‘Wicked’ Policy Challenges: Planning, Tools, and Directions for Driving Health Equity

Strategy Into Action

Bob Gardner and Steve BarnesCIHR Strategic Training Program in Public Health Policy

Theory to Action ForumFebruary 1, 2012

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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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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Impact of Health Inequities

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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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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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Canadians With Chronic Conditions Who Also Report Food Insecurity

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SDoH As a Complex Problem

Determinants interact and intersect with each other in a constantly changing and dynamic systemIn fact, through multiple interacting and inter-dependent economic, social and health systemsDeterminants have a reinforcing and cumulative effect on individual and population health

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Three Cumulative and Inter-Connecting Levels in Which SDoH Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health →

2. also because of broader social and economic inequality and exclusion→

3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the health and other systems →

1. gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. some communities and populations have fewer capacities, resources and resilience to cope with the impact of poor health

3. these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

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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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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

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

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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 andEquity Health Indicator Framework

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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

Equity Into Health System: Why

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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 priorities3. 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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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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Equity-Focused Planning Tools1. quick check to ensure equity is

considered in all service delivery/planning

2. take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery

3. assess current state of provider organization

4. determine needs of communities facing health disparities

5. assess impact of programs/interventions on health disparities and disadvantaged populations

1. simple equity lens

2. Health Equity Impact Assessment

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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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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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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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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HEIA Analysis1. 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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MOHLTC 2011 HEIA Template

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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

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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Scenario: Developing a Drop-in Program in a Poor Neighbourhood

•what make-up of this community?• are all poor?• what kinds of jobs?• diversity along ethno-cultural ,

language and immigration lines• what languages are spoken and

preferred?• asset and strength-based, not just

challenges and barriers•what SDoH differences within community?•what physical, environmental and other issues need to be considered – e.g. few parks, rail line or highways?•what mental health and related health and social services currently exist?

•needs assessment and gap analysis → prioritize mix of services→outreach to build on existing services and respected organizations→where to base the new service that is most convenient and effective

•translate material into appropriate languages•take SDoH into account in service planning/delivery•thinking about reach as well – who isn’t signing up or getting the services they need? •innovative options such as peer ambassadors/navigators

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Need Clear Theory of Change for Equity-Focused Planning

taking account of

social constraints &

conditions

not just individual

programs but coordination,

partnerships & collaboration

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enhanced access to primary care & health promotion

for most disadvantaged

up-stream heath conditions & opportunities

improve fastest for those in

greatest need

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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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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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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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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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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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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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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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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

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Appendix

• indicators, data and other success conditions• Wellesley Health Equity Roadmap

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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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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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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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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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Wellesley Roadmap II6 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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Wellesley Roadmap III9 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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• 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

Following Up

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