One crucial component of ensuring more equitable health care is good planning, and one effective tool is Health Equity Impact Assessment. We just published two new primers on HEIA and Mental Well-being Impact Assessment and we have been presenting a number of workshops to providers and planners. I recently did a workshop for Psychiatry Rounds at a leading teaching hospital in Toronto. In all these workshops we work through HEIA on hypothetical or real scenarios the particular program is addressing: the hypothetical scenarios developed for this workshop focused on what to do if there were inequitable rates of post-treatment re-admissions for people from poor neighbourhoods or who were less comfortable in English.
As it happened, participants raised a number of other issues for analysis, including post-partum support for new moms. And also as always happens, new issues or nuances surfaced. Providers here talked about the crucial need for solid conceptualization of new programs very early on in planning: carefully considering gaps in existing service mixes, who needs which types of services, which populations could possibly be missed by particular service directions, and through what specific pathways and mechanisms would the planned program address key determinants of health. The suggestion was to embed this initial conceptual analysis in the tool/process itself — perhaps elaborating this preliminary analysis in the workbook along similar lines as the initial scoping stage of the potential problem.
In realist or developmental evaluation, this is called the ‘theory of change’ or ‘program theory’ — carefully articulating the conceptual starting points, assumptions and evidence of how we think the program will work. We then test implementation and evaluative evidence against the ‘theory of change’ and adapt the assumptions and plan as necessary. HEIA could be useful in this iterative sense as well: conceptualizing a clear ‘theory of change’ before detailed program planning, running HEIA over the theory in a quick and preliminary way, adjusting the conceptual framework, fleshing out program planning, and then doing a fuller HEIA on the filled out plan. I’ve found in so many workshops that we can’t be too prescriptive or rigid about how the tool is used, and that if we are flexible, the HEIA process can be effective in many ways and settings.