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Acting on Social Determinants and Health Equity: An Equity Toolkit for Public Health
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Acting on Social Determinants and Health Equity: An Equity Toolkit for Public Health


This presentation examines the relationship between the social determinants of health and health equity. …

This presentation examines the relationship between the social determinants of health and health equity.

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

Published in Health & Medicine , Education
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  • POWER data age-standardized % of adults 2005self-reported = good proxy for clinical outcomes but exactly the point here, capturing people’s experience of their healthtwo things here, you have in your backgrounder:consistent gradient of health – however measuredhuge and damaging differences – 3 X as many low income as high report health to be only fair or poor
  • don’t know local context as well as everybody in this room – you will know best how to adaptbut do want to set out fairly full repertoire of strategies and programs – and success conditions for implementing
  • specifying the problem to solveissues that span health system: health promotion from PH and others is crucial, acute when people get sickone of most pressing system challenges everywhere = getting better balance btwn up-stream preventative and treatmentcrucial for sustainability and better health – and health equity, as this data shows burden and risk is highly inequitableOnt 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 = 3X than high income for men, over 2X for women harsh indictment of unequal system
  • In: that's impact on daily livesthat type of impact adds up over people's lives
  • need clear strategic understanding to be able to ground and connect actionbroad consensus around WHO framework
  • In: SDoH lead to gradient of health in chronic conditionsplus affect how people can deal with the conditions= big constraint on strategy to dealing with chronicOut: complex and reinforcing nature of social determinants on health disparities
  • idea of inter-sectionality – reflecting the fact that personal identities and group dynamics do not reflect a single line of oppression/identity such as gender, race or class, but their reinforcing and interacting natureimportant elaboration in SDoH analysis – recognizing that:the effect of determinants varies across people’s livesand that impact of inequalities is cumulativee.g. for children, research shows that:pre-natal and early years are especially sensitive to social conditions and can have a major impact on future healthintervening in early years to counteract adverse effects of wider social and economic inequalities has great potentialgrowing up in inadequate and inequitable social and family circumstances can store up a life-time of health problems
  • more specifically = need to make sense of SDoH to be able to act making healthcare more equitable can be crucialhighlights the crucial importance of social context and that community development is a key part of the equation for action
  • common themes in WHO and winder lit can be linked into this framework:seen as structural determinants -- many also see this level as being about inequitable risk and exposuremany also see inequitable vulnerability, often in terms of social capital and community resources and resilience2 and 3 can be seen as ways intermediary determinants play outemphasize how all these lines of inequality come together -> cumulative and reinforcing impactbut something can be done -> need policy and community action at all these levelsneed to specify different levels in which SDoH and structured inequality affect health -> different policy solutionsimplications for pub health:need for macro policy changes – role of pop’n health research and policy advocacyworking on the ground in many partnerships to address foundations of healthier communities and community health profiles to better understand needs and challengesensuring equitable access to ph services and paying particular attention to priority populations
  • Out – will set out a number of promising directions, tools and ideas on howthese fit nicely with NCCDH’s four key roles for ph in advancing equity
  • In: start from strategybroad-based strategic consensus and commitment on equitymajor priority within PHO, OPHA, equity working groupkey role of NCCDH,collaborations among urban PHUs across Canada, etc.a number of Public Health Units have been pioneering equity strategies and social determinants approachesSudbury’s 10 promising practicesSMN has developed comprehensive strategyWaterloo has focused especially on food insecurityPeterborough has been much involved in poverty reduction collaborationsToronto has emphasized health impact of increasing income inequality, racism and other determinantswide range of promising approaches, programs and interventions -> potential to share and build on all this local innovation
  • one of my themes throughout is alignment – that equity has a better chance of being institutionalized when aligned with – and essential to – key system prioritiesnot going to be easy = system is fragmented – LHINs, primary care, provincial programs, acute and up-stream, public health – let alone beyond health
  • but need to add to these promising starting points = strategic commitment + strategic opportunities + community engagementyour strategy emphasizes that this is a good window for acting on inequities
  • hospital readmissions = also is common interest/leverto enable better community-based service coordination need to match tools to purpose
  • need to match tools to purpose – isn’t one ‘magic’ tool for all situationscan adapt to particular care and disciplinary settings
  • some PHUs have used version of this kind of lens for years
  • some PHUs have used version of this kind of lens for years
  • increasing attention to this potential – from WHO, through most European strategies, PHAC, to Ontariokey PHO role in piloting and supporting PHUsexperience being built uphere?e.g. part of SNM equity plan is to do HEIA each year in every program area – so 26 so farquandary: don't reify planning tools do want this to contribute to better equity-focused planningbut better to think of as a process – as a tool to facilitate conversations and analysis about equityas a catalyst for analysisless worried about documentation that resultssecond practical quandary:people in the field say it is too difficult to do thoroughlyit is difficult to find consistent data on all the population categories and determinants to be considereddon’t be paralyzed by lack of data – draw on local community and practice leaders also for evidence of potential impactincreasing emphasis on rapid desk-top assessmentsagain, think facilitating tool rather than producing solid evidence
  • 2 things about cover: equity = good for health and why data is neededquandary again: don’t get paralyzed by inconsistent/inadequate datastart to collectthink of base of data that will be available in 5 years
  • PH as leaders here:strong epi resourcesmany PH have developed community health profilese.g. Waterloo partnered with LHIN – opportunity to embed epi and community traditions within wider system
  • OWHN inclusion research model – peer researchers
  • recognizing that what gets measured, matters
  • immunization -- note success in Saskatoon – res -> targeted interventions -> inequities leveled up + overall rate improvedwhat else?access to nutritionwalkability
  • many programs assess their services through client satisfaction surveys and look for high and improving satisfaction -> reduce any differences in satisfaction by gender, income, ethno-cultural background, etc.
  • not by chance – lot of hard work went into building equity and SDoH in – Connie Clement and many others
  • background on project – WHO, pilots here, this was Cdn Consortium, starting with hospitals, symposium in spring join uptool toidentify key directions and levers for operationalizing equity plan – what needs to be lined up to drive change across all these fronts? how to dovetail constituent projects?monitor – develop indicators and targets for each componentfor facilitating equity conversations -- how well are we doing on these key components?
  • a central driver on acute side is quality improvement -> key role for Health Quality Ontario as catalyst in accelerating use of evidence, brokering improvement focusing the system on common quality agendaparallels for Public Health Ontario? recent OPHA confrole of OPHA in on-the-ground QI partnerships/initiatives?PH will want to be part of any broad Provincial quality strategycollaborations with HQO?
  • and drill down more:what differences for different countries of origin?by length of time in Canada?and then build that knowledge into program planningpart of targeted interventions, soon
  • In: all of this equity planning loops back to qualityOut: so building equity into quality service delivery means different types of service mixes to take account of specific context and needs
  • emerging forms:CHCs as hubs of primary care, health promotion and related social servicesnetwork of neighbourhood multi-service centresschools with health and social services acting as hubs for their local communities – remember when PH nurses were in schoolsall as partners for PH in local communities
  • probably not much consistency across the systems in how priority pop’n are defined PHO projectquandary raised by colleague at Waterloo talk:often don’t have comprehensive local and specific datacan bring planning and interventions to a haltalways a question of balance – can’t be rash, but also cant be paralyzed by imperfect databuild on all available sources of local knowledge – incl community-based, practice experiencerationale for whyequity rationale:certain groups within society are most adversely affected by systemic health inequitiesgoal of many strategies is to raise the worst off, fastestnot just a social justice argument, but improving adverse health of worst off can contribute to more effective use of scarce healthcare resources, positively affect social productivity and cohesion, enhance overall population health, and underlying social disadvantage can be inter-generationalwill persist – if not worsen – if not addressedaccess to quality servicesmost disadvantaged populations have greater and more complex needsuniversal programs can leave vulnerable groups out – and behindspecific at-risk groups need specific interventionsuniversal programs will not be effective unless adapted to specific needs, constraints and dynamics of vulnerable populations
  • good e.g. of double role of PH: part of policy advocacy and developing on–the-ground work-around solutions
  • res evidence from acute side:poor communication due to language or cultural can contribute to misdiagnoses and inappropriate prescriptionsinability to read or understand instructions can lead to medication errors -> safety, cost and re-admission implicationspromising indications that good interpretation helps keep people out of hospital and get them out soonerthat action idea illustrates an impt pt:definitely a good idea – depending upon your local needsbut that doesn't mean you have to do itprobably good project for wide partnerships led by LHIN
  • Drilling down again:vulnerable pop'ns = immigrantswhat could be barriers here?Peel project as innovative example -- local research, partnerships with ethno-cultural gr, go where immigrant women are to encourage screeningToronto Public Health: health status indicator series Sept 2011
  • adverse health consequencescritical point of inequity within cancer care – CCQO event
  • another wrinkle – not simple gradientbut clear gap in being able to eat properly about 50% harder for lowest income than highest – worse for lower-middle
  • in other words, universalism without targeting – more specifically, without context
  • challenge in driving social change on complex issues -- what are key pathways to change? what are levers or enablers to drive change in those directionsone of NCCDH ley roles for PHsuch broad collaboration will be particularly important to Health Links and other system integration initiatives
  • many of you have done community health profiles for your areas
  • SM has comprehensive equity framework here Wppg RHA is most recent example from other prov
  • thinking more broadly
  • example of clearing house of equity initiatives in Europekey role for OPHA, PHO
  • our fluoridation HEIA
  • we have done policy orientated HEIAs recently of casinos, cuts of CSUMB
  • also key to policy change on SDoH is broader public awareness and mobilization lots of work underway on how to popularize and promote SDoH: RWJ, NCCDH, videos Ryan Meili book and new collaborative called Upstream
  • lesson from acute health care sector = building equity into provider planningECFAA requires hospitals and then other providers to develop quality improvement plans -> need to build equity in as key dimensionequity priorities will/can be built into accountability agreementsa promising direction several LHINs have taken up is to require providers to develop equity planshospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TCand other providers in CentralCHCs have developed a sector-wide plan in GTAnext stage for your strategy is action planfor public health at system level, provincial standards offer a key leverPHU could develop health equity plans showing how they are putting population health standards and requirements into practice detailing how equity and population-specific expectations and targets are being built into routine PHU performance management and accountabilities
  • basic ideas of health and social justice can be a powerful vision to drive action


  • 1. Acting on Social Determinants and Health Equity: An Equity Toolkit for Public Health Bob Gardner Windsor-Essex County Public Health November 29, 2013
  • 2. Problem to Solve: Systemic Health Inequities in Ontario clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health however measured -- by conditions, quality of life, life expectancy the gap between the health of the best off and most disadvantaged can be huge – and damaging 2
  • 3. Towards Health Equity Solutions will set out a toolkit of 18 ideas, directions and techniques • to build equity into public health planning and delivery • and well beyond health system -tackling the underlying roots of health inequality in the wider social determinants of health • solidly based in research evidence and years of best practices • action-orientated and manageable • measureable – so can monitor and assess progress • adaptable to specific organizational and local contexts the particularly good news = don’t need to start from scratch 3
  • 4. Today key message: • health inequities are pervasive, damaging and deep-rooted • but can be addressed through comprehensive health equity strategy and concerted action will set out a multi-facetted equity toolkit on how • ideas and directions, tools and techniques, you could adapt • will also highlight a few unintended consequences and challenges to watch for two exercises to test out these directions and tools at your tables lots of chance for discussion will start by looking at underlying social determinants of health 4
  • 5. Gradient of Health Across Many Conditions 5
  • 6. Windsor-Essex County Blood Pressure, Arthritis and Diabetes Rates by Income Quintile, 2007-2012 30 Percentage (%) 25 20 Quintile 1 Lowest income Quintile 2 15 Quintile 3 Quintile 4 10 Quintile 5 Highest income 5 0 High Blood Pressure December 4, 2013 | Arthritis Rates Diabetes Rates 6
  • 7. Impact of Health Inequities on How We Live Our Lives 7
  • 8. Impact of Health Inequities II • not just inequitable differences in 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 women Statistics Canada Health Reports Dec 09 8
  • 9. Acting on Social Determinants of Health December 4, 2013 | 9
  • 10. Canadians With Chronic Conditions Who Also Report Food Insecurity 10
  • 11. SDoH As a Complex Problem Determinants interact and intersect with each other → reinforcing and cumulative effect on: • individuals throughout their lives; and • on particular communities and populations In constantly changing and dynamic social and policy environments In fact, through multiple interacting and inter-dependent economic, social, environmental and health systems 11
  • 12. Acting Across Systems and Sectors even though roots of health inequities 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 POWER Study: Gender and Equity Health Indicator Framework December 4, 2013 | 12
  • 13. WHO Model Again: Focusing on the Right Policy Levels December 4, 2013 | 13
  • 14. Three Cumulative and Inter-Dependent Levels Shape Health Inequities → Different Opportunities for Public Health Action 1. because of inequitable access to → gradient of health in which more wealth, income, education and other disadvantaged communities have fundamental determinants of health 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 healthcare and other systems → these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need 14
  • 15. Think Big, But Get Going • contradictions of SDoH analysis: • • • • • keep the fundamentals of SDoH in mind, but get going: • • • • health inequities can seem so overwhelming and their underlying determinants so intractable → can be paralyzing a classic ‘wicked’ policy problem – meaning long-term action is needed across many govts, depts and sectors can't do everything at once don’t wait for perfect strategy or evidence that connects and understands everything make best judgement from available evidence and experience identify actionable and manageable initiatives that will make a difference innovate and evaluate → learn lessons and adapt start from where you are – and focus here is on building equity into public health practice December 4, 2013 | 15
  • 16. Health Equity = Reducing Unfair Differences • Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage • This concept: • is clear, understandable and actionable • identifies the problem that policies will try to solve • is also tied to widely accepted notions of fairness and social justice • The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes • A positive and forward-looking definition = equal opportunities for good health • Equity is a broad goal, including diversity in background, culture, race and identity
  • 17. Powerful Starting Point = Equity Is a Priority Within Public Health 17
  • 18. + Promising Strategic Environment can bring tradition, expertise and local strengths to key system challenges: • Excellent Care for All Act enshrines equity and population health as fundamental principles • Action Plan emphasizes keeping people healthier -- preventing chronic and other conditions, childhood obesity, screening, smoke-free → opportunity to demonstrate that these challenges can be met – and how PH has more experience than acute sector: • building necessary cross-sectoral collaborations • up-stream interventions to sustain healthier communities → opportunity for public health leadership December 4, 2013 | 18
  • 19. Starting Point: Solid Commitment + Strategic Opening + Community Engagement • can’t just be ‘experts’, planners or professionals who define issues and drive system transformation • have to build diverse voices and perspectives into planning • not just as occasional community engagement, but to identify fundamental service needs and priorities, and opportunities for creating healthier community structures and resources • and to evaluate how we are doing → need to start from communities and residents • involving all types of people – diverse cultures, backgrounds and perspectives, and unequal social and economic conditions? • specifically, how to involve and empower those not normally included • adapt different and innovative methods – e.g. principles of inclusion research, go where people are, build trust December 4, 2013 | 19
  • 20. 1. Operationalizing Commitment: Build Health Equity into All Planning and Delivery • • doesn’t mean all programs are all about equity but equity is built into working culture and routine planning → all programs take equity into account in planning their services and outreach • obvious example – given inequitable gradient of prevalence and impact of chronic diseases + impact of living conditions → CDPM programs have to take social determinants and community conditions into account • not so obvious example – from acute side • concern about reducing hospital re-admission rates → need to understand living and social conditions into which people are being discharged → need to ensure more intensive discharge planning and web of community-based support December 4, 2013 | 20
  • 21. 2. Into Practice Through Equity-Focused Planning • addressing impact of health disparities at system level requires a solid understanding of: • the needs of health-disadvantaged populations • gaps in available services for these populations • key barriers to equitable access to high quality care • at delivery level: • considering equity in all program planning means drilling down on above questions to identify specific needs and barriers for that particular service • requires an array of effective and practical equity-focused planning tools 21
  • 22. Always Plan through a Health Equity Lens Could this program or policy have a differential and inequitable impact on some populations or communities? Providers should apply this type of basic equity lens routinely – from strategic to service planning How do we need to take the specific needs of disadvantaged individuals and communities into account in planning and delivering this service? 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 draw on provider experience and community perceptions •if evidence indicates there could be inequitable impact → then drill down using fuller HEIA December 4, 2013 | 23
  • 23. First Exercise: Using a Health Equity Lens Could this program or policy 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 planning and delivering this service? At your tables, quickly apply this basic equity lens to a program you are working on We’ll then share the possible barriers, gaps and inequitable impacts you identified. And the innovations underway to address them. December 4, 2013 | 24
  • 24. • analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • using HEIA can help • uncover unintended consequences or nuances easily missed in program planning • embed equity into routine planning processes and working culture • ensure that projects not specifically about equity or particular populations, will take language, diversity, local community conditions, etc. into account • 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 • growing, if uneven, use: • across 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 promoted by Public Health Ontario 25
  • 25. 3. Collect SDoH/Equity Data need solid equity-orientated data • to identify gaps and needs of disadvantaged patients • to measure and monitor progress pilot project in 3 Toronto hospitals (and Toronto Public Health) to collect patient SDoH type data scaled up to all hospitals in Toronto Central LHIN valuable website of resources on how to collect and use this data Action idea = adapt and use framework in Windsor • at best, across public health settings and whole health system 27
  • 26. Make That Data Actionable promising practice = Public Health Observatories • consistent and coherent collection and analysis of pop’n health data • UK has system of observatories specializing in different spheres – London on inequities • Saskatoon Observatory is innovative example opportunity: public health to use its analytical capacity/expertise to support wider health system • partnering in community health profiles action idea = adapt observatory model regionally or provincially • role for PHO? 28
  • 27. 4. Build Knowledge We Can Act On need broad research base and expansive view of knowledge: • epidemiological – scale of disparities, disadvantaged communities/groups • population level linked datasets • community-based research = unique understanding of needs and interests of marginalized populations • evaluation – need to know what works and why, for which populations, in varying contexts systematic data collection + capacity to measure/monitor /evaluate + rich research evidence = knowledge to guide/ground action
  • 28. 5. Beyond Planning: Embed Equity in Targets, Deliverables, and Performance Management • clear consensus from research and policy literature, and consistent feature in comprehensive policies on health equity from other jurisdictions: • 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 = embedding equity into comprehensive performance measurement and management strategy 30
  • 29. Effective Public Health Equity Targets • • • • various national projects underway to develop equity indicators can also build equity into indicators already being collected → equity angle is to reduce inequitable differences faced by particular populations or communities on these indicators reducing impact of diabetes is prov priority • equity target = reduce differences in prevalence, complications and hospitalization rates by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions • achieving that will require targeted programming and proactive engagement with under-served communities • also good reform driver = can only be achieved through coordinated action similarly, common goal is increasing rates of childhood immunization • equity target = reduce the differentials in % of kids immunized by neighbourhood, gender, ethno-cultural background, etc. 31
  • 30. Challenges: Equity Indicators and Targets • • • • can’t just measure activity, like number or % of priority pop’n that participated in program • if theory of change for particular health program begins with enabling more exercise or healthier eating – then we measure change in that initial step need to measure contribution to health outcomes – even when impact only shows up in long-term need to assess reach • differentiate those with greatest need who need program/support most • are these populations signing up? • who stuck with program and what impact did it have on their health – and how this varies by sub-pop’n then adapt incentives and drivers • develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into funding and incentive system 32
  • 31. 6. Use Effective Levers to Institutionalize Equity • • • public health standards have been effective way to prioritize and embed equity: • as foundational element of high-performing public health • assessing needs, identifying priority populations, underlying SDoH interesting work underway to help implement: • PHO on how to assess and identify priority populations • alPHa/OPHA Health Equity Working Group is also an effective forum some lessons to be learned from acute side: • following equity standards arose out of WHO Health Promoting Hospitals project • adapted to Canadian context, starting with hospitals December 4, 2013 | 33
  • 32. Promising Practice: Actionable Equity Standards December 4, 2013 | 34
  • 33. 7. Align Equity in Public Health With Key System Priorities • • • showing how equity will be critical to achieving system goals and linking equity into central priorities will enhance uptake and success one overarching system priority is sustainability: • powerful case to be made for preventative programs and health promotion as key to reducing avoidable acute care use/costs another priority is chronic disease prevention and management • long been key focus of PH health promotion efforts • a challenge for health reform is finding cross-cutting goals/projects that can address a key issue and help to transform the wider health care system • reducing prevalence and impact of chronic disease could be such a common goal to integrate upstream health promotion, primary care and chronic care • and it necessarily involves cross-sectoral collaboration 35
  • 34. Always Drill Down: For Diabetes and Other Conditions, What Are Key Dimensions of Inequities? What Determinants and Barriers Underlie These Inequities? Windsor-Essex County Diabetes Rates by Immigration Status, 20072012 16 14 Percentage (%) 12 10 8 6 4 2 0 Born in Canada December 4, 2013 | Immigrant 36
  • 35. 8. Embed Equity into Quality • • • quality improvement is another key transformational driver across the health system taking social context and living conditions into account are part of good service delivery • when people face adverse social determinants of health → fewer resources to cope (from supportive social networks, to good food and being able to afford medication) • e.g. primary care guidelines on best care for people living in poverty providers and programs need to know this, to customize and adapt care to SDoH and specific needs and contexts • e.g. well-baby care has to be more intensive for poor or homeless women • to get beyond barriers, preventative screening and health promotion has to be delivered in languages and cultures of particular population/community 37
  • 36. Not Just at Individual Level: Build Equity-Driven Service Models peer programs • 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 • Waterloo has had peer program for over 20 years – nutrition, parenting, social support – partnering with community groups neighbourhood focus of many health promotion initiatives: • not just disease by disease, or lifestyle elements in isolation, but coordinated programming to meet local needs being part of hub-style multi-service centres • a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations • 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 and better overall coordination December 4, 2013 | 38
  • 37. 9. Priority Populations Target Programs and Resources for Equity Impact • consistent tradition within PH has been to identify priority populations and target services to: • those facing the harshest disparities – to raise the worst off fastest • or most in need of specific services – e.g. poor young moms • or the worst barriers to equitable access to high-quality services – newcomers, Aboriginal populations • this requires sophisticated analyses of the bases of inequities: • which requires good local research and detailed information • community health profiles to identify local disparities, unmet needs and gaps • community-based research to provide rich and deep local knowledge – especially for designing effective program solutions • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems 39
  • 38. Effective Targeting = Clear Focus • • • defining priority populations • not just a general or statistical category – bottom 20 %, all immigrants • but social groups who face particularly poor health or inequitable determinants of health – and why • these populations could occupy particular positions – precarious workers, recent immigrants – or may share common backgrounds, identities or other community interests – Aboriginal people, LGBTQ, homeless • could be people who live in particularly disadvantaged neighbourhoods get priority populations involved in what matters to them and what programs will meet their needs however defined, no population or community is ever homogeneous • need to drill down further – e.g. youth within Francophone African immigrants have specific needs December 4, 2013 | 40
  • 39. 10. Not Just Priority Populations: Target Systemic Barriers in Toronto and other cities: people without health insurance • immigrants in 3 month wait time, refugees, undocumented • inequitable access → delayed care and worse outcomes • TPH staff have played a key role in Scarborough Volunteer Clinic and networks 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 always = predictable and avoidable results of bad policy action idea = create local network to improve access for uninsured and/or refugees 41
  • 40. Problem = Newcomers Face Service Barriers One Solution = Interpretation as a Key Quality and Equity Lever •access to interpretation underlies wait times, safety and other acute system priorities •requirement that adequate interpretation be available wherever needed → improves quality and equity •equally crucial for health promotion •action idea = Windsor area LHIN, PH, acute, community health and other providers consider centralized/coordinated interpretation services December 4, 2013 | 42
  • 41. Inequitable Access to Preventative Care: Pap Smears Toronto Public Health: health status indicator series Sept 2011 43
  • 42. Problem = Under-Screened Populations Solution = Focused Community Partnerships lower screening rates in particular ethno-cultural or disadvantaged groups e.g. South Asian women in Peel → community-based research to assess why → broad partnerships of Public Health, providers and trusted community organizations to get beyond barriers → outreach to diverse community settings where women live, work
  • 43. 11. Health Promotion Through an Equity Lens • need to customize and concentrate health promotion programs to be effective for most disadvantaged • programs have to take account of inequitable resources of vulnerable individuals and communities • advice to manage chronic conditions by exercising depends upon affording a gym or being close to safe park • diet and nutrition are key – yet high degree of food insecurity • adjust programs to specific barriers and community needs • deliver in languages and cultures of particular population/community • go where people are -- e.g. CHCs/health promoters into malls • Immigrant Women's’ Health Centre, Sherburne, Aboriginal communities and other vans in Toronto December 4, 2013 | 45
  • 44. Windsor-Essex County Vegetable and Fruit Consumption Five or More Times a Day, by Income Category, 2009-2010 45 40 Percentage (%) 35 30 25 20 15 10 5 0 Lowest Income Lower-Middle Upper-Middle Highest Income Annual Household Income December 4, 2013 | 46
  • 45. Build Equity Upstream: Chronic Disease Prevention and Management start by identifying populations and communities at greater risk • South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America → design programs to meet specific needs build in equity target = 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 proactive empowerment of kids and ensuring equitable access to facilities, space and programs 47
  • 46. 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 specific 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 48
  • 47. 12. Key Lever for Acting on SDoH: Inter-Sectoral Collaboration and Coordination • equity-driven quality care is not just customizing immediate service delivery, but ensuring networks of community-based care and support • particularly important in less advantaged communities with less resources • needs good cross-sectoral coordination and planning • can identify community health needs, access barriers, fragmentation, service gaps, and how to address them • public health units and LHINs are pulling together or participating in crosssectoral planning tables • also Local Immigration Partnerships, Social Planning Councils • and looking beyond vulnerable individuals to the communities in which they live • providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth programs, etc. • a number of PHUs have been pioneering social determinants approaches through broad community collaborations on food security, poverty reduction and other facets of building healthier communities 49
  • 48. Structural Determinants of Health Inequities: and Simultaneously Always Local poor housing, high levels of poverty and precarious employment can be concentrated in particular neighbourhoods and areas, compounded by racism and other forms of social exclusion impact and severity of health inequities can also be concentrated in particular populations and neighbourhoods + inequitable access to healthcare and other services + services can be poorly coordinated and planned December 4, 2013 50
  • 49. 13. Plan Strategically/Act Locally • clear benefits of comprehensive national/prov health equity strategy: • but even best national strategy needs to be adapted/implemented locally • and even without national strategy, can still act locally • recent Wellesley comparative survey of local health equity strategies • many innovative local strategies at LHIN level, RHAs from other prov, PHUs • again, potential of PH: • many PHUs work closely with local partners in community collaborations, networks and planning forums • tradition of researching/understanding local health needs and challenges • Manitoba has provincial community health mapping initiative, • many Ontario PHUs have done local health mapping -- Toronto profiles, Waterloo partnered with LHIN December 4, 2013 | 51
  • 50. Realizing the Potential of Collaboration: Equity and Community-Driven Local Planning Forums pre-condition for coordination = creating effective local crosssectoral planning forums crucial to sustaining broad action needed to address deep-seated structural problems action idea = create Windsor health equity forums with concrete planning mandate • to develop a Windsor health equity plan? December 4, 2013 | 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 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 key issues such as harm reduction, dental care and access for noninsured people 52
  • 51. 15. Realizing the Potential of Equity-Driven Innovation potential: • huge number of 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 • NCCDH bringing together SDoH PHNs • another advantage of local equity forum • role for PHO or OPHA? 54
  • 52. 16. Add Public Health Voice: Policy Advocacy • long tradition of advocating for healthy public policies • Healthy Cities movement • linking pop’n health into wide ranging issues -- climate change, city design, transportation • policy advocacy = one of key roles identified in NCCDH model • public health has unique position: • part of local govt • protected by provincial mandates and responsibilities • long been solidly based in local communities and collaborations • can use credible professional/evidence-based voice to intervene in public debates • need to identify most effective platforms and policy opportunities • and what the key issues are in your communities 55
  • 53. Policy Windows: II also partnership with community agencies, CHCs and other providers and public health – Peterborough extended to developing an online tool to track impact of these cuts current focus – again in broad collaborations – is on municipal housing plans to ensure they include this kind of flexible support December 4, 2013 | 57
  • 54. 17. Shifting the Frame: Health = Healthy and Equitable Communities Sudbury & other public health videos, flyers, etc. December 4, 2013 | © The Wellesley Institute 58
  • 55. 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 overarching 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 public pressure • key to equity-driven reform will also be empowering communities to imagine their own alternative health futures and to organize to achieve them 59
  • 56. Second Exercise From this equity toolkit, what are two or three ideas or directions that you could develop here? How would you adapt them to your context? December 4, 2013 | 60
  • 57. 18. Pull All This Together into a Strategic Roadmap • • • • from a large toolkit, develop a roadmap of what you will do – how and when can’t be a rigid blueprint, needs to be adapted and implemented flexibly to contexts and circumstances but need clear sense of direction and overall goals needs to pull various initiatives into a coherent and connected action plan
  • 58. Promising Practice: Potential of Equity Plans Demonstrated December 4, 2013 | 62
  • 59. Build a Cycle of Equity-Driven Planning and Innovation • • • • • not just a one-off plan but building equity into ongoing cycle of analysis, planning and implementation see Saskatoon health equity audit process embed equity into routine planning and performance management processes build evaluation and learning into continuous innovation December 4, 2013 | Innovation Analysis Plan and engage Evaluate Implement 63
  • 60. Health Equity and Community Mobilization • 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’ • health equity could be one of those ‘big’ unifying ideas.. • if we can shift the public and policy frame to see opportunities for good health and well-being as a basic right for all • if we frame the damaged health of marginalized populations as an indictment of an unequal society – but also show 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 better future for all • and showing that we can get there from here 64
  • 61. 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 • have set out a roadmap – of strategies, principles and tools -- to drive equity into action • there is a solid base of public health evidence, experience, commitment and community connections to build on • real opportunity within the current health and policy environment for public health to lead the way on equity 65