Health equity resources for lhi ns

Health Equity Into Action:Strategy, Planning and Other Resources for LHINs
Getting Data on Health Disparities
Bob Gardner
August 2010
August 25, 2010
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Health Disparities in Ontario
there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health
plus major differences between women and men
in addition, there are systemic disparities in access to and quality of care within the healthcare system
not just unfair, but health disparities make it more difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs
that’s why enhancing health equity has become a clear priority – from the Province to LHINs to many providers
and that’s why we need tools and approaches to build equity into effective system and service planning
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Impact of Disparities
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

these 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 how useful this resource was and how you would improve it
Following Up
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Thinking About/Acting on Equity
Bob Gardner
August 2010
August 25, 2010
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Health Equity = Reducing Unfair Differences
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 also 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
Health equity is a broad concept that also prioritizes diversity:
reflecting the increasing diversity of Ontario society and the fact that racism and ethno-cultural differences are important determinants of health disparities
recognizing that services that reflect and speak to the diversity of cultures are essential to an equitable system
Impact of achieving health equity would
extend far beyond enhancing individual and collective well being
also contribute to overall social cohesion, shared values of fairness and equality, economic productivity, and community strength and resilience
Health Equity II

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Foundations of Health Disparities 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 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

POWER Study
Gender and
Equity
Health Indicator
Framework
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Canadians With Chronic Conditions Who Also Report Food Insecurity
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SDoH As a Complex Problem
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
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Look Widely for Policy Solutions and Adapt Flexibly to Local/Provincial Circumstances
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
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Getting at the Roots of Health Inequalities
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
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Wellesley Roadmap for Action on the Social Determinants of Health
look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities;
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;
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;
set and monitor targets and incentives – cascading through all levels of government and program action;
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Wellesley Roadmap II
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;
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Wellesley Roadmap III
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 through effective funding and knowledge sharing;
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.
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Think Big, But Get Going
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

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
Equity Into Health System: Why
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Toronto Central:
Lower Income, More Physician Visits For Arthritis
Proportion of Residents with physician visits for Arthritis is higher in Lower Income neighbourhoods, especially females.
Neighbourhood Income Quintiles
Toronto Community Health Profiles Partnership, www.torontohealthprofiles.ca

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Toronto Central:Lower Income, Lower Hip Replacement Rate
Age Standardized Rates. Total Hip Replacements per 100,000 Population by Neighbourhood Income Quintiles. Source: Institute for Clinical Evaluative Sciences (ICES) November 2006

Gender and Treatment Disparities
broad social and healthcare provider consensus that discrimination between women and men is no longer acceptable
but research has shown that women are less likely than men to receive:
standard heart medication
dialysis treatment
admission to intensive care units
certain surgical procedures – cardiac catherization, kidney transplants, knee arthroplasty (replacement)
surgeons and referring physicians respond in surveys that sex of patient has no effect on their clinical decisions
so…..
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Gender and Treatment Disparities II
to see if there were differences by gender in clinical practice
standardized male and female patients went to family physicians and orthopaedic surgeons
presented with the same scripted clinical scenario
found striking differences:
orthopaedic surgeons were 22X more likely to recommend male for total knee arthroplasty than female
family physicians were 2X more likely for male
Source: Borkhoff et al, CMAJ, March 11, 2008
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Immigrants and Treatment Disparities
POWER data indicates that because of our universal system, access to primary healthcare is high, but…
the % of recent immigrants who were satisfied with being able to get a routine check up and with care from their doctor for an urgent problem was about 1/3 less than for Canadian-born
in both these cases, immigrants here for over ten years had only slightly lower or about the same rates as Canadian-born
the % of people who speak neither English or French who were satisfied with care from their doctor for an urgent problem was also about 1/3 less
Wellesley research in St James Town in Toronto highlighted quality of care dimensions – it found that recent immigrants preferred to go to providers who were able to speak their own language and understand their culture
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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
Equity Into Health System: Why II
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Further Resources
The Wellesley Institute has many pages on health equity and health reform http://wellesleyinstitute.com
Health Equity Council http://healthequitycouncil.ca
Rainbow Health Network http://www.rainbowhealthnetwork.ca
Ontario Women’s Health Network http://www.owhn.on.ca
Ethno-Racial People with Disabilities http://erdco.ca
a virtual Health Equity Toolkit is being developed by a Toronto-based collaboration of Scadding Court Community Centre, CAMH and others – its blog is at http://www.smallstepsbigdifference.blogspot.com
August 25, 2010
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Following Up
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Health Equity Strategy
Bob Gardner
August 2010
August 25, 2010
31

LHIN-Level Health Equity Strategy
comprehensive strategy developed in 2008 for Toronto Central LHIN
a broad 12-point action plan and 50+ specific recommendations to:
address and reduce inequitable access to healthcare;
build equity into service delivery, planning and performance management;
effectively target programs and resources to reduce barriers and meet the needs of disadvantaged communities;
support cross-sectoral action and collaboration; and
encourage system change and innovation to reduce health disparities in Toronto.
many recommendations have been acted on
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For Other LHINs?
local conditions and priorities will vary and strategies developed for particular contexts – such as this for Toronto Central – will not be applicable in other LHINs
nor does every LHIN need such a comprehensive strategy
but there is also no need to totally ‘reinvent the wheel’:
the overall direction, principles and foundations set out in the Toronto Central framework could be a useful starting point for others
the specific directions can be adapted to local needs, and new directions and local priorities can be developed as needed
August 25, 2010
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Strategic Alignment and Coherence
whatever the overall strategy developed in a LHIN, one critical success condition is alignment:
the range of specific initiatives and investments addressing equity need to be well coordinated as part of a coherent strategy
then the different initiatives will complement and build on each other
part of this coherence is clear overall strategic understanding, vision or commitment to equity
in other words, a LHIN must clearly articulate what success looks like to it in terms of a more equitable health system
August 25, 2010
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the fundamental goal is to ensure equitable access to high quality healthcare regardless of social position
can do this through a two pronged strategy :
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
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
High-Level Theme: Double Strategy
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Overview:How LHINs Can Act on Health Equity
defining equity as a pre-condition of a high-performing health system -> building this into a coherent equity strategy
building equity into planning and resource allocation
developing 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
using levers to hand:
requiring equity plans from providers
building equity into expectations, deliverables, accountability agreements and overall performance management
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How LHINs Can Act on Health Equity II
aligning equity with system priorities and drivers
building equity into diabetes and other chronic disease prevention and management strategies
using an equity lens to assess wait times, ALCs and other system priorities
targeting some resources and investment to maximize equity impact:
whether barriers such as language and cost
or particular health disadvantaged or vulnerable populations
evaluating impact to identify what interventions and policies work, in what varying contexts, and how
creating the forums and infrastructure to share innovation and promising practices -> building a cycle of learning and innovation
August 25, 2010
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Equity in Tough Times
one of the critical challenges facing LHINs in the current tough fiscal climate is ensuring equity does not fall off the agenda
more generally, LHINs and other stakeholders need to ensure that equity is considered in funding allocation and in any coming move to more pay-for-performance models
August 25, 2010
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Key Messages
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
there is a solid base of healthcare provider experience, commitment and community connections to build on
a great deal of equity-focused planning and innovative delivery is already going on – challenge is to build on this potential
have set out overall strategic approaches, principles and tools to drive equity into action -> experiment and innovate
many within the health system have long experience and strong commitment to equity -> build on this to drive coordinated and coherent system-wide equity agenda into action
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Following Up
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Start From a Solid Strategic Commitment
Bob Gardner
August 2010
August 25, 2010
41

Start From a Solid Strategic Commitment
need to make equity one of driving priorities for health system and reform
equity and a population health focus are among key principles enshrined in new Excellent Care for All Act = opening and context
need clear provincial strategy for equity:
implicit from MOHLTC, but promised ten year strategy has not been released
need strategic coherence across health system in approach to equity
LHINs need to explicitly prioritize equity
cascading down to providers also prioritizing equity within their planning, service delivery and resource allocation
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August 25, 2010

Start From a Clear Commitment
some LHINs have made equity an explicit priority within their IHSPs
others see equity as a foundational theme that underlies all their priorities and activities
others are less clear, identifying particular programs or activities as focusing on equity issues
the current IHSPs are set, but LHINs could explicitly incorporate equity as a priority in their next generation
in the meantime, a commitment to equity can be highlighted in several ways
some LHINs have passed board motions setting out a clear commitment and direction
others have an equity or diversity vision
August 25, 2010
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Following Up
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Build Equity Into Planning
Bob Gardner
August 2010
August 25, 2010
45

Equity-Focused Planning
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 this requires an array of effective and practical equity-focused planning tools
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Equity-Focused Planning Tools
procedures to ensure equity is considered in all service delivery/planning
take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery
assess current state of provider organizations
determine needs of communities facing health disparities
assess impact of programs/interventions on health disparities and disadvantaged populations
simple equity lens
Health Equity Impact Assessment
equity audits and/or HEIA, Gender-Based Analysis
equity-focused needs assessment
equity-focused evaluation
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Health Equity Impact Assessment
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
intended to be relatively easy-to-use tool
essentially prospective
piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI
refined template and developed a new workbook
HEIA is being used in Toronto Central and other LHINs and providers across the province
HEIA is being incorporated into a “health in all policies’ framework by MOHLTC
increasing attention to potential – from WHO, through most European strategies, PHAC, to MOHLTC and LHINs
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HEIA in Ontario
the basics of the Ontario model for HEIA is captured in a one-page template (following)
a workbook was developed in 2009 to support use of the tool
both available at TC LHIN equity page
August 25, 2010
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HEIA Template
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Ontario HEIA: 4 Step Process
after screening – identifying projects where HEIA would be useful, where there could be differential impact or outcomes
template asks how the planned program or initiative affects health equity for particular populations
list of health disadvantaged populations – not meant to be exhaustive
potential impact on social determinants of health
then assess potential positive and negative impacts of the initiative on the population(s) based on best available evidence -- and indicate where more information is needed
develop means to build on positive and mitigate negative impacts and build that into planned service or program
planners indicate how implementation of the initiative will be monitored to assess its impact
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Early Experience in Ontario:Using HEIA
generally designed for planning forward:
easy-to-use tool to ensure equity factors are taken into account in planning
can be an effective way to ensure equity is incorporated into routine planning throughout an organization
but providers in pilot phases and initial implementation – and experience from other jurisdictions -- identified other uses:
for strategic and operational planning
for assessing whether programs should be re-aligned or continued
to build equity principles into evaluation and quality improvement
August 25, 2010
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Supporting HEIA in Practice
MOHLTC has piloted tool in several more LHINs and is currently developing resources
individual providers and networks are using HEIA for their planning
the Wellesley Institute has provided many workshops on how to realize the potential of HEIA
recent workshops include:
to a mental health planning group of Toronto Central LHIN
to an equity planning group in a major hospital
to a more general conference of mental health providers and networks in Central LHIN on overall equity strategy, the importance of good planning and the potential of HEIA as one vital part of the repertoire of planning tools and resources
August 25, 2010
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Hypothetical Case for Workshopping HEIA
Our experience in these workshops is that it is important to have concrete cases that the particular group can work through
This is a hypothetical example that has proven useful:
You are planning to develop diabetes outreach in a specific neighborhood or area. You want to improve people’s ability to monitor and manage their own care, and to get residents hooked into primary care for ongoing support and monitoring. Use the HEIA tool to help plan this programme.
Other cases are in the various workshops on previous page
August 25, 2010
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Further Resources on HEIA
Wellesley has developed a page on HEIA with links to a wide range of international and Canadian resources
Among key international resources is the Australian HIA Connect site and its associated blog
Other general health equity resources include :
Health Equity Council http://healthequitycouncil.ca
Rainbow Health Network http://www.rainbowhealthnetwork.ca
Ontario Women’s Health Network http://www.owhn.on.ca
Ethno-Racial People with Disabilities http://erdco.ca
Health Equity Toolkit – blog is at http://www.smallstepsbigdifference.blogspot.com
August 25, 2010
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Following Up
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Use Available Levers to Drive Equity Planning and Action
Bob Gardner
August 2010
August 25, 2010
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a promising direction several LHINs have taken up is to require providers to develop equity plans
these plans are 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
Providers Developing Organizational Health Equity Plans
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Building on Experience
hospitals in Toronto Central and Central LHINs developed equity plans
and other providers in Central have done plans
Toronto Central required hospital CEOs and Board Chairs to sign off on the plans -> ensuring high-level organizational attention and commitment
explicit templates were developed in Toronto Central
resources and guidance were developed in Central
any other LHIN deciding to require or encourage its providers to develop equity plans can adapt these templates
other LHINs can also draw on lessons learned in these LHINs
August 25, 2010
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these plans achieved their objectives of building awareness of equity within the organizations and beginning to embed equity in planning and decision-making
the Toronto Central hospitals developed comprehensive plans
these plans were then analyzed – reports on next page
Impact of Equity Plans

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

Impact of Equity Plans II
a further goal of the plans was to build connections among providers for addressing common equity issues and identify cross-cutting and system-wide issues
in Central:
issues identified in the hospital plans were incorporated into individual hospital deliverables -> they report quarterly on progress
in Toronto Central:
an existing network – the Hospitals Collaborative on Marginalized Populations – served as the forum for developing common templates and approaches to developing the plans and for discussing implications of their findings and lessons learned
three immediate issues identified in many of the 18 plans – systematizing interpretation, equity and diversity-relevant data and services for uninsured populations -- were moved on by the LHIN
next steps:
Toronto Central hospitals are required to refresh their plans under their current HSAAs by fall 2010, and a new template has been developed for this
commitments and priorities identified in the refreshed plans will be built into next HSAAs
August 25, 2010
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Using Levers to Hand:Funding and Resource Allocation
the provincial Aging at Home program required a certain proportion of projects to be deemed innovative
similarly, LHINs could determine that a certain proportion of Aging at Home, primary care or other funding would be directed towards health disadvantaged neighbourhoods or areas, access barriers or particular populations
where appropriate, LHINs could require that programs demonstrate their ability to provide services in the languages of the community
LHINs could require proponents to demonstrate that they have considered equity in all funding applications:
for example, one LHIN required short-listed applicants for funding under the second generation of Aging at Home to have completed a Health Equity Impact Assessment of their proposed initiative
August 25, 2010
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clear in new Excellent Care for All Act that priorities will be driven through performance management and guidelines
all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds
LHINs can build in specific equity expectations and deliverables
will vary by community and provider -- but could include:
undertaking appropriate equity-focused planning
providing sufficient appropriate interpretation and services in languages of community
identifying areas where access to services is inequitable and developing plans to address barriers and gaps
ensuring service utilization matches appropriately with demography and needs of their catchment profile
developing specific services or outreach to particular disadvantaged populations – homeless, isolated immigrant seniors, etc.
Beyond Planning: Building Equity Into Performance and System Management

Following Up
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Building Equity Into Performance Management
Bob Gardner
August 2010
August 25, 2010
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Targets and Incentives
vital part of comprehensive policy on health equity
setting targets – whether reducing access barriers or overall disparities or enhancing services to particular disadvantaged populations
need good indicators to assess progress towards targets:
that build on available reliable data and make the most sense in the particular context
then closely monitor indicators
build expectations regarding targets into accountability agreements and funding
disseminate progress towards targets widely for public scrutiny
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Building On Experience
another result of TC LHIN hospital equity plans = development of hospital clinical equity indicators by the Centre for Research on Inner City Health
also considerable work being done by researchers, the Association of Ontario Health Centres and other provider associations and networks, LHINs and others on equity indicators
any LHIN can build on this indicator work already being done
further ideas for how to develop equity targets on next slide
need to build these equity targets and objectives into routine performance management and provider planning
August 25, 2010
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Building Equity Targets for Ontario
there are broad provincial and LHIN targets for priorities such as diabetes
a number of LHINs have identified areas where diabetes incidence is highest ->
a good service target has been proposed for diabetes = high/increasing % of people who get best standard care
need to drill down in specific areas that have high equity impact
many programs assess their services through client satisfaction surveys and similar methods -- providers generally look for high and improving satisfaction
-> build equity into these targets:
equity target = reduce differences in incidence, complications and rates of hospitalization between populations or areas
equity target = reduce differences by gender, income, ethno-cultural background
equity target = ensuring access and use of primary health care does not vary inequitably by income level, immigration status, neigbourhood, gender, race, etc.
equity target = reduce any differences in satisfaction by gender, income, ethno-cultural background, etc.
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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
a workshop was held on what kinds of data on equity and diversity are available, how the existing data sets can be effectively used, and what further types of data are needed
presentations and resources from the day and report from working group to Collaborative were published on partner sites including http://www.healthequitycouncil.ca/dev
Need Data to Underlie Equity Strategy/Action
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Following Up
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Align Equity With Provincial Priorities and System Drivers
Bob Gardner
August 2010
August 25, 2010
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Align Equity With Provincial Priorities and System Drivers
greater chance of success for equity strategy if aligned with provincial priorities:
diabetes, wait times, mental health
mental health and diabetes are particularly sensitive to social conditions
chronic disease prevention and management programs cannot be successful unless they take account of social conditions and constraints
critical to enabling people with mental health challenges to recover , manage condition or live in the community are a continuum of community supports that take into account the social exclusion, poverty and other challenges people face
these priorities will not be achieved unless planning/delivery takes equity into account
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August 25, 2010
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Align Equity With Provincial Priorities and System Drivers II
equity also supports other system drivers
better access to primary care is key to reducing pressure on ER wait times and ALC
reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over-prescriptions -> enhanced quality and cost effectiveness
taking lived conditions/experience into account – meaning equity and diversity -> essential to high quality patient-centred care
reducing higher expenditures on vulnerable populations due to health disparities -> can contribute to overall sustainability
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Following Up
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Target Investment for Equity Impact
Bob Gardner
August 2010
August 25, 2010
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© The Wellesley Institute
www.wellesleyinstitute.com
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Target Investment for Equity Impact
target services to specific areas or populations:
those facing the harshest disparities – to raise the worst off fastest
or most in need of specific services
or the worst barriers to equitable access to high-quality services
this requires sophisticated analyses of the bases of disparities:
i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc.
which requires good local research and detailed information – speaks to great potential of community-based research to provide rich local needs assessments and evaluation data
involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems

several LHINs have identified vulnerable populations – recent immigrants, people with concurrent disorders, homeless
e.g. the North York West region within Central LHIN has been identified as high need – diverse population, high % of racialized population, high risk factors, lack of access to primary care
or disadvantaged neighbourhoods facing concentrated health and social problems
in Toronto and other cities: people without health insurance – primarily immigrant/refugees – are especially vulnerable:
many community initiatives to provide access
Women’s College Network on Noninsured is forum for coordination
recently held research conference showing critical barriers to access and good care and resulting adverse health outcomes for vulnerable people
August 25, 2010
Target Populations

Target Barriers
a critical equity challenge in an increasingly diverse society is language
was clear in hospital equity plans in Central
identified as critical issue in hospital equity plans and other Toronto Central planning -> major project to develop more systematic coordinated approach to interpretation in downtown hospitals
other LHINs could hook up to this – or at least keep it on horizon
could also link into Healthcare Interpreters Network
another critical barrier to equitable access is remoteness and transportation
have been innovative community-based and volunteer transportation
highlights key role of LHINs in enabling such critical supports for health and in supporting cross-sectoral collaborations
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solid evidence that enhancing primary care is one of key ways to improve care of disadvantaged
lack of access to primary care has been identified as a key issue for Prov and LHINs
recognizing that most of primary care levers are outside LHIN mandate -> need to collaborate
concentrate new investments or coordination initiatives in particular regions or neighbourhoods, or in particular populations such as refugees or uninsured
LHINs are all about integration and coordination:
will be experimenting and innovating with enhanced coordination and partnerships for primary care
with different kinds of community-based service delivery and on-the-ground coordination
-> locate these innovations in high-need areas
Through an Equity Lens:Primary Care

Following Up
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Equity-Focused Evaluation
Bob Gardner
August 2010
August 25, 2010
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Equity-Focused Evaluation
Ministry and LHINs need to fund and enable evaluation – not just as a tacked-on expectation and not ties to accountability regimes
need to figure our what interventions and approaches work, in what contexts and why
can’t just measure activity – number or % of pop’n that participated in a program
need to measure health outcomes – even when impact only shows up in long-term
need to assess reach -- who isn’t signing up?
need to differentiate those with greatest need = who programs most need to reach and keep to have an impact
-> develop funding and evaluation weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system
-> investment in policy directions and program interventions that will have the strongest equity impact
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Following Up
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Building Equity-Focused Innovation
Bob Gardner
August 2010
August 25, 2010
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Building on Potential of Community-Based Service Initiatives and Innovation
huge number of community and front-line initiatives already addressing equity across province
CHCs especially, community organizations based out of specific ethno-cultural communities
many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities
for homeless people:
CAISI database so records are accessible from many providers
travelling psychiatrists, nurses and other providers
Baby and Me passport
Street Health report as CBR into action
but
experience and lessons learned are not being shared systematically
potential of promising interventions is not being realized
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Enabling Equity-Driven Innovation
to drive equity-focused innovation and effective interventions, we need to be able to:
collate and analyze all the useful intelligence gained from equity-focused planning
capture and share information on local initiatives, and build on local front-line insights
share the resulting knowledge across regions – and beyond
assess the most promising initiatives or directions rigorously
scale up promising initiatives across the province where appropriate
need to create forums and infrastructure for this innovation knowledge management
and need to build equity-focused innovation into incentives and drivers -- cascading from Prov to LHINs to providers
expectation that X% of budget will be devoted to equity-orientated innovation
ear-marked funds for equity innovation
88

Following Up
89

Partnerships and Community Engagement
Bob Gardner
August 2010
August 25, 2010
90

Community Engagement Into Equity Planning
assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context -> need ongoing engagement with the population and/or specific community-based research or needs assessment
analyzing how to design services to meet specific barriers or population needs will also benefit from engaging the affected population
similarly, monitoring and assessing the impact of service initiatives also needs:
research and input from the affected population
health outcome data stratified by population and determinants
91

Community Engagement
community engagement is mandated in the LHINs’ legislation
all LHINs have devoted staff and resources to putting this into practice
community engagement staff in some regions – such as the GTA – regularly meet and exchange information and experience
a number of LHINs have equity or diversity advisory committees, working groups or action groups
some LHINs have recognized that standard consultative techniques of e surveys, town halls, liaising with provider networks, etc. will not work for more isolated or marginalized populations
several have employed innovative deliberative dialogue forums to ensure the full range of community voices and interests is fed into their strategies
August 25, 2010
92

Further Resources
Wellesley prepared a backgrounder as a kind of planning checklist:
while it was originally prepared in 2006 and is therefore dated, some of its key points remain valid
in particular, there are sections on how to build diversity and space for the voices of the most marginalized communities into engagement
there are also reviews of experience in other jurisdictions on our page
the Change Foundation held a symposium on community engagement with LHINs in 2009
August 25, 2010
93

Following Up
94

Acting on the Social Determinants of Health
Bob Gardner
August 2010
August 25, 2010
95

Cross-Sectoral Planning Through an Equity Lens
cross-sectoral coordination and planning are key ways to put wider SDoH into action
many European national strategies emphasize local adaptation and cross-sectoral collaboration:
British Health Action Zones were examples of concentrated local investments in community economic development and targeted healthcare and social service improvements
potential of comprehensive community initiatives:
collaborative cross sectoral efforts – for poverty reduction, community development, health disparities
Vibrant Communities, Social Planning Councils and others are developing cross-sectoral planning forums and processes in many communities around poverty and inequality – with clear implications for health
96

97
Cross-Sectoral Collaboration at Local and Regional Levels
in Canada, some Regional Health Authorities have developed service 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, school board, business, community, Aboriginal and other leaders
in Ontario public health are key players in addressing health disparities on the ground
a number of public health units have been pioneering social determinants approaches -- Sudbury, Waterloo, Toronto
often involved in community collaborations

Equity-Focused Innovation:Hub Models of Integrated Care
hub-style multi-service centres in which a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations
Winnipeg Regional Health Authority and Manitoba Family Services and Housing have partnered on a new model to integrate health and social service delivery – one-stop access models in various communities to deliver a broad range of health and social services directly and to refer on to other agencies when services aren’t available
some new satellite CHCs are being developed in designated high-need areas in Toronto will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location
Ontario provincial associations representing CHCs, mental health and community service agencies have been promoting idea -- including to LHIN CEO provincial planning table
98

Watch for Pitfalls:Avoiding Fragmentation
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?
99

Following Up
100

Health equity resources for lhi ns

by Wellesley Institute on Aug 25, 2010

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Health equity resources for lhi ns — Presentation Transcript

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