Health Equity into Policy Action: A Policy Conversation at MOHLTC
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Health Equity into Policy Action: A Policy Conversation at MOHLTC

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This presentation provides critical insights on how to transform health equity into policy action. ...

This presentation provides critical insights on how to transform health equity into policy action.

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

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Health Equity into Policy Action: A Policy Conversation at MOHLTC Health Equity into Policy Action: A Policy Conversation at MOHLTC Presentation Transcript

  • Health Equity Into Policy Action: A Policy Conversation at MOHLTC Bob Gardner Director of Public Policy February 12, 2007 © The Wellesley Institute www.wellesleyinstitute.com
  • Wellesley Institute • funds community-based research on the relationships between housing, poverty and income distribution, social exclusion and other social and economic inequalities and health • provides workshops, training and other capacity building support to non-profit community groups • works to identify and advance policy alternatives and solutions to pressing issues of urban health • works in diverse collaborations and partnerships for progressive social change • all of this is geared to addressing the pervasive impact of the social determinants of health © The Wellesley Institute www.wellesleyinstitute.com
  • Unique Hybrid • lots of policy institutes and think tanks – but few focus on SDoH and urban health • many provide training and capacity building – but not all have an explicit goal of rebuilding community capacity lost in funding cuts and constraints • few focus on funding CBR or have an extensive community training programme in methods • no other institute brings all three strands together – all focused on SDoH © The Wellesley Institute www.wellesleyinstitute.com
  • Introduction • health disparities are pervasive, persistent and solidly rooted in overall social and economic inequality • but, action is possible: – many jurisdictions have developed comprehensive policies and programs to address health inequity – and there are enough indications of how these policies can be effective – there are huge numbers of on-the-ground initiatives addressing both the underlying social foundations and the effects of health disparities – including very many in Ontario – there is much we can learn from, and adapt to Ontario situation – there is real potential for innovation and experimentation • my goal today is to highlight some promising pointers and directions that can address health inequities, and ways to think about connecting up these initiatives in a coherent and integrated way © The Wellesley Institute www.wellesleyinstitute.com
  • Starting Points: Pre-Conditions for Success • clear strategic vision of equity – has been considerable discussion of what a well-performing health system looks like – need to be just as clear on defining features of health equity and an equitable health system • clear understanding of the roots of health disparities both within the health system and in wider social inequalities → to guide policy and interventions • a coherent and integrated policy framework to make connections between sectors and initiatives and to ground investments and programmes © The Wellesley Institute www.wellesleyinstitute.com
  • Pre-Conditions II • identifying the key places and levers where policy change can most effectively be made to happen – and will make the most difference to health equity • incentives and enablers to support system change and programme/delivery action • long-term commitment – one of clearest lessons from abroad is that tackling health disparities takes time • but combined with a willingness and capacity to experiment and innovate • workable indicators to guide/monitor implementation and an infrastructure and working culture to learn from and build on success and innovation © The Wellesley Institute www.wellesleyinstitute.com
  • Defining Health Equity: Reducing Unfair Differences • the most common sense of health equity is working to reduce differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage – clear, understandable & actionable – it identifies the problem that policies will try to solve – it’s also tied to widely accepted notions of fairness and social justice • this definition sees health equity as the absence of socially structured inequalities and differential outcomes • but also need a more forward-looking vision to guide and inspire action © The Wellesley Institute www.wellesleyinstitute.com
  • A Positive Vision of Health Equity • as equal opportunities for good health • nested in a society in which poverty, inequality and social exclusion – and their impacts on ill health – have been reduced • consumer driven care and delivery, with individual and community needs at the heart of planning • culturally appropriate care – crucial in diverse society • equitable access to a full and seamless continuum of health and social services • health and human services systems that focus on the most disadvantaged • investing ‘up-stream’ in preventive and health promotion © The Wellesley Institute www.wellesleyinstitute.com
  • Health Disparities Are Well Documented • the Ontario Health Quality Council used risk-adjusted rates of death in hospital following a stroke as an indicator of health equity in its first 2006 report – mortality in the LHIN with the worst rates was 36% higher than in the best • Canada-wide disparities have been equally well documented – life expectancy at birth, on average, is five to 10 years less for First Nations and Inuit peoples than for all Canadians – while infant mortality rates have been declining overall, infant mortality rates in Canada’s poorest neighbourhoods remain two-thirds higher than those of the richest neighbourhoods • all advanced countries – even those with best overall health – have significant disparities in health outcomes – considerable evidence that health disparities have increased in many countries → often the immediate challenge is seen to be preventing health disparities from continuing to worsen © The Wellesley Institute www.wellesleyinstitute.com
  • Roots Lie in Social Determinants of Health • clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion • impact of key determinants such as early childhood development, education, employment, working conditions, income distribution, social exclusion, housing and 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 disparities © The Wellesley Institute www.wellesleyinstitute.com
  • International Policy Responses • increasing international and high-level attention: – international organizations such as the World Health Organization, especially its Commission on SDOH, and the European Union • coordinated national policies are being highlighted in many European and other rich countries: – for many this is still at the high-level policy stage – few have implemented comprehensive policies – but a clear consensus that integrated cross-sector policy frameworks are needed • and a clear consensus that supporting a wide range of regional, local and community initiatives is also essential © The Wellesley Institute www.wellesleyinstitute.com
  • Lines of Policy Approaches • common formulation sees three levels of policy action on health disparities – with different objectives: 1. addressing the needs of the most disadvantaged populations and communities – to reduce the harsh impact of health disparities 2. narrowing the gap between the most disadvantaged and wealthiest groups – which means raising the health of the most disadvantaged faster 3. reducing the overall gradient of health disparities – making health outcomes less unequal • the latter is seen to be the most inclusive – but few governments have taken this most comprehensive approach – most analysts see that action on these three levels can be complementary – certainly not contradictory – I think policy addressing all these levels will be key – and will try to illustrate how this can be thought of in a coordinated way • there is also debate about the best ‘entry-points’ – where in the inter- dependent system of social determinants should policy intervene: – I'll be arguing that policy addressing different issues simultaneously – but in a connected way – is key © The Wellesley Institute www.wellesleyinstitute.com
  • Equity Policy Frameworks in Other Countries • a number of countries have made lessening health disparities a high national priority and have developed cross-sectoral policy frameworks and/or action plans • focus here on macro social and economic policy – will return to health • not meant to be a comprehensive survey -- will only highlight three among many interesting possibilities • these examples can provide: – ideas that could be adapted to Ontario situation – lessons learned on how to develop an integrated policy framework and cross-sector collaboration – inspiration that cross-sector policy collaboration and action is possible – and can have an impact © The Wellesley Institute www.wellesleyinstitute.com
  • Sweden • social welfare policy was seen to be key to reducing health disparities • coordinated national policy to reduce the number of people at risk of social and economic vulnerability – focus on inclusive labour market, anti-discrimination, childcare, affordable housing and other policies – equitable access to improved health care was seen to be just one part of this broader package • emphasized partnerships with community service providers and organizations – in both policy development and service delivery • arose out of a very different political culture with strong consensus on social solidarity © The Wellesley Institute www.wellesleyinstitute.com
  • United Kingdom • key things came together: – New Labour government identified inequality as a crucial issue – Reducing Health Inequalities: an Agenda for Action 1999 – 2003 Programme for Action with concrete targets by 2010 – UK Presidency of EU in 2005 focused on health disparities • Programme for Action goals focused on raising living standards, early childhood development, employment, building healthy communities, and broad national redistributive and social policies • it also emphasized delivering action at the local level through effective partnerships and collaborations and targeting the most deprived areas © The Wellesley Institute www.wellesleyinstitute.com
  • UK II: Multi-Level Action • local initiatives in disadvantaged communities to improve living conditions and address social exclusion are central: – Health Action Zones, designed to combine community development with targeted health care access and service improvements – combined social support and health care in deprived areas – the Citizen’s Advice Bureau in Blackpool – “Fit to Work” partnership of local government, health authority and non-profit social entrepreneur agency to link neighbourhood regeneration to health in inner- city London – Engaging Communities Learning Network to share information on what is working locally – part of Programme strategy to ‘mainstream’ equity initiatives and learning into public service • while there was a significant focus on social and economic policy, that didn’t mean that changes within the health system were not also crucial: – targeted interventions to improve the health of the poorest fastest – generally as part of community/local initiatives as above – equitable access as a key goal – mandated community participation in health care planning – more emphasis on preventive programmes © The Wellesley Institute www.wellesleyinstitute.com
  • UK III: Possible Lessons • some pointers for ‘political/structural success conditions: – the Programme argued that links across government are essential to sustaining long-term change and spelled out specific targets for key Departments – a 2005 status report assessed how each Department was doing against the targets – most were on target – concrete targets and public scrutiny were certainly part of that progress – so too was high level attention and support – e.g. social exclusion unit in Cabinet Office, clear commitments from Prime Minister • the Programme of Action included inter-related activities and expectations from national, regional and local authorities • it emphasized multi-sector government/community partnerships and collaborations © The Wellesley Institute www.wellesleyinstitute.com
  • Netherlands • health disparities were recognized as a major issue through the 1980s and the Ministry of Health launched multi-year research-based approaches in 90s • unique in systematically assessing the effectiveness of targeted interventions directed to addressing socio-economic disadvantage, mediating the effects of wider inequality, community-based health promotion, access to care, etc. • results were built into overall national strategy to address health disparities • some lessons: – planning and progress meetings of researchers, officials and political leaders were important to building broad support and maintaining momentum – one obstacle was relative weakness of Ministry of Health in relation to other spheres – other Ministries didn’t see reducing health inequalities as their responsibility until re-framed – e.g. providing access to affordable housing was understandable rather than better health through better housing – progress is always shaped by political/electoral vagaries – adoption of provisions was frequently delayed © The Wellesley Institute www.wellesleyinstitute.com
  • Better Policy Coordination: Saskatchewan • coordinating table of ADMs -- Human Services Integration Forum – to promote inter-agency collaboration and integrated planning and service delivery – current priorities include strengthening families’ capacities, early childhood support, increased opportunities for youth, increase well-being and employment situations, improve coordination and integration of services, etc. • broader effects may be even more important: – also developed regional coordination bodies to link wide range of agencies and activities – which in turn provides space/encouragement for interesting local integration in areas such as Saskatoon © The Wellesley Institute www.wellesleyinstitute.com
  • Better Policy Coordination II: Quebec • provincial strategy coordinates health and related social spheres – in one Ministry • Health and Wellbeing Council encourages inter-sectoral action • widespread consultation and involvement of community sector in policy development • comprehensive 10 year plan to address social determinants and wellbeing • all Ministries are required to consult the Ministry of Health and Social Services on new legislation or regulations that could impact health • regional health authorities are required to develop integrated plans with social services • local health authorities must coordinate with non-health services © The Wellesley Institute www.wellesleyinstitute.com
  • Lessons Learned in Other Jurisdictions • one vital key to health equity lies outside health system -- building equity into all macro social and economic policy: – not just as one factor among many to be balanced, but as core priority – always a political question • cross-cutting collaborations across government is essential – and that requires high-level commitment and champions • creating as integrated and broad a policy framework as possible to ground and guide this collaboration/coordination is also key: – very difficult – few countries’ policies appear to be truly integrated – but clear that the more integrated → more chance of success • political and governmental structures are important – one factor in success of UK in developing an overall strategy is centralization of power at national level – we know that constitutional and jurisdictional barriers are critical in Canada – regardless of FPT Task Forces © The Wellesley Institute www.wellesleyinstitute.com
  • Comparative Lessons Learned II • there is no magic blueprint but a range of directions and approaches that can be adapted • everything can’t be tackled at once: – split strategy into actionable components – phase them in – but coordinate though a cohesive overall framework • some technical lessons from other countries: – build equity considerations into policy at design stage – use tools such as Health Equity Impact Assessments – clear targets/indicators and public reporting of progress against them • and some quandaries as to who and how: – Health leads in most jurisdictions – how that was smoothed out in the face of inevitable departmental rivalries and differences is a key question © The Wellesley Institute www.wellesleyinstitute.com
  • Cross-Sectoral Multi-Level Collaboration • clear conclusion from experience of other jurisdictions is that action on equity cannot just come from senior governments • de-centralization and regionalization are seen to be crucial: – not just in the sense of regional health care planning, governance and delivery, but cross- sector collaborations among local governments, health authorities, community-based service providers and other stakeholders – MESH process arising out of Aboriginal health centres in Australia begins from community involvement in defining local needs to allocate resources to most disadvantaged • collaborations and partnerships were emphasized and local and community initiatives were seen to be a vital source of innovation • in many countries regional health authorities can be an important enabler and lever for creating these collaborations – e.g. a number of leading Regional Health Authorities across Canada have identified addressing health disparities and social determinants of health as a top priority © The Wellesley Institute www.wellesleyinstitute.com
  • Regional Cross-Sector Collaboration in Practice: LHINs • can see LHINs reform as another opportunity for acting on equity in a comprehensive and coordinated way • the primary role of LHINs is to integrate health care planning and provision to better reflect and serve local needs • many have recognized importance of social determinants, but how to implement? • LHINs will need to collaborate/coordinate beyond health → chance to be innovative from the start – the Province could mandate -- and fund – that each LHIN will establish cross-sectoral planning tables to foster policy and programme collaboration to address health disparities and to address the underlying social and economic determinants of health – would need to build incentives and expectations to ensure LHIN participation in such collaborative planning tables and processes © The Wellesley Institute www.wellesleyinstitute.com
  • Within Health System • have seen statistics and analyses that health care system has less impact on health than social and economic factors • but that doesn’t mean that how the health system is organized and how services and care are delivered are not crucial to tackling health disparities • all countries see the health system as an indispensable element of comprehensive strategy around health equity, including: – overall system architecture that supports equity – reducing barriers to equitable access – primary care as a key enabler of health equity – targeted services for the most disadvantaged areas or populations – culturally competent and appropriate high-quality care that reflects the full diversity of population – regionalization and supporting local initiatives © The Wellesley Institute www.wellesleyinstitute.com
  • Starting With Equity as Core Health System Priority • tremendous window of opportunity as the new provincial strategy is being developed • should incorporate equity as a core priority: – as an over-arching commitment to equal opportunities for good health for all – plus a clear recognition that additional resources and investment will be focussed on most disadvantaged – with concrete objectives, indicators, and resources and incentives to reach them – not just at the Ministry level, but cascading expectations for LHINs and all programmes and providers © The Wellesley Institute www.wellesleyinstitute.com
  • Health System Architecture • financing can have an important effect on equity: – the balance between public and private provision/funding: • considerable evidence that greater private share can have adverse impact on equitable access to health care • for example, the more services that involve user fees → greater barriers for poorer people – equitable allocation – meaning more funds to areas with greater need • so too can the balance between hospital and other institutional versus community-based delivery – latter can more easily be targeted to disadvantaged populations • what is sometimes called ‘connecting tissue’ of IT, the culture/infrastructure to support innovation, linking research into policy/practice – ensure this includes community-based research and innovation, and doesn’t create digital or other access barriers – collect the kind of systematic and comparable data needed for equity and diversity planning – income, race, ethno-cultural, sexual orientation, etc. • Ontario is going through a comprehensive transformation of system → chance to build equity into the basic architecture and fabric of new system © The Wellesley Institute www.wellesleyinstitute.com
  • Reduce Barriers to Access to Care • critical part of health equity strategy is to identify and reduce barriers to access: – affordability – availability – considerable variation in access to specialist, primary and other care by region and neighbourhood → need targeted remedial plans – language and culture → put most positively, ensure culturally competent care and build anti-racism/oppression approach into service provision • key mechanisms are CHCs, public health and other community-based service providers that focus on under-served communities • many of the best of these local programmes involve collaboration beyond health: – CHCs, child care and other partners working together on early years programmes – the development of the new satellite CHCs in designated areas in Toronto — with primary care and social and other services out of the same facilities – is one among many examples of complementary services from different agencies being provided together in community locations; © The Wellesley Institute www.wellesleyinstitute.com
  • LHINs and Equity • the LHINs have all recognized health disparities – to some degree – in the first Integrated Health Service Plans • implementing equity will require in each LHIN: – planning tools such as diversity lenses and health equity impact assessments – targeted investment and programmes in disadvantaged neighbourhoods – governance that builds in the voices and interests of whole community – including marginalized and traditionally excluded – willingness and capacity to pilot new ways of addressing barriers or supporting hard-to-serve communities – encouraging on-the-ground collaborations and partnerships among health care providers and beyond • and provincial enabling policy and resources: – consistency and sustainability will only be assured if the Ministry sets equity standards that all LHINs must implement and provides the necessary funds – plus targets and expectations – reduce health disparity in region by X%, ensure utilization patterns reflect diversity and needs of local population – plus provincial infrastructure to help share best practices across LHINs © The Wellesley Institute www.wellesleyinstitute.com
  • Looking to other Provinces • Interior Health in BC has developed a social determinants-based plan – Beyond Health Services and Lifestyle • several Alberta RHAs have developed operational and planning links with local social services and one has emphasized community capacity building as key to addressing health • non-health agencies in Alberta are also creating cross-sectoral planning and action forums around housing, poverty and other determinants • Saskatoon is developing cross-sectoral action on health equity: – began from local research documenting shocking disparities among neighbourhoods – will focus interventions in the poorest neighbourhoods – locating services and links in schools, relying on First Nations elders to guide programming • 18 big city Medical Officers of Health are working together on strategies to address urban health disparities • the Centre Lea Roback provides determinants focussed research and planning support to Montreal’s public health department and other cross- sector forums © The Wellesley Institute www.wellesleyinstitute.com
  • Primary Care: Equity Focused • considerable international evidence that expanding primary care can reduce health disparities • major reforms underway in Ontario – how to build equity in? – focus increased primary care in areas with poorest access or health status – in terms of policy levers: it may be easiest to establish CHCs, but can also try to encourage location of other practice forms in poorer areas • can also see primary care reform as a lever for wider changes – – many CHCs now see working beyond health and linking to agencies working on wider determinants of health as part of their mandate – can this be built into other forms of enhanced primary care – social workers, brokers, health educators in FHTs? – how could local community governance shape primary care – enhanced FHTs with community boards? © The Wellesley Institute www.wellesleyinstitute.com
  • Targeted Intervention/Investment To Most Disadvantaged • a defining principle of health equity strategies is that everyone does not need or receive the same kind of services: – to address and ameliorate the worst effects of health disparities requires targeting resources and services to specific areas or populations – this requires sophisticated analyses of particular disparities and inequities – i.e. is the main problem language barriers to access, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. – also requires detailed information and good local research – an involvement of local communities and stakeholders with local knowledge is critical to understanding the real problems • community-based and community-driven service development has tremendous potential to be innovative and responsive – will give a few examples and then discuss how this community-driven innovation can be built upon to drive wider reforms © The Wellesley Institute www.wellesleyinstitute.com
  • Multicultural Health Brokers Cooperative from Edmonton • arose out of a small project initiated by public health to support the growing – and often isolated -- immigrant and refugee communities in early 90s • provides intensive pre-natal and infant support to women and families facing language and cultural barriers within health care and overall social exclusion • saw that they needed to extend beyond point of service delivery → idea of broker: – connect people to full range of health and social services they need and advocate for clients – provide continuity in a fragmented system – support innovative self-help initiatives organized by clients themselves • and beyond even further: – have developed collaborations with schools, social services and other agencies to address access gaps and barriers – provide multicultural training to agencies and service development assistance to public health and regional health authorities © The Wellesley Institute www.wellesleyinstitute.com
  • Street Health • nursing and other primary care for homeless people in downtown Toronto • as needs became clear → expanded programmes – harm reduction, referrals to housing and other services, support in working through eligibility maze of social assistance programmes • and beyond the health care system: – ID Project – to help homeless people apply for documents needed to secure eligibility for programmes and provide secure places to store ID – community-based research to: • identify eligibility barriers to ODSP for homeless people with disabilities and pilot effective support programme to help people secure assistance for which they are eligible • survey the service needs/barriers of homeless people © The Wellesley Institute www.wellesleyinstitute.com
  • Up Stream Through an Equity Lens • investing in better chronic care management, preventive care and health promotion are seen to be vital elements of health reform • needs to be planned and implemented through an equity lens – anti-smoking, exercise and other health promotion programmes need to take account of the particular social, cultural and economic factors that shape risky behaviour in poorer communities – specific efforts need to be made to address language, cultural and other barriers to disadvantaged communities getting the health promotion information and support they need: • a great deal of valuable culturally appropriate and translated health promotion work is going on through ethno-cultural and other specific community groups • which highlights one direction to building the necessary community capacities to be able to take action on health promotion – the Ontario Prevention Clearinghouse is a key resource © The Wellesley Institute www.wellesleyinstitute.com
  • Equitable Access to Health Promotion for Most Disadvantaged • equity-driven health promotion would ensure preventive, dental care, sexual and reproductive health, immunization and related services are provided equitably in disadvantaged communities: – it is vital that such services be located directly in the neighbourhoods that need them most – e.g. public health workers in every school and multi-service neighbourhood agency in poor or under-served areas – increasing public health capacity to provide services in the languages of local communities – great potential of community-based research to provide rich local needs assessments and evaluation data • current revisions of mandatory health program standards should include addressing inequitable health and underlying social and economic determinants – a model to build determinants and equity into public health programming has been developed by the Sudbury & District Health Unit © The Wellesley Institute www.wellesleyinstitute.com
  • Count Us In • a Wellesley funded project with Ontario Women’s Health Network, Ontario Prevention Clearinghouse, Toronto Public Health and other partners • project was on the barriers homeless and marginalized women face in access to crucial health and social services → key insights to program planning and improvement (an example of kind of CBR needed to drive equity interventions) • but also developed a new way of doing research • inclusion research trains, supports and involves homeless and other marginalized women in doing the research themselves • a form of peer-driven research that yields richer, more nuanced and deeper understanding • a circle of investigation with inclusion researchers from the community being researched and professionals to create new policy approaches © The Wellesley Institute www.wellesleyinstitute.com
  • Inclusion Research Brings Equity Into Health Promotion • original project went on to conduct inclusion research focus groups in three Ontario cities to develop a new strategy for preventing stroke among women • it found that marginalized women have a clear understanding of the social determinants of health and highly value inclusion; prefer learning in intimate group settings; and knew little of the risks of stroke • a new health promotion strategy emerged from the research -- targeted awareness campaigns to marginalized women, and innovative outreach led by lay educators • clinics were held in one city as a result of the research and a partnership was created in another to deliver a pilot project with inclusion researchers as co-facilitators • in addition, this research provided the necessary ‘Canadian’ experience so that some inclusion researchers were able to get jobs in the social service sector © The Wellesley Institute www.wellesleyinstitute.com
  • Policy Framework for Innovation • have been arguing that the way to proceed on massive challenge of health disparities is by ‘chunking out’ actionable projects, by experimenting and by relying on community-based and other front-line innovations • first of all, will need a framework to support experimentation and innovation: – common data and information platforms – funding for pilot projects – dedicated funding lines to LHINs for pilots, and expectations that each LHIN will undertake innovations – looking for results and value, but also need funding regimes that don’t over- burden • then need a provincial infrastructure to: – systematically trawl for and identify interesting local innovations and experiments – evaluate and assess potential beyond the local circumstances – share info widely on lessons learned – scale up or implement widely where appropriate • all to create a permanent cycle and culture of front-line driven innovation © The Wellesley Institute www.wellesleyinstitute.com
  • Community Engagement • clear conclusion from other countries and RHAs in other provinces is that community involvement is vital to implementing equity • this means ensuring that the widest range of priorities, needs, preferences and perspectives are incorporated into health planning: – new forums and mechanisms to bring the voices of disadvantaged and vulnerable communities in – specific targeted outreach strategies • it also means means extending representation and accountability to all: – including communities traditionally excluded – some of the tools are diversity and equity planning checklists to ensure LHIN, agency and other boards and planning bodies are representative © The Wellesley Institute www.wellesleyinstitute.com
  • LHINs as Window of Opportunity for Community Engagement • community engagement is part of legislated mandate, and the LHINs have made a good start with extensive consultations for their first IHSPs • but chance to think bigger: – to embed responsive and effective new forms of involving people in planning and priority setting from the start – e.g. neighborhood forums sending priorities up to LHIN-wide community- consumer forums to assess, balance and advise LHIN boards – particular and sustained efforts to involve marginalized communities – the innovations needed will vary by region, but will include partnering with agencies or community organizations marginalized people trust, linking with grass-roots organizations, going where poor people are rather than making them come to you, translation, providing child care and honoraria, etc. • and, as always, to make this happen will require: – clear provincial direction and expectations – adequate funding and support to the LHINs • and to make it happen most effectively – an infrastructure to share community engagement best practices widely © The Wellesley Institute www.wellesleyinstitute.com
  • Conclusion: Directions for Policy Action • dramatic improvements in health disparities require broad cross- sectoral changes in public policy that will reduce social and economic inequality: – start by building better coordination across Ministries – look for collaborations on issues with broad consensus – child poverty – and initiatives that will show results and build momentum – joined up schools, local health and social services to enhance early years services for high-need families and communities – re-frame issues from what other Ministries should do to reduce health disparities to common goals – investments that build social cohesion and enhance human capital • local and community collaborations will be crucial – LHINs must support partnerships and innovation in addressing roots of health disparities © The Wellesley Institute www.wellesleyinstitute.com
  • Directions II • make equity a core objective in new overall health strategy – and cascade down concrete equity expectations to LHINs and local providers • ensure the basic architecture of the health system supports equity – financing, allocation, information management, planning structures, etc. • and develop a systematic and carefully linked suite of initiatives: – tackle structural barriers to equitable access – target increased resources and programmes to areas/communities facing worst disparities and/or who could benefit the most – support innovative forms of community-based provision that address disparities on the ground – CHCs, public health, community agencies – expand access to primary care, especially in under-served areas © The Wellesley Institute www.wellesleyinstitute.com
  • Directions III • all of this will need to be sensitive to varying local circumstances and community needs – vital role for new LHINs – with appropriate central support and direction from Ministry – looking for best balance between enough local flexibility for innovation and meeting specific needs, and provincial standards and resources to ensure equity is effectively addressed across the province • there isn’t a precise blueprint → experiment and pilot – but always systematically – to be able to assess what is working (and build on it) and what isn’t (to learn lessons and move on) – create a constant cycle of innovation, evaluation, adjustment and learning © The Wellesley Institute www.wellesleyinstitute.com
  • Further Resources • the European Union has been focusing on health inequalities – its Closing the Gap project seeks to promote action in individual member countries and share information on national policies, best practices and new initiatives across Europe http://www.health-inequalities.eu/ • the World Health Organization’s European office has established a Special Commission on the Social Determinants of Health http://www.euro.who.int/socialdeterminants – useful source of data, comparative and analytical work, country profiles, new and emerging initiatives and shared best practices – I also particularly like the Commission’s series of Knowledge Networks on health systems, social exclusion, gender and other key areas • these sites will link to country and departmental sites in Sweden, the UK and other countries cited here – but one that is particularly relevant here is Tackling Health Inequalities: Status Report on the Programme of Action a 2005 Department of Health report assessing progress on the action plan and health inequality targets in each Ministry • the International Journal for Equity in Health has interesting comparative research, analytical pieces and issue surveys © The Wellesley Institute www.wellesleyinstitute.com