Central LHIN Leaders’ Briefings: Building Health Equity into Action

1. Bob Gardner November 2009 Meetings of Community Providers on Health Equity Plans © The Wellesley Institute www.wellesleyinstitute.com 1

2. • scale of health disparities • concept of health equity • bigger picture: health equity and social determinants • acting on health equity within the health system • building equity into all planning and delivery – highlighting some frameworks and resources for equity-focused planning • targeting some % of programs and resources for equity impact • identifying key drivers and enablers to move an equity agenda forward • potential of community-based initiatives and cross- sectoral collaborations © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 2

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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 10 www.wellesleyinstitute.com 10

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13. • 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 December 8, 2009 www.wellesleyinstitute.com 13

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 December 8, 2009 www.wellesleyinstitute.com 14

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 December 8, 2009 www.wellesleyinstitute.com 15

17. • To reduce the scale and severity of disparities • Not only improving the health and health opportunities of the most vulnerable and disadvantaged • But benefiting people along the gradient: o the kinds of integrated comprehensive primary care needed by those with the most pressing and complex needs – will benefit all o reducing language and cultural barriers will benefit many newcomers and those who have difficulty receiving services in English, not just those who face the harshest health disparities © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 17

18. • the point of all this analysis is to be able to identify what policy and program changes are needed to reduce health disparities • one problem is that 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: o need to split strategy into actionable components and phase them in o but coordinate through a cohesive overall framework © The Wellesley Institute www.wellesleyinstitute.com 18 www.wellesleyinstitute.com 18

19. • timing is everything: • need to recognize that fundamental policy action on equity takes time – need patience and long view • pick some ‘quick wins’ -- issues and levers that will show progress and build momentum for action on equity • pick issues and direct resources to areas that will have the greatest equity impact o either in terns of meeting the health needs of most disadvantaged populations o or addressing most important barriers to health equity • need to start somewhere – and we’re in healthcare system © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 19

20. • even though roots of health disparities lie in far wider social and economic inequality • this doesn’t mean that how the health system is organized and how services and care are delivered are not crucial to tackling health disparities • many countries have been developing comprehensive multi- sectoral strategies to reduce health disparities • in all of them, transforming the health system is an indispensable element, including: o reducing barriers to equitable access to high quality care o targeted interventions to improve the health of the poorest fastest – often as part of community/local initiatives © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 20

21. 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 December 8, 2009 www.wellesleyinstitute.com 21

23. 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 Proportion of Residents with physician visits for Arthritis is higher in Lower Income neighbourhoods, especially females. Neighbourhood Income Quintiles Toronto Community Health Profiles Partnership, www.torontohealthprofiles.ca © The©Wellesley Institute The Wellesley Institute 23 www.wellesleyinstitute.com 23 www.wellesleyinstitute.com

24. Toronto Central: Hip Replacement Rate, TC LHIN, 2004/05 144 150 #/100,000 100 68 50 0 Lowest Income Highest Income Despite poorer health and greater need/potential to benefit from diagnosis and treatment in lower income groups, the hip replacement rate is over twice as high in the highest income neighbourhoods. Age Standardized Rates. Total Hip Replacements per 100,000 Population by Neighbourhood Income Quintiles. .Source: Institute for Clinical Evaluative Sciences (ICES) November 2006 © The©Wellesley Institute The Wellesley Institute 24 24 www.wellesleyinstitute.com www.wellesleyinstitute.com

25. • 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 25 www.wellesleyinstitute.com 25

26. • 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 26 www.wellesleyinstitute.com 26

27. • 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 December 8, 2009 www.wellesleyinstitute.com 27

28. • addressing health disparities in service delivery and planning requires a solid understanding of: o key barriers to equitable access to high quality care o the specific needs of health-disadvantaged populations o gaps in available services for these populations • this requires good information • and effective and practical equity-focused planning tools © The Wellesley Institute www.wellesleyinstitute.com 28 © The Wellesley Institute 28

29. 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 – has been piloted in populations, access barriers and Toronto and MOHLTC is related equity issues in program considering 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© The Wellesley Institute 29 29 www.wellesleyinstitute.com

30. • a promising direction is to have providers undertake specific equity planning exercises 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 • more effectively build equity into planning, resource allocation and routine delivery • pull their many existing initiatives together into a coherent overall equity strategy • build connections amongst providers for addressing common equity issues • hospitals in Toronto Central and Central LHINs developed equity plans broadly meeting those objectives © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 30

31. http://www.torontoevaluation.ca/tclhin/index.html © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 31

32. • 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: o undertaking appropriate equity-focused planning o providing sufficient services in languages of community and appropriate interpretation o identifying areas where access to services is inequitable and developing plans to address barriers and gaps o ensuring service utilization matches appropriately with demography and needs of their catchment profile o developing specific services or outreach to particular disadvantaged populations – homeless, isolated seniors, etc. © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 32

33. • 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 • need to build these equity targets and objectives into routine performance management and routine provider planning © The Wellesley Institute 33 www.wellesleyinstitute.com 33

34. • we know there will be clear targets for priorities such as diabetes and mental health → build equity into targets: • Central has identified areas where diabetes incidence is highest → equity target = reduce differences in incidence, complications and rates of hospitalization among areas across Central • similarly, systemic inequities in depression → equity target = reduce those differences by gender, income, region • many providers assess their services through consumer 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 34 www.wellesleyinstitute.com 34

35. • assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context o this can benefit from ongoing community 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: o research and input from the affected population on impact o health outcome data stratified by population and determinants © The©Wellesley Institute The Wellesley Institute 35 35 www.wellesleyinstitute.com www.wellesleyinstitute.com

36. • underlying all this planning, monitoring of indicators and assessing progress against objectives and targets = data on: • service use patterns, differentiated by population and by determinants of health-type data • health outcomes data, 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 © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 36

37. • theme of presentations and resources was that a great deal can be done now with existing sources of data → don’t need to wait for better data or consensus definitions before beginning to act • but also recognized need for common and coordinated system level solutions and directions → need to begin these wider discussions within LHIN and beyond o tremendous potential if this is done on coordinated prov basis • presentations and resources from the day and report from working group to Collaborative were published o distributed to hospitals, other providers and stakeholders, and LHIN o all available on partner sites including http://www.healthequitycouncil.ca/dev © The WellesleyInstitute © The Wellesley Institute www.wellesleyinstitute.com 37 37 www.wellesleyinstitute.co

38. • equity is essential to provincial priorities • e.g. diabetes is particularly sensitive to social conditions • prevention and management programs cannot be successful unless they take account of social conditions and constraints • 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 • reducing higher expenditures on vulnerable populations due to health disparities → can contribute to overall and sustainability © The Wellesley Institute 38 www.wellesleyinstitute.com 38

39. • 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 The Wellesley Institute 39 39 www.wellesleyinstitute.com www.wellesleyinstitute.com

40. • North York West region has been identified as high need – diverse population, high % of racialized population, high risk factors, lack of access to primary care • problems include concentrated poverty and inadequate services and infrastructure • 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 © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 40

41. • one of identified equity challenges for North York General hospital was language: • identified as critical issue in hospital equity plans and other Toronto Central planning → major project to develop more systematic coordinated approach to interpretation in downtown hospitals • could hook up to this – or at least keep it on horizon • could also link into Healthcare Interpreters Network • another critical barrier to equitable access in parts of Central – and other LHINs – is remoteness and transportation • have been innovative community-based and volunteer transportation • highlights key role of LHINs in enabling such critical supports for health © The Wellesley Institute 41 www.wellesleyinstitute.com 41

42. • 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 in priority areas within Central • concentrate new investments or coordination initiatives in those areas • recognizing that most of primary care levers are outside LHIN mandate © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 42

43. • 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 been partnering 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 • Ontario provincial associations representing CHCs, mental health and community service agencies have been promoting idea -- including to LHIN CEO provincial planning table • more immediately, many CHCs offer expanded services or co-located partnerships with other providers © The©Wellesley Institute The Wellesley Institute 43 43 www.wellesleyinstitute.com www.wellesleyinstitute.com

44. • Central has identified this as a key direction • 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 • working with public health -- even though outside the LHINs and with different boundaries – is vital • Social Planning Councils are developing cross-sectoral planning forums and processes in many communities around poverty and inequality – clear implications for health • a key lesson of LHIN experience to date is that existing networks and partnerships are a huge resource to build on • → identify key networks to enhance equity coordination and delivery in priority areas and support them © The Wellesley Institute 44 www.wellesleyinstitute.com 44

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

47. • 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 • thinking bigger, the Ministry of Health Promotion is starting to take a healthy communities approach to planning health promotion -- implies wider community development and capacity building approaches © The Wellesley Institute 47 www.wellesleyinstitute.com 47

48. • huge number of community and front-line initiatives already addressing equity – across this LHIN and province • + equity focused planning – through provider equity plans, HEIA or other tools -- will yield useful information on existing system barriers and the needs of disadvantaged populations, and on promising and successful programme interventions • we need to be able to: o collate and analyze all the useful intelligence gained from provider equity- focused planning o capture and share information on local initiatives, and build on local front-line insights o share the resulting knowledge across the LHIN – and beyond o assess most promising initiatives or directions o scale up promising initiatives across the province where appropriate © The WellesleyInstitute © The Wellesley Institute www.wellesleyinstitute.com 48 48 www.wellesleyinstitute.co

49. • health disparities are pervasive and damaging → high public policy priority • the roots of these disparities lie in far wider social and economic inequality, but much can be done within the health system • a great deal of equity-focused planning and delivery is already going on • there is a solid base of healthcare provider experience, commitment and community connections to build on • with the right strategy, tools and commitment, progress can be made in enhancing health equity © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 49

50. • back to bigger picture • following is a roadmap for comprehensive integrated policy action on determinants of health and health inequality © The Wellesley Institute December 8, 2009 www.wellesleyinstitute.com 50

51. 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 The Wellesley Institute 51 51 www.wellesleyinstitute.com www.wellesleyinstitute.com

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

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

54. • 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 December 8, 2009 www.wellesleyinstitute.com 54