Drawing Out Links: Health Equity, Social Determinants of Health and Social Policy


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This presentation provides insight on health equity, social determinants of health and social policy.

Bob Gardner, Director of Policy
Steve Barnes, Policy Analyst
Follow us on twitter @wellesleyWI

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  • Ont 2005 age standardized 25>
  • getting more specific on concrete impact of health disparities on quality of livesactivities of ¼ of low income people are limited by pain = 2X than high income
  • In: that's impact on daily livesthat type of impact adds up over people's lives
  • can say the same about many social problems
  • reinforcing nature of social determinants on health disparitiesreally impt for key strategy = crucial part of managing diabetes esp. is good nutrition
  • previousdata shows complex and reinforcing nature of social determinants on health disparitiespractical implications = health promotion and CDPM has to take SDoH into accountand beyond – social policy in many areas has to think about underlying structural basis of many problems in systemic inequality and exclusion
  • when we’re working with particular populations or neighbourhoods – need to think at all these levels and their inter-connectionparticular populations are worse off in terms of SDOH – precarious workers, homeless – face worse healthdisadvantage can be concentrated in particular places -- poor or racialized neighbourhoods – and over the generations in particular groups – long-term poor
  • which highlights the crucial importance of social context and that community development is a key part of the equation for action
  • this is overview – will flesh out how
  • OWHN model of inclusive research as one way
  • increasing attention to potential – from WHO, through most European strategies, PHAC, to Ontariobeen used in many settings :all programs within one Toronto hospital are undertaking HEIAalso in some community-based programs
  • recognizing that what gets measured, mattersnot just health system
  • not just in negative sense of identifying barriers and gaps, but what could be enablers and directions for innovationpeers have been from particular ethno-cultural communities or neighbourhoods or are newcomers, PHAs, drug users or others with particular lived experience
  • many jurisdictions: Italian example for immigrant pop’ns
  • SSM was one of these big ideas and tremendous work of AOHC and allies
  • Drawing Out Links: Health Equity, Social Determinants of Health and Social Policy

    1. 1. Drawing Out Links: Health Equity,Social Determinants of Health and Social Policy Bob Gardner & Steve Barnes Graduate Class on Research Methods, Social Work, University of Toronto January 23, 2012
    2. 2. Outline• set out how the Wellesley Institute, as an independent progressive research and policy think tank, supports research, policy analysis and community mobilization to drive social change in the foundations of health inequities;• identify the potential and challenges of applied research across a range of methodologies – from local community-based research, through quantitative analysis of trends in income and health inequalities, through comparative policy research;• explore how to ‘translate’ solid research into policy impact• draw parallels between the social determinants of health and health equity strategy and contemporary social problems;• discuss key challenges for social policy and community building in the coming period of austerity.January 24, 2012 | 2www.wellesleyinstitute.com
    3. 3. A Parallel: Health Equity Strategy Into Action• health inequities are pervasive and damaging• but these inequities can be addressed through comprehensive health equity strategy• and by focusing policy, programs and resources on particularly health disadvantaged populations by: • identifying priority populations and systemic barriers • plan the most effective mix of focused services and support to meet the priority populations’ diverse needs • embed equity into system performance management thorough population-specific targets and incentives • evaluate effectiveness and impact, and build these learnings into continuous improvement• and acting well beyond health -- tackling the underlying roots of health inequality in the wider social determinants of health • through community-based innovation, cross-sectoral collaborations and fundamental social and policy change to reduce inequality • and the community and political mobilization to demand and drive the necessary policy changes 3
    4. 4. The Problem to Solve = Health Disparities in Ontario•there is a clear gradient in healthin which people with lowerincome, education or otherindicators of social inequality andexclusion tend to have poorerhealth•+ major differences betweenwomen and men•the gap between the health ofthe best off and mostdisadvantaged can be huge – anddamaging•impact and severity of theseinequities can be concentrated inparticular populations 4
    5. 5. Gradient of Health Across Many Conditions5
    6. 6. 6
    7. 7. Impact of Disparities• not just a gradient of health and impact on quality of life• 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 • 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 womenStatistics Canada Health Reports Dec 097
    8. 8. Foundations of Health Disparities (and Parallels to Other Problems) Lie in Social Determinants of Health•clear research consensus that rootsof health disparities lie in broadersocial and economic inequality andexclusion•impact of inadequate earlychildhood development, poverty,precarious employment, socialexclusion, inadequate housing anddecaying social safety nets on healthoutcomes is well established hereand internationally•we need comprehensive strategy todrive policy action and social changeacross these determinants•these same systemic factors shapemany other social problemsJanuary 24, 2012 | 8www.wellesleyinstitute.com
    9. 9. Complexity: Canadians With Chronic Conditions Who Also Report Food Insecurity 9
    10. 10. SDoH As a Complex ProblemDeterminants interact andintersect with each other in aconstantly changing and dynamicsystemIn fact, through multipleinteracting and inter-dependenteconomic, social and healthsystemsDeterminants have a reinforcingand cumulative effect onindividual and population healthSimilar dynamic complexity inother spheres of social policy 10
    11. 11. Three Cumulative and Inter-Connecting Levels in Which SDoH Shape Health Inequities1. because of inequitable access to 1. gradient of health in which more wealth, income, education and disadvantaged communities have other fundamental determinants poorer overall health and are at of health → greater risk of many conditions2. also because of broader social and 2. some communities and economic inequality and populations have fewer exclusion→ capacities, resources and resilience to cope with the impact of poor health3. because of all this, disadvantaged and vulnerable populations have 3. these disadvantaged and more complex needs, but face vulnerable communities tend to systemic barriers within the health have inequitable access to the and other service systems → services and support they need11
    12. 12. Need to look at how theseother systems shape theimpact of SDoH: •access to health services can mediate harshest impact of SDoH to some degree •community resources and resilienceCan apply similar lens tosystemic and communityfactors that shape broadersocial inequality: •social services can mediate •structure and strengths of communities shape impact and dynamics of inequalitiesJanuary 24, 2012 | 12www.wellesleyinstitute.com
    13. 13. Why Worry About Policy?• We are all interested in tackling social and economic inequality, whether: • developing strategies for government action • advocating for particular program investments • getting governments to act on evidence or research• what is needed to ensure that vulnerable populations have good health? • comprehensive health and related services • information to enable individuals to better manage their health care • investment in research and service/program development • and many changes beyond health care and research: • community capacity and resource building • addressing underlying social determinants of health• all of these changes flow through government policy in one way or another• maximizing the policy impact of research is one critical part of winning the necessary progressive policy 13
    14. 14. Starting Points: Research, Knowledge and Policy ImpactKnowledge exchange involves:• different forms of knowledge -- research, practice-based, lessons learned, community experience• different purposes -- making a case for investment, innovation or policy changeTo turn knowledge, program proposals or research into policy action requires : 1. getting research findings or the policy case to the right people – in terms they can use 2. understanding the environment in which govt policy decisions are made 3. being able to identify the policy implications of your research or identified community needs -- and to translate that into concrete policy options to solve the problems you have found 4. assessing the most effective policy options – pros and cons, costs, risk management 5. being able to make an effective – and winning -- case for your policy recommendations 6. partnering with those with specific policy and knowledge exchange expertise and experience 7. grounding your research and policy advocacy in wider campaigns and alliances for social change will maximize its impact 14
    15. 15. Maximizing Policy ImpactTo have policy impact we need to:• understand the political and policy environment and policy process within governments• analyze the problem(s) identified by research or community needs, and develop potential policy solutions• assess the pros and cons and cost benefits of various policy options• choose and promote policy options that can work• make a convincing case for them -- at best, with concrete recommendations that can be acted on• develop a targeted knowledge exchange strategy to get the analysis and options to those who can decide 15
    16. 16. Identify the Policy ImplicationsAssess implications of research What can be done with thisfindings or program – ‘so what” knowledge – ‘now what’•new needs or gaps in existing •service providers adapt or expandservices identified services, govts fund•community preferences or •programs and resource allocationspriorities determined reflect community priorities•barriers to getting services or •program or policy changes tosupport identified reduce barriers•innovations or ‘best practices’ •other providers take them up•evaluating what initiatives work – •adapt and generalize to driveand how, for whom, and in what innovationcontexts•systemic inequities uncovered •policy changes to address systemic foundations of inequities 16
    17. 17. Knowledge → ‘policy-ready’• to get your findings or case to the intended decision makers – in ways they can understand and use – always involves translation • into the very different languages and mind sets of govts • into ‘policy speak’• and very concrete – translating your findings into: • specific actionable policy options and recommendations • that will work in the existing policy environment • couched in the formats – cabinet briefing notes – and frameworks – cost-benefit analysis and risk management – that govts use• the more ‘policy ready’ → the more chance for influence 17
    18. 18. Know Your Policy Environment• to be able to do policy relevant research and influence policy change, you need to know: • the policy framework for your particular issue • e.g. which levels of govt, and which Ministries or depts govern your issue? • what are the main formal policies that shape your area? • just as impt – what are the unstated assumptions and constraints that shape the sphere? • what are trends in govt funding and policy in the area? • how policy is developed: • players, processes and tempo • constraints -- risk averse, short-termism, crisis-driven • and some specific aspects of the government of the day: • how does your issue relate to its overall agenda? • where is it in the electoral cycle? 18
    19. 19. Think of Policy Development as Process• a particular policy – or policy framework – is the result of decisions made about how to address a particular objective or problem • sometimes this can be a deliberate decision not to address the particular issue• within the public service there is a generally a careful process of: • identifying objectives • assessing a range of possible actions to achieve the result • analyzing them against number of factors – effectiveness, cost, risk, political context, public and community support, etc. • always trade-offs, compromise , different “publics” affected 19
    20. 20. Analyzing Policy Options• policy options are the different legislative, program, funding, and other ways governments can act to meet defined objectives• to identify the best options, think of a wide range of factors such as • how complex and big a policy change you are looking for • impact (balancing criteria such as equity, efficiency, stability) • cost – be specific -- is it short-term, capital or operating, one-time or continuing, etc.? • versus benefits – specify here too – are the benefits short-term or more long term -- such as eventual reduced health care expenditures as a result of upstream investment in health promotion and prevention? • timing – how long to show an impact?• for government, assessing pros-cons, risks and cost-benefits is a standard part of policy process • for you, posing recommendations/demands in terms used and understood within the policy process increases your credibility and usability 20
    21. 21. Making the Case to Policy Makers• know your audience -- and the policy environment and way of thinking within govts • pick the right person/level to make pitch to – with the authority and levers to act • be aware of their position and constraints• think translation: from options to a winnable case • framed in ways that resonate with policy makers • making complex issues understandable and actionable • with a human story for elected officials especially (and the media)• customize reports for policy audiences • separate/short policy implications summaries • in terms they understand and with concrete recommendations they can act on • use the forms they are used to – decks and briefing notes • e.g. always address cost benefits, risk management, options and other factors that govt policy makers think about • all geared to different levels and functions within govt – e.g. different for Deputy Minister than mid-level policy analyst 21
    22. 22. Making the Case to Policy Makers II• meeting is best, plus covering letter/brief • consider your most effective ‘line-up’ to make the case• not just one-time, but systematic outreach and follow up with policy makers • follow up meetings • as part of long-term strategy to build relationships with key policy makers in your spheres• always a question of balance: • need hard-nosed analysis • always stay grounded in movement/community principles → limit on room to compromise • but also strategically opportunistic → maximize chance of winning case 22
    23. 23. Take the ‘Long View’• significant policy change can take many years• but also look for immediate winnable issues • to build momentum and hope • but be careful of co-optation and short-term reforms that deflect from long-term goals• Caledon Institute for Social Policy has term “relentless incrementalism”• have good peripheral vision -- situate your issue in relation to • other comparable issues → to build coalitions – the wider the better, with ‘unusual suspects’ as well • the overall govt policy agenda -- back to ‘fit’• be prepared for set-backs: • even the most compelling evidence and well crafted brief doesnt always drive policy • politics does 23
    24. 24. It’s Also/All About Power• driving policy change on complex/contentious issues is not just about presenting the best evidence and case• governments and politicians have to have the political will to act• long history of HIV/AIDS movement = have to be forced• critical importance of political and community mobilization: • building and staying grounded in community movements • building/sustaining broad coalitions for change 24
    25. 25. Get Some Help• policy analysis is a specialized trade and the policy world is a complex and difficult environment• community organizations, service providers and researchers can’t drop everything and become policy analysts and advocates• so draw on specialized expertise in knowledge exchange• partner with organizations with policy expertise• back to need for systematic strategy: • partner with govts early in policy or research process • build relationships • see knowledge exchange as dynamic and iterative process 25
    26. 26. Parallel: Health Inequities = ‘Wicked’ Problem• health inequities and their underlying social determinants of health are classic ‘wicked’ policy problems: • shaped by many inter-related and inter-dependent factors • in constantly changing social, economic, community and policy environments • action has to be taken at multiple levels -- by many levels of government, service providers, other stakeholders and communities • solutions are not always clear and policy agreement can be difficult to achieve • effects take years to show up – far beyond any electoral cycle• have to be able to understand and navigate this complexity to develop solutions• we need to be able to: • identify the connections and causal pathways between multiple factors • articulate the mechanisms or leverage points that we assume drive change in these factors and population health as a whole • identify the crucial policy levers that will drive the needed changes • specify the short, intermediate and long-term outcomes expected and the preconditions for achieving them.• same for other spheres of social policyJanuary 24, 2012 26
    27. 27. Think Big, But Get Going• challenge = health inequities and social inequalities 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• need to start somewhere: • focus today is on engaging with and understanding social services and support to meet needs of disadvantaged populations and understand the structural roots, of poverty, exclusion and other social problems 27
    28. 28. Parallel: Start From The Community• goal is to reduce health disparities and speak to needs of most vulnerable communities – who will define those needs?• can’t just be ‘experts’, planners or professionals • have to build community into core planning and priority setting • not as occasional community engagement, but to identify equity needs and priorities, and to evaluate how we are doing • many providers have community advisory panels or community members on their boards • can also build on innovative methods of engagement – e.g. citizens’ assemblies or juries in many jurisdictions• need to develop community engagement that will work for disadvantaged and marginalized communities: • in the language and culture of particular community • has to be collaborative • sustained over the long-term • has to show results – to build trust • need to go where people are • need to partner with trusted community groups28
    29. 29. And With Equity-Focused Planning• Public Health Ontario has developed an equity assessment framework for public health units.• a number of Public Health Units have developed and use equity lens: • Toronto has a simple 3 question lens -- not just for public health, but other departments • Sudbury has used an equity planning tool for several years• MOHLTC and many LHINs have used Health Equity Impact Assessment• advantage of using the similar tools = build up comparable experience and data• lever = could enable/require LHINs, PHUs and service providers to undertake HEIA or other equity planning processes • for all new programs and those focusing on particular populations • to be eligible for particular funding 29
    30. 30. Parallel Beyond Planning: Embed Equity in System Performance Management• 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 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• need comprehensive performance measurement and management strategy• then choose appropriate equity targets and indicators for particular populations/communities 30
    31. 31. Building Equity Targets• build equity into indicators already being collected → equity angle is to reduce differences between these populations/communities and others or PHU as a whole on these indicators• also drill down – e.g. a number of PHUs and LHINs have identified areas or populations where diabetes prevalence is highest • equity target = reduce differences in incidence, complications and rates of hospitalization by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions• similarly, common goal is reducing childhood obesity → if goal is to increase the % of kids who exercise regularly • equity target = reduce the differentials in % of kids who exercise by neighbourhood, gender, ethno-cultural background, etc. • and achieving that won’t be just a question of education and awareness, but facilities and proactive empowerment of kids – and ensuring equitable access to resources, space and programs 31
    32. 32. Parallel Success Condition = Better Data•looking abroad for promising practices= Public Health Observatories in UK • consistent and coherent collection and analysis of pop’n health data • specialization among the Observatories – London focuses on equity issues•interest/development in WesternCanada – Saskatoon•national project to develop healthdisparity indicators and data•Toronto PH is addressing complexitiesof collecting and using race-based data•key direction = explore potential ofequity/SDoH data for Ontario•in addition, innovative thinkingemerging around dynamic systemsmodeling meeting population health 32
    33. 33. Build Equity Into Priority Issues: Chronic Disease Prevention and Management•very clear gradient in incidence andimpact of chronic conditions•chronic disease prevention andmanagement programs cannot besuccessful unless they take healthdisparities and wider social conditionsinto account•some populations and communitiesneed greater support to prevent andmanage chronic conditions•anti-smoking, exercise and other healthpromotion programmes need toexplicitly foreground the particularsocial, cultural and economic factorsthat shape risky behaviour in poorercommunities– not just the usual focuson individual behaviour and lifestyle•need to customize and concentratehealth promotion programs to beeffective for most disadvantaged 33
    34. 34. Not Just at Individual Level: 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 • poorer people also face greater barriers – e.g. availability/cost of transportation, childcare, language, discrimination → facilitated access is especially important• e.g. Community Health Centre model of care • explicitly geared to supporting people from marginalized communities • comprehensive multi-disciplinary services covering full range of needs• public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities34
    35. 35. Extend That → Address Roots of Health Inequities in Communities• look beyond vulnerable individuals to the communities in which they live • 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 support, etc.• across Canada, leading Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building: • Saskatoon began from local research documenting shocking disparities among neighbourhoods • focused interventions in the poorest neighbourhoods – e.g. differences in immunization rates between poor and other neighbourhoods decreased • beyond health – locating services in schools, relying on First Nations elders to guide programming, etc. • wide collaboration among public health, municipality, business, community leadersJanuary 24, 2012 | 35www.wellesleyinstitute.com
    36. 36. Through Cross-Sectoral Planning• cross-sectoral coordination and planning are the glue that binds together coordinated action on SDoH • public health departments and LHINs are pulling together or participating in cross-sectoral planning tables on health issues – can get beyond institutional silos • Local Immigration Partnerships, Social Planning Councils, poverty reduction initiatives, etc • healthy communities initiatives funded by the Ministry of Health Promotion and Sport• look for insight and inspiration from ‘out of angle’ sources: • e.g. community gardens and kitchens can contribute to food security to some degree, and sports programs contribute to health, but they can also help build social connectedness and cohesion 36
    37. 37. Equity-Driven Innovation: Integrated Community-Based 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• Quebec has long had such comprehensive integrated community centres• 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• not just health -- schools as service hubs is being developed -- think back to earlier eras with public health nurses in schools 37
    38. 38. Extend That → Build Community-Level Action• all leading jurisdictions with comprehensive equity strategies combine national policy with local adaptation and concentrated investment• many cities have developed neighbourhood revitalization strategies • Toronto’s priority neighbourhoods, Regent’s Park• promising direction = comprehensive community initiatives: • broad partnerships of local residents, community organizations, governments, business, labour and other stakeholders coming together to address deep-rooted local problems – poverty, neighbourhood deterioration, health disparities • collaborative cross-sectoral efforts – employment opportunities, skills building, access to health and social services, community development • e.g. of Vibrant Communities – 14 communities across the country to build individual and community capacities to reduce poverty • Wellesley review of evidence = these initiatives have the potential to build individual opportunities, awareness of structural nature of poverty and local mobilization → into policy advocacy38
    39. 39. Parallel: Evaluating Complex Equity Interventions• how do we know what works = crucial importance of evaluation• far too complex to pick apart all the causal relations and patterns of influence: • very difficult to attribute particular changes to particular components of the overall initiative • will never meet RCT gold standard of proof – that approach can’t capture complexity • but that doesnt mean particular initiative is ineffective• impact can take many years to show up • but that doesn’t mean nothing is happening• traditional evaluation of one program in isolation or of a particular population among many will not capture this complexity• potential of more ‘realist’ approach – M + C = O • evaluating impact of interventions – but always in particular contexts • and sometimes we look at what works in particular population or social contexts rather than form of intervention• and we evaluate our framework of theory of change • we identified levers in our strategy – did they prove to be important in practice? • looking for indications that the change mechanisms unfold as we expected, that the direction of causal influence and impact is as we expected ,etc • looking for evidence that outcomes anticipated are being achievedJanuary 24, 2012 39
    40. 40. Complexities: Building Equity Targets• can’t just measure activity: • number or % of priority pop’n that participated in program • need to measure health outcomes – even when impact only shows up in long- term • so if theory of change for health program begins with enabling more exercise or healthier eating – then we measure that initial step• need to assess reach • who isn’t signing up? who needs program/support most? • who stuck with program and what impact it had on their health – and how this varies within the pop’n• and assess impact through equity lens • need to differentiate those with greatest need = who programs most need to support and keep to have an impact• then adapt incentives and drivers • develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system 40
    41. 41. Parallel: Watch for Unintended Consequences• health promotion that emphasizes individual health behaviour or risks without setting it in wider social context • can lead to ‘blame the victim’ portrayals of disadvantaged who practice ‘risky’ behaviour • focus on individual lifestyle in isolation without understanding wider social forces that shape choices and opportunities won’t succeed• universal programs that don’t target and/or customize to particular disadvantaged communities • inequality gap can widen as more affluent/educated take advantage of programs• programs that focus on most disadvantaged populations without considering gradients of health and need • the quintile or group just up the hierarchy may be almost as much in need • e.g. access to medication, dental care, child care and other services for which poorest on social assistance are eligible do not benefit working poor • supporting the very worst off, while not affecting the ‘almost as worse off’ is unlikely to be effective overall 41
    42. 42. 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 state 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’ 42
    43. 43. Health Equitycould be one of those ‘big’ unifying ideas.. • if we see opportunities for good health and wellbeing as a basic right of 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 43
    44. 44. Following Up• 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• email at bob@wellesleyinstitute.com• we 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 44