health equity impact assessment: potential for lhins

Health Equity Impact Assessment:

Potential for LHINs

Central Local Health Integration Network

Speaking Notes

Bob Gardner

Director, Healthcare Reform and Public Policy

October 19, 2009

Equity-Driven 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

• and this requires an array of effective and practical

equity-focused planning tools

• HEIA is one part of this repertoire of equity-focused

planning tools

© The Wellesley Institute

www.wellesleyinstitute.com2

Where HEIA Fits in

Repertoire of Equity-

Focused Planning Tools

1. ensure equity is taken into

account in all service

delivery/planning

2. assess potential impact of

service initiatives/policies on

disadvantaged populations,

access barriers and related

equity issues

3. determine needs of

communities facing health

disparities

4. assess impact of

interventions on health

disparities and disadvantaged

populations

1. simple equity lens

2. HEIA

3. equity-focused needs

assessment

4. equity-focused evaluation



Health Equity Impact

Assessment

• planning tool that analyzes potential impact of service initiatives or

policy changes on health disparities and/or health disadvantaged

populations

– can help to plan new services, policy development or other initiatives

– can also be used to assess/realign existing programs

– essentially prospective

• arose out of broader health impact assessments, which have been

increasingly used in many jurisdictions in last 15 years

– one key reason was increasing policy attention to SDoH and health

disparities → need explicit equity focus

– at same time, need for shorter and more focused processes –

sometimes called Rapid HIA -- had been recognized

– HEIA is seen to be relatively easy-to-use tool



Components of HEIA

1. screening – projects where

HEIA would be useful

2. scoping – which pop‟n and

health effects to consider

3. assessing potential equity

risks and benefits –

specifying particular pop‟n

4. developing recommendations

– to promote positive or

mitigate negative effects

5. report results to decision

makers

6. monitoring and evaluation –

of effectiveness of

recommendations

• while HEIA is sometimes

promoted as easy-to-use „first-

pass‟ planning tool

• does not mean it is only about

1 – 3

• experts argue core of HEIA is

in fact 4 – developing

recommendations to address

equity implications



Piloted In Toronto and

Ontario

• Ontario surveyed best practice jurisdictions:

– Wales and New Zealand were furthest advanced

– but increasing interest in other jurisdictions

• MOHLTC equity unit developed a one page tool and

accompanying „how-to‟ guide – first used in Aging at

Home initiatives in 2008

• partnership of MOHLTC, Toronto Central LHIN and

Wellesley Institute to consult, refine and pilot test in

spring-summer 09

• the hope was that HEIA may have potential in other

LHINs as well



Draft Ontario HEIA: 4 Step

Process

1. template asks how the planned program or initiative affects health

equity for particular disadvantaged populations

– setting out a list of health disadvantaged populations – although

list is not meant to be exhaustive

– also asking about potential impact on social determinants of

health

2. on the basis of the best available information and evidence,

planners assess potential positive and negative impacts of the

initiative on the population(s) (and indicate where more information

is needed)

3. and then develop strategies to build on positive and mitigate

negative impacts

4. and finally, planners indicate how implementation of the initiative

will be monitored to assess its impact© The Wellesley Institute


Toronto Consultations on

HEIA: Phase 1

• goals were to get reactions to basic idea, advice on developing most

effective tool and advice on designing pilot phase

– while tightly focused on HEIA, the sessions were also expected to yield

broader input on health equity strategy

– and to continue to lay foundations for ongoing dialogue on moving

health equity forward

– which they did

• Phase 1 consultations completed in March:

– seven sessions with 67 people

– full range of providers – hospitals, CHCs, multi-service agencies – and

sectors – mental health, seniors, acute, primary care – and specific

consumer table

– significant enthusiasm for idea and momentum for implementation

– report summarizing input to partners at end of March



Lessons from Consultations

I: Participants Defined

Success As …

• when operationalizing health equity becomes more than the work of the “equity people”

• when a provider asks, “How can we include more people in this program?” ”What barriers do we have to look for?”“Are we as effective as we could be at supporting every population?” -- i.e., providers have enough awareness of health equity to ask these questions in their service planning and evaluation

• when an organization embeds HEIA across its decision-making models so that health equity becomes a core value and one of the criteria to be weighed in all decisions




II: Clarify Purpose and

Audience

• primary purpose for HSPs could be to:

• improve attention to equity within planning

• contribute to equity being solidly incorporated into program and

strategic planning

• raise awareness about health equity throughout the organization;

• primary purpose for MOHLTC and LHINs could be to:

• ensure equity impact is routinely considered in planning

• make HEIA part of resource allocation and program planning

and approval processes – e.g. a LHIN could:

• require providers to demonstrate they have used HEIA in funding

applications

• use data from filled out HEIAs in program and resource allocation

decisions




III: Design

• need to be aware of many audiences that could use tool, and

different purposes

• one-page tool would be great, but accessibility and clarity are more

important

• needs preamble with clear statement of principle and purpose

• shift language to more positive

• add prompts, definitions and case studies

• align language and concepts to show decision makers that tool

complements their strategic priorities and supports efficiencies

• use checklist of questions rather than form to fill out

• develop as electronic interactive tool with built-in prompts and online

resources: e.g., definitions, descriptions, case studies, links to web-

based resources, links to mentors who can provide direct support



Revised Tool

• in response to consultations:

– template was revised

– a new workbook was developed to support easy and consistent

use

• the workbook:

– provides definitions, examples, prompts and possible questions

– is set up to help users work through the HEIA process in a step-

by-step way

– users simply fill out the appropriate tables in workbook itself to

complete their HEIA

• the workbook was designed so it can be adapted to

become a Web-based interactive resource



Phase 2: Piloting HEIA

• Phase 2 pilot phase took place in July to test revised tool and new

workbook in practice

• three settings with varying planning cases/initiatives:

– hospital program in diverse urban setting

– support program for patients‟ families of specialized downtown

hospital

– community support services for seniors

• through flexible methods

– Wellesley introduced tool and goals of pilot

– participants either filled it out on their own or we undertook

facilitated planning exercises using the tool

– participants filled out evaluation survey on how process went

and advice on further changes to tool



Key Findings From Pilot

• significant support/momentum for using HEIA

• the tool was seen to be easy to use

• the workbook was an essential addition

• participants were able to effectively use the tool to

identify:

– barriers to access and appropriate care

– potential impacts of the planned program on particular

disadvantaged populations

• they felt it did or could build awareness of equity issues

within their organization, but needed to be widely

implemented to achieve this



Project Completed and

Report Delivered in August

• key message = while making some recommendations for revisions,

we felt it was „good enough to go‟ for widespread implementation

• recommendations included:

– intensive promotion and communication were going to be key to

widespread implementation

– Ministry and LHINs need to decide for what purposes HEIA will

be used, whether it will be mandatory, etc.

– a number of revisions to structure/focus of HEIA tool

– accompanying resources that would be needed – including

eventual on-line version

– organizing comprehensive implementation and roll out

– building systematic evaluation strategy in from the start



National Interest

• Senate Sub-Committee on Population Health

recommended HIA be used to ground government

decision-making and related equity data, research and

planning mechanisms in its recent report

• PHAC has commissioned a review of HEIA in other

jurisdictions

• PHAC is holding consultations in Oct

• parallel workshop on how HEIA and social determinants

and outcome indicators can be adapted for Aboriginal

health planning purposes



Moving Forward on HEIA:

Success Conditions and Key

Directions

• if a LHIN were to adopt HEIA, these are some success

conditions

– based on both piloting in Toronto and wider international

experience

• start from clear definition and strategy for health equity

– then specify where HEIA and equity-focused planning fits in

overall equity strategy

– develop clear definitions and data on potentially affected

populations and communities

– ensure clear focus/scope: which determinants of health, which

access barriers, etc.



Roll Out

• need systematic communications and roll-out plans:

– lesson of lack of uptake for Aging at Home is that providers can‟t

adopt new planning tool if they don‟t know about it, and won‟t if

they aren‟t encouraged/supported

– need to make goals and focus of HEIA very clear

– need to also indicate what resources will be available to support

providers in using HEIA

• decisions for Ministry:

– all LHINS, whichever want to, pilot in a few more?

– what centralized/common support to LHINs and providers?



Building Capacities to Use

HEIA

• need support from LHIN for effective use

– in pilot, participants received extensive orientation briefing and

had participated on initial consultations, and could call up

consultants

– with more widespread implementation, can anticipate questions

and need for advice/assistance from significant numbers

– many jurisdictions have workshops to support users

– even electronic tool will require technical back-up and assistance

• so LHINs need to build in internal capacities to support

providers – let alone to analyze and build on results



Where to Locate Capacity?

• debate in international circles on consultant vs. capacity

building models:

– if goal is widespread use by providers, then easy-to-use tool and

effective support -- i.e. capacity building model is best

• consensus among practitioners and experts that

significant methodological expertise in health impact

assessment is needed

• as always = resource question

– effective use and widespread roll-out will require devoted

resources from both LHINs and providers

– incremental and experimental roll-out could begin within existing

resources



Clarify LHIN Purposes

• a LHIN could use HEIA to:

– build awareness of health equity within and across HSPs

– ensure that HSPs take equity into account in their planning and

service delivery

– build up a fuller picture of equity challenges/opportunities and

needs of disadvantaged populations

– help LHINs set priorities and allocate resources for greatest

equity impact

• different goals → different HEIA strategy and techniques

– e.g. the latter two require more systematic processes to collate

and analyze results of many HEIAs



Context Is Everything

• need to be aware of context in which HEIA will be used:

– separate program or provider wide

– major hospital or small community-based provider

– specific barrier or disadvantaged population to which program is

directed

• and resources devoted to HEIA:

– both at provider level

– and by LHIN and/or Ministry

• understanding context is crucial for both effective

implementation and systematic evaluation



Decide How Seriously To

Drive Implementation

• decide whether use of HEIA is voluntary – and how

strongly encouraged – or mandatory – and how strongly

supported and enforced

– international lesson = explicit requirements – or at least

significant incentives – are key to widespread implementation

• then what kinds of incentives and levers to use to

encourage/drive use of HEIA

– special ear-marked funding or consultant support to begin to use

HEIA – especially at start

– requiring providers to demonstrate they have used HEIA in

planning out a potential project whenever they apply for funds

– requirements within Service Accountability Agreements that

providers use HEIA in appropriate circumstances© The Wellesley Institute


What About the Community?

• a premise of the draft Ontario HEIA – and many others – is that:

– assessing the potential impact of initiatives on particular

populations requires solid understanding of that population's

health situation, needs and context

– this can benefit from ongoing community engagement with the

population and/or specific needs assessment

• analyzing possible mitigation strategies will also benefit from

engaging the affected population in designing the necessary service

changes

• similarly, monitoring and assessing the impact of the initiative – and

how HEIA contributed -- also needs:

– research and input from the affected population on impact

– outcome data stratified by population and determinants



How Could LHINs Use HEIA

Results?

• LHINs could use results from HEIA in their planning and resource

allocation decisions

– using analysis of information in filled out HEIA forms as one

factor in resource allocation and program approval decisions

– using information to shape provider-specific performance

objectives and expectations

– as a source of intelligence and information on equity barriers,

disadvantaged populations and interesting and innovative

initiatives

• could also use HEIA for internal purposes

– apply it to major planning initiatives within the LHINs – e.g.

mental health or diabetes priorities

– starting internally is one option for staging implementation and

gradually building support© The Wellesley Institute


What’s Needed in Tool?

• depending upon the LHIN‟s purpose – i.e. building equity-focused

planning among HSPs and/or using HEIA within resource allocation

decision making – will want to ensure:

– results are easy to interpret

– results lend themselves to ranking and comparisons for

decisions

– HEIA yields useable information on current access barriers,

vulnerable populations and service innovations

• from user point of view, HEIA needs to be:

– easy to use – current form is good enough

– has to be accompanied by workbook

– need to take account of different IT and planning capacities, and

comfort of participants



Monitor and Evaluate

• whatever decisions are made about scope of

implementation, purposes and incentives, keep track of:

– which providers are using HEIA

– for what purposes and in what context

– with what results

• develop a systematic evaluation strategy from the outset:

– MOHLTC developed a Survey Monkey evaluation questionnaire

for pilot – could encourage all participants to use it

– supplement with more intensive interview-based evaluation

research with a smaller sample after a year of implementation

– define what „success‟– effective use of HEIA -- looks like

– evaluate progress against this goal



And a Note on Evaluating

Complex Interventions

• requires clear theory: use of HEIA → better equity-

focussed planning → better quality and more effectively

targeted services → reduced disparities

• goal is to understand how HEIA works in specific

circumstances → build up comprehensive understanding

of dynamics and potential of HEIA and equity-focused

planning

• recognize that simple tools won‟t suit all purposes

• if HEIA is seen as easy-to-use tool for service planning

• can‟t expect it to be useful for more complex or systemic

planning purposes



Building on Knowledge from

HEIA

• one broader hope is that HEIA will yield useful information on

existing system barriers and the needs of disadvantaged

populations, and on promising and successful programme

interventions

– LHINs will need to capture and share this information, and build

on these local front-line insights

– is there a potential to share the resulting knowledge among

LHINs and scale up across the province where appropriate?

– what resources do the LHINs and MOHLTC need to be able to

realize this potential?

• this knowledge management challenge applies in many other areas

– insights and case studies form hospital equity plans, experience of

equity-focused service innovations across the LHIN, etc.



Coordination

• at best, MOHLTC could:

– develop an HEIA tool and promote its use to all LHINs

– provide centralized support to encourage consistency of

approach and effective use

– move quickly to develop an on-line version

• if that doesn‟t prove possible -- or in the meantime -- individual

LHINs can implement HEIA in a coordinated fashion:

– could be interesting GTA LHIN coordinated project

– use same tool, record any adaptations to local contexts

– share experience on how it is working

– look for consistent purposes and approaches

– try to monitor and evaluate within consistent approaches



Follow-Up

• the implementation and impact of HEIA will continue to evolve and

we would be very interested in any further thoughts on

– how LHINs and Ministry can implement HEIA

– how you think it might fit in your area

– your experience with considering and using HEIA

• my email is [email protected]

• we developed a page on HEIA resources at

http://www.wellesleyinstitute.com/health-equity-impact-assessment-

heia-resources

• further resources on health equity strategy, health reform and the

social determinants of health are available on our site at

http://wellesleyinstitute.com



mailto:[email protected]

http://www.wellesleyinstitute.com/health-equity-impact-assessment-heia-resources











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health equity impact assessment: potential for lhins

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