Health Equity Resources for LHINs 9-30

Thinking About/Acting on Equity Bob Gardner August 2010 August 27, 2010

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

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

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

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

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

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;

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;

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.

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

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

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

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…..

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

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

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

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 27, 2010

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 [email_address]
I would be interested in any comments on how useful this resource was and how you would improve it

Health Equity Resources for LHINs 9-30

by Wellesley Institute on Aug 27, 2010

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Health Equity Resources for LHINs 9-30 — Presentation Transcript

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