This presentation discusses health equity for immigrants and refugees. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Health Equity For Immigrants
and Refugees: Driving Policy
Action
Bob Gardner
Migrant and Refugee Children: Entitlement and
Access to Health Care in Canada
National Seminar: Montreal
March 26-7, 2013

2. Outline
• inequitable health and access to care for immigrant
and refugee communities is a complex problem –
with huge unfair and avoidable human costs
• we know what the problem is and what changes are
needed to solve it
• we need sophisticated policy analysis and political
strategy to drive the needed changes
• will set out what a strategy for change could look like
• the policy cases that need to be made
• effective and ways to make those cases
• illustrate by sharing some experience/examples from
Ontario
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3. Systemic Health Inequities Faced by Immigrant
Communities = ‘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 gear solutions to specific needs, barriers and
situations of specific populations – such as immigrants and
refugees
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4. Think Big, But Get Going
• the point of all this social determinants and policy analysis
is to be able to identify the changes needed to reduce
health disparities
• but health disparities can seem so overwhelming and their
underlying social determinants so intractable → can be
paralyzing
• have big goals and think strategically, but get going
• make best judgment from evidence and experience
• identify actionable and manageable initiatives
• experiment and innovate
• learn lessons and adjust
• demonstrating success → build momentum for change
• need to start somewhere – start where you are and where
you can make a difference
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5. First, Clarify the Problem To Solve
• emerging but clear evidence of health impacts:
• inequitable access to health care and other services
• inequitable treatment and quality
• inequitable health outcomes
• playing out differently in different populations
→ different needs and barriers to good care
→ different program and policy solutions
• how people came to be uninsured – and their
legal and social circumstances – is quite
different
→ different policy solutions
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6. Then Develop Solid Strategy
• have to be able to understand and navigate this complexity to
develop solutions by identifying:
• the key pathways to change that will make fundamental difference to
population health overall or the particular problem/community
• the crucial policy levers that will drive the needed changes
• and need to understand the policy context or environment for
achieving the needed changes
• identifying the best opportunities:
• being alive to policy windows as they emerge
• knowing who controls the policy levels we want to change
• and where needed changes will get the most traction
• and making solid business case
• actionable policy options
• designed for particular level of government/decision maker
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7. And Policy Analysis/Advocacy
• research demonstrating inequitable
access → delayed care and worse
outcomes
• analysis of federal cuts to refugee health
care
→ predictable and avoidable adverse
impact on particularly vulnerable people
• building the policy case(s)
e.g. IFH cuts → increased healthcare
costs/demands at prov and provider
levels
• to demonstrate common interests
• well designed policy briefs with
actionable alternatives
• and sustained interaction with policy
makers
• build alliances and coordination
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8. And Innovative Advocacy
• political activism
• ‘white coat’ guerillas
• clinicians effectively using their professional prestige and platforms
• media work
• coalitions, networks and direct action
• lots of ‘insider’ work with policy makers
+ with a service face
• on-the-ground service innovations
• plus enormous individual advocacy for refugees needing care
• to mitigate adverse impact of cuts and deliver best care to vulnerable
populations = constant demonstration that alternatives are possible
+ multi-level strategy always needs a Plan B:
• looking ahead – how to keep issue alive
• continuing to document adverse consequences –Refugee HOMES
documentation tool established by clinicians, revising HEIA
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9. Need Action at Different System and Organizational Levels
Need to Move Different Policy Levers
Health Equity for
Immigrants &
Refugees
Broad SDoH &
Policy
Environment
Provincial
Health Care
Systems
Regional Health
Authorities
Hospital, Community
& Other Providers

10. Driving Action: Federal Level
• key immediate challenge:
• rescind the cuts to IFH
• not much chance → advocacy to make impacts of cuts and
operation of remaining insurance program a little less bad
• key strategy has been building broad awareness and
partnerships
• powerful symbolism of so many national health
organizations supporting demands
• always make the connections – link IFH demands
into need for more equitable immigration policy
more generally
• and better settlement strategy and resources
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11. Driving Action: Provincial Level
• the case to be made:
• IFH cuts will adversely effect already health
disadvantaged populations
• will increase avoidable costs to be borne by prov
• action needed:
• clear commitment to make up difference and ensure
access to care
• clear directions to providers to serve refugees
• ensure resources
• monitor increased costs and adverse effects –
encourage/require providers to use survey
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12. Driving Action: Local Level
• Regional Health Authorities are key location for addressing problem
• can establish coordinating or problem solving groups
• can direct providers to ensure access
• can direct providers to document health and cost impacts
• Toronto Central led on refugee issue for LHINs:
• it has long history of commitment to equity
• providers and activists on this issue have been well connected to the
LHIN and provided considerable input
• have been addressing problems of uninsured – e.g. systematize referral
and payment relationships between CHCs and hospitals
• but also municipal govts – e.g. Toronto
• Public Health and Board of Health highlighted adverse health situation
of undocumented
• Council adopted a ‘Sanctuary City’ type policy to provide services
regardless of legal immigration status
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13. Driving Action: Provider Level
• build on existing resources and networks:
• CHCs have had provincial funding – now also midwives
• Women’s College Hospital Network on Noninsured is forum for
local coordination
• what providers can do:
• ensure no discrimination – right through their organization –
and that refugees are never denied care
• develop contingency plans to deal with effects of IFH cuts
• add their voice opposing inequitable impacts – let alone
increased pressure on their services
• join with refugee doctors in systematically collecting info on
patient consequences
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14. Looking Beyond IFH
Never Just Equitable Access, But Quality For All
• adverse social context and living conditions for many immigrants
→ can increase risk of mental and physical illness
+ fewer resources to cope (from supportive social networks, to good
food and being able to afford medications)
• for high quality person-centred care
→ providers and programs need to customize and adapt care to
population needs and contexts
→ good communications and provider-patient relationship means taking
the full range of people’s needs/situations into account
• e.g.. more intensive case management, referral planning and post-
discharge follow-up for health disadvantaged
• in an increasingly diverse society, high quality care = culturally
competent care:
• requires organizational resources, commitment and operationalization
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15. Back to Strategy/Back to the Front-Line
• think big, but act where you are/where you can
• providers and activists coming together to address a
horrible problem:
• innovative clinics and other ‘work-around’ solutions
• community based services to provide comprehensive
health, social and other support
• improve equitable access to health care and opportunities
for good health for immigrant and refugee communities
• complex challenges need multi-level solutions
• need to map out all the factors and forces that need
to be shifted and coordinated to accomplish goal
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16. Equitable Health Care for Immigrant
Communities
Mapping Enablers and Success Conditions
Link Into
Professional Ensure Funding,
Training, Diversity Accountability, &
Build Immigrant and Equity Other Incentives
Care Into Explicit Policies Align with Broadly Based
Equity Standards & Changes Needed Provider Coordinating
Quality Networks & Cross-
Improvement Sectoral
Collaboration
Enable Front-Line
Service Delivery Political &
Work-Arounds & Community
Innovations Mobilization
Broader Policy
Build Awareness Environment:
Across the Health More Equitable
Opportunities to
Care System Health Care for
Shift
Refugees
Immigration
Policy

17. Key Messages
• health disparities are pervasive and deep-seated –
but can’t let that paralyze us
• do need a comprehensive and coherent
immigrant/refugee health equity strategy – but don’t
wait for perfect strategy
• do need to immediately oppose damaging policies
such as IFH cuts – but always keep long-term goals in
mind
• think big and think strategically – but get going
• there is a solid base of evidence, provider
experience, commitment and community connections
to build on
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18. Key Messages II
• key success conditions for enhancing health equity for immigrant
and refugee communities:
• solid research and policy analysis
• demonstrate what success looks like through service
innovations however/wherever you can
• keep connected
• make a solid case for reform – geared to different decision-
makers and partners
• all within a coherent strategy – well-focused, multi-level and
long-term
• use the platforms we have
• build partnerships and coalitions to drive mobilization
• try to shift the frame of public debate and discourse
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