The Lessons and Benefits of Health Equity Impact Assessment

Erika Espinoza, is the Knowledge Exchange Lead for the North Region of Ontario within CAMH's Provincial Systems Support Team. The interview was recorded as part of the Health Equity Impact Assessment (HEIA) Tool Community of Interest with funds from the Evidence Exchange Network (EENet).

Health Equity: Lessons &; Benefits of HEIA from CAMH Education Network on Vimeo.

Health equity impact assessment - new journal article

New journal article from Sue Povall, Fiona Haigh, Debbie Abrahams and Alex Scott-Samuel at IMPACT.

Abstract

The World Health Organization's Commission on Social Determinants of Health has called for ‘health equity impact assessments' of all economic agreements, market regulation and public policies. We carried out an international study to clarify if existing health impact assessment (HIA) methods are adequate for the task of global health equity assessments. We triangulated data from a scoping review of the international literature, in-depth interviews with health equity and HIA experts and an international stakeholder workshop. We found that equity is not addressed adequately in HIAs for a variety of reasons, including inadequate guidance, absence of definitions, poor data and evidence, perceived lack of methods and tools and practitioner unwillingness or inability to address values like fairness and social justice. Current methods can address immediate, ‘downstream’ factors, but not the root causes of inequity. Extending HIAs to cover macro policy and global equity issues will require new tools to address macroeconomic policies, historical roots of inequities and upstream causes like power imbalances. More sensitive, participatory methods are also required. There is, however, no need for the development of a completely new methodology.

More: heapro.oxfordjournals.org/content/early/.../heapro.dat012.shor...

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.

New Report: Working for Equity in Health

Thanks to Adam Coutts.

The Working for Equity in Health context, situation analysis and evidence review presents a comprehensive overview of the evidence linking work, worklessness, social protection and health inequalities in Europe. It is hoped that this report will help stimulate policy makers, practitioners and researchers to think differently about how they might minimise the risks of widening health inequalities and approach the goal of improving the health of communities and populations.

Published 16 January 2012

Eliminating Health Inequities: every woman and every child counts

This International Federation of Red Cross and Red Crescent Societies (IFRC) report uses a human rights framework to tackle health inequities. It provides key evidence on how health inequities can and should be addressed through a holistic approach.

It argues that health inequities, and the resulting social injustice, are closely linked with poverty, gender inequality and human rights violations which in turn, have an impact on education, transport, health, agriculture, and overall well-being.

Interventions should therefore be multi-sectoral, going beyond health to address social and economic determinants – malnutrition, alcohol abuse, poor housing, indoor air pollution and poverty, among others.

There are some nice case studies from Egypt, Bangladesh, Malawi, Ecuador, Afghanistan, Cameroon, Democratic Republic of Congo, Austria, Democratic People's Republic of Korea, and Eritrea.

Click here to download the report.


Key recommendations:

Governments:   take the lead in prioritizing equity

• Ensure universal access
  Governments should ensure universal access to evidence-based public health interventions for all and allocate health resources according to need.
• Enable informed decision-making
  Governments should make accurate health information available to all so that everyone, particularly the most vulnerable, can make informed deci- sions about their health.
• Take a holistic approach
  Governments should promote equality, solidarity, participation, non-discrim- ination and non-violence in all aspects of society, not just health, because tackling health inequities means tackling inequities in society in general.
• Harness the power of a volunteer network
  Governments should make the most of Red Cross Red Crescent volunteers, who form part of the world’s largest humanitarian network, to eliminate health inequities. Volunteers are uniquely capable of reaching the most marginalized groups. Some volunteers are themselves members of these and, therefore, are an entry point for reaching those whom the formal health sector fails to reach.

National Societies:   scale up efforts

• Reach the unreached
  Through their extensive volunteer networks, National Societies need to scale up their activities to bring prevention, treatment, care and support to those who are left out of the formal health system – the women and children who have the least access to appropriate health services. National Societies should expand their reach by encouraging health-seeking behaviours, as well as fostering social inclusion and peace.
• Encourage prioritization and informed decision-making
  National Societies should use their status as auxiliaries to government to engage decision-makers to prioritize health equity and equity in all aspects of society and to hold authorities accountable.
• Develop powerful partnerships
  In order to eliminate health inequities as quickly and effectively as possible, National Societies should engage in meaningful dialogue with key stakehold- ers and form strategic partnerships to increase the effectiveness of advocacy.

Donors:   create an enabling environment

• Maintain and increase funding levels
  Given the current global economic crisis, any cuts in healthcare funding for mother-and-child programmes will have a devastating effect on the target groups – many will be exposed to even greater health risks and deeper lev- els of poverty. Peer pressure has meant that some donors have maintained their levels of funding, despite difficult economic circumstances in their own countries.
• Align commitments with identified gaps
  Encourage skilled and adapted human resources for health, the coverage of essential mother, child and youth health interventions, and integration with other Millennium Development Goals (MDGs). Donors must ensure a well-balanced, effective and adapted response to bridge the gaps in the health of woman, child and young people.
• Remember spending on health makes good economic and social sense
  Health spending is an investment that yields returns in individual and population health, education, and economic growth.
• Continue to innovate in health financing
  In order to increase and improve health services in the world’s poorest countries, innovative funding mechanisms are necessary, which require the participation of a range of actors.
• Start with the person, not the project or programme
  Investment in a comprehensive, multi-sectoral, integrated health approach is the only way forward. Standalone projects do have an impact, but the impact is limited. If a child is immunized but the mother dies in childbirth because of health service failures, the child’s welfare could hardly be con- sidered to have improved.

National Societies together with civil society:   help broker effective support

• Become a responsible stakeholder for development
  Representatives from civil society organizations, the private sector and academia should play a greater role in helping their governments broker an international commitment that puts health inequity issues high on the development agenda. They should also ensure they commit to supporting countries in implementing effective measures to reduce the health gap, particularly for mothers and children. Civil society has a key role to play in being the voice of the voiceless.
• Hold policy-makers to account
  Ensure that parliamentarians represent all their constituents, and take the right legislative and budgetary decisions. Ensure they hold themselves, and their executives, to account.