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Driving Health Equity Into Action: Policy Change and Community Mobilization to Address the Social Determinants of Health Bob Gardner Ryerson University Promoting Health Equity Conference February 12, 2011
[object Object]
will set out how these disparities can be addressed through comprehensive health equity strategy
acting on health equity within the health system
building equity into all planning and delivery
targeting some programs and resources for equity impact
aligning equity with key system drivers
embedding equity in performance management and service delivery
and well beyond healthcare -- tackling the underlying roots of health inequality in the wider social determinants of health
through community-based innovation, cross-sectoral collaborations and fundamental social and policy change to reduce inequality
community and political mobilization to demand and drive the necessary policy changesOutline 2
The Challenge = Health Disparities in Ontario ,[object Object]
+ major differences between women and men
the gap between the health status of the best off and most disadvantaged can be huge – and damaging
in addition, there are systemic disparities in access to and quality of care within the health care system3
4
5
6
Impact of Disparities inequality in how long people live ,[object Object]
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 7
8 www.welleseyinstitute.com Foundations of Health Disparities Roots Lie in Social Determinants of Health  ,[object Object]
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,[object Object]
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 health9
Planning For Complexity of SDoH POWER Study Gender and Equity Health Indicator Framework 10
Health Equity = Reducing Unfair Differences ,[object Object]
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,[object Object]
but health disparities can seem so overwhelming and their underlying social determinants so intractable -> can be paralyzing
think big and think strategically, but get goingmake best judgment from evidence and experience identify actionable and manageable initiatives that can make a difference experiment and innovate --- learn lessons and adjust gradually build up coherent sets of policy and program actions – and keep evaluating ,[object Object],building equity into health system and the wider context of addressing the social determinants of health through community action and policy change
[object Object]
how the health system is organized and how services and care are delivered is still crucial to tackling health disparities
consistent theme in WHO, EU and all the major international reports and in the many countries that have developed comprehensive multi-sectoral strategies to reduce health disparities
in all of them, transforming the health system is an indispensable element, including:reducing barriers to equitable access to high quality care targeted interventions to improve the health of the poorest, fastest up-stream investments in primary and preventative care directed to most vulnerable delivering a full continuum of services in coordinated way at community/local level Equity Into Health System: Why 13
it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care ,[object Object],in addition, there are systemic disparities in access and quality of healthcare that need to be addressed ,[object Object]
unless we address inequitable access and quality, healthcare and community support services could make overall disparities even worseEquity Into Health System: Why II 14
[object Object]
can do this through a three pronged strategy: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 aligning equity with system drivers and embedding it in provider organizations and performance management  targetingsome 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 Equity Into Health System: How 15
Equity Into Health System: How II while health disparities are pervasive and deep-rooted, they can be changed through policy and program action comprehensive strategy developed in 2008 for Toronto Central LHIN many recommendations have been acted on other LHINs are also prioritizing and moving to address health disparities  16
Start From The Community ,[object Object]
can’t just be ‘experts’, planners or professionals
have to build community into core planning and priority setting
not as occasional community engagement
but to identify equity needs and priorities
and to evaluate how we are doing

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Driving Health Equity into Action: Policy Change and Community Mobilization to Address the Social Determinants of Health

  • 1. Driving Health Equity Into Action: Policy Change and Community Mobilization to Address the Social Determinants of Health Bob Gardner Ryerson University Promoting Health Equity Conference February 12, 2011
  • 2.
  • 3. will set out how these disparities can be addressed through comprehensive health equity strategy
  • 4. acting on health equity within the health system
  • 5. building equity into all planning and delivery
  • 6. targeting some programs and resources for equity impact
  • 7. aligning equity with key system drivers
  • 8. embedding equity in performance management and service delivery
  • 9. and well beyond healthcare -- tackling the underlying roots of health inequality in the wider social determinants of health
  • 10. through community-based innovation, cross-sectoral collaborations and fundamental social and policy change to reduce inequality
  • 11. community and political mobilization to demand and drive the necessary policy changesOutline 2
  • 12.
  • 13. + major differences between women and men
  • 14. the gap between the health status of the best off and most disadvantaged can be huge – and damaging
  • 15. in addition, there are systemic disparities in access to and quality of care within the health care system3
  • 16. 4
  • 17. 5
  • 18. 6
  • 19.
  • 20. 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
  • 21. even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women Statistics Canada Health Reports Dec 09 7
  • 22.
  • 23. 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
  • 24.
  • 25. In constantly changing and dynamic system
  • 26. In fact, through multiple interacting and inter-dependent economic, social and health systems
  • 27. Determinants have a reinforcing and cumulative effect on individual and population health9
  • 28. Planning For Complexity of SDoH POWER Study Gender and Equity Health Indicator Framework 10
  • 29.
  • 31. is clear, understandable and actionable
  • 32. identifies the problem that policies will try to solve
  • 33. is also tied to widely accepted notions of fairness and social justice
  • 34. The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes
  • 35. A positive and forward-looking definition = equal opportunities for good health
  • 36.
  • 37. but health disparities can seem so overwhelming and their underlying social determinants so intractable -> can be paralyzing
  • 38.
  • 39.
  • 40. how the health system is organized and how services and care are delivered is still crucial to tackling health disparities
  • 41. consistent theme in WHO, EU and all the major international reports and in the many countries that have developed comprehensive multi-sectoral strategies to reduce health disparities
  • 42. in all of them, transforming the health system is an indispensable element, including:reducing barriers to equitable access to high quality care targeted interventions to improve the health of the poorest, fastest up-stream investments in primary and preventative care directed to most vulnerable delivering a full continuum of services in coordinated way at community/local level Equity Into Health System: Why 13
  • 43.
  • 44. unless we address inequitable access and quality, healthcare and community support services could make overall disparities even worseEquity Into Health System: Why II 14
  • 45.
  • 46. can do this through a three pronged strategy: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 aligning equity with system drivers and embedding it in provider organizations and performance management targetingsome 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 Equity Into Health System: How 15
  • 47. Equity Into Health System: How II while health disparities are pervasive and deep-rooted, they can be changed through policy and program action comprehensive strategy developed in 2008 for Toronto Central LHIN many recommendations have been acted on other LHINs are also prioritizing and moving to address health disparities 16
  • 48.
  • 49. can’t just be ‘experts’, planners or professionals
  • 50. have to build community into core planning and priority setting
  • 51. not as occasional community engagement
  • 52. but to identify equity needs and priorities
  • 53. and to evaluate how we are doing
  • 54. how:
  • 55. many hospital have community advisory panels
  • 56. CHCs have community members on their boards
  • 57. innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries
  • 58. community-based research, needs assessment and evaluation17
  • 59.
  • 60. cascading down to all providers prioritizing equity in their overall strategic plans and then into service delivery and resource allocation18
  • 61.
  • 62.
  • 63. provincial priorities – e.g. diabetes, wait times, mental health, ALCs – are all sensitive to social conditions and will not be achieved unless planning/delivery takes equity into account19
  • 64.
  • 65. key barriers to equitable access to high quality care
  • 66. the specific needs of health-disadvantaged populations
  • 67. gaps in available services for these populations
  • 68. need to understand roots of disparities:
  • 69. i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc.
  • 70. which requires good local research and detailed information – speaks to great potential of community-based research
  • 71. involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems
  • 72. requires an array of effective and practical equity-focused planning tools20
  • 73.
  • 74.
  • 75.
  • 76. setting targets for reducing access barriers, improving health outcomes of particular populations, etc
  • 77. developing realistic and actionable indicators for service delivery
  • 78. closely monitoring progress against the targets and indicators
  • 79. disseminating the results widely for public scrutiny
  • 80. tying funding and resource allocation to performance22
  • 81.
  • 82. key lever = all hospitals, CHCs and other providers sign Service Accountability Agreements with LHINs that govern flow of funds
  • 83. can build specific expectations and deliverables into those agreements
  • 84. will vary by community and provider -- but could include:
  • 85. undertaking appropriate equity-focused planning to identify areas where access to services is inequitable and developing plans to address barriers and gaps
  • 86. stratifying quality indicators by equity – e.g. reducing hospital readmission rates is common objective->equity angle is to reduce any inequitable differences in readmission rates by language ability or neighbourhood Embed Equity In Performance Management 23
  • 87.
  • 88. build equity into existing targets:
  • 89.
  • 90.
  • 91. identify access barriers, disadvantaged populations, service gaps and opportunities in their catchement areas and spheres
  • 92. develop programs and services to address those gaps and better meet healthcare needs of disadvantaged communities
  • 93. these provider plans have the potential to:
  • 94. raise awareness of equity within the organizations
  • 95. build equity into planning, resource allocation and routine delivery
  • 96. pull their many existing initiatives together into a coherent overall equity strategy
  • 97. build connections among providers for addressing common equity issuesUse Promising Tools/Levers: Equity Plans 25
  • 99.
  • 100.
  • 101. 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
  • 102. three hospitals are collaborating on how to collect and incorporate equity data
  • 103. but don’t wait for perfect data
  • 104. hospitals have been using postal code data as proxy for income
  • 105. idea = no health research that doesn’t include SDoH dataPrecondition: Equity-Relevant Data 27
  • 106.
  • 107.
  • 108. poor neighbourhoods with high % of racialized population in many big cities
  • 111. solid evidence that enhancing primary care is one of key ways to improve care of disadvantaged
  • 112.
  • 113. South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America
  • 115. risk increases with time since immigrationCreatore et al CMAJ Aril 19, 2010 Target Populations 29
  • 116.
  • 117. LHINs need to specifically require hospitals to ensure interpretation is available in languages of their community
  • 118. need to fund centralized interpretation services to support smaller agencies
  • 119. in some other areas, distance and isolation are the critical determinants
  • 120. in Toronto and other cities: people without health insurance – primarily immigrants/refugees:
  • 121. many community initiatives to provide access
  • 122. Women’s College Hospital Network on Noninsured is forum for coordination
  • 123. recently held research conference showing critical barriers to access and good care and resulting adverse health outcomes for vulnerable people
  • 124. equity is complex – ‘wicked’ policy problems
  • 125. but not all of it = avoidable disparities and workable solution
  • 126. eliminate the three month wait for OHIP for new immigrants30
  • 127. Canadians With Chronic Conditions Who Also Report Food Insecurity 31
  • 128.
  • 129. up-stream initiatives need to be planned and implemented through an equity lensvery clear gradient in incidence – and impact – of chronic conditions some populations and communities have fewer resources to prevent and manage chronic conditions need to build this greater need for support into CDPM planning and resource allocation a very interesting primer has been developed by Health Nexus, the Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support
  • 130.
  • 131. 34
  • 132.
  • 133. patient-centred care means taking the full range of people’s specific needs into accountsocial context and living conditions are part of this when people face adverse social determinants of health -> can increase risk of mental and physical health challenges and 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 needs and contexts more intensive case management, referral planning and post-discharge follow-up 35
  • 134.
  • 135. explicitly geared to supporting people from marginalized communities
  • 136. comprehensive multi-disciplinary services covering full range of needs-> look beyond vulnerable individuals to the communities in which they live have to take SDoH into account in program design -> meeting full range of needs means moving beyond healthcare focus on community development as part of mandate providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth support, etc. 36
  • 137.
  • 138.
  • 139. but what sectors? for what purposes?
  • 140. addressing wider SDoH is the glue for collaboration into action
  • 141. public health departments and LHINs are pulling together or participating in cross-sectoral planning tables -> Prov should make this an explicit expectation
  • 142. Local Immigration Partnerships , Social Planning Councils
  • 143. the Ministry of Health Promotion and Sport is developing a healthy communities strategic approach
  • 144. cross-sectoral planning to ground health promotion
  • 145. at best, this implies wider community development and capacity building approaches38
  • 146.
  • 147.
  • 148. health equity strategies in European and other leading jurisdictions combine:
  • 149. national level macro strategies to reduce social health inequalities
  • 150. with local or regional implementation and adaptation
  • 151. British example: Health Action Zones and other models were designed to combine community economic development with targeted healthcare and social service improvements
  • 152. that is the potential of LHINs and RHAs-> build equity into regional planning and coordination
  • 153.
  • 154. broad partnerships of local residents, community organizations, governments, business, labour and other stakeholders
  • 155. coming together to address deep-rooted local problems – poverty, neighbourhood deterioration
  • 156. collaborative cross-sectoral efforts – for poverty reduction, community development, health disparities
  • 157. Vibrant Communities – 14 communities across the country to build individual and community capacities to reduce poverty
  • 158. Wellesley review of evidence = these initiatives have the potential to build:
  • 160. awareness of structural nature of poverty
  • 161. local mobilization -> into policy advocacy41
  • 162.
  • 163.
  • 164.
  • 165. e.g. Ministries, LHINs and other public bodies always considering SDoH in strategic and program planning -- from where to locate primary care to how to design health promotion
  • 166. and more ‘joined-up’ policy processes:
  • 168. led from central authorities
  • 170.
  • 171. Community Health Centres, community mental health, community organizations based out of specific ethno-cultural communities
  • 172. e.g. many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities
  • 174. CAISI database so records are accessible from many providers
  • 175. travelling psychiatrists, nurses and other providers
  • 176. my Baby and Me passport
  • 177. Street Health report as community-based research into action
  • 178. this progressive service delivery = beacon of inspiration for other sectors + constant living demonstration that action is possible
  • 179. but not being systemically shared or built upon ….44
  • 180.
  • 181. collate and analyze all the useful intelligence gained from equity-focused planning
  • 182. capture and share information on local initiatives, and build on local front-line insights
  • 183. share the resulting knowledge across regions – and beyond
  • 184. assess the most promising initiatives or directions rigorously
  • 185. scale up promising initiatives across the province where appropriate
  • 186. need to create forums and infrastructure for this innovation knowledge management
  • 187. and need to build equity-focused innovation into incentives and drivers -- cascading from Prov to LHINs to providers
  • 188. expectation that X% of budget will be devoted to equity-orientated innovation
  • 189. ear-marked funds for equity innovation45
  • 190.
  • 191. but in the long run, also need fundamental changes in over-arching state social policy and underlying structures of economic and social inequality
  • 192. these kinds of huge changes come about not because of good analysis but through widespread community mobilization and public pressure
  • 193. 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
  • 194. 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’46 February 11, 2011
  • 195.
  • 196. and showing that we can get there from here47 February 11, 2011
  • 197.
  • 198. do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy
  • 199. think big and think strategically – but get going
  • 200. there is a solid base of evidence, provider experience, commitment and community connections to build on
  • 201. have set out a roadmap – of strategies, principles and tools -- to drive equity into action through policy change and community mobilization
  • 202. many within the health system and beyond have long experience and strong commitment to equity -> build on this to drive coordinated and coherent system-wide equity agenda into action
  • 203. work in partnerships and collaborations well beyond the health care system to address the underlying determinants of health inequalities48
  • 204.
  • 205. my email is bob@wellesleyinstitute.com
  • 206. 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 equityFollowing Up 49
  • 207. Wellesley Roadmap for Action on the Social Determinants of Health look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 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; develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; act across silos – inter-sectoral and cross-government collaboration and coordination are vital; set and monitor targets and incentives – cascading through all levels of government and programme action; 50
  • 208.
  • 209. eliminating unfair and inefficient barriers to access to the care people need;
  • 210.
  • 211. integrated health, child development, language, settlement, employment, and other community-based social services;51
  • 212. Wellesley Roadmap III 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. 52
  • 213. © The Wellesley Institute www.wellesleyinstitute.com 53

Editor's Notes

  1. Out: health equity is all about reducing inequalities in health outcomesneed to start by understanding nature, impact and roots of current health disparities
  2. that’s the problem we are trying to solve
  3. mental health is crucial component of overall well-being – also major provincial prioritysame social gradient of mental health
  4. key point is gradient in alldiabetes is key prov and central priority – almost 3x incidence in lower income as high
  5. getting more specific on concrete impact of health disparities on quality of livesactivities of ¼ of low income people are limited by pain = 2X than high income
  6. In: that's impact on daily livesthat type of impact adds up over people's lives
  7. so search for pathways from particular determinants to health effects is illusionaryintroduce term if needed to further illustrate complexity of landscape? 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 natureOut: what is the impact of all this?
  8. another way of looking at this complexity and what to do about itcommunity resilience and capacities operates at key intersections herethis highlights that SDoH can be driven into action on the ground through:community-based development or capacity building e.g. community development workers in many CHCscross-sectoral collaborations – many local mh groups and networkscross-sectoral planning tables and processesto drive local coordinated action e..g comprehensive community initiatives such as Vibrant Communities or common pattern in European health equity strategies of concentrated/coordinated local investment/focus
  9. theme – learning from others
  10. Principle applies throughout system – at provider and often at program level as well
  11. practical local example – esp. impt to UHN
  12. openingsmany hospitals have CABs or panelsLHINs are mandated to undertake community engagement
  13. opportunistic = greater chance of success for equity strategy if aligned with
  14. Sick Kids analysis of patients by neighbourhood income levelneed to match tools to purpose
  15. theme: use levers to hand – Ls can require use of such tools
  16. recognizing that what gets measured, matters
  17. appropriate -- meaning especially that every plan need not be huge and cannot add excessively to agency workload
  18. In: analysis of 18 TCL hospital equity plansstay tuned – we are currently analyzing the refreshes all hospitals did and will be reporting in springOut: a major focus of this report was how to build equity into performance management
  19. not just being an immigrantbut where people came from and what conditions they find themselves in here:more precarious position in labour marketfacing racism and dynamics of social exclusion
  20. could hook up to this – or at least keep it on horizoncould also link into Healthcare Interpreters Network
  21. reinforcing nature of social determinants on health disparitiessignificance for key priority = crucial part of managing diabetes esp. is good nutrition
  22. same principle applies – working up-stream to prevent people getting sick and needing more acute treatmentwatch for opportunities for collaborative planning and action as MHP rolls out this approach
  23. one leading example Sudbury
  24. and identify issue for wider collaboration and advocacy
  25. many jurisdictions: Italian example for immigrant pop’nscould consider for Central for any expansion
  26. how many involved in planning with LHINs?
  27. how many involved in planning with LHINs?
  28. In: based upon extensive international and Cdn researchthis is quick overviewall these issues are complex and are analyzed in more detail elsewheremy experience is more in health policy, but most of these actions are not set in health system itselfwill detail some more fully that intersect with your sectors and challenges
  29. SSM was one of these big ideas and tremendous work of AOHC and allies
  30. summary again