Driving Health Equity for Kids: From the Earliest Years to Transforming the System
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Driving Health Equity for Kids: From the Earliest Years to Transforming the System

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This presentation provides the history of health equity for children and how we need to transform the system. ...

This presentation provides the history of health equity for children and how we need to transform the system.

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

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    Driving Health Equity for Kids: From the Earliest Years to Transforming the System Driving Health Equity for Kids: From the Earliest Years to Transforming the System Presentation Transcript

    • Achieving Health Equity for Kids: Whatever it Takes Hospital for Sick Children Conference Bob Gardner, PhD March 30, 2010 © The Wellesley Institute www.wellesleyinstitute.com
    • • Start with big picture – fundamental roots of inequality in children's health lie in wider structures of social and economic inequality → action needed at macro policy level • But what happens in healthcare system is still vital • Analyze how to embed equity in planning and service delivery • strong strategic commitment from the top • equity-focused planning and performance management • And how to address particular health disadvantaged populations or access barriers • Circle back to social inequality – one way hospitals and providers can address SDoH is through • cross-sectoral collaborations and planning • building understanding of SDoH and inequality into service delivery • partnering with community providers and others to address roots of inequality © The Wellesley Institute www.wellesleyinstitute.com 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 • concentrated disadvantage and poor health in particular communities – poor, immigrant, socially excluded and isolated • 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 © The Wellesley Institute www.wellesleyinstitute.com 3
    • © The Wellesley Institute www.wellesleyinstitute.com 4
    • • from the start: while infant mortality rates have been declining overall, rates in Canada’s poorest neighbourhoods remain two-thirds higher than those of the richest neighbourhoods • to the end: inequality in how long people live • difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women + inequality in how well people live: • more sophisticated analyses add the pronounced gradient in morbidity to mortality → taking account of quality of life and developing data on 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) © The Wellesley Institute www.wellesleyinstitute.com 5
    • • 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 © The Wellesley Institute 6 www.welleseyinstitute.com
    • 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 individuals throughout their lives and on overall population health © The Wellesley Institute www.wellesleyinstitute.com 7
    • • important elaboration in SDoH analysis – recognizing that: • the effect of determinants varies across people’s lives – so need to analyze impact on children and youth specifically • and that impact of inequalities is cumulative • for children: • research showing that pre-natal and early years are especially sensitive to social conditions and can have a major impact on future health • that intervening in early years to counteract adverse effects of wider social and economic inequalities has great potential • growing up in inadequate and inequitable social and family circumstances can store up a life-time of health problems © The Wellesley Institute www.wellesleyinstitute.com 8
    • • 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 children’s health and health system © The Wellesley Institute 9 www.wellesleyinstitute.com
    • 1. 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 2. 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, health system 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 © The Wellesley Institute www.wellesleyinstitute.com 10
    • 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 – 50> recommendations many recommendations have been acted on other LHINs are also prioritizing and moving to address health disparities © The Wellesley Institute www.wellesleyinstitute.com 11
    • • goal is to ensure equitable access to high quality healthcare regardless of social position • 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 www.wellesleyinstitute.com 12
    • • need to start from clear vision of what high quality children's healthcare looks like – and how crucial equity is to achieving that vision • then make equity one of driving priorities for health system and reform • define equity as an essential part of high-performing health system – as Ontario Health Quality Council • in fact, stronger argument that equity is pre-condition to success on quality, efficiency and patient-centred priorities • need clear provincial strategic commitment to health equity • cascading down through LHINs’ strategic plans and policies • and to expectations to all providers that equity is among their central priorities © The Wellesley Institute www.wellesleyinstitute.com 13
    • • 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 can: • raise awareness of equity within the organizations • build equity into planning, resource allocation and routine delivery • pull existing initiatives together into a coherent overall equity strategy • build connections among providers for addressing common equity issues • imagine the great potential if all specialized children's hospitals and providers developed equity plans in integrated manner © The Wellesley Institute www.wellesleyinstitute.com 14
    • • greater chance of success for equity strategy if aligned with provincial priorities: diabetes, wait times, mental health • all these priorities are particularly sensitive to social conditions • e.g. chronic disease prevention and management programs cannot be successful unless they take account of social conditions and constraints • risks people face and resources available to them vary over life course --- need to analyze specifically for kids • e.g. diabetes is also crucial for children’s health • recognized to be an increasing threat to future generations • illustrates the case for early investment -- preventing childhood diabetes is crucial to avoiding a lifetime of health problems • supporting resources and opportunities for healthy behaviours for kids can help to prevent chronic conditions later on © The Wellesley Institute www.wellesleyinstitute.com 15
    • • 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 www.wellesleyinstitute.com 16
    • • has been piloted and refined in Toronto and is being implemented in LHINs across the province • 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 a checklist to anticipate possible equity implications • could adapt for specific dynamics of children and youth health and service provision • think of potential: • if all children's hospital and other specialized children’s health services began using HEIA → build up great deal of comparable evidence, insight and experience quickly © The Wellesley Institute www.wellesleyinstitute.com 17
    • • all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds • can build in specific expectations – will vary by community and provider -- but could include: • undertaking appropriate equity-focused planning • ensuring service utilization matches appropriately with demography and needs of their catchment profile • providing sufficient services in languages of community and appropriate interpretation • identifying areas where access to services is inequitable and developing plans to address barriers and gaps • developing specific services or outreach to particular disadvantaged populations – homeless young moms, immigrant kids, racialized youth, etc. © The Wellesley Institute www.wellesleyinstitute.com 18
    • • second theme of overall strategic framework is to target services to: • those kids 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. • highlights need to collect equity-focused data and do HEIA-type planning • also requires good local research and detailed information – speaks to great potential of community-based research to provide rich needs assessments and evaluation data + incentives and funds to develop equity initiatives © The Wellesley Institute 19 www.wellesleyinstitute.com
    • • having identified key barriers to equitable access and outcomes for kids • if critical barrier is language → expand translation and interpretation services • if issues is differential treatment for racialized or new immigrants → cultural competence training and requirements • if issue is poor conditions in which kids live – and to which they will be discharged → • financial and other support to parents • support with costs not covered under OHIP – drugs, transportation, childcare • enhanced community support – likely working in partnership with providers • if issue is parents/kids don’t have health card → • provide services to uninsured resident kids for free © The Wellesley Institute www.wellesleyinstitute.com 20
    • • taking social inequalities into account when designing children’s health services • My Baby and Me Passport • peer ambassador type support for well babies and mothers • align health equity with other key priorities • investing in children – and in health of most disadvantaged kids - - has to be central to poverty reduction strategy • cross-sectoral coordination and planning are vital ways to act on wider SDoH • every LHIN should support or establish cross-sectoral planning tables • with expectations that hospital and other providers undertake cross-sectoral collaborations © The Wellesley Institute www.wellesleyinstitute.com 21
    • • idea of comprehensive community initiatives – Vibrant Communities, healthy city movements • British Health Action Zones, German ‘social cities’ and other models were designed to combine community economic development with targeted healthcare and social service improvements • in Canada, some Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building: • Saskatoon 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 © The Wellesley Institute www.wellesleyinstitute.com 22
    • • has been increasing interest in 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 • some new satellite CHCs 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 • also considerable experience/evidence for potential of: • early years centres • investing in comprehensive and integrated services for children at highest risk and with most complex problems • earlier eras of public health nurses in schools • idea of childcare centres also providing broader child development and social support – both on-site and linking into community services © The Wellesley Institute 23 www.wellesleyinstitute.com
    • • there is always much to be learned from policies, programs and initiatives in other jurisdictions • proven success of ‘head start’ type programs • a number of countries have made lessening health disparities a top national priority and have developed cross-sectoral policy frameworks and/or action plans: • England, Scotland, Australia, New Zealand • many European countries, especially Nordic • also increasing international and high-level attention: • WHO Commission on Social Determinants of Health -- and its knowledge network on early child development • European Union, with its Closing the Gap and Determine projects to tackle health disparities • reducing poverty and investing in comprehensive programs to address health inequalities for children are central to all these strategies © The Wellesley Institute www.wellesleyinstitute.com 24
    • • 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 • scale up promising initiatives across the province where appropriate • creating a forum and infrastructure for this innovation knowledge management is crucial • but who takes it up? • innovation doesn’t fit nicely into Ministry and other institutional boundaries • whatever the form, needs to be collaboration with Ministries, Prov associations, other stakeholders? • idea of collaborative of children's hospitals and other providers creating forums to share and build innovation on children’s health equity © The Wellesley Institute www.wellesleyinstitute.com 25
    • • health professionals, hospitals and other providers have considerable prestige and influence with pubic and policy makers • plus there is general public support for improving the lives and opportunities of children • can use that standing to advocate for health equity for children: • think if Sick Kids and its counterparts were to make public commitments that it is intolerable that some of its kids do worse than others because of poverty and inequality, and they are going to make sure their programs do something about it • or that they will provide the best care to every kid regardless of where they were born or whether they have an OHIP card • think of the impact of leading providers and experts developing a Charter or Manifesto for Children’s Health Equity © The Wellesley Institute www.wellesleyinstitute.com 26
    • • 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 www.wellesleyinstitute.com 27
    • 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 28 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 29 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 30 www.wellesleyinstitute.com
    • The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley Institute www.wellesleyinstitute.com 31