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Mechanisms for Advancing Health Equity

Ohio’s Policy Assessment Tool: Q&A With Two of the Tools’ Drafters on Use of the Tool to Improve Health Equity

June 29, 2022


Across the country, states and localities are using a variety of strategies to assess the health, equity, and racial impacts of legislative and administrative policies. Recognizing the need for a health equity assessment tool, the Health Equity Network of Ohio recently launched an analytic tool to support implementation of a Health and Equity in All Policies approach in Ohio. In this Q & A, two of the tools’ drafters discuss the opportunities the tools presents to advance health equity in their state.

Across the country, states and localities are using a variety of strategies to assess the health, equity, and racial impacts of legislative and administrative policies. For example, racial equity impact statements examine and describe how historically disadvantaged racial and ethnic groups may be affected by proposed laws or programs, while a Health in All Policies (HiAP) approach integrates health considerations into policymaking across sectors to improve health outcomes.

A health equity assessment tool can inform policymakers about the ways in which seemingly unrelated policies may directly or indirectly harm health.  For example, constructing a major highway may seem ideal to reduce traffic congestion and improve transportation routes, but the project may simultaneously force families out of their homes, disrupt neighborhood and social ties (potentially leading to increased violence), exacerbate air pollution, and decrease the local area’s accessibility for families who cannot afford to maintain personal vehicles.

Developing processes and tools for implementing equity assessment initiatives can be challenging. Recognizing the need for a health equity assessment tool in Ohio, the Health Equity Network of Ohio (HEN), a coalition co-led by the Ohio Public Health Association (OPHA), recently launched an analytic tool to support implementation of a Health and Equity in All Policies (HEiAP) approach in Ohio. The Health Equity Assessment tool “is intended to inform policymakers of any potential negative health and equity impacts, prior to making any final decisions, and is designed to complement existing legislative and administrative processes.”

The Network discussed the Health Equity Assessment Tool and its development with two key drafters: Carla Hicks, Member of the OPHA Governing Council, and Robert Jennings, past OPHA President and Executive Director, National Public Health Information Coalition. 

Q. What is a Health and Equity in All Policies (HEiAP) approach and how does it compare to a Health in All Policies approach (HiAP)?

A. Both HiAP and HEiAP approaches look beyond traditional health care services to analyze how other determinants and sectors may influence health. Both approaches emphasize social determinants of health (SDOH), which are the range of non-medical factors that influence health outcomes, such as income, environment, and exposure to discrimination. The primary difference between the two approaches is that HEiAP explicitly centers health equity.

According to the CDC, HiAP may be effective in assessing areas where equity may be improved. In contrast, Hicks explained that “a significant difference is… that [HEiAP] focuses directly on [improving] health equity… within the social determinants of health.” In other words, HEiAP “expands [the HiAP] concept to focus on how decisions affect equity as well as health, because inequities are critical factors in determining health outcomes.” As Jennings explained, “the key focus is equity in the Health and Equity in All Policies initiative.”

Q. Last year’s stimulus, the American Rescue Plan Act (ARPA), provided billions of dollars to state and local governments to support pandemic recovery. How are you encouraging local governments to use the Health Equity Assessment tool to guide expenditure of ARPA funds?

A. Funding can be crucial to promoting health equity. Accordingly, the Health Equity Network (HEN) focused on developing the Health Equity Assessment tool in anticipation of the second round of ARPA funding. Hicks stated, “Before funds are distributed, we want [policymakers] to look at [funds] through a health equity lens. So, the expectation is that those dollars will address both health and equity and [policymakers will] think about who gets to use them and how they are distributed.”

The HEN hopes ARPA funds will be used to promote both health and equity, specifically by addressing SDOH and risk factors that led to COVID-19 disparities among certain communities.  Jennings added, “COVID-19 exacerbated the inequities. This [tool] can help us put our money where our mouth is and it’s an ideal place to start. Hopefully, this is only the beginning. Hopefully we continue to address inequity through proper funding for those communities that are most in need.”

Q. What opportunities have you encountered in creating this tool?

A. The Ohio Public Health Association began working on the Health Equity Assessment tool in 2015 with a focus on evaluating legislative proposals. Since then, OPHA members discussed the HEiAP approach with stakeholders and interest groups from across the state and have expanded the tool’s intended reach beyond legislative analysis. Carla said, “We have … been able to expand the tool’s use beyond the legislative and administrative use… so that [it] can impact other areas… [it can be] the lens to look at all sectors that impact health.”

Beyond state-level policy-making, OPHA’s work with the HEN led them to realize that the Health Equity Assessment tool could be used to evaluate local level decisions and to assess how grant and other funding is allocated. Carla added, “It is a tool that can be used across the board, using a standardized model to evaluate how you are impacting health. If we look at some of the existing inequities, they are rooted in the past and present public health policy.”

Jennings further explained that sharing the tool with legislators presented valuable opportunities to educate them about health disparities and health equity and to describe the fiscal benefits of investing in upstream efforts to promote equitable health outcomes.

Q. What do you see as key elements of the HEiAP analytic tool?

A. The Health Equity Assessment tool emphasizes several key elements. First, accessibility is essential. According to Carla “A key element is usability. You don’t have to be an expert in health or equity; it provides the definitions to help those who use it.”

Second, the tool is carefully designed to draw attention to the potential health consequences of a policy. Robert explained, “An important function of the tool is that it makes you look at the determinants of health that often get ignored, such as transportation, access, housing, etc.”

Finally, the tool increases transparency around decision-making processes: if policymakers make decisions that are likely to harm health, they must first publicly recognize and acknowledge the potential consequences of their actions. 

Q. What were your priorities for the HEiAP analytic tool?

A. In contemplating priorities for the HEiAP analytic tool, Carla and Robert emphasized the importance of permanently embedding health equity considerations in policymaking.

Carla explained, “We were looking to make sustainable change and to look at the determinants of health beyond healthcare services… We wanted to create a sustainable movement toward good health.” In particular, they wanted to draw attention to persistent health inequities, such as disparities in infant mortality, in order to improve Ohio’s health outcomes and raise its national health ranking.

Jennings added, “We would like [use of the tool] to become routine and for health to always be considered. I think most people like to believe that health is always being considered, but there is no vehicle for policymakers to ensure that health is considered. It is important that policies are either improving or neutral, not negative towards health outcomes. Unless it’s brought up, these decisions may not be in the conversation”.

Thank you to Carla Hicks and Robert Jennings for their health equity leadership and for sharing their experience and expertise with the Network.

This post was written by Emely Sanchez J.D., Legal Fellow, Network for Public Health Law—Mid-States Region Office.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document do not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.

Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.