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Thinking About Health Equity/
   Acting on Health Equity
                Bob Gardner
     Medical and Health Sciences Forum
           University of Toronto
              January 26, 2012
Key Messages
• health disparities are pervasive and damaging
• 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 changes



                                                                              2
The Problem to Solve = Health
            Disparities in Ontario
•there is a clear gradient in health
in which people with lower
income, education or other
indicators of social inequality and
exclusion tend to have poorer
health
•+ major differences between
women and men
•the gap between the health of
the best off and most
disadvantaged can be huge – and
damaging
•impact and severity of these
inequities can be concentrated in
particular populations


                                        3
Gradient of Health Across Many
              Conditions




4
Impact of Health Inequities




5
Impact of Health Inequities II
• not just a gradient of health and impact on quality
  of life
• inequality in how long people live
          • difference btwn life expectancy of top and bottom
            income decile = 7.4 years for men and 4.5 for women
          • 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


6
Foundations of Health Disparities Roots Lie in
        Social Determinants of Health

•clear research consensus that roots
of health disparities lie in broader
social and economic inequality and
exclusion

•impact of inadequate early
childhood development, poverty,
precarious employment, social
exclusion, inadequate housing and
decaying social safety nets on health
outcomes is well established here
and internationally

•we need comprehensive strategy to
drive policy action and social change
across these determinants


January 30, 2012 |
                                                   7
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Canadians With Chronic Conditions
 Who Also Report Food Insecurity




                                    8
SDoH As a Complex Problem
Determinants interact and
intersect with each other in a
constantly changing and
dynamic system
In fact, through multiple
interacting and inter-
dependent economic, social
and health systems
Determinants have a
reinforcing and cumulative
effect on individual and
population health
                                 9
Three Cumulative and Inter-Connecting Levels
    in Which SDoH Shape Health Inequities
1.   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 conditions

2.   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 health


3.   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 →

10
Health Inequities = ‘Wicked’ Problem
•    health inequities and their underlying social determinants of health are classic
     ‘wicked’ policy problems:
      • shaped by many inter-related and inter-dependent factors
      • in constantly changing social, economic, community and policy environments
      • action has to be taken at multiple levels -- by many levels of government,
         service providers, other stakeholders and communities
      • solutions are not always clear and policy agreement can be difficult to achieve
      • effects take years to show up – far beyond any electoral cycle
•    have to be able to understand and navigate this complexity to develop solutions
•    we need to be able to:
      • identify the connections and causal pathways between multiple factors
      • articulate the mechanisms or leverage points that will drive change in these
         pathways and in population health as a whole
      • analyze the policy changes needed to act on these levers
      • specify the short, intermediate and long-term outcomes expected and the
         preconditions for achieving them.



January 30, 2012                                                                      11
Think Big, But Get Going
• challenge = health inequities can seem so overwhelming and
  their underlying social determinants so intractable → can be
  paralyzing
• think big and think strategically, but get going
   • make best judgment from evidence and experience
   • identify actionable and manageable initiatives that can make a
      difference
   • experiment and innovate
   • learn lessons and adjust – why evaluation is so crucial
   • gradually build up coherent sets of policy and program actions –
      and keep evaluating
• need to start somewhere:
   • focus today is on engaging with and providing services and
      support to meet needs of priority populations
   • which & where depends on analysis of needs, resources, gaps
      and opportunities, and community resources and structures

                                                                    12
Health Equity = Reducing Unfair
               Differences
• Health disparities or inequities are differences in health outcomes that
  are avoidable, unfair and systematically related to social inequality and
  disadvantage

• This concept:
    • is clear, understandable and actionable
    • identifies the problem that policies will try to solve
    • is also tied to widely accepted notions of fairness and social justice

• The goal of health equity strategy is to reduce or eliminate socially and
  institutionally structured health inequalities and differential outcomes

• A positive and forward-looking definition = equal opportunities for good
  health
• Equity is a broad goal, including diversity in background, culture, race
  and identity
Planning For
Complexity of SDoH


Need to look at how
these other systems
shape the impact of
SDoH:
      •access to health
      services can mediate
      harshest impact of
      SDoH to some degree
      •community resources
      and resilience are impt

POWER Study: Gender and
Equity Health Indicator Framework

January 30, 2012 |
                                    14
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Equity Into Health System: Why
• even though roots of health disparities lie in far wider social
  and economic inequality
• 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

                                                                            15
Equity Into Health System: Why II
1. it’s in the health system that the most
   disadvantaged in SDoH terms end up sicker and
   needing care
  • equitable healthcare and support can help to mediate the
    harshest impact of the wider social determinants of health on
    health disadvantaged populations and communities
2. in addition, there are systemic disparities in access
   and quality of healthcare that need to be
   addressed
  •   people lower down the social hierarchy can have poorer
      access to health services, even though they may have more
      complex needs and require more care
  •   unless we address inequitable access and quality, healthcare
      and community support services could make overall
      disparities even worse

                                                                     16
Equity Into Health System: How
• goal is to ensure equitable health regardless of social
  position
• can do this through a multi-pronged strategy:
      1.        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 outreach
      2.        aligning equity with system drivers and priorities
      3.        embedding equity in provider organizations’ deliverables, incentives
                and performance management
      4.        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
      5.        while thinking up-stream to health promotion and addressing the
                underlying determinants of health

January 30, 2012                                                                                 17
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




                                                    18
Start From The Community
• goal is to reduce health disparities and speak to needs of
  most vulnerable communities – who will define?
• 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
• how:
     • many hospital have community advisory panels
     • CHCs have community members on their boards
     • innovative methods of engagement – e.g. citizens’ assemblies or
       juries in many countries
     • community-based research, needs assessment and evaluation

19
And Start From a Solid Strategic
                 Commitment
• need to make equity one of driving priorities for health
  system and reform
   • equity and a population health focus are among key principles enshrined in
     new Excellent Care for All Act = opening and context
• need clear provincial strategy for equity:
   • implicit from MOHLTC, but promised ten year strategy has not been released
   • equity and population health are in public health standards
   • need strategic coherence across health system in approach to equity
• LHINs, CCACs, and other coordinating agencies need to
  prioritize equity – and many have
• cascading down to all providers prioritizing equity in their
  overall strategic plans and then into service delivery and
  resource allocation
                                                                                  20
Align Equity With Health System Drivers
•    Excellent Care For All Act and quality agenda
•    providers have to develop Quality Improvement Plans
      • hospitals first reported April 2011
      • other providers will report in subsequent years
      • equity should be developed as one of dimensions to report on – but
         wasn’t really in frost hospital plans
•    patient-centred care → means taking the full range of people’s specific
     needs into account → customizing delivery and quality for more health
     disadvantaged populations with greater/more complex needs
•    improving safety requires addressing equity barriers
      • inadequate interpretation services can lead to mis-diagnoses, people not
         being able to follow medication, etc.
•    provincial priorities – e.g. diabetes, wait times, mental health, ALCs are all
     much affected by inequitable health and access – and will not be achieved
     unless planning/delivery takes equity into account

21
Into Practice Through Equity-Focused Planning

• addressing health disparities in service delivery and planning
  requires a solid understanding of:
     • key barriers to equitable access to high quality care
     • the specific needs of health-disadvantaged populations
     • gaps in available services for these populations
• need to understand roots of disparities:
     • i.e. is the main problem language barriers, lack of coordination among
       providers, sheer lack of services in particular neighbourhoods, etc.
     • which requires good local research and detailed information – speaks
       to great potential of community-based research
     • involvement of local communities and stakeholders in planning and
       priority setting is critical to understanding the real local problems
• requires an array of effective and practical equity-focused
  planning tools

22
Health Equity Impact Assessment
• increasing attention to potential – from WHO, through most European
  strategies, PHAC, to MOHLTC and LHINs
• planning tool that analyzes potential impact of program or policy change
  on health disparities and/or health disadvantaged populations
    •   can help to plan new services, policy development or other initiatives
    •   can also be used to assess/realign existing programs
    •   intended to be relatively easy-to-use tool
    •   essentially prospective, helping plan forward
• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI
    • HEIA is being used in Toronto Central and other LHINs and providers across the
      province
    • Toronto Central has required HEIA within recent funding application processes
      for Aging at Home, and refreshing hospital equity plans
    • required in last generation of TC hospital equity plans and many hospitals are
      extending its use

                                                                                  23
Beyond Planning: Embed Equity in System
          Performance Management
• clear consensus from research and policy literature, and
  consistent feature in comprehensive policies on health equity
  from other countries:
   • setting targets for reducing access barriers, improving health
      outcomes of particular populations, etc
   • developing realistic and actionable indicators for service delivery
      and health outcomes
   • tying funding and resource allocation to performance
   • closely monitoring progress against the targets and indicators
   • disseminating the results widely for public scrutiny
• need comprehensive performance measurement and
  management strategy
• then choose appropriate equity targets and indicators for
  particular populations/communities

                                                                      24
Success Condition: Effective Equity Targets
• innovative work underway to develop equity indicators – but don’t need
  to wait
• build equity into existing targets:
     • reducing diabetes incidence is prov and LHIN priority
      → equity target = reduce differences in incidence, complications and rates of
        hospitalization between populations or areas
     • a good service target has been proposed for diabetes = high/increasing % of
        people who get best standard care
     → reduce differences by gender, income, ethno-cultural background
• need to drill down in specific areas that have high equity impact:
     → ensuring access and use of primary health care does not vary inequitably by
       income level, immigration status, neigbourhood, gender, race, etc.
• many programs assess their services through client satisfaction surveys
  and look for high and improving satisfaction
     → reduce any differences in satisfaction by gender, income, ethno-cultural
       background, etc.


25
Challenges: Equity Targets That Work
•   can’t just measure activity:
      • number or % of priority pop’n that participated in program
      • need to measure health outcomes – even when impact only shows up in long-
        term
      • so if theory of change for health program begins with enabling more exercise
        or healthier eating – then we measure that initial step
•   need to assess reach
      • who isn’t signing up? who needs program/support most?
     • who stuck with program and what impact it had on their health – and how this
        varies within the pop’n
•   and assess impact through equity lens
      • need to differentiate those with greatest need = who programs most need to
        support and keep to have an impact
•   then adapt incentives and drivers
      • develop weighting that recognizes more complex needs and challenges of
        most disadvantaged, and builds this into incentive system



                                                                                  26
Success Condition = Better Data

•looking abroad for promising practices =
Public Health Observatories in UK
    •   consistent and coherent collection and
        analysis of pop’n health data
    •   specialization among the Observatories
        – London focuses on equity issues
•interest/development in Western Canada
•national project to develop health
disparity indicators and data
•Toronto PH is addressing complexities of
collecting and using race-based data
•key direction = explore potential of
equity/SDoH data for Ontario
•pilot project in 3 Toronto academic
hospitals to collect equity data

                                                 27
Use Available Levers: Equity Plans

• a promising direction several LHINs have taken up is to require providers
  to develop equity plans
     • hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation
        in TC
     • and other providers in Central
     • CHCs have developed a sector-wide plan in GTA
•   these plans are designed to:
     • identify access barriers, disadvantaged populations, service gaps and
        opportunities in their catchement areas and spheres
     • develop programs and services to address those gaps and better meet
        healthcare needs of disadvantaged communities
• these provider plans have the potential to:
     • raise awareness of equity within the organizations
     • build equity into planning, resource allocation and routine delivery
     • pull their many existing initiatives together into a coherent overall equity
       strategy
     • build connections among providers for addressing common equity issues

                                                                                        28
Toronto Central LHIN Hospital Equity Plans
                       http://www.torontoevaluation.ca/tclhinrefresh




January 30, 2012 |
                                                                       29
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Target Investment for Equity Impact
• target services to:
    • those facing the harshest disparities – to raise the worst off fastest
    • or most in need of specific services
    • or the worst barriers to equitable access to high-quality services
• this requires resources
    • lever = certain % of LHIN budgets to be equity targeted
• this requires sophisticated analyses of the bases of disparities:
    • i.e. is the main problem language barriers, lack of coordination among
      providers, sheer lack of services in particular neighbourhoods, etc.
    • which requires good local research and detailed information – speaks to great
      potential of community-based research to provide rich local needs
      assessments and evaluation data
    • involvement of local communities and stakeholders in planning and priority
      setting is critical to understanding the real local problems

                                                                  30
Target Populations
•    vulnerable populations will vary:
      • poor neighbourhoods with high % of racialized population in many big cities
      • Aboriginal communities across the prov
      • isolated rural areas
•    solid evidence that enhancing primary care is one of key ways to improve care of
     disadvantaged
      • lack of access to primary care has been identified as a key issue for Prov and
          LHINs
      → concentrate new FHTs or other initiatives in particular regions or
          neighbourhoods, or in particular populations such as refugees or uninsured
•    need to drill down with good research:
      • South Asian immigrants had 3X and Caribbean and Latin American 2X risk of
          diabetes than immigrants from Western Europe or North America
            • greater risk for women
            • risk increases with time since immigration
      Creatore et al CMAJ Aril 19, 2010




31
Target Barriers
•    one of critical equity challenges for many LHINs, hospitals and other providers in
     diverse communities is language
      • LHINs need to specifically require hospitals to ensure interpretation is
          available in languages of their community
      • need to fund centralized interpretation services to support smaller agencies
•    in some other areas, distance and isolation are the critical determinants
•    in Toronto and other cities: people without health insurance – primarily
     immigrants/refugees:
      • many community initiatives to provide access
      • Women’s College Hospital Network on Noninsured is forum for coordination
      • research conference showing critical barriers to access and good care and
          resulting adverse health outcomes for vulnerable people
      • equity is complex – ‘wicked’ policy problems
      • but not all of it = avoidable disparities and workable solution
      • eliminate the three month wait for OHIP for new immigrants




32
System Coordination
• where complex care has been organized in provincial or
  regional networks and resources devoted to coordination
  and creating a continuum of care:
      • cancer, cardiac
      → less inequitable access
• still access barriers can persist:
      • e.g. lower levels of screening in some ethno-cultural
        communities or areas
      • peer health ambassadors and other community-based solutions
        are promising
• lesson = combine comprehensive system-wide
  coordination and local/grass-roots initiatives for specific
  populations

January 30, 2012 |
                                                                  33
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Never Just Equitable Access, But Quality:
           Customize Service Delivery
• 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
    • health promotion has to be delivered in languages and cultures of
      particular population/community
    • focus in acute sectors and 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

                                                                             34
Not Just at Individual Level: Build Equity-
               Driven Service Models
• drill down to further specify needs and barriers:
   • health disadvantaged populations have more complex and greater
       needs for services and support → continuum of care especially
       important
   • poorer people also face greater barriers – e.g. availability/cost of
       transportation, childcare, language, discrimination → facilitated access
       is especially important
• e.g. Community Health Centre model of care
   • explicitly geared to supporting people from marginalized communities
   • comprehensive multi-disciplinary services covering full range of needs
• public health and many community providers have established ‘peer
  health ambassadors’ to provide system navigation, outreach and health
  promotion services to particular communities

35
Extend That → Address Roots of Health
                Inequities in Communities
• 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 for many PHUs
        and CHCs
      • providing and partnering to provide related services/support such as
        settlement, language, child care, literacy, employment training, youth
        support, etc.
      • build local service partnerships -- many PHUs partner with CHCs,
        ethno-cultural, neighbourhood specific and other community
        providers and groups to support particular population
January 30, 2012 |
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Equity-Driven Innovation: Hub Models of
                 Integrated Care
• hub-style multi-service centres in which a range of health and
  employment, child care, language, literacy, training and social
  services are provided out of single ‘one stop' locations

    • many countries have clinics that provide both health and wider social services
      in one place
    • some new satellite CHCs are being developed in designated high-need areas in
      Toronto will involve the CHCs delivering primary and preventive care and
      other agencies providing complementary social services out of the same
      location

• not just health -- idea of schools as service hubs is being
  developed
    • think back to earlier eras with public health nurses in schools
    • start by putting hubs in schools in most disadvantaged areas
    • concentrated and integrated services for most disadvantaged kids have proven
      to be effective investment


                                                                                  37
Build Equity Upstream: Chronic Disease Prevention
                  and Management
•very clear gradient in incidence and
impact of chronic conditions
•chronic disease prevention and
management programs cannot be
successful unless they take health
disparities and wider social conditions
into account
•some populations and communities
need greater support to prevent and
manage chronic conditions
•anti-smoking, exercise and other health
promotion programmes need to
explicitly foreground the particular
social, cultural and economic factors
that shape risky behaviour in poorer
communities– not just the usual focus
on individual behaviour and lifestyle
•need to customize and concentrate
health promotion programs to be
effective for most disadvantaged → if
not, will widen inequities


                                                      38
Build SDoH In:
Cross-Sectoral Planning Through an Equity Lens
• cross-sectoral coordination and planning are much
  emphasized in public health and health policy circles
   • but what sectors? for what purposes?
• addressing wider SDoH is the glue for collaboration into
  action
   • public health departments and LHINs are pulling together or
     participating in cross-sectoral planning tables → Prov should make this
     an explicit expectation
   • Local Immigration Partnerships, Social Planning Councils
• the Ministry of Health Promotion and Sport developed
  a healthy communities strategic approach
   • cross-sectoral planning to ground health promotion
   • at best, this implies wider community development and
     capacity building approaches

                                                                          39
Equity-Driven Collaboration and
                   Coordination
• across Canada, leading Regional Health Authorities have
  developed operational and planning links with local social
  services or emphasized community capacity building:
     • Saskatoon is developing cross-sectoral action on health equity:
         • began from local research documenting shocking disparities among
           neighbourhoods
         • focusing interventions in the poorest neighbourhoods – locating services
           in schools, relying on First Nations elders to guide programming, etc.
         • wide collaboration among public health, municipality, business,
           community, Aboriginal and other leaders
• in Ontario public health are key players in addressing health
  disparities on the ground
     • a number of public health units have been pioneering social determinants
       approaches -- Sudbury, Waterloo, Toronto, Peterborough
     • generally through broad community collaborations

40
Extend That → Build on/from Local and
           Regional Initiatives
• there is always much to be learned from policies, programs
  and initiatives in other jurisdictions
• all leading jurisdictions with comprehensive equity
  strategies combine:
   • national level macro strategies to reduce social health
     inequalities
   • with local or regional implementation and adaptation
   • concentrated local investment and coordination
   • British example: Health Action Zones and other models were
     designed to combine community economic development with
     targeted healthcare and social service improvements
• that is the potential of LHINs and RHAs
   → build equity into regional planning and coordination


                                                                  41
Extend That → Build On/From
              Community-Level Action
• many cities have developed neighbourhood revitalization strategies
   • Toronto’s priority neighbourhoods, Regent’s Park
• promising direction = comprehensive community initiatives:
   • broad partnerships of local residents, community organizations,
     governments, business, labour and other stakeholders coming
     together to address deep-rooted local problems – poverty,
     neighbourhood deterioration, health disparities
   • collaborative cross-sectoral efforts – employment opportunities, skills
     building, access to health and social services, community development
   • e.g. of Vibrant Communities – 14 communities across the country to
     build individual and community capacities to reduce poverty
   • Wellesley review of evidence = these initiatives have the potential to
     build individual opportunities, awareness of structural nature of
     poverty and local mobilization → into policy advocacy


42
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

                                              43
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 state
  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’



                                                                          44
Health Equity
could be one of those ‘big’ unifying ideas..
   • if we see opportunities for good health and wellbeing as a
     basic right of all
   • if we see the damaged health of disadvantaged and
     marginalized populations as an indictment of an unequal
     society – but that focused initiatives can make a difference
   • if we recognize 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

                                                                45
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
• there is a solid base of evidence, provider experience, commitment and
  community connections to build on

• have set out a roadmap – of strategies, principles and tools -- to drive
  equity into action through policy change and community mobilization
• 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
• work in partnerships and collaborations well beyond the health care
  system to address the underlying determinants of health inequalities


46
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
  http://wellesleyinstitute.com
• my email is bob@wellesleyinstitute.com
• I would be interested in any comments on the ideas
  in this presentation and any information or analysis
  on initiatives or experience that address health
  equity

                                                     47
Wellesley Roadmap for Action on the
    Social Determinants of Health
1. look widely for ideas and inspiration from jurisdictions with comprehensive
   health equity policies, and adapt flexibly to Canadian, provincial and local needs
   and opportunities;
2. address the fundamental social determinants of health inequality – macro policy
   is crucial, reducing overall social and economic inequality and enhancing social
   mobility are the pre-conditions for reducing health disparities over the long-
   term;
3. develop a coherent overall strategy, but split it into actionable and manageable
   components that can be moved on;
4. act across silos – inter-sectoral and cross-government collaboration and
   coordination are vital;
5. set and monitor targets and incentives – cascading through all levels of
   government and programme action;




                                                                 48
Wellesley Roadmap II
6  rigorously evaluate the outcomes and potential of programme initiatives and
   investments – to build on successes and scale up what is working;
7 act on equity within the health system:
   • 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;


                                                               49
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.




                                                               50

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Thinking About Health Equity, Acting on Health Equity

  • 1. Thinking About Health Equity/ Acting on Health Equity Bob Gardner Medical and Health Sciences Forum University of Toronto January 26, 2012
  • 2. Key Messages • health disparities are pervasive and damaging • 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 changes 2
  • 3. The Problem to Solve = Health Disparities in Ontario •there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health •+ major differences between women and men •the gap between the health of the best off and most disadvantaged can be huge – and damaging •impact and severity of these inequities can be concentrated in particular populations 3
  • 4. Gradient of Health Across Many Conditions 4
  • 5. Impact of Health Inequities 5
  • 6. Impact of Health Inequities II • not just a gradient of health and impact on quality of life • inequality in how long people live • difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women • 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 6
  • 7. Foundations of Health Disparities Roots Lie in Social Determinants of Health •clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion •impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally •we need comprehensive strategy to drive policy action and social change across these determinants January 30, 2012 | 7 www.wellesleyinstitute.com
  • 8. Canadians With Chronic Conditions Who Also Report Food Insecurity 8
  • 9. SDoH As a Complex Problem Determinants interact and intersect with each other in a constantly changing and dynamic system In fact, through multiple interacting and inter- dependent economic, social and health systems Determinants have a reinforcing and cumulative effect on individual and population health 9
  • 10. Three Cumulative and Inter-Connecting Levels in Which SDoH Shape Health Inequities 1. 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 conditions 2. 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 health 3. 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 → 10
  • 11. Health Inequities = ‘Wicked’ Problem • health inequities and their underlying social determinants of health are classic ‘wicked’ policy problems: • shaped by many inter-related and inter-dependent factors • in constantly changing social, economic, community and policy environments • action has to be taken at multiple levels -- by many levels of government, service providers, other stakeholders and communities • solutions are not always clear and policy agreement can be difficult to achieve • effects take years to show up – far beyond any electoral cycle • have to be able to understand and navigate this complexity to develop solutions • we need to be able to: • identify the connections and causal pathways between multiple factors • articulate the mechanisms or leverage points that will drive change in these pathways and in population health as a whole • analyze the policy changes needed to act on these levers • specify the short, intermediate and long-term outcomes expected and the preconditions for achieving them. January 30, 2012 11
  • 12. Think Big, But Get Going • challenge = health inequities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing • think big and think strategically, but get going • make best judgment from evidence and experience • identify actionable and manageable initiatives that can make a difference • experiment and innovate • learn lessons and adjust – why evaluation is so crucial • gradually build up coherent sets of policy and program actions – and keep evaluating • need to start somewhere: • focus today is on engaging with and providing services and support to meet needs of priority populations • which & where depends on analysis of needs, resources, gaps and opportunities, and community resources and structures 12
  • 13. Health Equity = Reducing Unfair Differences • Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage • This concept: • is clear, understandable and actionable • identifies the problem that policies will try to solve • is also tied to widely accepted notions of fairness and social justice • The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes • A positive and forward-looking definition = equal opportunities for good health • Equity is a broad goal, including diversity in background, culture, race and identity
  • 14. Planning For Complexity of SDoH Need to look at how these other systems shape the impact of SDoH: •access to health services can mediate harshest impact of SDoH to some degree •community resources and resilience are impt POWER Study: Gender and Equity Health Indicator Framework January 30, 2012 | 14 www.wellesleyinstitute.com
  • 15. Equity Into Health System: Why • even though roots of health disparities lie in far wider social and economic inequality • 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 15
  • 16. Equity Into Health System: Why II 1. it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care • equitable healthcare and support can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities 2. in addition, there are systemic disparities in access and quality of healthcare that need to be addressed • people lower down the social hierarchy can have poorer access to health services, even though they may have more complex needs and require more care • unless we address inequitable access and quality, healthcare and community support services could make overall disparities even worse 16
  • 17. Equity Into Health System: How • goal is to ensure equitable health regardless of social position • can do this through a multi-pronged strategy: 1. 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 outreach 2. aligning equity with system drivers and priorities 3. embedding equity in provider organizations’ deliverables, incentives and performance management 4. 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 5. while thinking up-stream to health promotion and addressing the underlying determinants of health January 30, 2012 17
  • 18. 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 18
  • 19. Start From The Community • goal is to reduce health disparities and speak to needs of most vulnerable communities – who will define? • 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 • how: • many hospital have community advisory panels • CHCs have community members on their boards • innovative methods of engagement – e.g. citizens’ assemblies or juries in many countries • community-based research, needs assessment and evaluation 19
  • 20. And Start From a Solid Strategic Commitment • need to make equity one of driving priorities for health system and reform • equity and a population health focus are among key principles enshrined in new Excellent Care for All Act = opening and context • need clear provincial strategy for equity: • implicit from MOHLTC, but promised ten year strategy has not been released • equity and population health are in public health standards • need strategic coherence across health system in approach to equity • LHINs, CCACs, and other coordinating agencies need to prioritize equity – and many have • cascading down to all providers prioritizing equity in their overall strategic plans and then into service delivery and resource allocation 20
  • 21. Align Equity With Health System Drivers • Excellent Care For All Act and quality agenda • providers have to develop Quality Improvement Plans • hospitals first reported April 2011 • other providers will report in subsequent years • equity should be developed as one of dimensions to report on – but wasn’t really in frost hospital plans • patient-centred care → means taking the full range of people’s specific needs into account → customizing delivery and quality for more health disadvantaged populations with greater/more complex needs • improving safety requires addressing equity barriers • inadequate interpretation services can lead to mis-diagnoses, people not being able to follow medication, etc. • provincial priorities – e.g. diabetes, wait times, mental health, ALCs are all much affected by inequitable health and access – and will not be achieved unless planning/delivery takes equity into account 21
  • 22. Into Practice Through Equity-Focused Planning • addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations • need to understand roots of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • requires an array of effective and practical equity-focused planning tools 22
  • 23. Health Equity Impact Assessment • increasing attention to potential – from WHO, through most European strategies, PHAC, to MOHLTC and LHINs • planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • can help to plan new services, policy development or other initiatives • can also be used to assess/realign existing programs • intended to be relatively easy-to-use tool • essentially prospective, helping plan forward • piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI • HEIA is being used in Toronto Central and other LHINs and providers across the province • Toronto Central has required HEIA within recent funding application processes for Aging at Home, and refreshing hospital equity plans • required in last generation of TC hospital equity plans and many hospitals are extending its use 23
  • 24. Beyond Planning: Embed Equity in System Performance Management • clear consensus from research and policy literature, and consistent feature in comprehensive policies on health equity from other countries: • setting targets for reducing access barriers, improving health outcomes of particular populations, etc • developing realistic and actionable indicators for service delivery and health outcomes • tying funding and resource allocation to performance • closely monitoring progress against the targets and indicators • disseminating the results widely for public scrutiny • need comprehensive performance measurement and management strategy • then choose appropriate equity targets and indicators for particular populations/communities 24
  • 25. Success Condition: Effective Equity Targets • innovative work underway to develop equity indicators – but don’t need to wait • build equity into existing targets: • reducing diabetes incidence is prov and LHIN priority → equity target = reduce differences in incidence, complications and rates of hospitalization between populations or areas • a good service target has been proposed for diabetes = high/increasing % of people who get best standard care → reduce differences by gender, income, ethno-cultural background • need to drill down in specific areas that have high equity impact: → ensuring access and use of primary health care does not vary inequitably by income level, immigration status, neigbourhood, gender, race, etc. • many programs assess their services through client satisfaction surveys and look for high and improving satisfaction → reduce any differences in satisfaction by gender, income, ethno-cultural background, etc. 25
  • 26. Challenges: Equity Targets That Work • can’t just measure activity: • number or % of priority pop’n that participated in program • need to measure health outcomes – even when impact only shows up in long- term • so if theory of change for health program begins with enabling more exercise or healthier eating – then we measure that initial step • need to assess reach • who isn’t signing up? who needs program/support most? • who stuck with program and what impact it had on their health – and how this varies within the pop’n • and assess impact through equity lens • need to differentiate those with greatest need = who programs most need to support and keep to have an impact • then adapt incentives and drivers • develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system 26
  • 27. Success Condition = Better Data •looking abroad for promising practices = Public Health Observatories in UK • consistent and coherent collection and analysis of pop’n health data • specialization among the Observatories – London focuses on equity issues •interest/development in Western Canada •national project to develop health disparity indicators and data •Toronto PH is addressing complexities of collecting and using race-based data •key direction = explore potential of equity/SDoH data for Ontario •pilot project in 3 Toronto academic hospitals to collect equity data 27
  • 28. Use Available Levers: Equity Plans • a promising direction several LHINs have taken up is to require providers to develop equity plans • hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TC • and other providers in Central • CHCs have developed a sector-wide plan in GTA • these plans are designed to: • identify access barriers, disadvantaged populations, service gaps and opportunities in their catchement areas and spheres • develop programs and services to address those gaps and better meet healthcare needs of disadvantaged communities • these provider plans have the potential to: • raise awareness of equity within the organizations • build equity into planning, resource allocation and routine delivery • pull their many existing initiatives together into a coherent overall equity strategy • build connections among providers for addressing common equity issues 28
  • 29. Toronto Central LHIN Hospital Equity Plans http://www.torontoevaluation.ca/tclhinrefresh January 30, 2012 | 29 www.wellesleyinstitute.com
  • 30. Target Investment for Equity Impact • target services to: • those facing the harshest disparities – to raise the worst off fastest • or most in need of specific services • or the worst barriers to equitable access to high-quality services • this requires resources • lever = certain % of LHIN budgets to be equity targeted • this requires sophisticated analyses of the bases of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research to provide rich local needs assessments and evaluation data • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems 30
  • 31. Target Populations • vulnerable populations will vary: • poor neighbourhoods with high % of racialized population in many big cities • Aboriginal communities across the prov • isolated rural areas • solid evidence that enhancing primary care is one of key ways to improve care of disadvantaged • lack of access to primary care has been identified as a key issue for Prov and LHINs → concentrate new FHTs or other initiatives in particular regions or neighbourhoods, or in particular populations such as refugees or uninsured • need to drill down with good research: • South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America • greater risk for women • risk increases with time since immigration Creatore et al CMAJ Aril 19, 2010 31
  • 32. Target Barriers • one of critical equity challenges for many LHINs, hospitals and other providers in diverse communities is language • LHINs need to specifically require hospitals to ensure interpretation is available in languages of their community • need to fund centralized interpretation services to support smaller agencies • in some other areas, distance and isolation are the critical determinants • in Toronto and other cities: people without health insurance – primarily immigrants/refugees: • many community initiatives to provide access • Women’s College Hospital Network on Noninsured is forum for coordination • research conference showing critical barriers to access and good care and resulting adverse health outcomes for vulnerable people • equity is complex – ‘wicked’ policy problems • but not all of it = avoidable disparities and workable solution • eliminate the three month wait for OHIP for new immigrants 32
  • 33. System Coordination • where complex care has been organized in provincial or regional networks and resources devoted to coordination and creating a continuum of care: • cancer, cardiac → less inequitable access • still access barriers can persist: • e.g. lower levels of screening in some ethno-cultural communities or areas • peer health ambassadors and other community-based solutions are promising • lesson = combine comprehensive system-wide coordination and local/grass-roots initiatives for specific populations January 30, 2012 | 33 www.wellesleyinstitute.com
  • 34. Never Just Equitable Access, But Quality: Customize Service Delivery • 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 • health promotion has to be delivered in languages and cultures of particular population/community • focus in acute sectors and 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 34
  • 35. Not Just at Individual Level: Build Equity- Driven Service Models • drill down to further specify needs and barriers: • health disadvantaged populations have more complex and greater needs for services and support → continuum of care especially important • poorer people also face greater barriers – e.g. availability/cost of transportation, childcare, language, discrimination → facilitated access is especially important • e.g. Community Health Centre model of care • explicitly geared to supporting people from marginalized communities • comprehensive multi-disciplinary services covering full range of needs • public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities 35
  • 36. Extend That → Address Roots of Health Inequities in Communities • 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 for many PHUs and CHCs • providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth support, etc. • build local service partnerships -- many PHUs partner with CHCs, ethno-cultural, neighbourhood specific and other community providers and groups to support particular population January 30, 2012 | 36 www.wellesleyinstitute.com
  • 37. Equity-Driven Innovation: Hub Models of Integrated Care • hub-style multi-service centres in which a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations • many countries have clinics that provide both health and wider social services in one place • some new satellite CHCs are being developed in designated high-need areas in Toronto will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location • not just health -- idea of schools as service hubs is being developed • think back to earlier eras with public health nurses in schools • start by putting hubs in schools in most disadvantaged areas • concentrated and integrated services for most disadvantaged kids have proven to be effective investment 37
  • 38. Build Equity Upstream: Chronic Disease Prevention and Management •very clear gradient in incidence and impact of chronic conditions •chronic disease prevention and management programs cannot be successful unless they take health disparities and wider social conditions into account •some populations and communities need greater support to prevent and manage chronic conditions •anti-smoking, exercise and other health promotion programmes need to explicitly foreground the particular social, cultural and economic factors that shape risky behaviour in poorer communities– not just the usual focus on individual behaviour and lifestyle •need to customize and concentrate health promotion programs to be effective for most disadvantaged → if not, will widen inequities 38
  • 39. Build SDoH In: Cross-Sectoral Planning Through an Equity Lens • cross-sectoral coordination and planning are much emphasized in public health and health policy circles • but what sectors? for what purposes? • addressing wider SDoH is the glue for collaboration into action • public health departments and LHINs are pulling together or participating in cross-sectoral planning tables → Prov should make this an explicit expectation • Local Immigration Partnerships, Social Planning Councils • the Ministry of Health Promotion and Sport developed a healthy communities strategic approach • cross-sectoral planning to ground health promotion • at best, this implies wider community development and capacity building approaches 39
  • 40. Equity-Driven Collaboration and Coordination • across Canada, leading Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building: • Saskatoon is developing cross-sectoral action on health equity: • began from local research documenting shocking disparities among neighbourhoods • focusing interventions in the poorest neighbourhoods – locating services in schools, relying on First Nations elders to guide programming, etc. • wide collaboration among public health, municipality, business, community, Aboriginal and other leaders • in Ontario public health are key players in addressing health disparities on the ground • a number of public health units have been pioneering social determinants approaches -- Sudbury, Waterloo, Toronto, Peterborough • generally through broad community collaborations 40
  • 41. Extend That → Build on/from Local and Regional Initiatives • there is always much to be learned from policies, programs and initiatives in other jurisdictions • all leading jurisdictions with comprehensive equity strategies combine: • national level macro strategies to reduce social health inequalities • with local or regional implementation and adaptation • concentrated local investment and coordination • British example: Health Action Zones and other models were designed to combine community economic development with targeted healthcare and social service improvements • that is the potential of LHINs and RHAs → build equity into regional planning and coordination 41
  • 42. Extend That → Build On/From Community-Level Action • many cities have developed neighbourhood revitalization strategies • Toronto’s priority neighbourhoods, Regent’s Park • promising direction = comprehensive community initiatives: • broad partnerships of local residents, community organizations, governments, business, labour and other stakeholders coming together to address deep-rooted local problems – poverty, neighbourhood deterioration, health disparities • collaborative cross-sectoral efforts – employment opportunities, skills building, access to health and social services, community development • e.g. of Vibrant Communities – 14 communities across the country to build individual and community capacities to reduce poverty • Wellesley review of evidence = these initiatives have the potential to build individual opportunities, awareness of structural nature of poverty and local mobilization → into policy advocacy 42
  • 43. 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 43
  • 44. 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 state 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’ 44
  • 45. Health Equity could be one of those ‘big’ unifying ideas.. • if we see opportunities for good health and wellbeing as a basic right of all • if we see the damaged health of disadvantaged and marginalized populations as an indictment of an unequal society – but that focused initiatives can make a difference • if we recognize 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 45
  • 46. 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 • there is a solid base of evidence, provider experience, commitment and community connections to build on • have set out a roadmap – of strategies, principles and tools -- to drive equity into action through policy change and community mobilization • 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 • work in partnerships and collaborations well beyond the health care system to address the underlying determinants of health inequalities 46
  • 47. 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 http://wellesleyinstitute.com • my email is bob@wellesleyinstitute.com • I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity 47
  • 48. Wellesley Roadmap for Action on the Social Determinants of Health 1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long- term; 3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; 4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital; 5. set and monitor targets and incentives – cascading through all levels of government and programme action; 48
  • 49. Wellesley Roadmap II 6 rigorously evaluate the outcomes and potential of programme initiatives and investments – to build on successes and scale up what is working; 7 act on equity within the health system: • 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; 49
  • 50. 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. 50

Editor's Notes

  1. Ont 2005 age standardized 25>
  2. 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
  3. In: that's impact on daily livesthat type of impact adds up over people's lives
  4. reinforcing nature of social determinants on health disparitiesreally impt for key strategy = crucial part of managing diabetes esp. is good nutrition
  5. previousdata shows complex and reinforcing nature of social determinants on health disparitiespractical implications = health promotion and CDPM has to take SDoH into account
  6. when we’re working with particular populations or neighbourhoods – need to think at all these levels and their inter-connectionfor today: particular populations are worse off in terms of SDOH – precarious workers, homeless – face worse healthdisadvantage can be concentrated in particular places -- poor or racialized neighbourhoods – and over the generations in particular groups – long-term poor
  7. which highlights the crucial importance of context
  8. theme – learning from others
  9. Principle applies throughout system – at provider and often at program level as well
  10. practical local example – esp. impt to UHN
  11. openingsmany hospitals have CABs or panelsLHINs are mandated to undertake community engagement
  12. challenge = system is fragmented – LHINs, primary care, provincial programs, acute and up-stream, two ministries, public health – let along beyond health
  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. 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
  19. could hook up to this – or at least keep it on horizoncould also link into Healthcare Interpreters Network
  20. all of this equity planning loops back to quality
  21. not just in negative sense of identifying barriers and gaps, but what could be enablers and directions for innovationpeers have been from particular ethno-cultural communities or neighbourhoods or are newcomers, PHAs, drug users or others with particular lived experience
  22. many jurisdictions: Italian example for immigrant pop’nscould consider for Central for any expansion
  23. how many involved in planning with LHINs?
  24. how many involved in planning with LHINs?
  25. key role for OPHA
  26. SSM was one of these big ideas and tremendous work of AOHC and allies
  27. summary again