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Driving Local Action on Health Equity
 

Driving Local Action on Health Equity

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This presentation examines the ways in which local action can achieve health equity. ...

This presentation examines the ways in which local action can achieve health equity.

Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI

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  • POWER data age-standardized % of adults 2005overall patterns – 3 X as many low income as high report health to be only fair or poor self-reported = good proxy for clinical outcomes but exactly the point here, capturing people’s experience of their health
  • don’t know local scene – you will know best how to adaptbut do want to set out fairly full repertoire of strategies and programs
  • more specifically = need to make sense of SDoH to be able to act use this to explore idea of SDoH operating at different levels =making healthcare more equitable can be crucialhighlights the crucial importance of social context and that community development is a key part of the equation for actiondifferent policy solutions for each
  • also community-orientated public health
  • again, CHCs demonstrate how to ensure significant community input
  • a promising direction several LHINs have taken up is to require providers to develop equity planshospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TCand other providers in CentralCHCs have developed a sector-wide plan in GTAthese plans are designed to:identify access barriers, disadvantaged populations, service gaps and opportunities in their catchment areas and spheresdevelop programs and services to address those gaps and better meet healthcare needs of disadvantaged communitiesthese provider plans have the potential to:raise awareness of equity within the organizationsbuild equity into planning, resource allocation and routine deliverypull their many existing initiatives together into a coherent overall equity strategybuild connections among providers for addressing common equity issuescould do this in Hamilton, or:build equity into QIPs, as suggested earlierconsider cross-sectoral equity planning -- later
  • adverse social context and living conditions-> 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 operationalizationnot just in negative sense of identifying barriers and gaps, but what could be enablers and directions for innovationpeers have been from particular ethno-cultural communities or neighbourhoods or are newcomers, PHAs, drug users or others with particular lived experience
  • hubs ---from provider and funder points of view = more efficient use of scarce resources
  • not just being an immigrantbut where people came from and what conditions they find themselves in here:more precarious position in labour marketfacing racism and dynamics of social exclusion
  • partner/support local innovations – refugee clinincs and other work-arounds+ policy advocacy = eliminate the three month wait for OHIP for new immigrants
  • consistent evidence that:poor communication due to language or cultural can contribute to misdiagnoses and inappropriate prescriptionsinability to read or understand instructions can lead to medication errors -> safety, cost and re-admission implicationspromising indications that good interpretation helps keep people out of hospital and get them out soonerTC LHIN centralized system came out of broad collaboration and good policy advocacy Access Aliance was leader in this – and in demonstrating that a systemtic appraoch to interpretation can workfor providers to meet these requirements, they will need to:know the language needs of the communities they servethis is far more than just the languages of those who come to them for servicesalso need to know who is not coming in because of language and other barriers = unmet needand it doesn't mean just basic demographic data on languages spokenit means what language people are most comfortable receiving care in -> providers assessing community needs far better, and integrating that richer knowledge into their planning
  • In: SDoH lead to gradient of health in chronic conditionsplus affect how people can deal with the conditionsOut: complex and reinforcing nature of social determinants on health disparities
  • but – as always -- through an equity lensneed to enable – info and other resources, mentoring, supportgiven systemic inequalities in health opportunities and resources – some are going to need more support than othersneed to also recognize barriers many will face – language, literacy, living conditionspromising idea of peer health ambassadors again
  • have to expect a prolonged era of austerity, restraint and limited public investment – with implications for all our fieldsAOHC was part of thisissue to watch for and advocate for locally - ensuring municipality takes health and equity into account in housing plan and in use of downloaded housing funds from prov
  • also crucial to community mobilization is to shift way health is understoodto build public awareness of the structural drivers of health – the SDoH
  • basic ideas of health, fairness and social justice can be a powerful vision to drive action

Driving Local Action on Health Equity Driving Local Action on Health Equity Presentation Transcript

  • Driving Local Action on Health Equity Bob Gardner North Hamilton Community Health Centre June 19, 2013
  • Problem to Solve: Systemic Health Inequities in Ontario •there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health •+ major differences between women and men •the gap between the health of the best off and most disadvantaged can be huge – and damaging •impact and severity of these inequities can be concentrated in particular populations and neighbourhoods 2
  • And Locally Code Red series on health inequities by neighbourhoods: • 21 years difference in age at death • major differences in health outcomes across many measures plus inequitable access to health care in poorest areas • 50% higher rates of emergency department visits in downtown core • 2X for psychiatric emergencies • less access to primary care 3July 2, 2013 | www.wellesleyinstitute.com
  • Today • these health disparities are deep-seated and complex • but they can be tackled addressed through comprehensive health equity strategy and concerted action • means acting on health equity within the health system • will set out elements of a roadmap to build equity into health planning and delivery • CHC have long played a crucial role in driving equity into action • also have to act well beyond health care -- tackling the underlying social determinants of health • through community-based innovation, cross-sectoral collaborations and fundamental social and policy change to reduce inequality • again, with examples and opportunities for CHCs 4
  • Planning For Complexity even though roots of health disparities lie in social and economic inequality need to also look at how these other systems shape the impact of SDoH: •access to health services can mediate harshest impact of SDoH to some degree •so too can responsive social services •structure, resources and resilience of communities shape impact and dynamics of inequalities 5July 2, 2013 | www.wellesleyinstitute.com
  • Building Equity Into the Health System: How 1. building health equity into all health care planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach • Health Equity Imapct Assessment is one tool 2. aligning equity with system drivers and priorities • quality improvement, chronic disease prevention and management, wait times, Health Links • none of these directions can succeed without taking equity barriers, social determinants of health and differential risks and needs into account • action idea = all Hamilton hospitals and CHCs to include equity indicators in their QIPs • aligning with key priorities also enhances chance for success and sustainability of equity focus 6July 2, 2013
  • Building Equity Into the Health System: II 3. identifying those levers that will have the greatest impact on reducing health inequities and driving system change • solid interntional evidence that enhanced primary care is one of key means to improve inequitable health care and health for disadvantaged populations • improving primary care is a major Ministry priority • Family Health Teams, Health Links and many other initiatives are part of this • Community Health Centre model of care is the only sector • explicitly geared to supporting people from marginalized communities • with comprehensive multi-disciplinary services covering full range of needs 7July 2, 2013 | www.wellesleyinstitute.com
  • Building Equity Into the Health System: III 4. embedding equity in provider organizations’ deliverables, accountabilities and performance management – in the incentives and pressures that really drive the system • a big problem for primary care is the doctor-driven incentives of other models • CHCs are working to develop a comprehensive performance measurement and management system 5. targeting some resources or programs to reducing health disparities or improving the health of the most disadvantaged, fastest 6. investing up-stream in health promotion and addressing the underlying determinants of health 7. enabling equity-focused innovation • a huge range of promising and innovative programs have been developed by Community Health Centres, hospitals, networks and other providers to address the needs of disadvantaged communities. • we need to share lessons learned, evaluate and identify what is working, and build on the enormous amount of local imagination and innovation going on 8
  • Where to Start? • can’t just be ‘experts’, planners or professionals who define issues and drive system transformation • have to build diverse voices and community needs into planning • not just as occasional community engagement • but to identify fundamental needs and priorities • and to evaluate how we are doing → need to start from communities and clients + through an equity lens: • not all clients are the same – diverse cultures, backgrounds and perspectives, and unequal social and economic conditions • how to involve all types of clients? • specifically, how to involve and empower those not normally included • adapt different and innovative methods – e.g. principles of inclusion research + thinking about the communities in which they live and the social determinants that shape their opportunities for health 9July 2, 2013 | www.wellesleyinstitute.com
  • Ensure Planning Is Community Driven • many hospitals and other providers have community advisory committees • LHINs do a great deal of community engagement • CHCs have community boards • CHCs demonstrate how to really build community interests/voices into planning and delivery → lessons for other sectors make this community engagement real • for all providers: • community committees’ recommendations must be responded to by mgmt • committees make decisions over a proportion of discretionary budget • for LHINs: • build local health and well- being councils, with information and other resources so they can work effectively • give these local councils control over a proportion of discretionary budget 11July 2, 2013 | www.wellesleyinstitute.com
  • Collaborative Equity Planning 12July 2, 2013 | www.wellesleyinstitute.com • to meet accountability requirements from Toronto Central LHIN • developed common equity principles • identified common priorities to work on together: • interpretation • building equity into CHC performance management system • uninsured • action idea: similar joint equity plan for local CHCs (+ others?) • action idea = Hamilton health equity plan, building on Roundtable in spring
  • Never Just Equitable Access, But Quality: Build Equity-Driven Service Models • drill down to further specify needs and barriers: • health disadvantaged populations have more complex and greater needs for services and support → customizing care mix to meet those needs → continuum of care especially important • also face greater access barriers – e.g.. availability/cost of transportation, childcare, language, discrimination → facilitated access and effective navigation/transitions is crucial • all of this is CHC model of care = constant demonstration about how to deliver comprehensive equity-driven care • pre-condition = need to know social context/conditions of community/clients • language, income, immigration history • project in Toronto Central to collect such data directly • as electronic health records are being developed, ensure equity and social determinants data is built in 13
  • Extend Equity-Driven Service → Address Roots of Health Inequities in Communities build on equity-orientated models • CHCs, public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to communities facing particular barriers • hub-style multi-service centres → • coordinated services -- a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations • based solidly in local communities and responding to local needs and priorities → can become important community ‘space’ and support community capacity building look beyond vulnerable individuals to the communities in which they live → meeting full range of needs means moving beyond health care • focus on community development as part of mandate for CHCs • providing and partnering to provide comprehensive services/support such as settlement, language, child care, literacy, employment training, youth programs, etc. 14July 2, 2013 | www.wellesleyinstitute.com
  • • vulnerable populations will vary in different places: • poor neighbourhoods with high % of racialized population in many big cities • newcomers = major theme of earlier Roundtable • highlights importance of community health profiles • identifying ‘priority populations’ is key public health strategy and mandate of CHCs is to serve most vulnerable • action idea = create local primary care coordinating tables to bring CHCs, Health Links, Family Health Teams, public health and other providers together • action idea = HNHB primary care initiatives to apply HEIA to plans and adopt explicit equity objectives and targets Invest in Health Disadvantaged Populations or Communities 15
  • Target Systemic Barriers •in Toronto and other cities: people without health insurance • immigrants in 3 month wait time, refugees • inequitable access → delayed care and worse outcomes • CHCs and community clinics provide some access • Women’s College Hospital Network on Noninsured is forum for coordination •federal cuts to refugee healthcare → adverse impact on particularly vulnerable people → increased healthcare costs/demands at prov and provider levels •action idea = create local network or initiatives to improve access for uninsured and/or refugees 16
  • Addressing Systemic Barriers: Interpretation as a Key Quality and Equity Lever precondition for equity • ensuring that adequate interpretation is available wherever needed → improves quality and equity • LHINs using available levers → formal requirement on all providers + alignment • access to interpretation also underlies wait times, safety and other system priorities •action idea = Hamilton providers consider centralized/coordinated interpretation services 17July 2, 2013 | www.wellesleyinstitute.com
  • Canadians With Chronic Conditions Who Also Report Food Insecurity 18
  • Health Promotion Through an Equity Lens • programs have to take account of inequitable resources of vulnerable individuals and communities • advice to manage diabetes or heart problems by exercising depends upon affording a gym or being close to safe park • if not customized, generic health promotion programs can widen disparities as better off take them up disproportionately • adjust programs to inequitable risks and specific barriers • South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America (Creatore et al CMAJ Aril 19, 2010) • deliver in languages and cultures of particular population/community • go where people are -- e.g. CHCs/promoters into malls • action idea = Immigrant Women's’ Health Centre, Aboriginal communities and other vans • CHCs lead/demonstrate how equity-driven health pomrotion can be done 19July 2, 2013 | www.wellesleyinstitute.com
  • Pulling it All Together: Local Cross-Sectoral Planning • cross-sectoral coordination and planning can identify community health needs, access barriers, fragmentation, service gaps, and how to address them • public health departments and LHINs are pulling together or participating in cross-sectoral planning tables • Local Immigration Partnerships, Social Planning Councils • such broad collaboration will be particularly important to Health Links and other system integration initiatives • and coordinated services are particularly important in less advantaged communities with less resources • also key means to address deep-seated health inequities and wider SDoH at community level • CHCs have long played a key role in developing and connecting these resources and partnerships 21
  • Equity and Community-Driven Local Planning pre-condition for this kind of coordinated action = creating an effective cross-sectoral planning forum action idea = create local health equity forum with concrete planning mandate can build on earlier roundtable Looking for Ideas : SETO •arose out of community concern re access •brings together public health, CHCs, shelters, researchers and service providers serving marginalized communities in south-east Toronto •for an overview of SETo’s development see http://knowledgex.camh.net/researchers/pr ojects/semh/profiles/Pages/seto.aspx •ongoing collaboration and idea sharing → supports service coordination and problem solving •emphasized concrete demonstration projects → many with lasting impact •advocacy with institutions and governments around results of projects and key issues such as harm reduction, dental care and access for non-insured people 22July 2, 2013 | www.wellesleyinstitute.com
  • Back to Community Again: Build Momentum and Mobilization • sophisticated strategy, solid equity-focused research, planning and innovation, and well-targeted investments and services are key • but in the long run, also need fundamental changes in over-arching social policy and underlying structures of economic and social inequality • these kinds of huge changes come about not just because of good analysis, but through widespread community mobilization and public pressure • key to equity-driven reform will also be empowering communities to imagine their own alternative vision of different health futures and to organize to achieve them • we need to find ways that governments, providers, community groups, unions, and others can support each others’ campaigns and coalesce around a few ‘big ideas’ 25
  • © The Wellesley Institute www.wellesleyinstitute.com Shifting the Frame Sudbury & other public health July 2, 2013 | www.wellesleyinstitute.com 26
  • Health Equity • could be one of those ‘big’ unifying ideas.. • if we see opportunities for good health and well-being as a basic right for all • if we see the damaged health of disadvantaged and marginalized populations as an indictment of an unequal society – but that focused initiatives can make a difference • if we recognize that coming together to address the social determinants that underlie health inequalities will also address the roots of so many other social problems • thinking of what needs to be done to create health equity is a way of imagining and forging a powerful vision of a progressive future • and showing that we can get there from here 27
  • Key Messages • health inequities are pervasive and deep-seated – but can’t let that paralyze us • do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy • think big and think strategically – but get going where you are • have set out a roadmap – of strategies, tools and ideas -- to drive equity into action through policy change and community mobilization where CHCs come in: • demonstrating every day that something can be done about systemic inequities -- by delivering the best possible health care to disadvantaged communities • working in partnerships and collaborations well beyond health care to address the underlying determinants of health • I see CHCs as a beacon and inspiration – showing change is possible and how to move towards a more equitable health future 28