Evaluating program planning using an equity framework

Introduction

‘‘The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition,’’ ¹ as stated by the constitution of the World Health Organization (WHO). Health is influenced by varying biological, structural, and social determinants, which all differ depending on the individual and population of focus. Equity is defined by WHO as the ‘‘absence of unfair, avoidable, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality.’’ ² Leaders and organizations have a responsibility to ensure their programs and services are planned, implemented, and evaluated with the purpose of ensuring equity in meeting their mandate. Numerous personal, social, economic, and environmental factors termed as social determinants of health encompass the conditions in which people live and work, variably affecting the quality of their life. In the Canadian context, 17 social determinants of health are identified as a high priority, significantly impacting residents' health. These include income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety network, health services, geography, Indigenous ancestry, gender, race, immigration, globalization, and disability. ³ These determinants serve as double-edged swords with the potential to maneuver individuals toward either positive or negative health outcomes based on the social networks, institutions, governments, and organizations that surround them. ³ As such, leaders and organizations need to have an intimate understanding of the social determinants of health of the people and communities they serve that can be used to inform the implementation of services and policies within the organization. Organizations can achieve this by routinely applying an equity lens to their services and embedding the lens in their planning activities to ensure equity is prioritized upfront.

Queen Square Family Health Team (QSFHT) aims to provide accessible, equitable, patient-centred team-based primary care to its local community in Brampton, Ontario. QSFHT is committed to providing wrap-around care services that are proven to improve health outcomes. ⁴ Through its program planning, QSFHT identified insufficient local access to health services in newly developed neighbourhoods. To explore expanding health services in this region, a better understanding of the gaps in care was needed. Knowing this region consisted of individuals new to Canada, and the cultural diversity of the neighbourhoods, it was important to ensure an equity-based lens was foundational to the planning approach. Quantitative and qualitative data was sourced from community stakeholders within the health and social service sectors that were then assessed to make conclusions on specific health trends and needs of the community. In addition, the community was engaged directly to gain a greater understanding of their health needs.

This paper describes and evaluates the planning process undertaken to determine how it adhered to the principles of health equity. To conduct this evaluation, Ontario Health's Equity, Inclusion, Diversity, and Anti-Racism Framework is used to determine which areas of action were successful and which areas require further focus. This evaluation is meant to assess the equity efforts of the health service planning and is not a presentation of the health service planning initiative.

Method

To evaluate the equity efforts of the planning work undertaken, the framework was selected as it is a local, available resource for health planning in Ontario. The framework was developed with the intent to provide independent, expert examination of Ontario Health’s current assets focused on health equity, inclusion, diversity, and anti-racism, and to recommend a framework and approach to improve access, outcomes, and experiences across Ontario’s healthcare system. ⁵ Its development was guided by multiple actions, including, a series of engagement consultations with internal stakeholder’s at Ontario Health and external stakeholders across Ontario, the completion of a high-level scan of relevant health equity information within the public domain, and engagement with Black team members and leaders at Ontario Health. ⁵

The framework contains 11 components, each delineating a key area of action (Figure 1). ⁶ Ontario Health determined two key uses of the framework, the first use being within the Ontario Health organization itself and the second use being across the healthcare system in Ontario. ⁵ Ontario Health intended this framework to be used as a foundation for system planning by service provider organizations, to inform policies, practices, processes, and supports to advance equity, inclusion diversity, and address anti-racism. ⁵ Therefore, this framework is being used to evaluate whether the efforts taken in the expansion planning initiative achieves this key use outlined by Ontario Health.OPEN IN VIEWER

Discussion

Each component of the framework is used to assess the program planning efforts undertaken.

Include and engage key voices

Throughout this process, multiple stakeholders were engaged in order to gain greater insight into the health needs of those living in the region (Table 1). Community organizations and members of the community were engaged in meaningful collaboration and exchange of ideas to determine what is the health status of the community, what are some of their prevalent health needs and the role QSFHT can play in improving the health of the community. The stakeholder engagements also allowed QSFHT to explore opportunities for care coordination and collaboration.

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Table 1.

Type of community organizations engaged and nature of engagement.

Type of community organization	Nature of engagement
Data centre	The team provided FSA-level census data that was used to develop sociodemographic profile to gain a quantitative understanding of the social determinants of health (SDoH) of the region.
Local hospital system	As an essential healthcare partner providing emergency department services, the goal of the initiative is to reduce reliance on this service and provide care upstream. A data sharing arrangement allowed us to review emergency department usage data at the FSA level to identify opportunities for service needs and prevention strategies.
Culturally based community health service providers	This group included providers who provide culturally competent care in the region. Some were known to the organization and others were new connections. These stakeholders were engaged early and allowed for constructive conversations on how QSFHT can work collaboratively with these organizations to optimally serve the population. With a new Transgender Health program at QSFHT, one such engagement led to a new relationship with a local organization specializing in care for the LGBTQ2S+ community. QSFHT joined the organization’s regional collaborative and is now an active member in sharing resources and coordinating care.
Other community services	During a meeting between representatives from QSFHT and Home and Community Care Support Services, a common perspective was echoed that this region needs increased resources for its seniors’ population—which ended up being one of the services that could be enhanced through the initiative. QSFHT regularly collaborates with the local CMHA organization, and it was identified that any expansion should include mental health and addictions and future pathways be part of the model.

Recommendations and conclusion

Health leaders and organizations have a responsibility to meet community members and patients where they are to ensure equitable care is being delivered and community members can trust their local healthcare system can meet their needs. Community organizations must take a leadership role in advancing health equity by planning, delivering, improving, and advocating for the services and systematic changes that will allow its local community members to realize their highest attainable standard of health.

Using this framework to evaluate program planning efforts identified that regionally derived census data, and the partnership with agencies that serve specific populations helped strengthen the approach to equity, while the need to engage Indigenous populations and develop implementation efforts with racism top of mind identify key areas for further efforts in advancing equity. This provides focus for the organization’s leadership on its next planning steps.

Use of this framework can help leaders assess their efforts in advancing equity and prioritize where further resources or investment are required. While this effort was undertaken for a specific region in Ontario, the process could be replicated across the province. National or international use of such a process would require examining the framework to ensure it identified the populations of focus for the geographic region and any local health system differences. However, the use of an agreed upon regional framework helps to ensure leaders are focusing on the right elements in addressing equity when planning for health resources.

Leaders play a key role in advancing equity. For instance, with forming and fostering partnerships, making equity a strategic priority for the organization and embedding it in the culture. These steps help advance an organization’s approach to equity. Achieving equity is a journey. Leveraging tools such an equity framework can help support leaders to follow this journey and demonstrate successes and gaps along the way.