Health Equity for Immigrants and Refugees: Driving Policy Action

Health Equity For Immigrants and Refugees: Driving Policy

Action

Bob Gardner

Migrant and Refugee Children: Entitlement and Access to Health Care in Canada

National Seminar: MontrealMarch 26-7, 2013

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Outline

• inequitable health and 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 12, 2023 | www.wellesleyinstitute.com

Systemic Health Inequities Faced 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

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Think Big, But Get 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


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First, Clarify the Problem 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


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Then Develop Solid Strategy• 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


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

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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


Need Action at Different System and Organizational LevelsNeed to Move Different Policy Levers

Broad SDoH & Policy

Environment

Regional Health Authorities

Hospital, Community

& Other Providers

Health Equity for Immigrants &

Refugees

Addressing Broader SDoH,

Immigration Policy.

Policy, Accountability, & Funding

Local Priorities, Policies,

Allocation of Resources

Institutional Policies & Service

Delivery

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Driving Action: Federal Level

• 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


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Driving Action: Provincial Level

• 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


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Driving Action: Local Level• 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


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Driving Action: Provider Level• 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


Looking Beyond IFHNever Just 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

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Back to Strategy/Back to 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


More Equitable Health Care for

Refugees

Build Awareness Across the Health Care System

Enable Front-Line Service Delivery Work-Arounds & Innovations

Build Immigrant Care Into Explicit Equity

Standards & Quality Improvement

Link Into Professional Training, Diversity and

Equity Policies

Ensure Funding, Accountability, & Other

Incentives Align with Changes Needed

Broadly Based Provider Coordinating Networks

& Cross-Sectoral Collaboration

Political & Community Mobilization

Broader Policy Environment:

Opportunities to Shift Immigration Policy

Equitable Health Care for Immigrant Communities

Mapping Enablers and Success Conditions

Key Messages

• health disparities 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

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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


Health Equity for Immigrants and Refugees: Driving Policy Action

Education

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