Gardner oahpp april 8 2010

Bob Gardner Ontario Agency for Health Protection and Promotion April 8, 2010 © The Wellesley Institute www.wellesleyinstitute.com

1. how health disparities in Ontario and Canada can be addressed through comprehensive health equity strategy 2. how equity strategy can be driven into action through • equity-focused planning and aligning equity with key system drivers and priorities • building equity into ongoing performance and system management, and routine service delivery • investing in promising interventions, and pulling them together within a coherent overall strategy and an integrated and coordinated program • sharing and building on front-line and local initiatives, evaluation, and other enablers for innovation 3. highlighting key directions and enablers for building successful action on health equity within public health 4. ideas and opportunities for Agency 2

• 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 status of the best off and most disadvantaged can be huge – and damaging • in addition, there are systemic disparities in access to and quality of care within the healthcare system 3

• If all Ontarians had the same health as Ontarians with higher incomes, the POWER project has estimated that: • 318,000 fewer people (166,000 women and 152,000 men) would be in fair or poor health • 231,000 fewer people (110,000 women and 121,000 men) would be disabled • 3,373 fewer deaths each year (947 women and 2,426 men) among Ontarians living in metropolitan areas 8

• not just inequality in how long people live • difference btwn life expectancy of top and bottom income decile in Canada = 7.4 years for men and 4.5 for women • but also inequality in how well people live: • more sophisticated analyses take account of quality of life and the pronounced gradient in morbidity → health adjusted life expectancy • even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women (Statistics Canada Health Reports Dec 09) 9

• clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion • impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally • real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities 10

POWER Study Gender and Equity Health Indicator Framework 11

Determinants interact and intersect with each other in a constantly changing and dynamic system In fact, through multiple interacting and inter- dependent economic, social and health systems Determinants have a reinforcing and cumulative effect on individual and population health 13

• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage • this concept: • is clear, understandable and actionable • identifies the problem that policies will try to solve • is tied to widely accepted notions of fairness and social justice • the goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes • a positive and forward-looking definition = equal opportunities for good health 14

• there is always much to be learned from policies, programs and initiatives in other jurisdictions • a number of countries have made lessening health disparities a top national priority and have developed cross- sectoral policy frameworks and/or action plans: • Sweden has a comprehensive public health policy, focusing on reducing social inequality and exclusion • England developed a cross-Departmental strategy with targets and reporting mechanisms • Scotland, Australian states, New Zealand • many European countries, especially Nordic • also increasing international and high-level attention: • WHO Commission on Social Determinants of Health • European Union, with its Closing the Gap and Determine projects to tackle health disparities 15

• focus and balance of national strategies varies but a key theme = addressing roots of inequality through macro social and economic policy • integrated policy geared to reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long-term; • early child investment is common theme • as is poverty reduction • develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on • act across silos – inter-sectoral and cross-government collaboration and coordination are vital • Health in All Policies frameworks • cross-Ministerial coordinating forums • local and community-level coordination and interventions are key 16

• the point of all this analysis is to be able to identify policy and program changes needed to reduce health disparities • but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing • think big and think strategically, but get going • 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 focus here is on population health, and health promotion and protection 17

• 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 • at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social position 18

• how the health system is organized and how services and care are delivered is still crucial to tackling health disparities • considered a determinant in most countries' conceptual and planning frameworks • in all those countries with comprehensive multi-sectoral strategies to reduce health disparities, transforming the health system is an indispensable element: • reducing barriers to equitable access to high quality care • targeted interventions to improve the health of the poorest, fastest • up-stream investments in primary and preventative care directed to most vulnerable • delivering these services in coordinated way at community/local level 19

while health disparities are pervasive and deep-rooted, they can be changed through policy and program action comprehensive strategy developed in 2008 for Toronto Central LHIN many recommendations have been acted on other LHINs are also prioritizing and moving to address health disparities 20

• goal is to ensure equitable access to high quality healthcare regardless of social position/circumstances • 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 21

• align equity with system drivers: • equity is pre-condition to quality and efficiency agendas • essential part of high-performing health system – Ontario Health Quality Council • align with system priorities: • can’t solve wait times or chronic conditions without addressing equity • build equity into priority setting and service planning • build equity into performance management: • targets and incentives • requirements and accountabilities • cascading through the system -- Prov → LHINs, agencies, etc.→ providers 22

• 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 • 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 • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • and requires an array of effective and practical equity-focused planning tools 23

1. quick check to ensure equity is 1. simple equity lens considered in all service delivery/planning 2. Health Equity Impact 2. take account of disadvantaged Assessment – has been piloted in populations, access barriers and Toronto and MOHLTC is related equity issues in program considering wider roll-out planning and service delivery 3. assess current state of provider organization 3. equity audits and/or HEIA 4. determine needs of communities facing health disparities 4. equity-focused needs 5. assess impact of assessment programs/interventions on health disparities and 5. equity-focused evaluation disadvantaged populations 24

• 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 Toronto in 2009 by MOHTLC, Toronto Central LHIN AND WI • refined and workbook was added • being used in Toronto Central and other LHINs and providers across the province • increasing attention to potential – from WHO, through most European strategies to MOHLTC and LHINs • HEIA is intended to be relatively easy-to-use tool 25

• a promising direction several LHINs have taken up is to have providers undertake specific equity planning exercises designed to: • identify access barriers, disadvantaged populations, service gaps and opportunities in their catchement areas and spheres • develop programs and services to address those gaps and better meet healthcare needs of disadvantaged communities • these provider plans have the potential to: • raise awareness of equity within the organizations • build equity into planning, resource allocation and routine delivery • pull their many existing initiatives together into a coherent overall equity strategy • build connections among providers for addressing common equity issues 26

http://www.torontoevaluation.ca/tclhin/index.html 27

• comprehensive policies on health equity from other countries include: • setting targets or defining indicators – that build on available reliable data and make the most sense in the particular context • closely monitoring progress against the indicators or targets • disseminating the results widely for public scrutiny • and, at the same time, need to build equity targets and objectives into routine performance management and provider planning • e.g. into service accountability agreements between LHINs and hospitals and other providers 28

• can’t just measure activity: • number of people or % of pop’n that participated in program • need to measure health outcomes – even when impact only shows up in long-term • need to assess reach • who isn’t signing up? who needs program/support most? • and assess impact through equity lens • need to know who stuck with program and what impact it had on their health – and how this varies • need to differentiate those with greatest need = who programs most need to support and keep to have an impact • → develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system • many programs assess their services through client satisfaction surveys and similar methods • providers look for high and improving satisfaction → equity target = reduce any differences in satisfaction by gender, income, ethno-cultural background, etc. 29

• precondition for all this planning, monitoring indicators, and assessing progress against objectives and targets is reliable data on: • health outcomes and behaviour, differentiated by population, neighbourhood and income, education, ethno-cultural background and other determinants of health • service use patterns, also stratified • how well service use reflects catchment and community make-up • trends in all of this – to monitor impact and progress • when hospitals in Toronto Central began working on their equity plans it became very clear that they simply did not have the necessary data to do equity-driven planning • recognized as key issue in MOHLTC and LHINs • project now underway in downtown hospitals to collect SDoH patient data • similar challenges for public health? • and why not coordinate development of best equity-relevant data? 30

• target services to specific areas or populations: • those facing the harshest disparities – to improve the health of the worst off fastest • or those most in need of specific services • or to 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 31

• investing in better chronic care prevention and management are vital elements of health reform • chronic disease prevention and management programs cannot be successful unless they take health disparities and wider social conditions into account • 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 – poor, Aboriginal and other vulnerable communities face greater incidence and greater challenges in managing diabetes – at the same, time these communities tend to have less access to good food, safe open space and recreational facilities to encourage exercise, etc. – the Toronto diabetes atlas produced by ICES found that only 25% of people in low-income neighbourhoods participated in weekly sports – versus 75% from high-income – built environment is also key -- Atlas found that people in low-income areas walked more for transportation purposes but less for exercise 32

• integrated diabetes program developed out of the London InterCommunity Health Centre: – began from far greater incidence and impact in local Hispanic community – CHC, community groups and others worked closely together – language specific and culturally sensitive services – preventative and promotion services offered where people went – e.g. shopping malls – also saw that social conditions had to be addressed → referrals to social service support, advocacy around employment and other problems • a valuable primer has been developed by Health Nexus, Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH% 20Final.pdf 33

• potential: • huge number of community and front-line initiatives already addressing equity across province • + equity focused planning through provider equity plans, HEIA or other tools will yield useful information on existing system barriers and the needs of disadvantaged populations • and we’ll be seeing more and more promising and successful program interventions • but • these initiatives and interventions are not being rigorously assessed • experience and lessons learned are not being shared systematically • potential of promising interventions is not being realized 34

• cross-sectoral coordination and planning are seen to be key ways to put wider SDoH into action • key to British and European strategies are local investments in community economic development and targeted healthcare and social service improvements • Vibrant Communities and other comprehensive community initiatives, 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 • at best, a healthy communities approach to planning health promotion implies wider community development and capacity building approaches 35

• 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 • Ontario provincial associations representing CHCs, mental health and community service agencies have been promoting idea -- including to LHIN CEO provincial planning table 36

• link this hub thinking/model to other key equity reforms such as enhanced primary care: • many countries have clinics that provide both health and wider social services in one place • 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 • not just health -- idea of schools as service hubs is being developed • think back to earlier eras with public health nurses in schools – start by putting these health promotion in schools in most disadvantaged areas • then link them into a network of services they can refer kids onto when needed • concentrated and integrated services for most disadvantaged kids have proven to be effective investment 37

• defining equity as a pre-condition of a high-performing public health system → into coherent equity strategy • building equity into planning and sharing equity-focused planning tools, techniques, expertise and experience • ensuring the equity-relevant data that is a success condition for planning and operationalizing equity • developing and enabling equity-orientated evaluation to identify what interventions and policies work • creating the forums and infrastructure to build on local innovation and promising practices 38

• major priority within OPHA, collaboration among urban PHUs across Canada, etc. • a number of Public Health Units have been pioneering social determinants approaches • Sudbury has developed comprehensive strategy • Waterloo has focused especially on food insecurity • Toronto has emphasized health impact of increasing income inequality • wide range of promising approaches, programs and interventions → potential to share and build on all this local innovation • Ministry of Health Promotion is moving towards a healthy community planning approach – potentially more equity- orientated 39

• uneven • while there are many examples of public health leadership and innovation • many other PHUs have not acted consistently on SDoH approaches or health disparities • let alone, there isn’t a coherent strategy across the wider health system → still need • to enhance and deepen consistent approach/commitment • strategic coherence across public health system in approach to equity • frameworks and tools to be able to drive equity commitments into action 41

• build on widespread commitment and many excellent initiatives across public health in Ontario • challenge: • pull all this together into coherent system-wide equity strategy • with OPHA, MOHs and other key partners • identify gaps and system-wide challenges • use flexible approach/methods • don't need to have a precise blueprint at the start • iterative – start with some early strategy pieces • then pull together think tanks, roundtables and other collaborations to flesh out • goal of comprehensive overall strategy in several years 42

• provincial standards offer a possible lever • require each PHU to develop a health equity plan showing how it was putting population health standards and requirements into practice • and then: • call a province-wide roundtable to share, debate and learn from all the individual plans • which can be build into a coherent overall strategy • and simultaneously develop specific expectations and targets and build these into routine PHU performance management and accountabilities 43

• a number of PHUs have developed and use equity lens: • Toronto has a simple 3 question lens -- not just for public health, but other departments • Sudbury has used an equity planning tool for several years • could require PHUs to undertake HEIA • as part of overall standards/expectations; or • to be eligible for particular programs or funding • advantage of using the same tool as being used in LHINs = build up comparable experience and data 44

• looking abroad for promising practices = Public Health Observatories in UK • consistent and coherent collection and analysis of pop’n health data • specialization among the Observatories – London focuses on equity issues • interest/development in Western Canada – Saskatoon • national project to develop health disparity indicators and data • Toronto PH is addressing complexities of collecting and using race- based data • key direction = explore potential of equity/SDoH data for Ontario • in addition, innovative thinking emerging around dynamic systems modeling meeting population health • key role for Agency in leading within public health system and linking into other data initiatives? 45

• there are broad Prov, LHIN and PHU targets for priorities such as diabetes or empowering healthy behaviours → build equity into these targets • a number of PHUs and LHINs have identified areas where diabetes incidence is highest • equity target = reduce differences in incidence, complications and rates of hospitalization among populations or areas • if goal is to increase the % of kids who exercise regularly • equity target is to reduce the differentials in % of kids who exercise by neighbourhood, gender, ethno-cultural background, etc. • and that won’t be just a question of education and awareness but facilities and proactive empowerment of kids 46

• target can’t just be increasing exercise rates and decreasing smoking → equity target = reduce those differences by gender, income, region • drilling down: equity target = • ensuring take-up of health promotion programs does not vary inequitably by income level, neigbourhood, gender, race, etc. • in fact, take-up – and sticking with the programs -- is highest in most disadvantaged communities with greatest needs 48

• identified potential of various tools and approaches: • HEIA • requiring explicit equity plans from PHUs and programs • identifying workable and effective equity targets • analyzing how to build these into ongoing performance management • role of Agency? • adapting planning tools to population health focus and public health settings • promoting equity-focused planning to front-line • learning from experience → adapting/improving 49

• health promotion that emphasizes individual health behaviour or risks without setting it in wider social context • can lead to ‘blame the victim’ portrayals of disadvantaged who practice ‘risky’ behaviour • focus on individual lifestyle in isolation without understanding wider social forces that shape choices and opportunities won’t succeed • universal programs and promotion that doesn’t target and/or customize to particular disadvantaged communities • inequality gap can widen as more affluent/educated take advantage of programs • programs that focus on most disadvantaged populations without considering gradients of health and need • i.e. the quintile or group just up the hierarchy may be almost as much in need • e.g. access to medication, dental care, child care and other services for which poorest are eligible may not benefit working poor • supporting the very worst off, while not affecting the ‘almost as worse off’ is unlikely to be effective overall 50

• key way of addressing SDoH at ground level • British example of comprehensive policy: Health Action Zones and other models were designed to combine community economic development with targeted healthcare and social service improvements • similar in other leading countries – German ‘social cities’ • in Canada, some Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building: • Saskatoon is developing cross-sectoral action on health equity: • began from local research documenting shocking disparities among neighbourhoods • focusing interventions in the poorest neighbourhoods – locating services in schools, relying on First Nations elders to guide programming, etc. • wide collaboration among public health, municipality, business, community, Aboriginal and other leaders 51

• MHP’s healthy communities strategy is far more comprehensive and integrated than previous approaches • but the improved cross-sectoral planning it envisions will still operate within separate risk behaviours or health conditions • these conditions and challenges are very much inter- dependent and cumulative in individuals’ lives and community dynamics • avoid ‘risk’ silos in ‘healthy communities’ by: • enabling a community to define its own health priorities better, providing better access to good food, exercise facilities and information/support to manage own health → will benefit all these priority areas • developing health promotion programs that address a neighborhood's full range of challenges in a comprehensive way 52

• have been emphasizing the potential of local collaboration and cross- sectoral planning – not just for better health care and promotion, but addressing SDoH • but health system is fragmented – LHINs, primary care, provincial programs, acute and up-stream, two ministries, public health • public health is integrated into RHAs in other provinces • need to find ways to work beyond jurisdictional boundaries to develop cross-sectoral collaborations beyond health • concrete local issue-orientated planning is most likely to succeed in breaking silos down – e.g. planning tables around diabetes, emergency planning • has been happening with many PHUs and LHINs, but inconsistent and uneven • why not build collaboration in? • MOHLTC has not required LHINs to undertake cross-sectoral collaborations • why not lead from public health side = make this explicit expectations/requirements of PHUs? 53

• key lever = build equity-focused collaboration into incentives and drivers • expectation that X% of budget will be devoted to equity-orientated innovation, sustaining cross-sectoral initiatives or planning, etc. • ear-marked funds for equity innovation and collaboration efforts • build on public health tradition = many have pioneered cross-sectoral action addressing wider determinants • could Agency fund/support cross-sectoral collaborations and initiatives – getting beyond most programs that can’t fund outside their narrow boundaries? • partner with other jurisdictions and agencies – PHAC, other provinces • Agency to be centre of expertise on equity and SDoH-orientated collaboration 54

• increasing international, Cdn and Ont interest in more strategic and realist evaluation • figuring our what interventions and approaches work, for which populations, in what contexts and why • also drawing on more flexible public health approaches that incorporate insights of community-based and participatory research • to drive investment in directions and interventions that will have the most equity impact • role for Agency? • centre of expertise in evaluation applied to public health strategy and delivery • vital link between public health and other players in health system • part of mandate of getting research evidence into practice • look to international – development of Centre of Public Health Excellence within NICE in UK 55

• 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 • indentify promising initiatives or directions • share the resulting knowledge across regions – and beyond • rigorously evaluate promising to se what interventions work and in what contexts • scale up promising initiatives across the province where appropriate • is that innovation knowledge management a key role for Agency? • in collaboration with Ministries, prov associations, other stakeholders? • challenge has always been that innovation doesn’t fit nicely into Ministry and other institutional boundaries 56

• health disparities 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 • we have enormous resource of promising practices and on-the- ground experience – challenge is to build on this potential • have set out overall strategic approaches, principles and tools to drive equity into action → experiment and innovate • public health has long experience and strong commitment to equity → build on this to drive coordinated and coherent system- wide equity agenda into action • Agency is well placed to play vital leadership and enabling role 57

• 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 58

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; 59

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; 60

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. 61

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. 62

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Gardner oahpp april 8 2010

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Gardner oahpp april 8 2010 — Presentation Transcript