Health Equity for Immigrants and Refugees: Driving Policy Action

Health Equity for Immigrants and Refugees: Driving Policy Action

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  Health Equity ForImmigrants and Refugees: Driving Policy Action Bob Gardner Migrant and Refugee Children: Entitlement and Access to Health Care in Canada National Seminar: Montreal March 26-7, 2013
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  Outline • inequitable healthand access to care for immigrant and refugee communities is a complex problem – with huge unfair and avoidable human costs • we know what the problem is and what changes are needed to solve it • we need sophisticated policy analysis and political strategy to drive the needed changes • will set out what a strategy for change could look like • the policy cases that need to be made • effective and ways to make those cases • illustrate by sharing some experience/examples from Ontario April 4, 2013 | www.wellesleyinstitute.com 2
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  Systemic Health InequitiesFaced by Immigrant Communities = ‘Wicked’ Problem • health inequities and their underlying social determinants of health are classic ‘wicked’ policy problems: • shaped by many inter-related and inter-dependent factors • in constantly changing social, economic, community and policy environments • action has to be taken at multiple levels -- by many levels of government, service providers, other stakeholders and communities • solutions are not always clear and policy agreement can be difficult to achieve • effects take years to show up – far beyond any electoral cycle • have to be able to gear solutions to specific needs, barriers and situations of specific populations – such as immigrants and refugees April 4, 2013 3
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  Think Big, ButGet Going • the point of all this social determinants and policy analysis is to be able to identify the changes needed to reduce health disparities • but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing • have big goals and think strategically, but get going • make best judgment from evidence and experience • identify actionable and manageable initiatives • experiment and innovate • learn lessons and adjust • demonstrating success → build momentum for change • need to start somewhere – start where you are and where you can make a difference April 4, 2013 | www.wellesleyinstitute.com 4
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  First, Clarify theProblem To Solve • emerging but clear evidence of health impacts: • inequitable access to health care and other services • inequitable treatment and quality • inequitable health outcomes • playing out differently in different populations → different needs and barriers to good care → different program and policy solutions • how people came to be uninsured – and their legal and social circumstances – is quite different → different policy solutions April 4, 2013 | www.wellesleyinstitute.com 5
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  Then Develop SolidStrategy • have to be able to understand and navigate this complexity to develop solutions by identifying: • the key pathways to change that will make fundamental difference to population health overall or the particular problem/community • the crucial policy levers that will drive the needed changes • and need to understand the policy context or environment for achieving the needed changes • identifying the best opportunities: • being alive to policy windows as they emerge • knowing who controls the policy levels we want to change • and where needed changes will get the most traction • and making solid business case • actionable policy options • designed for particular level of government/decision maker April 4, 2013 | www.wellesleyinstitute.com 6
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  And Policy Analysis/Advocacy • research demonstrating inequitable access → delayed care and worse outcomes • analysis of federal cuts to refugee health care → predictable and avoidable adverse impact on particularly vulnerable people • building the policy case(s) e.g. IFH cuts → increased healthcare costs/demands at prov and provider levels • to demonstrate common interests • well designed policy briefs with actionable alternatives • and sustained interaction with policy makers • build alliances and coordination 7
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  And Innovative Advocacy • political activism • ‘white coat’ guerillas • clinicians effectively using their professional prestige and platforms • media work • coalitions, networks and direct action • lots of ‘insider’ work with policy makers + with a service face • on-the-ground service innovations • plus enormous individual advocacy for refugees needing care • to mitigate adverse impact of cuts and deliver best care to vulnerable populations = constant demonstration that alternatives are possible + multi-level strategy always needs a Plan B: • looking ahead – how to keep issue alive • continuing to document adverse consequences –Refugee HOMES documentation tool established by clinicians, revising HEIA April 4, 2013 | www.wellesleyinstitute.com 8
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  Need Action atDifferent System and Organizational Levels Need to Move Different Policy Levers Health Equity for Immigrants & Refugees Broad SDoH & Policy Environment Provincial Health Care Systems Regional Health Authorities Hospital, Community & Other Providers
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  Driving Action: FederalLevel • key immediate challenge: • rescind the cuts to IFH • not much chance → advocacy to make impacts of cuts and operation of remaining insurance program a little less bad • key strategy has been building broad awareness and partnerships • powerful symbolism of so many national health organizations supporting demands • always make the connections – link IFH demands into need for more equitable immigration policy more generally • and better settlement strategy and resources April 4, 2013 | www.wellesleyinstitute.com 10
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  Driving Action: ProvincialLevel • the case to be made: • IFH cuts will adversely effect already health disadvantaged populations • will increase avoidable costs to be borne by prov • action needed: • clear commitment to make up difference and ensure access to care • clear directions to providers to serve refugees • ensure resources • monitor increased costs and adverse effects – encourage/require providers to use survey April 4, 2013 | www.wellesleyinstitute.com 11
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  Driving Action: LocalLevel • Regional Health Authorities are key location for addressing problem • can establish coordinating or problem solving groups • can direct providers to ensure access • can direct providers to document health and cost impacts • Toronto Central led on refugee issue for LHINs: • it has long history of commitment to equity • providers and activists on this issue have been well connected to the LHIN and provided considerable input • have been addressing problems of uninsured – e.g. systematize referral and payment relationships between CHCs and hospitals • but also municipal govts – e.g. Toronto • Public Health and Board of Health highlighted adverse health situation of undocumented • Council adopted a ‘Sanctuary City’ type policy to provide services regardless of legal immigration status April 4, 2013 | www.wellesleyinstitute.com 12
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  Driving Action: ProviderLevel • build on existing resources and networks: • CHCs have had provincial funding – now also midwives • Women’s College Hospital Network on Noninsured is forum for local coordination • what providers can do: • ensure no discrimination – right through their organization – and that refugees are never denied care • develop contingency plans to deal with effects of IFH cuts • add their voice opposing inequitable impacts – let alone increased pressure on their services • join with refugee doctors in systematically collecting info on patient consequences April 4, 2013 | www.wellesleyinstitute.com 13
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  Looking Beyond IFH NeverJust Equitable Access, But Quality For All • adverse social context and living conditions for many immigrants → can increase risk of mental and physical illness + fewer resources to cope (from supportive social networks, to good food and being able to afford medications) • for high quality person-centred care → providers and programs need to customize and adapt care to population needs and contexts → good communications and provider-patient relationship means taking the full range of people’s needs/situations into account • e.g.. more intensive case management, referral planning and post- discharge follow-up for health disadvantaged • in an increasingly diverse society, high quality care = culturally competent care: • requires organizational resources, commitment and operationalization 14
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  Back to Strategy/Backto the Front-Line • think big, but act where you are/where you can • providers and activists coming together to address a horrible problem: • innovative clinics and other ‘work-around’ solutions • community based services to provide comprehensive health, social and other support • improve equitable access to health care and opportunities for good health for immigrant and refugee communities • complex challenges need multi-level solutions • need to map out all the factors and forces that need to be shifted and coordinated to accomplish goal April 4, 2013 | www.wellesleyinstitute.com 15
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  Equitable Health Carefor Immigrant Communities Mapping Enablers and Success Conditions Link Into Professional Ensure Funding, Training, Diversity Accountability, & Build Immigrant and Equity Other Incentives Care Into Explicit Policies Align with Broadly Based Equity Standards & Changes Needed Provider Coordinating Quality Networks & Cross- Improvement Sectoral Collaboration Enable Front-Line Service Delivery Political & Work-Arounds & Community Innovations Mobilization Broader Policy Build Awareness Environment: Across the Health More Equitable Opportunities to Care System Health Care for Shift Refugees Immigration Policy
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  Key Messages • healthdisparities are pervasive and deep-seated – but can’t let that paralyze us • do need a comprehensive and coherent immigrant/refugee health equity strategy – but don’t wait for perfect strategy • do need to immediately oppose damaging policies such as IFH cuts – but always keep long-term goals in mind • think big and think strategically – but get going • there is a solid base of evidence, provider experience, commitment and community connections to build on 17
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  Key Messages II •key success conditions for enhancing health equity for immigrant and refugee communities: • solid research and policy analysis • demonstrate what success looks like through service innovations however/wherever you can • keep connected • make a solid case for reform – geared to different decision- makers and partners • all within a coherent strategy – well-focused, multi-level and long-term • use the platforms we have • build partnerships and coalitions to drive mobilization • try to shift the frame of public debate and discourse April 4, 2013 | www.wellesleyinstitute.com 18