Gardner aohc conf june 11 2010 equity strategy into action

Bob Gardner AOHC 2010 Conference Health Equity: Pushing the Boundaries June 11, 2010 © The Wellesley Institute www.wellesleyinstitute.com

• conference has been fleshing out a powerful vision of what health equity looks like • now will set out a comprehensive roadmap for how to get there • how equity strategy can be driven into action within the health system • and well beyond the health system -- tackling the underlying roots of health inequality in the wider social determinants of health • how all of this has to be combined with community and political mobilization to demand and drive the necessary policy changes • and the crucial role CHCs do and can play in mobilizing for these kinds of changes © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 2

• health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing • think big and think strategically, but get going • everything can’t be tackled at once --need to split strategy into actionable components and phase them in • make best judgment from evidence and experience • identify actionable and manageable initiatives that can make a difference • experiment and innovate • learn lessons and adjust – why evaluation is so crucial • gradually build up coherent sets of policy and program actions – and keep evaluating • need to start somewhere – and community based primary care is one of most important directions © The Wellesley Institute 4 July 23, 2010 www.wellesleyinstitute.com

• even though roots of health disparities lie in far wider social and economic inequality • it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care • equitable healthcare and proactive health promotion can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities • in addition, there are systemic disparities in access and quality of healthcare that need to be addressed • people lower down the social hierarchy tend to have poorer access to health services, even though they may have more complex needs and require more care • unless we address inequitable access and quality, healthcare and health promotion could make overall disparities even worse © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 5

• goal is to ensure equitable access to high quality healthcare regardless of social position and ensure that all individuals and communities get the care they need • can do this through a two pronged strategy : 1. building health equity into all health planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach 2. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers • looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 6

• goal is to reduce health disparities and speak to needs of most vulnerable communities – who will define? • have to build community into core planning and priority setting • not as occasional community engagement • but to identify equity needs and priorities • and to evaluate how we are doing • CHCs: • long experience and innovative models • chance to lead the system here © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 7

• need to make equity one of driving priorities for health system and reform • equity and a population health focus are among key principles enshrined in new Excellent Care for All Act = opening • need clear provincial strategy for equity: • implicit from MOHLTC, but promised ten year strategy has not been released • Ministry of Health Promotion is moving towards a healthy community planning approach – potentially more equity-orientated • need strategic coherence across health system in approach to equity • that needs to cascade down: • to LHINs and on to providers • CHCs = already there, chance to show that serious commitment/action is possible © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 8

• greater chance of success for equity strategy if aligned with provincial priorities wait times, diabetes, etc. • in fact, equity is pre-condition to success in other system priorities • better access to primary care is key to reducing pressure on ER wait times and ALC • reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over-prescriptions → enhanced quality and cost effectiveness • taking lived conditions/experience into account – meaning equity and diversity → essential to high quality patient-centred care • reducing avoidable higher expenditures on vulnerable populations due to health disparities → can contribute to overall sustainability © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 9

• addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations and kids • need to understand roots of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • requires an array of effective and practical equity-focused planning tools © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 10

• planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • can help to plan new services, policy development or other initiatives • can also be used to assess/realign existing programs • essentially prospective • piloted in several LHINs – being implemented more broadly • so prov and LHIN support • CHCs have long been ‘early adopters’-- doing equity planning – whatever the tools and names • so chance to lead on demonstrating how to build equity into the core of service planning and how to adapt HEIA and other planning tools to really reflect community needs © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 11

• funding and resource allocation tied to performance is inevitable • building equity into performance required is a key driver of change • need to be aware of contradictions: • narrow compliance models can stifle innovation and responsiveness • watch for perverse incentives – to serve well only • simple numerical indicators and targets can’t capture complexity of care needs of supporting marginalized pop’n • so – as everywhere – need an equity lens on performance mgmt systems • CHCs have track record of high-quality service and community grounding to lead on how to build equity in © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 12

• target services to specific areas or populations: • those facing the harshest disparities – to raise the worst off fastest • or most in need of specific services • or the worst barriers to equitable access to high-quality services • this requires sophisticated analyses of the bases of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research to provide rich local needs assessments and evaluation data • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems © The Wellesley Institute 13 July 23, 2010 www.wellesleyinstitute.com

• vulnerable populations will vary: • poor neighbourhoods with high % of racialized population in many big cities • Aboriginal communities across the prov • isolated rural areas • need to drill down with good research: • South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America • greater risk for women • risk increases with time since immigration Creatore et al CMAJ Aril 19, 2010 • CHCs do this – again, chance to lead system • one driver – Min requires every LHIN to identify most vulnerable populations within its area and develop strategies to reduce the disparities they face © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 14

• one of critical equity challenges for many LHINs, hospitals and other providers in diverse communities is language • LHINs need to specifically require hospitals to ensure interpretation in languages of their community • need to fund centralized interpretation services to support smaller agencies • in some other areas, distance and isolation are the critical determinants • in Toronto and other cities: people without health insurance – primarily immigrant/refugees: • many community initiatives to provide access • Women’s College Network on Noninsured is forum for coordination • recently held research conference showing critical barriers to access and good care and resulting adverse health outcomes for vulnerable people © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 15

• investing in better chronic care prevention and management are vital elements of health reform • up-stream initiatives need to be planned and implemented through an equity lens • very clear gradient in incidence – and impact – of chronic conditions • some populations and communities need greater support to prevent and manage chronic conditions • need to build these specific needs into CDPM planning and resource allocation • diabetes, mental health and other priorities wont succeed if they don’t incorporate equity • CHC already leading – London pioneers • and already doing cross-sectoral → lead across sectors in e very community © The Wellesley Institute 16 July 23, 2010 www.wellesleyinstitute.com

• more emphasis on health promotion is vital to long-term sustainability of system and population health • consistent data on variations of risk factors along the social gradient • anti-smoking, exercise and other health promotion programmes need to explicitly foreground the particular social, cultural and economic factors that shape risky behaviour in poorer communities – not just the usual focus on individual behaviour and lifestyle • need to customize and concentrate health promotion programs especially for most disadvantaged • if this isn’t done → can unintentionally widen disparities as better off take up programs more © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 17

• we’ve been hearing about key directions to address SDoH on the ground • by always considering SDoH in strategic and program planning • from where to locate primary care to how to design health promotion • by collaborating across sectors and beyond health in service delivery: • with homeless and settlement agencies, schools, language specific community groups • by driving vital networks – like Rainbow Health Network © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 19

• hub-style multi-service centres in which a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations • Winnipeg Regional Health Authority and Manitoba Family Services and Housing have partnered on a new model to integrate health and social service delivery – one-stop access models in various communities to deliver a broad range of health and social services directly and to refer on to other agencies when services aren’t available • some new satellite CHCs are being developed in designated high- need areas in Toronto will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location • AOHC and other provincial associations representing mental health and community service agencies have been promoting idea © The Wellesley Institute 20 July 23, 2010 www.wellesleyinstitute.com

• not just cross-sectoral coordination and planning but addressing the roots of health inequalities at a local level • collaboration again -- allying with Colour of Poverty and other anti-oppression community organizing • building potential of comprehensive community initiatives: • key to British and European national strategies are local investments in community economic development and targeted healthcare and social service improvements • Vibrant Communities, Social Planning Councils and others are developing cross-sectoral planning forums and processes in many communities around poverty and inequality – with clear implications for health © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 21

• huge number of community and front-line initiatives already addressing equity across province • CHCs especially, community mental health, community organizations based out of specific ethno-cultural communities • services and actions grounded in the reality of social determinants of health and health inequalities and that speak to the whole range of people’s and community’s needs • e.g. many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities • this progressive service delivery = beacon of inspiration for other sectors + constant living demonstration that action is possible © The Wellesley Institute 22 July 23, 2010 www.wellesleyinstitute.com

• but experience and lessons learned are not being shared systematically and potential of promising interventions is not being realized • to drive equity-focused innovation and effective interventions, we need to be able to: • collate and analyze all the useful intelligence gained from equity-focused planning • capture and share information on local initiatives, and build on local front-line insights • share the resulting knowledge across regions – and beyond • assess the most promising initiatives or directions rigorously • scale up promising initiatives across the province where appropriate • need to create forums and infrastructure for this innovation knowledge management • and cultures to create learning organizations • and need to build equity-focused innovation into incentives and drivers -- cascading from Prov to LHINs to providers • expectation that X% of budget will be devoted to equity-orientated innovation • ear-marked funds for equity innovation © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 23

• 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 state social policy and underlying structures of economic and social inequality • these kinds of huge changes come about not because of good analysis but through widespread community mobilization and social pressure • key to equity-driven reform will also be empowering communities to imagine their alternative 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’ © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 24

could be one of those ‘big’ unifying ideas.. • if we see opportunities for good health and wellbeing as a basic right of all • if we see these pervasive health disparities as not only incredibly damaging to so many, but also as an indictment of an unequal society • if we recognize that coming together to address the social determinants that underlie health inequalities will benefit many other spheres – from better early child development to building a non-racist society • if we see that addressing the roots of so many of our social problems requires broad collaboration and mobilization • charter is next step of imagining that vision of a progressive future • and showing that we can get there from here © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 25

• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com • my email is bob@wellesleyinstitute.com • I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 26

1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long- term; 3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; 4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital; 5. set and monitor targets and incentives – cascading through all levels of government and program action; © The Wellesley Institute 27 July 23, 2010 www.wellesleyinstitute.com

6 rigorously evaluate the outcomes and potential of program initiatives and investments – to build on successes and scale up what is working; 7 act on equity within the health system: • making equity a core objective and driver of health system reform – every bit as important as quality and sustainability; • eliminating unfair and inefficient barriers to access to the care people need; • targeting interventions and enhanced services to the most health disadvantaged populations; 8 invest in those levers and spheres that have the most impact on health disparities such as: • enhanced primary care for the most under-served or disadvantaged populations; • integrated health, child development, language, settlement, employment, and other community-based social services; © The Wellesley Institute 28 July 23, 2010 www.wellesleyinstitute.com

9 act locally – through well-focussed regional, local or neighbourhood cross- sectoral collaborations and integrated initiatives; 10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities; 11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country; 12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective program and policy instruments, and into a coherent and coordinated overall strategy for health equity. © The Wellesley Institute 29 July 23, 2010 www.wellesleyinstitute.com

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley Institute July 23, 2010 www.wellesleyinstitute.com 30

Gardner aohc conf june 11 2010 equity strategy into action

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