Equity from the Start: The way ahead in Ontario

alPHa Toronto October 22, 2009Michael M. Rachlis MD MSc FRCPC

www.michaelrachlis.com

Outline

• Why is reducing health inequities particularly hard work in Ontario?

• Why is it hard work everywhere?

• How do we go forward?

“There is a remarkable consistency and repetition in the findings and recommendations for improvements in all the information we reviewed. Current submissions and earlier reports highlight the need to place greater emphasis on primary care, to integrate and coordinate services, to achieve a community focus for health and to increase the emphasis on health promotion and disease prevention. The panel notes with concern that well-founded recommendations made by credible groups over a period of fifteen years have rarely been translated into action.”

Ontario Health Review panel 1987

3

Ontario health policy– No health goals

– No provincial health plan

– No official MOHLTC strategic plan

– Many provincial policy directions are in draft form and are not publicly available,

• e.g. MOHLTC Chronic Disease Management and Prevention plan.

– Few service frameworks

• Stroke, cancer, heart disease…

– MOHLTC priorities given to the LHINs are phrased about treating illness

– Little coordination of overall social policy4

Why is reducing health inequities particularly hard work in Ontario?

• The weak Canadian confederation

• North American values

• North American style government– Lavis 2004

% G

DP

Why is it hard work everywhere?

• Unsupportive values for primary prevention and health promotion

“Medicine (Health) is a social science and politics is nothing but medicine writ large!”

Dr. Rudolf Virchow 1848

If politics is health writ large...

• Fundamental change in a society’s pattern of health requires structural change in society’s values, interests, and institutions

• Some powerful interests will be threatened and will use their power to oppose change

• Those favouring the status quo will emphasize the treatment of sick individuals and downplay opportunities to promote population health

How do we move forward?

CIHR Conceptual Framework of Population Health

3. Life-Course

Race, Ethnicity,

2. Proximal Determinants of Health: Physical & social environments Biological factors

7. Healthcare Outcomes

6. Health Services/System Interventions

1. Upstream Forcespoliticalsocial

culturaleconomicspiritual

ecologicaltechnological

4. From Individuals

SocietiesTo

Gender, SES, &Geography

5. Disparities in sub populations

We’re talking about public policy, so what is your analytic framework?

• Institutional Rational choice?

• Multiple Streams?

• Punctuated Equilibrium?

• Advocacy Coalition Framework?

The Root Method, aka Rational-Comprehensive (See: http://www.d.umn.edu/~schilton/3221/LectureNotes/3221.RationalityVsMuddlingThrough.2003.Spring.html)

• Specify all ends• Specify weights for all the ends. • Examine all possible sets of means. • Evaluate each set of means against ends, assigning a

score to how well the means achieve each end. • For each set of means, calculate its overall measure

based on the weighted average of its scores on achieving the different ends.

• Choose the set of means with the highest score.

The Branch Method, aka Incremental

(See: http://www.d.umn.edu/~schilton/3221/LectureNotes/3221.RationalityVsMuddlingThrough.2003.Spring.html)

• Ends and means are intimately intertwined,. • Only a few means are considered and only those

which don't represent too much of a departure from the status quo.

• Evaluation of means is crude. • Choice among the means is determined by

agreement among interested parties rather than by summary indicators arising from the analysis.

• Agreement is the only empirical indicator of virtue, because values are not usually clear-cut or even shared.

Key elements of the Advocacy Coalition Framework • Factors external to the subsystem

– Stable factors which typically don’t change for a generation or more, E.g. the constitution, climate, economic system

– Dynamic factors which tend to change every 5-10 years, E.g. governing coalition, weather, business cycle

• The formal decision-making process• The informal decision-making process• Values – how the world should work• Causal beliefs – how the world really works• Interests – how the world works for me• Information

From: P. Sabatier and J. Lomas

Key principles of the Advocacy Coalition Framework

• While the type of policy developed mainly depends upon activity within the policy subsystem, most but not all significant policy change is initiated by perturbations in the environment external to the subsystem

• Policy is developed in subsystems• This reinforces Branch-style policy making and frustrates

Inter-sectoral action for health• Observations of at least a decade are usually required to

understand policy change. • Broad coalitions develop over time• Information is usually the weakest policy determinant• Under certain conditions, policy systems “learn”

What is the role for information?

• It’s always incomplete– It’s impossible to have a synopsis of all

there is to know on something

• Often used after the fact to bolster one’s own points or to knock down those of the other coalition

• Rarely used primarily

How can we inject knowledge into Policy?

Under certain conditions, policy systems and actors “learn”-- Policy oriented learning –

“relatively enduring alterations in thought or behavior intentions that result from experience/and/or new information and are concerned with the attainment or revision of policy objectives” (P Sabatier)

Conditions for policy oriented learning

– There are > 2 coalitions with conflicting positions – The issue is of moderate importance to both coalitions. – There is a forum available for debate. – There is an audience– There are consequences to losing the debate

• Moving the yardsticks– Learning is amplified if the forum is run according to

professional norms and when the problem is amenable to quantification.

Moving the Yardsticks

Advocacy Coalition Framework from P. Sabatier and J. Lomas

How do we move forward?

Let’s take off the blindfolds!

Special issues for Public health in reducing inequalities

• Most of us are employed directly by the state• The double edged sword – one to use on others,

one to fall on ourselves• Public health is seen around the cabinet table as

part of the health empire• Public health is funded and sometimes

administered directly by the state– The importance of coalitions and citizen

engagement

Public health is seen around the cabinet table as part of the health empire

When the Minister of Health is talking about public health issues he is still seen as the Minister of Health, devourer of other people’s lunches

Do one-fifth of older Canadian women need to take benzodiazepines?

Do we care what we’re paying for?

The Inverse Care Law

"the availability of good medical care tends to vary inversely with the need for it in the population served."

Tudor Hart J. The inverse care law. Lancet 1971; i: 405-412.

Age-standardized mortality rates, urban Canada, 1971 to 1996.

Source: Statistics Canada, Catalogue 82-003. Health Reports, 2002;13(suppl):57.

Ratio = 1.4

What about partnering with our health care system colleagues?

• The LHINs are starting to have equity plans

• The health system could really use public health’s perspective and expertise

• God will provide the extra resources!

The health care system can play an important role in reducing health disparities. (OHQC 2007)

• Improve the accessibility of the health system through outreach, location, physical design, opening hours, and other policies.

• Improve the patient-centredness of the system by providing culturally competent care, interpretation services, and assisting patients and families surmount social and economic barriers to care.

• Cooperate with other sectors to improve population health.

Saskatoon neighbourhood analysis boundaries, excluding industrial and development areas, 2005

Legend

Affluent neighbourhoods

Rest of Saskatoon

Low income neighbourhoods

Source: Saskatoon Health Region, Public Health Sevices

Saskatoon Health Region

Rate Ratio (% higher)Core neighbourhoods: Affluent

Hospitalizations

Suicide Attempts 15.58 (1458%)

Diabetes 12.86 (1186%)

Physician Visits

Mental Disorders 2.28 (128%)

Diabetes 2.11 (111%)

This does not by any means suggest that complete public health integration with the LHINs would be a good thing. Certainly, in the

current context that would be a bad thing.

Population Health Focus• Support from the top

– Cabinet level social policy coordination based upon a strong value placed on equity

– Common boundaries for governance and services

– E.g. SK Human Services Integration Forum, PQ Public Health Laws

• Push from the bottom– Citizen engagement where the state meets citizens

– E.g. OK Kids Halton, Champlain Cardiovascular Prevention Network, Regent Park Pathways to Education,

– South Riverdale gets the lead out

How could public health work more effectively in

coalitions?

Inequity Equity

“…empowerment of local communities is a necessary step in the rejuvenation of

public health.”

Dr. Robert Beaglehole

Sounds a lot like democracy!

Look for those policy windows!

• The anti-poverty agenda

• The economic downturn

• Re-organization of health system > election

• Early childhood learning

• Health impact assessments?

• Watch your back!– The other side is better organized

Summary:

• There are serious disparities in health status which are related to disparities in the determinants of health

• Public health needs to more analytic to be more effective. Unshackled rage is only effective if there are thousands of people who get angry with you.

• We need different provincial government institutions to facilitate whole government action on inequities

• We need to engage communities to light the spark for action

“Courage my Friends, ‘Tis Not Too Late to Make a Better World!”

TC Douglas (per Tennyson)