4 March 2013

Building Health and Equity Into Policy: Health Equity Impact Assessments

Guest post by Dr Bob Gardner, Director of Policy at the Wellesley Institute

Addressing 'wicked' policy and social problems such as systemic health inequities and their underlying social determinants requires comprehensive and coordinated action across government and other sectors -- and that needs good planning.  Health equity impact assessments have been emphasized here in Ontario and in many other jurisdictions as one key way to ensure equity is embedded in planning.

Wellesley has been undertaking more specifically policy orientated angles on health equity impact assessment (HEIA).  When a Commission was established in Ontario to examine the reform of the social assistance system we worked with a broad collaborative of public health, Community Health Centres, hospitals and other health care organizations to provide input.  The theme of our several briefs and meeting with the Commissioners was how to ensure that any reformed system took population health and health equity into account and we set out concrete recommendations on how to create a health enabling system.

We then developed a series of analyses that we explicitly framed as policy-orientated HEIAs.  We called this series the Real Cost of ... because we were often unfortunately arguing that a particular policy or direction would have an adverse and inequitable impact on health, especially for particular vulnerable populations.  These papers dissect the population health implications of the particular policy, review available evidence on the expected impact of implementation, identify health and equity consequences of implementation, and recommend ways to avoid or mitigate that adverse impact.  We have done such Real Cost analyses of:

  • proposed Toronto budget cuts to social and community programs;
  • federal reductions in health care programs for refugees.  Again, this came out of working with a broad collaboration of researchers, clinicians and community organizations, and we have subsequently set out action steps that various levels of government and providers need to undertake to address the consequences of the federal cuts.  We have also continued to comment as the policy unfolded: for example, when the government released its list of designated safe countries -- which had drastic implications for  the levels of services available to refuges categorized on this list.  We presented to the Toronto Board of Health and to other committees on the health challenges facing refugees and undocumented people.
  • Ontario's proposed cuts to a particularly important and flexible social assistance program called Community Start-Up and Maintenance Benefits.  This project subsequently led to developing a map-based on-line tracking tool to monitor the social impact of these changes in communities across the province.
  • Recent debates on whether a casino should be located in Toronto -- here also, we working collaboratively with public health and other partners, held a forum on the health equity implications of casinos and problem gambling, and presented to the Toronto Board of Health, which recommended not proceeding with a casino.

These policy-orientated HEIAs have proven useful in several ways:

  • as a solid analytical tool -- rapidly assessing issues within this framework can quickly provide evidence-based findings and recommendations to effectively intervene in current policy issues;
  • these Real Cost HEIAs  have proven to be an important resources for health care and other partners in addressing the particular issues at both policy and program levels;
  • they have had some immediate success in contributing to shifts in the particular policies -- for  example, the proposed Toronto budget cuts were significantly softened, the planned CSUMB cuts were reduced, and many municipal councillors and the Toronto Board of Health have opposed a casino in Toronto.  Of course, these analyses were only one part of much wider mobilization that contributed to these changes, but they were arguably an important part.
  • finally, by highlighting concretely how population health, the social determinants of health and health equity need to be built into the development of many kinds of policy, across many spheres of government, these HEIAs can contribute to a reframing of how policy is developed -- and can help move towards really implementing comprehensive Health in All Policies approaches.