'Wicked' Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health...

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‘Wicked’ Policy Challenges: Tools, Strategies and Directions for Driving

Mental Health and Health Equity Strategy Into Action

Bob Gardner & Nimira LalaniCanadian Mental Health Association-Ontario

January 24, 2011

May 2, 2023 1

May 2, 2023 2© The Wellesley Institute

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Starting Points: Policy Challenges

• how to ensure mental health is incorporated into:• health policy, planning and delivery in general• non-health spheres – from social services through justice

to education• how to integrate and coordinate across policy fields/govt

depts • sometimes called ‘joined up govt ‘or ‘whole of govt approaches’

• huge challenge → need to address on many fronts• one front = potential of planning tools such as

impact assessment in grounding and driving action



Starting Points II: Driving an Equity Agenda

• we have been working on the similar challenge of ensuring that equity is embedded in healthcare planning and delivery, and that underlying social determinants of health are addressed• how to get beyond lip service commitment to equity• within health -- how to align with system drivers, performance

management and quality improvement• beyond health – how to identify and mobilize for the necessary policy

changes to reduce overall social and economic inequality and address the social determinants of health

• some interesting parallels that can be drawn upon• and, of course, equity and mental health need to be integrated

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Today• start with policy challenges around mental health• then explore some lessons learned in equity strategy:

• focusing on the scope and value of equity-focused planning• esp. Health Equity Impact Assessment as it is being developed in Ont• we may explore one HEIA case study in which it was used in the

development of LHIN mental health strategy• then back to mental health strategy into action:

• will outline Mental well-being Impact Assessment as it has been developed in the UK

• and interest in Canada• then small groups to assess potential here

• back to draw together some conclusions and next steps

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Foundations of Health Disparities 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

• real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities



Canadians With Chronic Conditions Who Also Report Food Insecurity



SDoH As a Complex Problem•Determinants interact and intersect with each other•In constantly changing and dynamic system•In fact, through multiple interacting and inter-dependent economic, social and health systems•Determinants have a reinforcing and cumulative effect on individual and population health

POWER StudyGender andEquityHealth IndicatorFramework

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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


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Think Big, But Get Going• the point of all this analysis is to be able to identify policy and program

changes needed to reduce health disparities

• but health disparities 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 – and our common focus is on population health and our more specific focus is on driving equity through the health system



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 proactive health promotion 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 tend to 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 health promotion could make overall disparities even worse

• at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social position

Equity Into Health System: Why



• goal is to ensure equitable access to high quality healthcare regardless of social position

• can do this through a two pronged strategy:1. building health equity into all health planning and delivery

• doesn’t mean all programs are all about equity• but all take equity into account in planning their services and

outreach2. 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

Equity Into Health System: How



Equity Into Health System How II: Strategy Into Action

1. health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy

2. equity strategy can be driven into action within the health system and in provider institutions through• equity-focused planning and aligning equity with key system drivers such as

sustainability and quality, and priorities such as ER, ALC, mental health, etc.• building equity into ongoing performance and system management, and

routine service delivery• investing in promising interventions to reduce barriers and enhance equitable

care• sharing and building on front-line and local initiatives, evaluation, and other

enablers for innovation3. focus today is on one facet of this overall strategy -- equity-focused planning –

and more specifically on one promising planning tool -- Health Equity Impact Assessment


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

• we need to analyze the contours and foundations of disparities:• i.e. is the main problem language barriers, lack of coordination among providers,

availability of services in particular neighbourhoods?• which requires good local research and detailed information – speaks to great

potential of community-based research and specific equity plans within provider organizations

• involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems

• this 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• increasing attention to potential – from WHO, through most European

strategies, PHAC, to MOHLTC and LHINs• planning tool that analyzes potential impact of program or policy

change 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• intended to be relatively easy-to-use tool • essentially prospective, helping plan forward

• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI• HEIA is being used in Toronto Central and other LHINs and providers across the

province • HEIA is being incorporated into a “health in all policies’ framework by MOHLTC

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HEIA Into Practice• generally designed for planning forward:

• easy-to-use tool to ensure equity factors are taken into account in planning• but providers in pilot phases – and experience from other

jurisdictions -- identified other uses:• for strategic and operational planning• for assessing whether programs should be re-aligned or continued• to build principles into evaluation and quality improvement

• another lesson 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

HEIA Template

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Ontario HEIApreliminary stage = scoping

• could the policy or initiative have a differential or inequitable impact on different groups?

1. 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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Mental well-being Impact Assessment

• specific tool –or rather planning repertoire – to ensure mental health is built into policy development and service planning

• developed because practitioners and advocates felt mental health was not being sufficiently emphasized in general HIA

• developed in the UK with significant government support• the MWIA toolkit and other health impact resources are

available at http://www.apho.org.uk/resource/item.aspx?RID=95836

http://www.apho.org.uk/resource/item.aspx?RID=95836

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The MWIA ToolkitAims to:• To provide a practical framework to:• Raise awareness and understanding of mental well-being. • Enable a range of stakeholders to begin to identify the impact a particular policy,

service, programme or project is having on mental well-being.• Encourage stakeholders to explore ways to maximize potential positive impacts

and minimize potential negative ones.• Enable stakeholders to explore and develop local indicators to monitor and

evaluate progress on promoting mental well-being.The toolkit contains:• An introduction & overview• A screening toolkit• An assessment toolkit that could be used for rapid or comprehensive impact

assessment• Determinants and protective factors for mental well-being• Guidance on developing indicators for mental well-being• Appendices to support the MWIA process


MWIA development so far…• Lewisham & Lambeth developed first MWIA toolkit • NW NIMHE, University of Liverpool, Liverpool PCT and Capital of Culture

saw opportunity to develop the work at policy level (2005)• Review of eight impact assessment tools demonstrated that mental well-

being not being fully addressed within HIA (2005)• Revised toolkit to take on review of evidence base on mental well-being

& tested out with public policy and others• Comprehensive MWIA on Liverpool Capital of Culture (2006/07)• Published toolkit as ‘A Living & Working document’ March 2007• National & international dissemination, ongoing evaluation and

monitoring• MWIA central theme in Well London three year BIG Lottery project• Supported implementation - WM Champions, NW Pioneers 2nd stage,

East Midlands, training development• Now established national steering group to inform national policy and

direction on improving mental health and well-being and assessing impact of a wide range of government policies and guidance (2008).



Potential• potential =

• contribute to more efficient and comprehensive planning that embeds mental health

• can help build comprehensive view of mental well-being• demonstrate across policy spheres the need to build mental

health in• demonstrate in service providers that importance of mental health

to so many spheres → transform working culture to take mental health into account

• interest in Canada – • PHAC has working group• will be exploring how to adapt MWIA model to Cdn context


Connections: Taking the Social Determinants of Mental Health Into Account

• MWIA toolkit sets out various determinants & protective factors of mental health:• Population characteristics • Enhancing sense of control• Increasing resilience & community assets• Facilitating community participation• Promoting social inclusion

• these are very similar to those in HEIA template



MWIA Into Practice: Diabetes?• diabetes prevention and management = a major provincial and LHIN priority,

and key health issue for many• LHINs have explicit diabetes strategies• but we know:

• People living with a serious mental illness are at higher risk for a wide range of chronic physical conditions.

• People living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population.

• Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes.

• how do we ensure mental health is solidly embedded into diabetes strategy – and into the programs and resources that drive the strategy into action

• will work through MWIA to see



HEIA Into Practice: Small GroupsSeveral options – one for each?1. explore how mental health would be integrated into a

community-based diabetes prevention and treatment/maintenance program• go through the MWIA steps quickly to determine how mental health needs to

be taken into account in developing such a program

2. explore how mental health would be integrated into a LHIN diabetes strategy• use the MWIA toolkit to identify how mental health will need to be taken

into account in the strategy• will then come back together to discuss lessons learned• don’t worry about coming to substantive conclusions – really just

trying out potential of planning tools



Key Messages• we are facing key challenges:

• getting – and keeping – mental health on the policy agenda across government

• health disparities are pervasive and deep-seated – need comprehensive strategy and significant commitment

• but can’t let that paralyze us• do need comprehensive and coherent health equity and

mental health strategy (in fact, strategy that integrates both) – but don’t wait for perfect strategy

• think big and think strategically – but get going



Key Messages II• for both mental health – and health equity – we have solid evidence, know the

challenges, and know the levers and drivers for change• not perfect – but enough to act

• 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 mental well-being and equity as vital issues• embed and operationalize them 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• another promising tool could be Mental Health well-being Assessment

• get involved in adapting?



Possible Next Steps?

• what do you think?



Possible Next Steps?• will governments commit to intensive HIAs?

• unlikely, certainly not at first• let’s return to our initial goal: raise awareness of mental health and get it

considered in policy development• while moving towards longer-term goals of implementing comprehensive ‘mental health

in all policies’ approaches• could we start with simple actionable tool?

• equivalent of health equity lens – which really just asks if differential or inequitable impact

• must incorporate broader view of mental well-being

Could this policy or program strengthen or weaken peoples’ ability to thrive and feel good about themselves and their lives?

Other ideas?



• 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

• Wellesley has developed a page on health impact and HEIA, including links to leading international sites and practitioners, at http://www.wellesleyinstitute.com/health-equity-impact-assessment-heia-resources

• my email is [email protected]• I 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

http://wellesleyinstitute.com/

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

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

mailto:[email protected]



Appendices

• data on health disparities• case study: applying HEIA to TC LHIN mental health

strategy• framework: planning to address complex problems

in complex social and policy environments• breaking down our assumption and approaches• clarifying our theory of change

• the big picture – roadmap for action on social determinants of health – and mental health



Data on Systemic Health Inequalities

• there is a clear gradient in health in which people with lower income, education or other lines of social inequality and exclusion tend to have poorer health• over ¼ of low income people in Ontario – 3 X high income – report their health

to be poor or only fair• 2-3 X as many low income as high income people have chronic conditions such

as diabetes or heart problems• ¼ of low income people reported their daily activities were prevented by pain =

2X than high income• difference btwn life expectancy of top and bottom income decile in Canada =

7.4 years for men and 4.5 for women• more sophisticated analyses take account of the pronounced gradient in

morbidity and quality of life → health adjusted life expectancy = even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women


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

• in addition, there are systemic disparities in access to and quality of care within the healthcare system

• plus major differences between women and men• not just unfair, but health disparities make it more difficult to achieve

provincial priorities such as ALCs, ER, mental health, diabetes, etc, and contribute to avoidable costs

• that’s why enhancing health equity has become a clear priority – from the Province to LHINs to many providers

• and that’s why we need tools and approaches to build equity into effective system and service planning

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Case Study: Using HEIA For TC LHIN Mental Health Strategy

• the goal:• ensure equity is adequately built into mental

health strategy• ensure strategy addresses systemic barriers to

access and quality care• ensure strategy will benefit most health

disadvantaged populations



1: Scoping Who Is Affected critical health disadvantaged pop’n equity issues all along life-course– racialized youth, poor seniorsdynamics of concurrent challenges

impact of racism and social exclusion, non-insured, need for customized servicesin TO? but newcomers, non -insuredabsolutelyabsolutely – and increasingly

critical importance of income inequality and poverty

place and isolation matters to mental health especially

gender – systemic differences and accesssexual orientation – well documented systemic discrimination and barriers



2: Drilling Down on Impact• for each of the vulnerable populations affected• did the strategy sufficiently identify?

• the specific needs of these specific disadvantaged populations• the access and quality barriers they face?

• unequal access to the social determinants of health and systemic barriers play out in people’s lives and in particular communities in cumulative, reinforcing and inter-dependent ways• clinical language of concurrent disorders or academic

language of inter-sectionality• was this complexity captured and built into strategy?



2: Drilling Down on Process• key goal = ensuring high-quality mental health services and

continuum of support for all• were those living with mental health challenges involved in

defining what quality means to them?• were they involved in indicator and measurement discussions?

• working backwards from ultimate goal = what would the best quality and continuum of care look like• through an equity lens?• to these different populations – from their different perspectives?

• were the voices of these different populations incorporated into planning process?



3: Addressing Needs and Barriers•Aboriginal populations

•homeless

•poor/economically vulnerable more generally

•newcomers and people facing language barriers

•were Aboriginal providers/networks built into planning process?•are specific Aboriginal-driven services being planned?•were existing resources – CAISI, providers, networks, successful programs – built on?•cross-sectoral collaborations – health, shelter, social services•linking to poverty reduction strategies and advocacy•interpretation and translation•cultural competence + resources and management•funding to specialized ethno-cultural community groups



4: Evaluation and Monitoring• evaluation goal = to figure out what works, in what contexts

and, most importantly, how and why • we break down our plan/strategy into stages to assess what happened• were key access barriers and service gaps identified and addressed?• were services planned and delivered effectively?

• full range of different service models and settings• coordinated into seamless continuum of care

• did service changes improve access and quality?• using clear quality and access indicators• and building in community voice – did identified populations think

these services made a difference to their well being?• ultimately, was mental health of identified populations improved and were

disparities reduced?



Theory of Change

why and how to do equity-focused planning



taking account of

social constraints &

conditions

not just individual

programs but coordination,

partnerships & collaboration



enhanced access to primary care & health promotion

for most disadvantaged

up-stream heath conditions & opportunities

improve fastest for those in

greatest need


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 program action;

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Wellesley Roadmap II6 rigorously evaluate the outcomes and potential of program 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 program and policy instruments, and into a coherent and coordinated overall strategy for health equity.

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'Wicked' Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health...

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Transcript of 'Wicked' Policy Challenges: Tools, Strategies and Directions for Driving Mental Health and Health...