This presentation examines the ways in which local action can establish an equitable health care system. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Health Equity Roadmap
Driving Local Action
Bob Gardner
Hamilton Health Equity Roundtable
Feb 27, 2013

2. Problem to Solve:
Systemic Health Inequities 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
•+ major differences between
women and men
•the gap between the health of
the best off and most
disadvantaged can be huge – and
damaging
•impact and severity of these
inequities can be concentrated in
particular populations and
neighbourhoods
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3. And Locally
Code Red series on health
inequities by
neighbourhoods:
• 21 years difference in age
at death
• major differences in health
outcomes across many
measures
plus inequitable access to
health care in poorest areas
• 50% higher rates of
emergence departments
visits in downtown core
• 2X for psychiatric
emergencies
• less access to primary care
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4. Three Cumulative and Inter-Dependent Levels
Shape Health Inequities
1. because of inequitable access to
wealth, income, education and other
fundamental determinants of health
→ gradient of health in which more
disadvantaged individuals and
communities have poorer overall
health and are at greater risk of
many conditions
2. also because of broader social and
economic inequality and exclusion
→ some communities and populations
have less infrastructure, resources
and resilience to cope with the
impact of poor health
3. because of all this, disadvantaged
and vulnerable populations have
more complex needs, but face
systemic barriers within the health
care and other systems
→ these disadvantaged and vulnerable
populations and communities tend to
have inequitable access to services
and support they need
4

5. Planning For Complexity
even though roots of health
disparities lie in social and
economic inequality
need to also look at how
these other systems shape
the impact of SDoH:
•access to health
services can mediate
harshest impact of
SDoH to some degree
•so too can responsive
social services
•structure, resources
and resilience of
communities shape
impact and dynamics of
inequalities
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6. • as a result of the social gradient of health, the most
disadvantaged in SDoH terms end up sicker and needing
care
• equitable healthcare and support 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 can 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 community support services could make
overall disparities even worse
Equity Into Health System: Why
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7. Building Equity Into the Health System: How
1. building health equity into all health care planning and delivery
• doesn’t mean all programs are all about equity
• but all take equity into account in planning their services and
outreach
2. aligning equity with system drivers and priorities
• quality improvement, chronic disease prevention and management,
wait times
• none of these directions can succeed without taking equity barriers,
social determinants of health and differential risks and needs into
account
• aligning with key priorities also enhances chance for success and
sustainability of equity focus
3. identifying those levers that will have the greatest impact on reducing
health inequities and driving system change
• e.g.. enhanced primary care
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8. Building Equity Into the Health System: II
4. embedding equity in provider organizations’ deliverables, incentives and
performance management – in the incentives and pressures that really drive the
system
5. targeting some resources or programs specifically:
• looking for investments and interventions that will have the highest impact
on reducing health disparities or improving the health of most
disadvantaged, fastest
• key access barriers – language, culture, availability
• addressing disadvantaged populations – poor, isolated, racialized, homeless
6. investing up-stream in health promotion and addressing the underlying
determinants of health
7. enabling equity-focused innovation
• a huge range of promising and innovative programs have been developed by
Community Health Centres, hospitals, networks and other providers to
address the needs of disadvantaged communities.
• we need to share lessons learned, evaluate and identify what is working, and
build on the enormous amount of local imagination and innovation going on
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9. Where to Start?
• can’t just be ‘experts’, planners or professionals who define issues and
drive system transformation
• have to build diverse voices and community needs into planning
• not just as occasional community engagement
• but to identify fundamental needs and priorities
• and to evaluate how we are doing
→ need to start from communities and patients
+ through an equity lens:
• not all patients are the same – diverse cultures, backgrounds and
perspectives, and unequal social and economic conditions
• how to involve all types of patients?
• specifically, how to involve and empower those not normally included
• adapt different and innovative methods – e.g. principles of inclusion
research
+ thinking also about the communities in which they live and the social
determinants that shape their opportunities for health
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10. And Start From a Solid Strategic
Commitment
• need to make equity one of driving priorities for health system
and its transformation
• 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 not in Action Plan
• equity and population health are in public health standards
• LHINs, CCACs, and other coordinating agencies need to prioritize
equity – and many have
• cascading down to all providers prioritizing equity in their overall
strategic plans and then into service delivery and resource
allocation
• action idea = Hamilton providers to make explicit strategic
commitment to acting on equity
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11. Into Practice Through Equity-Focused Planning
• at system level = 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
• at practice level = considering equity in all program and service planning
• obvious – given gradient of prevalence and impact of chronic diseases + impact of
living conditions → CDPM programs have to take social determents and
community conditions into account
• not so obvious – surgery seems purely clinical
• but concern about reducing re-admission rates → need to understand living and social conditions into
which people are being discharged
• requires an array of effective and practical equity-focused planning tools
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12. Always Plan through a Health Equity Lens
Could this program or direction have a
differential and inequitable impact on some
populations or communities?
How do we need to take the specific needs of
disadvantaged individuals and communities into
account in service planning/delivery?
if we don’t know → find out
• highlights importance of collecting better
equity-relevant data across the system
and by every provider
• can use proxy data from postal code =
neighbourhood characteristics from
census data
• can use case studies and small-scale
interview/chart review studies
• can draw on provider experience and
community perceptions
•if evidence is yes → then drill down using fuller
HEIA
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Providers should apply this
type of equity lens routinely
– from strategic to service
planning

13. Health Equity Impact Assessment
• analyzes potential impact of program or policy change on health
disparities and/or health disadvantaged populations
• can help us identify key barriers to equitable access, specific
needs of health-disadvantaged populations and service gaps
• can help uncover unintended consequences or nuances easily
missed in program planning
• it can help ensure that projects not specifically about equity or
particular populations, will take equity into account
• e.g. planning diabetes awareness and outreach – helps take
language, diversity, local community conditions, etc
• especially important for health service providers who are not
experienced with equity and for non-health organizations to take
the population health impact of their policies into account
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14. • first piloted and refined in Toronto in 2009 by MOHTLC, Toronto Central LHIN and
WI, further piloted in other LHINs, and rolled out to all
• template, workbook and other resources from Ministry at
http://www.health.gov.on.ca/en/pro/programs/heia
• growing, if uneven, use across all LHINs:
• Toronto Central has required HEIA within recent funding application
processes, and refreshing hospital equity plans → some hospitals have built
HEIA into their routine planning processes
• adaptation geared to public health settings and standards been developed
and piloted by Public Health Ontario
• primers on HEIA and a variant Mental Health Wellbeing Impact Assessment,
many Wellesley workshops and other resources can be found at
http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-
for-health-equity/heath-equity-impact-assessment
• action idea= all providers in Hamilton to pilot HEIA
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15. Align Equity With Health System Drivers
• Excellent Care For All Act and quality improvement agenda
• providers have to develop Quality Improvement Plans
• hospitals first reported April 2011
• other providers beginning to report
• equity should be developed as one of dimensions to report on –
but wasn’t really in hospital plans
• action idea = all Hamilton hospitals and CHCs to include equity
indicators in their QIPs
• will return to other drivers such as chronic disease prevention and
management, patient-centred care
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16. Embed Equity in Targets, Deliverables, Performance
Management and other System Drivers
• clear consensus from research and policy literature, and
consistent feature in comprehensive policies on health
equity from other countries:
• setting targets for reducing access barriers, improving
health outcomes of particular populations, etc
• developing realistic and actionable indicators for more
equitable service delivery and health outcomes
• tying funding and resource allocation to performance
• closely monitoring progress against the targets and
indicators
• disseminating the results widely for public scrutiny
• all this needs to be integrated into comprehensive
performance measurement and management strategy
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17. Success Condition: Effective Equity Targets
• innovative work underway to develop equity indicators – but
don’t need to wait
• build equity into existing targets:
• reducing avoidable hospitalization and/or readmissions is key
prov priority – and clearly good for patients
→ equity target = reduce inequitable differences in rates between
different populations or areas
• action idea = Hamilton hospitals to monitor differences in
avoidable admissions and re-admissions by neighbourhood
• and the same for person-centred care:
• satisfaction is widely used indicator of meeting patient needs
and perspectives
→ equity target = reduce differences in satisfaction by gender,
neighbourhood, language, etc.
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18. Success Condition = Better Data
•CHCs collect good data
•pilot project in 3 Toronto academic
hospitals to collect equity data – scaled up
to all hospitals in Toronto Central
•action idea = Hamilton hospitals to
develop appropriate model
•looking abroad for promising practices =
Public Health Observatories in UK
• consistent and coherent collection
and analysis of pop’n health data
• interest/development in Western
Canada
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19. • a promising direction several LHINs have taken up is to require providers to
develop equity plans
• hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation
in TC
• and other providers in Central
• CHCs have developed a sector-wide plan in GTA
• 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
Use Available Accountability Levers: Equity
Plans
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20. Toronto Central LHIN Equity Plans
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21. Never Just Equitable Access, But Quality:
Equity Into Quality Service Delivery
• adverse social context and living conditions
→ can increase risk of mental and physical illness
+ fewer resources to cope (from supportive social networks, to good
food and being able to afford medications)
• for high quality person-centred care
→ providers and programs need to customize and adapt care to
population needs and contexts
→ good communications and provider-patient relationship means taking
the full range of people’s needs/situations into account
• e.g.. more intensive case management, referral planning and post-
discharge follow-up for health disadvantaged
• in an increasingly diverse society, high quality care = culturally
competent care:
• requires organizational resources, commitment and operationalization
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22. Not Just Responsive Individual Care: Build
Equity-Driven Service Models
• drill down to further specify needs and barriers:
• health disadvantaged populations have more complex and greater
needs for services and support
• → continuum of care especially important
• also face greater access barriers – e.g.. availability/cost of
transportation, childcare, language, discrimination
• → facilitated access and effective navigation/transitions is especially
important
→ locate some Health Links initiatives in most vulnerable communities
and ensure equity is built into planning all initiatives
• action idea = apply HEIA and develop equity plan for the Hamilton
Central Health Link initiative out of McMaster Family Health Team
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23. Extend Equity-Driven Service → Address Roots of
Health Inequities in Communities
• build on equity-orientated models
• e.g.. Community Health Centre model of care is explicitly geared to
supporting people from marginalized communities with
comprehensive multi-disciplinary services covering full range of needs
• CHCs, public health and many community providers have established
‘peer health ambassadors’ to provide system navigation, outreach and
health promotion services to communities facing particular barriers
• look beyond vulnerable individuals to the communities in which they live
→ meeting full range of needs means moving beyond healthcare
• focus on community development as part of mandate for many PHUs
and CHCs
• providing and partnering to provide related services/support such as
settlement, language, child care, literacy, employment training, youth
programs, etc.
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24. Potential of Hub Models
hub-style multi-service centres around the world and across the country
• a range of health and employment, child care, language, literacy, training and
social services are provided out of single ‘one stop' locations
• can provide more ‘wrap-around’ integrated services from person’s point of
view
• based solidly in local communities and responding to local needs and priorities
→ can become important community ‘space’ and support community capacity
building
• from provider and funder points of view = more efficient use of scarce
resources
• can enable synergies among providers and better overall coordination
• emerging forms:
• CHCs as hubs of primary care, health promotion and related social services
• network of neighbourhood multi-service centres
• schools with health and social services acting as hubs for their local
communities
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25. 27
Target Investment for Equity Impact
• target services to:
• 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 resources
• lever = certain % of LHIN budgets to be equity targeted
• 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

26. • vulnerable populations will vary in different places:
• poor neighbourhoods with high % of racialized population in
many big cities
• Aboriginal communities across the prov
• identifying ‘priority populations’ is key public health strategy
• mandate of CHCs is to serve most vulnerable
• solid evidence that enhancing primary care is one of key ways
to improve care of disadvantaged
• equity target = ensuring access and use of primary health
care does not vary inequitably by income level, immigration
status, neigbourhood, gender, race, etc.
• action idea = HNHB primary care initiative to apply HEIA to
its plan and adopt explicit equity objectives and targets
Target Health Disadvantaged Populations
or Communities
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27. Target Barriers
•in Toronto and other cities: people without
health insurance
• immigrants in 3 month wait time,
refugees
• inequitable access → delayed care and
worse outcomes
• CHCs and community clinics provide
some access
• Women’s College Hospital Network on
Noninsured is forum for coordination
•federal cuts to refugee healthcare
→ adverse impact on particularly
vulnerable people
→ increased healthcare costs/demands at
prov and provider levels
•equity is ‘wicked’ policy problem, but not all of
it = predictable and avoidable results of bad
policy
•action idea = create local network or initiatives
to improve access for uninsured and/or
refugees
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28. Addressing Systemic Barriers: Interpretation as
a Key Quality and Equity Lever
•access to interpretation underlies
wait times, safety and other system
priorities – consistent evidence that:
• poor communication due to language or
cultural can contribute to misdiagnoses
and inappropriate prescriptions
• inability to read or understand instructions
can lead to medication errors → safety,
cost and re-admission implications
• promising indications that good
interpretation helps keep people out of
hospital and get them out sooner
•requirement that adequate
interpretation be available wherever
needed → improves quality and
equity
•action idea = Hamilton providers
consider centralized/coordinated
interpretation services
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29. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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30. Health Promotion Through an Equity Lens
• programs have to take account of inequitable resources of vulnerable
individuals and communities
• advice to manage heart problems by exercising depends upon
affording a gym or being close to safe park
• adjust programs to inequitable risks and specific barriers
• South Asian immigrants had 3X and Caribbean and Latin American 2X
risk of diabetes than immigrants from Western Europe or North
America (Creatore et al CMAJ Aril 19, 2010)
• deliver in languages and cultures of particular population/community
• go where people are -- e.g. CHCs/promoters into malls
• idea = Immigrant Women's’ Health Centre, Aboriginal communities
and other vans
• if not customized, generic health promotion programs can widen
disparities as better off take them up disproportionately
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31. Pulling it All Together: Acting on Patient and
Community Priorities
• one goal of LHIN and provider engagement should be building significant
community participation and influence into priority setting
• draw on experience at provider level:
• many hospitals have community advisory panels
• CHCs and many community-based providers have residents on their boards
• some forms of FHTs also have community governance
• build on insights from other countries – idea of participatory planning -- various
health councils or forums
• give the councils all the information they need → make recommendations on
promising initiatives and allocation of resources, and address tricky trade-off
issues
• make this real = allocate a % of LHIN discretionary budget to priorities or
initiatives identified by local planning forums or other means of engagement
• action idea = embed community/patient participation in provider expectations:
• providers determine most appropriate mechanism/forum for their context
• but all need to institutionalize some form of direct community/patient forums
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32. Pulling it All Together II: Local Cross-Sectoral Planning
• cross-sectoral coordination and planning can identify
community health needs, access barriers, fragmentation,
service gaps, and how to address them
• public health departments and LHINs are pulling together
or participating in cross-sectoral planning tables
• Local Immigration Partnerships, Social Planning Councils
• such broad collaboration will be particularly important to
Health Links and other system integration initiatives
• and coordinated services are particularly important in less
advantaged communities with less resources
• also key means to address deep-seated health inequities and
wider SDoH at community level:
• role of LHINs = connect and support these resources and
partnerships
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33. Pulling it All Together III: Potential of Local Equity
Plan?
strategy developed in 2008 for
Toronto Central LHIN -- many
recommendations have been acted
on
your and other LHINs have very
different community structures and
population health needs
but is there value in a Hamilton
equity plan within HNHB LHIN?
• could bring together healthcare
providers within the LHIN, but also
public health, non-healthcare
community organizations, business,
residents and other stakeholders
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34. Or, At Least, Local Equity Planning
Hamilton plan may not need to be
so comprehensive?
regardless -- pre-condition is
creating an effective cross-sectoral
planning forum
action idea = create local health
equity forum with concrete planning
mandate
Looking for Ideas : SETO
•arose out of community concern re access
•brings together public health, CHCs, shelters,
researchers and service providers serving
marginalized communities in south-east
Toronto
•for an overview of SETo’s development see
http://knowledgex.camh.net/researchers/pr
ojects/semh/profiles/Pages/seto.aspx
•ongoing collaboration and idea sharing →
supports service coordination and problem
solving
•emphasized concrete demonstration
projects → many with lasting impact
•advocacy with institutions and governments
around results of projects and key issues such
as harm reduction, dental care and access for
non-insured people
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35. Building on the Potential of Community-Based
Innovation and Initiatives
potential:
• huge number of community and front-line
initiatives already addressing equity across
province
• + equity focused planning will yield useful
information on existing system barriers and
the needs of disadvantaged populations
• and we’ll be seeing more and more
population-specific program interventions
but
• these initiatives and interventions are not
being rigorously assessed
• experience and lessons learned are not
being shared systematically
• so potential of promising interventions is
not being realized
need forums to share and build innovation
• another advantage of local equity forum –
like this roundtable
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36. © The Wellesley Institute
www.wellesleyinstitute.com
Shifting the Frame
Sudbury & other public health
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37. Back to Community Again: Build Momentum
and Mobilization
• sophisticated strategy, solid equity-focused research, planning and
innovation, and well-targeted investments and services are key
• but in the long run, also need fundamental changes in over-arching
social policy and underlying structures of economic and social inequality
• these kinds of huge changes come about not because of good analysis,
but through widespread community mobilization and public pressure
• key to equity-driven reform will also be empowering communities to
imagine their own alternative vision of different health futures and to
organize to achieve them
• we need to find ways that governments, providers, community groups,
unions, and others can support each others’ campaigns and coalesce
around a few ‘big ideas’
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38. Health Equity
• could be one of those ‘big’ unifying ideas..
• if we see opportunities for good health and well-being as a basic
right for all
• if we see the damaged health of disadvantaged and
marginalized populations as an indictment of an unequal society
– but that focused initiatives can make a difference
• if we recognize that coming together to address the social
determinants that underlie health inequalities will also address
the roots of so many other social problems
• thinking of what needs to be done to create health equity is a way
of imagining and forging a powerful vision of a progressive future
• and showing that we can get there from here
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39. Key Messages
• health inequities 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 evidence, provider experience, commitment and
community connections to build on
• have set out a roadmap – of strategies, principles and tools -- to drive
equity into action through policy change and community mobilization
• many within the health care system have long experience and strong
commitment to equity → build on this to drive coordinated and coherent
system-wide equity agenda into action
• work in partnerships and collaborations well beyond health care to
address the underlying determinants of health inequalities
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