Health equity - to kitchener community health day april 28 2010

Bob Gardner April 28, 2010 Community Health Day, Kitchener Health Equity: Opening Doors to Better Health for All © The Wellesley Institute www.wellesleyinstitute.com 1

• scale of health disparities → health equity is crucial • bigger picture: health equity and social determinants • how health disparities can be addressed through comprehensive health equity strategy • how equity strategy can be driven into action through • equity-focused planning and aligning equity with key system drivers and priorities • building equity into ongoing performance and system management, and routine service delivery • investing in promising interventions, and pulling them together within a coherent overall strategy and an integrated and coordinated program • sharing and building on front-line and local initiatives, evaluation, and other enablers for innovation • potential of community-based initiatives and cross-sectoral collaborations © The Wellesley Institute www.wellesleyinstitute.com 2

• there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and recent immigrants tend to have poorer health • + major differences between women and men • the gap between the health status of the best off and most disadvantaged can be huge – and damaging • in addition, there are systemic disparities in access to and quality of care within the healthcare system © The Wellesley Institute www.wellesleyinstitute.com 3 3

• If all Ontarians had the same health as Ontarians with higher incomes, the POWER project has estimated that: • 318,000 fewer people (166,000 women and 152,000 men) would be in fair or poor health • 231,000 fewer people (110,000 women and 121,000 men) would be disabled • 3,373 fewer deaths each year (947 women and 2,426 men) among Ontarians living in metropolitan areas © The Wellesley Institute www.wellesleyinstitute.com 8 8

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 10 10

• 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 www.welleseyinstitute.com © The Wellesley Institute 11 www.wellesleyinstitute.com 11

• Determinants interact and intersect with each other • In 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 © The Wellesley Institute www.wellesleyinstitute.com 13

POWER Study Gender and Equity Health Indicator Framework © The Wellesley Institute www.wellesleyinstitute.com 14 14

• 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 © The Wellesley Institute www.wellesleyinstitute.com 15

• 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 -- cultural competence – are essential to an equitable system • Impact of achieving health equity would • extend far beyond enhancing individual and collective well being • would also contribute to overall social cohesion, shared values of fairness and equality, economic productivity, and community strength and resilience © The Wellesley Institute www.wellesleyinstitute.com 16

• 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 • everything can’t be tackled at once --need to split strategy into actionable components and phase them in • make best judgment from evidence and experience • identify actionable and manageable initiatives that can make a difference • experiment and innovate • learn lessons and adjust – why evaluation is so crucial • gradually build up coherent sets of policy and program actions – and keep evaluating • need to start somewhere – and focus here is on health system © The Wellesley Institute 17 www.wellesleyinstitute.com 17

• 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: • also increasing international and high-level attention • in all of them, transforming the health system is an indispensable element, including: • reducing barriers to equitable access to high quality care • targeted interventions to improve the health of the poorest fastest – often as part of community/local initiatives • so even though roots of health disparities lie in far wider social and economic inequality • how the health system is organized and how services and care are delivered is crucial to tackling health disparities © The Wellesley Institute www.wellesleyinstitute.com 18 18

1. its in the health system that the most disadvantaged in SDoH terms end up sicker and needing care • equitable healthcare can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities 2. in addition, there are systemic disparities in access and quality of healthcare that need to be redressed • 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 could make overall disparities even worse • at the least, the goal is to ensure equitable access to care for all who need it, regardless of their social position © The Wellesley Institute www.wellesleyinstitute.com 19

• 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 © The Wellesley Institute 20 www.wellesleyinstitute.com 20

Toronto Central: Lower Income, More Physician Visits For Arthritis % With Physician Visits for Arthritis, Age 45-64, TC LHIN 2001-03 25 20 20 14 15 13 11 10 5 0 Low Income High Income Males Females © The Wellesley Institute 21 www.wellesleyinstitute.com 21

Toronto Central: Hip Replacement Rate, TC LHIN, 2004/05 144 150 #/100,000 100 68 50 0 Lowest Income Highest Income © The Wellesley Institute 22 www.wellesleyinstitute.com 22

• 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: o standard heart medication o dialysis treatment o admission to intensive care units o 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….. © The Wellesley Institute 23 www.wellesleyinstitute.com 23

• to see if there were differences by gender in clinical practice o standardized male and female patients went to family physicians and orthopaedic surgeons o presented with the same scripted clinical scenario • found striking differences: o orthopaedic surgeons were 22X more likely to recommend male for total knee arthroplasty than female o family physicians were 2X more likely for male Source: Borkhoff et al, CMAJ, March 11, 2008 © The Wellesley Institute 24 www.wellesleyinstitute.com 24

• while health disparities are pervasive and deep-rooted, they can be changed through policy and program action • comprehensive strategy developed in 2008 for Toronto Central LHIN – 50> recommendations • many recommendations have been acted on • other LHINs are also prioritizing and moving to address health disparities © The Wellesley Institute www.wellesleyinstitute.com 25 25

• goal is to ensure equitable access to high quality healthcare regardless of social position and that all individuals and communities get the care they need • can do this through a two pronged strategy : 1. building health equity into all health planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach 2. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers • looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable © The Wellesley Institute www.wellesleyinstitute.com 26

• need to make equity one of driving priorities for health system and reform o define equity as an essential part of high-performing health system – as Ontario Health Quality Council o in fact, stronger argument that equity is pre-condition to success on quality, efficiency and patient-centred priorities • need clear provincial strategy for equity: o implicit but promised MOHLTC ten year strategy has not been released o Ministry of Health Promotion is moving towards a healthy community planning approach – potentially more equity-orientated o need strategic coherence across health system in approach to equity • LHINs and other coordinating agencies need to prioritize equity • cascading down to clear prioritization from providers for their service delivery and resource allocation © The Wellesley Institute www.wellesleyinstitute.com 27 27

• 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 © The Wellesley Institute www.wellesleyinstitute.com 28 28

• 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 © The Wellesley Institute 29 www.wellesleyinstitute.com 29

• addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations and kids • need to understand roots of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • requires an array of effective and practical equity-focused planning tools © The Wellesley Institute www.wellesleyinstitute.com 30 30

1. quick check to ensure equity is 1. simple equity lens considered in all service delivery/planning 2. Health Equity Impact 2. take account of disadvantaged Assessment – piloted in several populations, access barriers and LHINs and MOHLTC is considering related equity issues in program wider roll-out planning and service delivery 3. assess current state of provider organization 3. equity audits and/or HEIA 4. determine needs of communities facing health disparities 4. equity-focused needs 5. assess impact of assessment programs/interventions on health disparities and 5. equity-focused evaluation disadvantaged populations © The Wellesley Institute 31 www.wellesleyinstitute.com 31

• planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • can help to plan new services, policy development or other initiatives • can also be used to assess/realign existing programs • essentially prospective • arose out of broader health impact assessments, which have been increasingly used in many jurisdictions in last 15 years • increasing attention to potential – from WHO, through most European strategies, to PHAC, and MOHLTC and LHINs • HEIA is seen to be relatively easy-to-use tool • Wellesley partnered to pilot and refine, further piloted in other LHINs and is now being implemented in Toronto Central and others © The Wellesley Institute www.wellesleyinstitute.com 32 32

• 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 • hospitals in Toronto Central and Central LHINs developed equity plans broadly meeting those objectives • and other providers in Central are now doing plans © The Wellesley Institute www.wellesleyinstitute.com 33 33

http://www.torontoevaluation.ca/tclhin/index.html © The Wellesley Institute www.wellesleyinstitute.com 34

• these plans were seen to achieve their objectives of building awareness of equity within the organizations and beginning to embed equity in planning and decision- making • in Central: issues identified in the hospital plans were incorporated into individual hospital deliverables → they report quarterly on progress • in Toronto Central: • the hospitals are required to refresh their plans under their current HSAAs • commitments and priorities identified in the refreshed plans will be built into next HSAAs • three immediate key issues identified in many of the 18 plans were moved on by the LHIN © The Wellesley Institute www.wellesleyinstitute.com 35

1. language is key barrier to access • cross-sectoral project analyzing how to enhance and streamline interpretation services • building on comparative international research 2. 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 • project with several Toronto hospitals to see how to collect patient SDoH data 3. huge barriers faced by people without health insurance • project led by GTA CHCs to analyze how to streamline available funds and practice © The Wellesley Institute www.wellesleyinstitute.com 36 36

• all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds • can build in specific expectations • will vary by community and provider -- but could include: • undertaking appropriate equity-focused planning • providing sufficient services in languages of community and appropriate interpretation • identifying areas where access to services is inequitable and developing plans to address barriers and gaps • 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. © The Wellesley Institute www.wellesleyinstitute.com 37

• vital part of comprehensive policy on health equity • setting targets or defining indicators – that build on available reliable data and make the most sense in the particular context • closely monitoring progress against the indicators or targets • disseminating the results widely for public scrutiny • another result of TC LHIN hospital equity plans = development of clinical indicators by CRICH • need to build these equity targets and objectives into routine performance management and routine provider planning © The Wellesley Institute 38 www.wellesleyinstitute.com 38

• there are broad targets for priorities such as diabetes or encouraging healthy behaviours → build equity into these targets: • a number of PHUs and LHINs have identified areas where diabetes incidence is highest → equity target = reduce differences in incidence, complications and rates of hospitalization between populations or areas • a good service target has been proposed for diabetes = high/increasing % of people who get best standard care → equity target = reduce differences by gender, income, ethno-cultural background • need to drill down in specific areas that have high equity impact: • ensuring access and use of primary health care does not vary inequitably by income level, immigration status, neigbourhood, gender, race, etc. • in fact, concentrate services in most disadvantaged communities with greatest needs • many programs assess their services through client satisfaction surveys and similar methods • providers look for high and improving satisfaction → equity target = reduce any differences in satisfaction by gender, income, ethno-cultural background, etc. © The Wellesley Institute www.wellesleyinstitute.com 39 39

• 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 © The Wellesley Institute www.wellesleyinstitute.com 40 40

• target services to specific areas or populations: o those facing the harshest disparities – to raise the worst off fastest o or most in need of specific services o or the worst barriers to equitable access to high-quality services • this requires sophisticated analyses of the bases of disparities: o i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. o 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 o involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems © The Wellesley Institute 41 www.wellesleyinstitute.com 41

• various LHINs have identified high need neighbourhoods – diverse population, high % of racialized population, high risk factors, lack of access to primary care • highlights the need for local cross-sectoral planning and collaboration beyond boundaries • need to link up with local social services, community service agencies, residents, public health, other LHINs in area • need to drill down with good research: • South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America • greater risk for women • risk increases with time since immigration Creatore et al CMAJ Aril 19, 2010 © The Wellesley Institute www.wellesleyinstitute.com 42

• one of critical equity challenges for many LHINs, hospitals and other providers in diverse communities is language • Sick Kids has significant federal funding for newcomers: • massive training in cultural competence throughout hospital • translation of many docs – including for other hospitals • community-based research to identify specific needs • in Toronto: people without health insurance – primarily immigrant/refugees: • 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 © The Wellesley Institute 43 www.wellesleyinstitute.com 43

• LHINs are all about integration and coordination: • will be experimenting and innovating with enhanced coordination and partnerships • with different kinds of community-based service delivery and on-the- ground coordination → locate in high-need areas • 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 © The Wellesley Institute www.wellesleyinstitute.com 44

• 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 © The Wellesley Institute 45 www.wellesleyinstitute.com 45

• investing in better chronic care prevention and management are vital elements of health reform • up-stream initiatives need to be planned and implemented through an equity lens • very clear gradient in incidence – and impact – of chronic conditions • some populations and communities need greater support to prevent and manage chronic conditions • need to build these specific needs into CDPM planning and resource allocation • a very interesting primer has been developed by Health Nexus, Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20F inal.pdf © The Wellesley Institute 46 www.wellesleyinstitute.com 46

• more emphasis on health promotion is vital to long-term sustainability of system and individual health • consistent data on variations of risk factors along the social gradient • anti-smoking, exercise and other health promotion programmes need to explicitly foreground the particular social, cultural and economic factors that shape risky behaviour in poorer communities– not just the usual focus on individual behaviour and lifestyle • need to customize and concentrate health promotion programs especially for most disadvantaged • if this isn’t done → can unintentionally widen disparities as better off take up programs more • the Ministry of Health Promotion is starting to take a healthy communities approach to planning health © The Wellesley Institute 47 www.wellesleyinstitute.com 47

• figuring our what interventions and approaches work, in what contexts and why • can’t just measure activity – number or % of pop’n that participated in 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 enroll 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 © The Wellesley Institute www.wellesleyinstitute.com 49 49

• cross-sectoral coordination and planning are seen to be key ways to put wider SDoH into action • key to British and European national strategies are local investments in community economic development and targeted healthcare and social service improvements • British Health Action Zones and other models were designed to combine community economic development with 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 © The Wellesley Institute www.wellesleyinstitute.com 50 50

• 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, 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 © The Wellesley Institute www.wellesleyinstitute.com 51 51

• 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 © The Wellesley Institute 52 www.wellesleyinstitute.com 52

• 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 © The Wellesley Institute www.wellesleyinstitute.com 53 53

• 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 forum sand 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 © The Wellesley Institute www.wellesleyinstitute.com 54 54

• 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 state social policy and underlying structures of economic and social inequality • these kinds of huge changes come about not just because of good analysis but through widespread community mobilization and social pressure • key to equity-driven reform will also be empowering communities to imagine their alternative health futures and to organize to achieve them © The Wellesley Institute www.wellesleyinstitute.com 55 55

• 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 • a great deal of equity-focused planning and innovative delivery is already going on – challenge is to build on this potential • there is a solid base of healthcare provider experience, commitment and community connections to build on • 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 © The Wellesley Institute www.wellesleyinstitute.com 56 56

• back to bigger picture • following is a roadmap for comprehensive integrated policy action on determinants of health and health inequality © The Wellesley Institute www.wellesleyinstitute.com 57

1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long- term; 3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; 4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital; 5. set and monitor targets and incentives – cascading through all levels of government and programme action; © The Wellesley Institute 58 www.wellesleyinstitute.com 58

6 rigorously evaluate the outcomes and potential of programme initiatives and investments – to build on successes and scale up what is working; 7 act on equity within the health system: o making equity a core objective and driver of health system reform – every bit as important as quality and sustainability; o eliminating unfair and inefficient barriers to access to the care people need; o 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: o enhanced primary care for the most under-served or disadvantaged populations; o integrated health, child development, language, settlement, employment, and other community-based social services; © The Wellesley Institute 59 www.wellesleyinstitute.com 59

9 act locally – through well-focussed regional, local or neighbourhood cross- sectoral collaborations and integrated initiatives; 10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities; 11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country; 12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective programme and policy instruments, and into a coherent and coordinated overall strategy for health equity. © The Wellesley Institute 60 www.wellesleyinstitute.com 60

• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com • my email is bob@wellesleyinstitute.com • I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity © The Wellesley Institute www.wellesleyinstitute.com 61

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Health equity - to kitchener community health day april 28 2010

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