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

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. 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. 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. Canadians With Chronic Conditions
Who Also Report Food Insecurity
4

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. 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
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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. 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
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9. 1. Powerful Starting Point = Equity As a Priority
Within Public Health
9

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
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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
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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. 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
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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. • 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. 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. 4. Use Available Levers: Potential of Equity Plans
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• 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. 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. 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. 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. 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. 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. 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
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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. 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
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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. Inequitable Access to Preventative Care: Pap
Smears
26
Toronto Public Health: health status indicator
series Sept 2011

27. Gradient of Health Across Many
Conditions
27

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
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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. 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. 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. 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. 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
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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
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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. 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. 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
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38. © The Wellesley Institute
www.wellesleyinstitute.com
15. Shifting the Frame:
Health = Healthy and Equitable Communities
Sudbury & other public health
videos, flyers, etc.
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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. 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. 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