute.com
• we 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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