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Acting on Social Determinants
and Health Equity:
Opportunities and Promising
Practices for Public Health
Bob Gardner
Ontar...
Problem to Solve:
Systemic Health Inequities in Ontario
clear gradient in health in
which people with lower
income, educat...
Outline
• health inequities are pervasive and damaging
• but these inequities can be addressed through comprehensive
healt...
Canadians With Chronic Conditions
Who Also Report Food Insecurity
4
SDoH As a Complex Problem
Determinants interact and intersect
with each other in constantly
changing and dynamic environme...
Planning For Complexity
even though roots of health
disparities lie in social and
economic inequality
need to also look at...
Three Cumulative and Inter-Dependent Levels Shape Health
Inequities → Different Opportunities for Public Health Action
1. ...
Acting on Complexity
• contradictions of SDoH analysis:
• health inequities can seem so overwhelming and their underlying
...
1. Powerful Starting Point = Equity As a Priority
Within Public Health
9
+ Promising Strategic Environment
can bring tradition, expertise and local
strengths to key system challenges:
• Excellent...
Solid Strategy + Strategic Opening +
Community Engagement
• can’t just be ‘experts’, planners or professionals who define ...
2. Into Practice Through Equity-Focused
Planning
• addressing impact of health disparities at system level requires a soli...
Always Plan through a Health Equity Lens
Providers should apply this type of basic
equity lens routinely – from strategic ...
• analyzes potential impact of program or policy change on health
disparities and/or health disadvantaged populations
• us...
3. Success Condition = Better Social
Determinants Data
•pilot project in 3 Toronto hospitals to
collect patient SDoH type ...
4. Use Available Levers: Potential of Equity Plans
16July 29, 2013 | www.wellesleyinstitute.com
• lesson from acute health...
5. Beyond Planning: Embed Equity in Targets, Deliverables,
Performance Management and other System Drivers
• clear consens...
Adapting Public Health Equity Indicators and
Targets
• OPHA/alPHa Working Group has developed indicators
• various nationa...
Challenges: Equity Indicators and Targets
• can’t just measure activity like number or % of priority pop’n that
participat...
6. Aligning Equity in Public Health With Key
System Priorities
• showing how equity will be critical to achieving system g...
Alignment II: to Quality and Person-Centred
Services
• taking social context and living conditions into account are part o...
7. Not Just at Individual Level: Build Equity-Driven
Service Models
peer programs
• CHCs, public health and many community...
23
8. Priority Populations
Target Programs and Resources for Equity Impact
• consistent tradition within PH has been to id...
Drilling Down: How to Focus on Particular
Populations
• defining priority populations
• not just a general or statistical ...
9. Target Barriers
in Toronto and other cities: people without
health insurance
• immigrants in 3 month wait
time, refugee...
Inequitable Access to Preventative Care: Pap
Smears
26
Toronto Public Health: health status indicator
series Sept 2011
Gradient of Health Across Many
Conditions
27
10. Health Promotion Through an Equity
Lens
• need to customize and concentrate health promotion
programs to be effective ...
Build Equity Upstream: Chronic Disease Prevention
and Management
start by identifying populations and
communities at great...
Watch for Unintended Consequences: Health
Promotion
• health promotion that emphasizes individual health behaviour or risk...
Structural Determinants of Health
Inequities -- and Always Local
poor housing, high levels of poverty and
precarious emplo...
11. Key Lever for Acting on SDoH: Cross-Sectoral
Collaboration and Coordination
• can identify community health needs, acc...
Plan Strategically/Act Locally
• clear benefits of comprehensive national/prov health equity strategy:
• but even best nat...
12. Realizing the Potential of Collaboration: Equity
and Community-Driven Local Planning Forums
pre-condition for this kin...
13. Realizing the Potential of Community-Based
Innovation and Initiatives
potential:
• huge number of initiatives already
...
14. Add Public Health Voice: Policy Platforms
and Opportunities
• long tradition of advocating for healthy public policies...
Policy Windows to Advance Health Equity II
cut to particularly important
component of social assistance – in
context of sh...
© The Wellesley Institute
www.wellesleyinstitute.com
15. Shifting the Frame:
Health = Healthy and Equitable Communities
Su...
Back to Community Again: Build Momentum
and Mobilization
• sophisticated strategy, solid equity-focused research, planning...
Health Equity
• could be one of those ‘big’ unifying ideas..
• if we see opportunities for good health and well-being as a...
Key Messages
• health disparities are pervasive and deep-seated – but
can’t let that paralyze us
• do need a comprehensive...
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Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health

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This presentation looks at the opportunities and practices that establish an effective public health system.

Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI

Published in: Health & Medicine, Technology
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Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health

  1. 1. Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health Bob Gardner Ontario Public Health Association Webinar July 25, 2013
  2. 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: particular 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. 3. Outline • health inequities are pervasive and damaging • but these inequities can be addressed through comprehensive health equity strategy and concerted policy and community action • means acting on health equity within the health system • will set out tips, tools and promising ideas on building equity into public health planning and delivery • and acting well beyond healthcare -- tackling the underlying roots of health inequality in the wider social determinants of health • some directions for community-based innovation, cross-sectoral partnerships, and collaborating/advocating for fundamental social and policy change to reduce inequality • again, with examples and opportunities for public health • will also highlight a few unintended consequences and challenges to watch for 3
  4. 4. Canadians With Chronic Conditions Who Also Report Food Insecurity 4
  5. 5. SDoH As a Complex Problem Determinants interact and intersect with each other in constantly changing and dynamic environments In fact, through multiple interacting and inter-dependent economic, social, environmental and health systems Determinants have a reinforcing and cumulative effect on: • individuals throughout their lives • and on communities and population health 5
  6. 6. Planning For Complexity even though roots of health disparities lie in social and economic inequality need to also look at how these other systems shape the impact of SDoH: •access to health services can mediate harshest impact of SDoH to some degree •so too can responsive social services •structure, resources and resilience of communities shape impact and dynamics of inequalities POWER Study: Gender and Equity Health Indicator Framework 6July 29, 2013 | www.wellesleyinstitute.com
  7. 7. Three Cumulative and Inter-Dependent Levels Shape Health Inequities → Different Opportunities for Public Health Action 1. because of inequitable access to wealth, income, education and other fundamental determinants of health → gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions 2. also because of broader social and economic inequality and exclusion → some communities and populations have less infrastructure, resources and resilience to cope with the impact of poor health 3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the healthcare and other systems → these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need 7
  8. 8. Acting on Complexity • contradictions of SDoH analysis: • health inequities can seem so overwhelming and their underlying determinants so intractable → can be paralyzing • are 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 that connects and understands everything • think big, but get going: • 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 8July 29, 2013 | www.wellesleyinstitute.com
  9. 9. 1. Powerful Starting Point = Equity As a Priority Within Public Health 9
  10. 10. + 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 10July 29, 2013 | www.wellesleyinstitute.com
  11. 11. Solid Strategy + 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 community needs into planning • not just as occasional community engagement, but to identify fundamental needs and priorities • and to evaluate how we are doing → need to start from communities and residents + through an equity lens: • how to involve 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 + thinking also about the communities in which they live and the social determinants that shape their opportunities for health 11July 29, 2013 | www.wellesleyinstitute.com
  12. 12. 2. Into Practice Through Equity-Focused Planning • addressing impact of health disparities at system level requires a solid understanding of: • the specific 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 • obvious example – given 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 web of community-based support • requires an array of effective and practical equity-focused planning tools 12
  13. 13. Always Plan through a Health Equity Lens Providers should apply this type of basic equity lens routinely – from strategic to service planning 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 13July 29, 2013 | www.wellesleyinstitute.com 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?
  14. 14. • 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 14
  15. 15. 3. Success Condition = Better Social Determinants Data •pilot project in 3 Toronto hospitals to collect patient SDoH type data – scaled up to all hospitals in Toronto Central •Toronto Public Health was part of pilot •action idea = adapt and scale up provincially • begin to consistently collect SDoH data on all programs, across all PHUs • at best across all sectors •promising practices = Public Health Observatories in UK • consistent and coherent collection and analysis of pop’n health data • interest/development in Western Canada -- Saskatoon Observatory 15
  16. 16. 4. Use Available Levers: Potential of Equity Plans 16July 29, 2013 | www.wellesleyinstitute.com • lesson from acute health care sector = building equity into provider planning is one crucial lever for operationalizing equity • equity priorities will/can be built into Quality Improvement Plans or accountability agreements with LHINs • a promising direction several LHINs have taken up is to require providers to develop equity plans → • identified data and research gaps → began to address • encouraged and institutionalized equity-driven innovation across the institutions • equity increasingly came to be seen as core business
  17. 17. 5. Beyond Planning: Embed Equity in Targets, Deliverables, Performance Management and other System Drivers • clear consensus from research and policy literature, and consistent feature in comprehensive policies on health equity from other countries: • setting targets for reducing access differentials, improving health outcomes of particular populations, etc • developing realistic and actionable indicators for more equitable service delivery and health outcomes • closely monitoring progress against the targets and indicators • tying funding and resource allocation to performance • disseminating the results widely for public scrutiny • all this as part of comprehensive performance measurement and management strategy 17
  18. 18. Adapting Public Health Equity Indicators and Targets • OPHA/alPHa Working Group has developed indicators • various national projects underway to develop equity indicators • PH can move quickly to adapt effective and actionable indicators • don’t need to re-invent the wheel -- adapt from other jurisdictions • 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 • e.g. reducing impact of diabetes is prov priority • equity target = reduce differences in prevalence, complications and rates of hospitalization by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions • also good reform driver = can only be achieved through coordinated action 18
  19. 19. 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 assess impact through equity lens • identify those with greatest need = who programs most need to support and keep to have an impact • are those who need program/support most signing up – reach question? • do they stick with program and what impact did it have on their health – and how does this vary within the pop’n? • then adapt incentives and drivers • develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system • need to measure health outcomes – even when impact only shows up in long- term 19
  20. 20. 6. Aligning 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 • it necessarily involves community-based programs and cross-sectoral collaboration • 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 a common goal to integrate upstream health promotion, primary care and chronic treatment, and hospital, community-based agencies and public health 20
  21. 21. Alignment II: to Quality and Person-Centred Services • taking social context and living conditions into account are part of good service delivery • when people face adverse social determinants of health → can increase risk of mental and physical health illness → fewer resources to cope (from supportive social networks, to good food and being able to afford medication) • providers and programs need to know this to customize and adapt care to SDoH and population needs and contexts • e.g. well-baby care has to be more intensive for poor or homeless women • to get beyond barriers, screening and health promotion has to be delivered in languages and cultures of particular population/community • so focus on priority populations means different types of service mixes to take account of their specific context and needs 21
  22. 22. 7. 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 • e.g. Waterloo has had peer program for over 20 years – nutrition, parenting, social support – partnering with community groups 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 • from provider and funder points of view = more efficient use of scarce resources and better overall coordination • can provide more ‘wrap-around’ integrated services from person’s point of view • based solidly in local communities and responding to local needs and priorities → can become important community ‘space’ and support community capacity building 22July 29, 2013 | www.wellesleyinstitute.com
  23. 23. 23 8. 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 • this requires sophisticated analyses of the bases of disparities: • 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
  24. 24. Drilling Down: How to Focus on Particular Populations • 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 • 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 • however defined, no population or community is ever homogeneous • need to drill down – e.g. youth vs. seniors within Francophone African immigrants -- to identify needs and plan interventions 24July 29, 2013 | www.wellesleyinstitute.com
  25. 25. 9. Target 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 25
  26. 26. Inequitable Access to Preventative Care: Pap Smears 26 Toronto Public Health: health status indicator series Sept 2011
  27. 27. Gradient of Health Across Many Conditions 27
  28. 28. 10. 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 28July 29, 2013 | www.wellesleyinstitute.com
  29. 29. 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 29
  30. 30. Watch for Unintended Consequences: Health Promotion • 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 30
  31. 31. Structural Determinants of Health Inequities -- and 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 31July 29, 2013
  32. 32. 11. Key Lever for Acting on SDoH: Cross-Sectoral Collaboration and Coordination • can identify community health needs, access barriers, fragmentation, service gaps, and how to address them • public health departments and LHINs are pulling together or participating in cross-sectoral planning tables • Local Immigration Partnerships, Social Planning Councils • and coordinated services are particularly important in less advantaged communities with less resources • not just about better coordination and planning • a number of public health units have been pioneering social determinants approaches through broad community collaborations on food security, poverty reduction and other facets of building healthier communities • look beyond vulnerable individuals to the communities in which they live → meeting full range of needs means moving beyond healthcare • focus on community development as part of mandate for many PHUs and CHCs • providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth programs, etc. 32
  33. 33. 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: • 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 • PH working closely with local partners in community collaborations, networks and planning forums 34July 29, 2013 | www.wellesleyinstitute.com
  34. 34. 12. Realizing the Potential of Collaboration: Equity and Community-Driven Local Planning Forums pre-condition for this kind of coordinated action = creating effective cross-sectoral planning forums institutions are also crucial to sustaining broad action needed to address deep-seated structural problems action idea = create local health equity forums with concrete planning mandate Looking for Ideas : SETO •arose out of community concern re access •brings together public health, CHCs, shelters, researchers and service providers serving marginalized communities in south-east Toronto •for an overview of SETo’s development see http://knowledgex.camh.net/researchers/pr ojects/semh/profiles/Pages/seto.aspx •ongoing collaboration and idea sharing → supports service coordination and problem solving •emphasized concrete demonstration projects → many with lasting impact •advocacy with institutions and governments around key issues such as harm reduction, dental care and access for non-insured people 35July 29, 2013 | www.wellesleyinstitute.com
  35. 35. 13. Realizing the Potential of Community-Based Innovation and Initiatives 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? 36
  36. 36. 14. Add Public Health Voice: Policy Platforms and Opportunities • long tradition of advocating for healthy public policies • Healthy Cities movement • linking pop’n health into wide ranging issues -- climate change, city design, transportation • key current direction is Health in All Policies • public health has unique position: • part of local govt – often with MOH on senior mgmt team • 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 37
  37. 37. Policy Windows to Advance Health Equity II cut to particularly important component of social assistance – in context of shift of resources/responsibilities to municipalities also partnership with community agencies and public health – Peterborough extended to developing an on-line tool to track impact of these cuts interest from PHUs to build into their community work 39July 29, 2013 | www.wellesleyinstitute.com
  38. 38. © The Wellesley Institute www.wellesleyinstitute.com 15. Shifting the Frame: Health = Healthy and Equitable Communities Sudbury & other public health videos, flyers, etc. July 29, 2013 | www.wellesleyinstitute.com 40
  39. 39. Back to Community Again: Build Momentum and Mobilization • sophisticated strategy, solid equity-focused research, planning and innovation, and well-targeted investments and services are key • but in the long run, also need fundamental changes in over-arching social policy and underlying structures of economic and social inequality • these kinds of huge changes come about not because of good analysis, but through widespread community mobilization and public pressure • key to equity-driven reform will also be empowering communities to imagine their own alternative vision of different health futures and to organize to achieve them • we need to find ways that governments, providers, community groups, unions, and others can support each others’ campaigns and coalesce around a few ‘big ideas’ 41
  40. 40. Health Equity • could be one of those ‘big’ unifying ideas.. • if we see opportunities for good health and well-being as a basic right for all • if we see the damaged health of disadvantaged and marginalized populations as an indictment of an unequal society • and can show that focused initiatives can make a difference • and demonstrate 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 42
  41. 41. Key Messages • health disparities are pervasive and deep-seated – but can’t let that paralyze us • do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy • think big and think strategically – but get going • have set out a roadmap – of strategies, principles and tools -- to drive equity into action through • 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 43

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