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Planning and the Health Equity Impact Assessment HEIA: a marriage of two tools


I Introduction
II Health equity and the HEIA
III Integrating HEIA into planning
IV References
V Resources

--submitted by Nimira Lalani and Ingrid Tyler, Public Health Ontario

I Introduction

Social and economic conditions are responsible for as much as 60% of the health of populations. [1] Inequalities in socio-economic status lead to health inequities. These are unfair and avoidable differences in health – also referred to as the social gradient of health. In the June 15, 2012 edition of the OHPE, the article Social Determinants of Health: planning to action [2] introduced an evidence-based equity planning instrument, the Health Equity Impact Assessment (HEIA) [3] recently launched in Ontario. In this complementary article, we elaborate on the HEIA and discuss how this tool can be used alongside other program planning frameworks to ensure that equity considerations are addressed.

II Health equity and the HEIA

The HEIA was developed to assess the health equity impacts of a policy, program or initiative. It is an easy-to-use, practical tool. Equity-focussed health impact assessment has been identified as one of the 10 promising practices to reduce social inequities in health. [4] Health equity planning tools have been used in a number of jurisdictions, including Australia, [5] New Zealand [6, 7] and the United Kingdom. [8]

The HEIA [3] was launched by The Ontario Ministry of Health and Long-Term Care (MOHLTC) in May 2012. It is a one-page template that covers how to include equity in health planning and decision-making. There are two complementary pieces: a workbook with step-by-step instructions on how to systematically and explicitly incorporate health equity into a broader planning framework, and a public health supplement.

The HEIA steps with some sample reflection questions are shown below:

Step 1: scoping. Which populations may experience significant unintended health impacts as a result of the planned policy, program or initiative?

Step 2: potential impacts. What are the unintended positive and negative health equity impacts and where is more information needed? 

Step 3: mitigation. In what ways can you reduce potential negative impacts and amplify the positive ones?

Step 4: monitoring. How can success be measured for each mitigation strategy identified?

Step 5: dissemination. How can this information be shared with stakeholders?

III Integrating HEIA into planning

In December 2012, Public Health Ontario delivered a webinar on Planning and the HEIA. [9] The objective of the presentation was to demonstrate how an evidence-informed planning model could be integrated with the HEIA. The webinar introduced participants to Public Health Ontario’s six-step planning model, highlighting how these steps are supported by the Online Health Program Planner (OHPP). [10] The OHPP is widely used by public health practitioners provincially, nationally and internationally to help them systematically work through each of the six planning steps. The tool is free and contains many sources of planning support, including a library of real community-level sample plans. The bulk of the webinar focused on the relationships between the program planning steps and the HEIA steps. A fictional HEIA case study was also presented.

The relationships between the steps in each tool are mapped below.

HEIA steps

PHO/OHPP Planning steps

Defining the issue

Step 1: preplanning

Step 1: scoping
Step 2: potential impacts
Step 3: mitigation

Step 2: situational assessment


Step 3: develop goals, populations of interest and objectives

Step 3: mitigation

Step 4: develop strategies, activities, and resources

Step 4: monitoring

Step 5: develop indicators

Step 5: dissemination

Step 6: review

During the presentation, participants were introduced to the following “tips and tricks” for integrating HEIA into planning:

  • The HEIA is a flexible tool that can be used in different ways depending on time available, scope of the project, evidence available, etc. For example it may be used as a quick “desktop” assessment, a slightly more intensive “rapid” assessment or a very “comprehensive” assessment.
  • Step 1 (HEIA ) / step 2 (planning): the HEIA can be a useful tool for figuring out when and how to include “priority groups” in the planning process, for maximum impact.
  • Step 1 (HEIA) / step 2 (planning): considering a broad range of evidence sources will strengthen your conclusions. For example, mainstream research evidence from a literature review can be combined with community consultations and the experiences of program planners to create a compelling picture of the situation.
  • Step 2 (HEIA) / step 2 (planning): applying Step 2 of the HEIA during situational assessment can help identify which populations may experience unintended negative health impacts as a result of a planned policy, program or initiative. Various areas should be considered including the fundamental determinants of health, health status, incidence of high-risk behaviours, and access to and use of programs and services.
  • Step 5 (HEIA) / step 6 (planning): the dissemination step of the HEIA may include sharing of literature reviews that informed your assessment, evidence and data gaps identified, facilitators and barriers to HEIA implementation and evaluation, planning case studies, etc.
  • While completing the HEIA as part of your planning process, you may identify gaps in the data as well as instances where the relationship between health inequities and social determinants of health are not clear-cut. It is important to document these gaps and areas of uncertainty, and bring them to light. This is a step that can bring us closer to our goal of achieving health equity.
  • In summary, integrating the two planning tools – HEIA and the OHPP – can facilitate planning through an equity lens, helping to ensure that the needs of less advantaged groups are clearly identified and addressed.

IV References

1.  Keon J, Pepin L. A healthy, productive Canada: a determinant of health approach. Ottawa: Senate of Canada, c2013. 2009 June [cited 2013 January 23]. Available from:

2. Ontario Health Promotion E-Bulletin [homepage on the Internet]. Health Nexus and Queen's Printer for Ontario, 1999-2003. Social Determinants of Health: planning to action. OHPE Bulletin  2012; 757. Available from:

3.  Ministry of Health and Long-Term Care [homepage on the Internet]. Toronto: Queen’s Printer for Ontario, c2008. HEIA Health Equity Impact Assessment; updated 2012 May 25 [cited 2013 January 23]. Available from:

4. Sudbury and District Health Unit. 10 promising practices to guide local public health practice to reduce social inequalities in health: technical briefing. Sudbury, ON; 2011.

5. Mahoney M, Simpson S, Harris E, Aldrich R, Stewart Williams J. Australia: Australasian Collaboration for Health Equity Impact Assessment (ACHEIA) 2004. Equity-focussed health impact assessment framework. Available at:

6. Ministry of Health [homepage on the Internet]. ManatūHauora, c2013. Available at: 6022/$File/whanau-ora-hia-2007.pdf

7.  Signal L. Martin J. Cram F. and Robson B. (2008). Health Equity Assessment Tool (HEAT): A Users Guide. Wellington: Ministry of Health. Available from:

8. West Midlands Public Health Observatory (WMPHO) [homepage on the Internet]. Birmingham: West Midlands Public Health Observatory, c2006. Introduction to health equity audit. Available from:

9. Public Health Ontario.Planning through an equity lens: incorporating the Health Equity Impact Assessment (HEIA) 2.0 Tool [PowerPoint presentation]. Toronto, ON: Queen’s Printer for Ontario; 2013.

10. Public Health Ontario, Dalla Lana School of Public Health. Toronto: Queen’s Printer for Ontario. Online Health Program Planner [Internet]. [cited 2013 January 23]. Available from:

V Resources

A healthy, productive Canada: a determinant of health approach. In this final report of the Senate Subcommittee on Population Health, it is acknowledged that good health comes from a variety of factors and influences and that 75% are not related to the health care system. The focus of the report is on improving the health of Canadians, reducing disparities and fostering Canada’ productively. Twenty-two recommendations for Canada are provided.

HEIA Health Equity Impact Assessment from the Ministry of Health and Long-Term Care. HEIA is a decision support tool which walks users through the steps of identifying how a program, policy or similar initiative will impact population groups in different ways. HEIA reveals unintended potential impacts. The end goal is to maximize positive impacts and reduce negative impacts that could potentially widen health disparities between population groups – in short, more equitable delivery of the program, service, policy etc. Effective use of HEIA is dependent on good evidence. The HEIA tool has four key objectives: 1. Help identify unintended potential health equity impacts of decision-making (positive and negative) on specific population groups; 2.Support equity-based improvements in policy, planning, program or service design; 3. Embed equity in an organization’s decision-making processes; and 4. Build capacity and raise awareness about health equity throughout the organization.

Actions taken by the Health Unit to reduce social inequities in health. Sudbury and District Health Unit This Sudbury and District Health Unit webpage contains a great collection of resources about social inequities. Included are documents that explain actions that the Sudbury district has already taken to reduce social inequities in its district, and plans for the next 10 years.

Equity-focussed health impact assessment framework (EFHIA). This 30-page document provides a concise introduction to EFHIA and an explanation of the factors to be considered at each step in the process. The process includes: Screening; Scoping; Impact identification; Impact assessment; Recommendations; Monitoring and Evaluation.

Health Equity Assessment Tool (HEAT): A Users Guide. This guide explains how to use the companion tool: the Health Equity Assessment Tool (HEAT). HEAT includes a set of 10 questions that guide assessment of policy, program or service interventions for their current or future impact on health inequalities. The questions cover four stages of policy, program or service development. These are: 1. Understanding health inequalities; 2. Designing interventions to reduce inequalities; 3. Reviewing and refining interventions; and 4. Evaluating the impacts and outcomes of interventions.

Introduction to health equity audit. This is a practical introduction to the fundamental principles and tasks that underpin health equity audits. Steps discussed include 1. Identify a broad issue (Where do I start?); 2. Choose the topic (How do I decide what to audit?); 3. Confirm and quantify inequity (How do I decide if inequity exists?); 4. Set standards, define interventions and embed the outcome in plans; and 5. Monitor progress.

Online Health Program Planner. The Online Health Program Planner (OHPP) is a collection of online, interactive worksheets that can help public health practitioners to make evidence-informed planning decisions. They are bundled into three processes:

  1. Program planning worksheets that support decisions about program design.
  2. Business case creation worksheets guide the development of recommendations about whether a project should move forward.
  3. Project management worksheets help iron out the implementation details of a project.

This free tool is currently available at

The OHPP includes a sample plan library designed to support Ontario public health units in meeting the OPH Standards. It contains real community plans on a variety of topics. These can be viewed, or imported into one’s account as a basis for building a new plan. There are over 12,000 visits to the OHPP each year, and over 3000 account holders.

This online tool was launched in 2008 and expanded in 2010. Currently it is being completely rebuilt for the PHO online environment. The new OHPP has a more modern look, and a variety of usability enhancements. Usability testing of the new OHPP is underway right now. It will be launched in the summer of 2013.

The PHO Capacity Building Services and Resources team provides ongoing support to the field, in using the OHPP.