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Advancing Health Equity: Building on Community-Based Innovation


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This presentation offers insights on how to advance health equity by building on community-based innovation.

Bob Gardner, Director of Policy
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Advancing Health Equity: Building on Community-Based Innovation

  1. 1. Advancing Health Equity: Buildingon Community-Based Innovation Bob Gardner Peel Cancer Screening Study: Knowledge Exchange Forum October 20, 2011
  2. 2. Key Messages• health inequities are pervasive and damaging• but these inequities can be addressed through comprehensive health equity strategy• part of this is focusing policy, programs and resources on health disadvantaged populations by: • identifying priority populations and key systemic access barriers • planning the most effective mix of services and support to meet priority populations’ diverse needs• peer health ambassadors is one promising direction that can address the specific needs and barriers faced by particular populations• this kind of community-based innovation on the ground is a crucial part of advancing equity 2
  3. 3. The Problem to Solve = Health Inequities in Ontario•there is a clear gradient in healthin which people with lowerincome, education or otherindicators of social inequality andexclusion tend to have poorerhealth+ major differences betweenwomen and men•the gap between the health ofthe best off and mostdisadvantaged can be huge – anddamaging+ inequitable access to health care•impact and severity of theseinequities can be concentrated inparticular populations 3
  4. 4. Foundations of Health Disparities Roots Lie in Social Determinants of Health•clear research consensus that rootsof health disparities lie in broadersocial and economic inequality andexclusion•impact of inadequate earlychildhood development, poverty,precarious employment, socialexclusion, inadequate housing anddecaying social safety nets on healthoutcomes is well established hereand internationally•we need comprehensive strategy todrive policy action and social changeacross these determinantsOctober 27, 2011 |
  5. 5. Three Cumulative and Inter-Connecting Levels in Which SDoH Shape Health Inequities1. because of inequitable access to 1. gradient of health in which more wealth, income, education and disadvantaged communities have other fundamental determinants poorer overall health and are at of health → greater risk of many conditions2. also because of broader social and 2. some communities and economic inequality and populations have fewer capacities, exclusion→ resources and resilience to cope with the impact of poor health3. because of all this, disadvantaged 3. these disadvantaged and and vulnerable populations have vulnerable communities tend to more complex needs, but face have inequitable access to services systemic barriers within the health and support they need and other systems →5
  6. 6. POWER Study Gender and Equity Health Indicator Framework Highlights1. How better access/care within health system can make a difference to most vulnerable2. Why we need to take SDoH into account in health service planning and delivery3. How the structure, resources and resilience of communities mediate the impact of SDoH 6
  7. 7. Think Big, But Get Going• challenge = health inequities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing → do need comprehensive social and economic strategy and action to address the foundations and impact of health inequities• think big and think strategically, but get going• need to start somewhere: • even though roots of health disparities lie in far wider social and economic inequality, the health system is still crucial to tackling health disparities • it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care • in addition, there are systemic disparities in access and quality of healthcare that need to be addressed• we want to ensure equitable access to high quality care• focus today is on engaging with and providing key preventative services and support to meet needs of particular populations 7
  8. 8. Specific Problem to Solve: Inequitable Access to Preventive Health Services100 88.4 83.6 80 78.4 65.7 66.7 60 48.4 44.7 White South Asian 40 29.2 20 0 General Practitioner Prostate-Specific Antigen Blood Test Mammogram Pap smear
  9. 9. High-Level: Health Equity Strategy Into Action1. building health equity into all health care planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach2. aligning equity with system drivers and priorities – such as chronic disease prevention and management, quality3. embedding equity in provider organizations’ deliverables, incentives and performance management4. 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 • looking to improve the health of most disadvantaged, fastest5. while investing up-stream in health promotion and addressing the underlying determinants of healthOctober 27, 2011 9
  10. 10. Drilling Down: Solutions for Particular Populations• taking social context and living conditions into account are part of good service delivery • health disadvantaged populations have more complex and greater needs for services and support → continuum of care especially important • also face greater barriers – e.g. availability/cost of transportation, childcare, language, discrimination → facilitated access is especially important • 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 population needs and social contexts: • health promotion and care have to be delivered in languages and cultures of particular population/community • focus in ECFAA on patient-centred care: → means taking the full range of people’s specific needs into account → more intensive case management, referral planning and post-discharge follow- up in acute side + targeted efforts to reach populations facing access barriers 10
  11. 11. Part of the Solutions: Community-Driven Innovationpublic health and many community providers have established‘peer health ambassadors’ to provide systemnavigation, outreach and health promotion services to particularcommunitiesPeer Health Ambassadors• Members of the community, from the community• Working with established healthcare providers to improve access and quality of care for targeted populations• including improving access to preventative screening 11
  12. 12. Wellesley Research ProjectPurpose• Survey the range and impact of Peer Health Ambassadors• Assess their potential to meet needs of marginalized populations• Identify key success conditions and enablers to realize this potentialMethods• Review of literature• Key informant interviews with 10 Toronto community organizations currently working with peer-based models 12
  13. 13. Findings: Great Potential• Peer Health Ambassadors are a promising model for improving health equity through eliminating barriers to health care and improving engagement • considerable variation in role, level of expertise and “peerness” • three broad areas -- navigating the system, health promotion, and as integrated into comprehensive service provision• Marginalized groups prefer healthcare providers who have personal experience with their problems, who understand their viewpoints, and who share key traits (race, gender, religion, sexuality, cancer, drug use, etc.)• When community impact is reported, the results are generally very positive 13
  14. 14. Findings: Facilitators to Effectiveness and Impact• Financial compensation• Initial and ongoing training/support/mentoring for peers• Clear roles and division of labour + flexibility to accommodate dynamic needs of both peers and communities being served• Participation of peers in program or service planning and development• Rigorous quality assurance at every stage• Program evaluation to improve practices 14
  15. 15. Findings: Barriers• Peer life-stage, ability to adapt their own health and lifestyle to work environment• Breach of peers’ personal boundaries by clients and co-workers, because of the highly personal nature of this work• Organizational capacity to support peer needs, service demands and client expectations• Client preferences for credentialed professionals or specific delivery settings• Resistance from professionals or institutions to community-based delivery• Unstable funding• Challenges in scaling up 15
  16. 16. Realizing the Potential of Peer Health Ambassador Initiatives• Enlist service users and community in planning and development• Provide ongoing training and support, driven by peer and community needs• Provide financial compensation, even during training• Allow for adaptability and flexibility of training and program to suit the needs of peer workers and clients• Monitor quality• Market the services using mediums that can reach the target population• Link into coordinated continuum of services and support to communities facing poorer access• Actively pursue alternative funding sources – beyond rigid project funding from government sources• Evaluate to understand what ‘works’ – for which particular populations, in what contexts – and build this learning into continuous improvement 16
  17. 17. Building on the Potential of Community-Based Innovation and Initiatives• potential: • huge number of community and front-line initiatives already addressing equity across province • + equity focused planning through HEIA or other tools 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 17
  18. 18. Key Messages• Need comprehensive strategy to address health inequities• Part of this is ensuring equitable access to high-quality care for all• Part of this is always addressing specific problems facing specific populations – inequitable access to cancer screening for particular communities• Peer ambassador type initiatives have shown great potential in being able to reach, support and involve marginalized populations 18
  19. 19. Following Up• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at• my email is• 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 19
  20. 20. Wellesley Roadmap for Action on the Social Determinants of Health1. 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; 20
  21. 21. Wellesley Roadmap II6 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: • making equity a core objective and driver of health system reform – every bit as important as quality and sustainability; • eliminating unfair and inefficient barriers to access to the care people need; • 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: • enhanced primary care for the most under-served or disadvantaged populations; • integrated health, child development, language, settlement, employment, and other community-based social services; 21
  22. 22. Wellesley Roadmap III9 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. 22