This presentation provides critical insights on how to drive mental health and health equity strategy into action. Bob Gardner, Director of Policy Nimira Lalani www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. ‘Wicked’ Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health Equity Strategy Into Action Bob Gardner & Nimira Lalani Canadian Mental Health Association-Ontario January 24, 2011 January 24, 2011 1

3. one front = potential of planning tools such as impact assessment in grounding and driving actionJanuary 24, 2011 2

5. and, of course, equity and mental health need to be integratedJanuary 24, 2011 3

6. © The Wellesley Institute www.wellesleyinstitute.com 4

10. 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

13. In constantly changing and dynamic system

14. In fact, through multiple interacting and inter-dependent economic, social and health systems

15. Determinants have a reinforcing and cumulative effect on individual and population health8

16. POWER Study Gender and Equity Health Indicator Framework 9

18. This concept:

19. is clear, understandable and actionable

20. identifies the problem that policies will try to solve

21. is also tied to widely accepted notions of fairness and social justice

22. The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes

23. A positive and forward-looking definition = equal opportunities for good health10

25. but health disparities can seem so overwhelming and their underlying social determinants so intractable -> can be paralyzing

27. unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse

28. 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 12

30. can do this through a two pronged strategy: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 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 Equity Into Health System: How 13

31. Equity Into Health System How II: Strategy Into Action health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy 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, mental health, etc. building equity into ongoing performance and system management, and routine service delivery investing in promising interventions to reduce barriers and enhance equitable care sharing and building on front-line and local initiatives, evaluation, and other enablers for innovation 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 14

33. key barriers to equitable access to high quality care

34. the specific needs of health-disadvantaged populations

35. gaps in available services for these populations

37. Equity-Focused Planning Tools quick check to ensure equity is considered in all service delivery/planning take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery assess current state of provider organization determine needs of communities facing health disparities assess impact of programs/interventions on health disparities and disadvantaged populations simple equity lens Health Equity Impact Assessment equity audits and/or HEIA equity-focused needs assessment equity-focused evaluation 16

41. HEIA Template 19

42. Ontario HEIA preliminary stage = scoping could the policy or initiative have a differential or inequitable impact on different groups? 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 assess potential positive and negative impacts of the initiative on the population(s) develop strategies to build on positive and mitigate negative impacts plan how implementation of the initiative will be monitored to assess its impact 20

44. developed because practitioners and advocates felt mental health was not being sufficiently emphasized in general HIA

45. developed in the UK with significant government supportthe MWIA toolkit and other health impact resources are available at http://www.apho.org.uk/resource/item.aspx?RID=95836 January 24, 2011 21

46. January 24, 2011 22

48. Raise awareness and understanding of mental well-being.

49. Enable a range of stakeholders to begin to identify the impact a particular policy, service, programme or project is having on mental well-being.

50. Encourage stakeholders to explore ways to maximize potential positive impacts and minimize potential negative ones.

52. A screening toolkit

53. An assessment toolkit that could be used for rapid or comprehensive impact assessment

54. Determinants and protective factors for mental well-being

55. Guidance on developing indicators for mental well-being

57. NW NIMHE, University of Liverpool, Liverpool PCT and Capital of Culture saw opportunity to develop the work at policy level (2005)

58. Review of eight impact assessment tools demonstrated that mental well-being not being fully addressed within HIA (2005)

59. Revised toolkit to take on review of evidence base on mental well-being & tested out with public policy and others

60. Comprehensive MWIA on Liverpool Capital of Culture (2006/07)

61. Published toolkit as ‘A Living & Working document’ March 2007

62. National & international dissemination, ongoing evaluation and monitoring

63. MWIA central theme in Well London three year BIG Lottery project

64. Supported implementation - WM Champions, NW Pioneers 2nd stage, East Midlands, training development

67. LHINs have explicit diabetes strategies

69. will work through MWIA to see27

71. don’t worry about coming to substantive conclusions – really just trying out potential of planning tools28

73. do need comprehensive and coherent health equity and mental health strategy (in fact, strategy that integrates both) – but don’t wait for perfect strategy

74. think big and think strategically – but get going29

81. Wellesley has developed a page on health impact and HEIA, including links to leading international sites and practitioners, at http://www.wellesleyinstitute.com/health-equity-impact-assessment-heia-resources

82. my email is bob@wellesleyinstitute.com

83. 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 equityFollowing Up 33

85. case study: applying HEIA to TC LHIN mental health strategy

89. in addition, there are systemic disparities in access to and quality of care within the healthcare system

90. plus major differences between women and men

91. not just unfair, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, mental health, diabetes, etc, and contribute to avoidable costs

92. that’s why enhancing health equity has become a clear priority – from the Province to LHINs to many providers

93. and that’s why we need tools and approaches to build equity into effective system and service planning36

96. equity issues all along life-course– racialized youth, poor seniors

97. dynamics of concurrent challenges

98. impact of racism and social exclusion, non-insured, need for customized services

99. in TO? but newcomers, non -insured

100. absolutely

101. absolutely – and increasingly

102. critical importance of income inequality and poverty

103. place and isolation matters to mental health especially

104. gender – systemic differences and access

105. sexual orientation – well documented systemic discrimination and barriersJanuary 24, 2011 38

110. homeless

111. poor/economically vulnerable more generally

112. newcomers and people facing language barriers

113. were Aboriginal providers/networks built into planning process?

114. are specific Aboriginal-driven services being planned?

115. were existing resources – CAISI, providers, networks, successful programs – built on?

116. cross-sectoral collaborations – health, shelter, social services

117. linking to poverty reduction strategies and advocacy

118. interpretation and translation

119. cultural competence + resources and management

120. funding to specialized ethno-cultural community groupsJanuary 24, 2011 41

122. Theory of Change why and how to do equity-focused planning January 24, 2011 43

123. taking account of social constraints & conditions not just individual programs but coordination, partnerships & collaboration 44

124. enhanced access to primary care & health promotion for most disadvantaged up-stream heath conditions & opportunities improve fastest for those in greatest need 45

125. Wellesley Roadmap for Action on the Social Determinants of Health look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 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; develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; act across silos – inter-sectoral and cross-government collaboration and coordination are vital; set and monitor targets and incentives – cascading through all levels of government and program action; 46

126. Wellesley Roadmap II 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; 47

127. 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 program and policy instruments, and into a coherent and coordinated overall strategy for health equity. 48

128. © The Wellesley Institute www.wellesleyinstitute.com January 24, 2011 49