Building on the Evidence: Advancing Health Equity for

Priority PopulationsBob Gardner

OPHA/HPO Fall ForumOctober 5, 2011

Powerful Starting Point = Equity As a Driving Priority Within Public Health

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Key Messages• health inequities are pervasive and damaging• but these inequities can be addressed through comprehensive health equity

strategy• and by focusing policy, programs and resources on particularly health

disadvantaged populations by:• identifying priority populations and systemic barriers• plan the most effective mix of focused services and support to meet the priority

populations’ diverse needs• embed equity into system performance management thorough population-specific targets

and incentives• evaluate effectiveness and impact, and build these learnings into continuous improvement

• and acting well beyond health -- 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• and the community and political mobilization to demand and drive the necessary policy

changes

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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

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Gradient of Health Across Many Conditions

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Impact of Disparities

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

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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

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Canadians With Chronic Conditions Who Also Report Food Insecurity

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SDoH As a Complex Problem

Determinants interact and intersect with each other in a constantly changing and dynamic systemIn fact, through multiple interacting and inter-dependent economic, social and health systemsDeterminants have a reinforcing and cumulative effect on individual and population health

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Three Cumulative and Inter-Connecting Levels in Which SDoH Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health →

2. also because of broader social and economic inequality and exclusion→

3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the health and other systems →

1. gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. some communities and populations have fewer capacities, resources and resilience to cope with the impact of poor health

3. these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

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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

POWER Study: Gender andEquity Health Indicator Framework

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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 we assume drive change in these

factors and population health as a whole• identify the crucial policy levers that will drive the needed changes• specify the short, intermediate and long-term outcomes expected and the

preconditions for achieving them.

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Nothing So Practical As A Good Theory

• English evaluation leader Ray Pawson quoting German sociologist Kurt Lewin• Pawson isn’t arguing for abstract theory, but for ensuring we are always clear

about • the assumptions we are making that underpin our work – whether planning a specific

service initiative or developing a broad multi-sectoral strategy• the pathways and factors that we assume will lead from the planning through service

delivery to the hoped-for impact• how we think all of this will vary depending upon the organizational, social or policy

context• there are many approaches and as many terms – theory of change, program

theory, framework for change• but the basic idea is to be really clear about starting points and premises

when planning any initiative • and it’s this set of assumptions, pathways and objectives in our theory of

change that we subsequently measure, monitor and evaluate

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Framework for Change for ‘Wicked’ Problem: Health Inequities

complex multi-level strategies to tackle health gaps:

• international frameworks such as WHO Commission on Social Determents

• European Union and other international initiatives• many individual countries

key features in all:• focus on inclusive labour market, childcare,

affordable housing, social security and other macro policies

• targets and deliverables for relevant programs and departments

• equitable access to quality health care is just one part of this broader package

• emphasized partnerships with community service providers and organizations – in both policy development and service delivery

• national strategies are implemented and adapted to local conditions

• emphasis on addressing needs and inequitable barriers facing particular populations

framework of change = all about reducing structured inequality :

• health inequities arise out of wider social determinants of health = won’t solve through health reform alone

• underlying structures of social and economic inequality need to be addressed by new policies

• policies need to be aligned with the incentives and processes that drive government

• key levers will vary – e.g. could be reducing prevalence of precarious employment

• has to involve collaboration and coordination across governments and with many community and non-government stakeholders

• need effective balance of high-level and macro with population-focused strategies and local and community mobilization

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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

High-Level: Health Equity Strategy Into Action

• 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 priorities3. 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

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Drilling Down: Why Focus on Particular Populations

1. equity rationale:• certain groups within society are most adversely affected by systemic health inequities• goal of many strategies is to raise the worst off, fastest• not just a social justice argument, but improving adverse health of worst off can

contribute to more effective use of scarce healthcare resources, positively affect social productivity and cohesion, enhance overall population health, etc.

2. health and underlying social disadvantage can be inter-generational• will persist –if not worsen – if not addressed

3. access• most disadvantaged populations have greater and more complex needs• universal programs can leave vulnerable groups out – and behind

4. specific at-risk groups need specific interventions• universal programs will not be effective unless adapted to specific needs, constraints

and dynamics of vulnerable populations

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Drilling Down: How to Focus on Particular Populations

• part of this is clarifying scope and terrain upon which we work• 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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Drilling Down: To Do What?

• really talking about focussed interventions and activities• scope of these interventions can vary

• policy interventions that could improver the social determinants of health that underlie the population’s inequitable health

• decisions to allocate more resources or develop programs specific to particular populations or problems

• designing services for particular populations or customized to their particular contexts

• so we need to always specify the focus• also need to specify goals of interventions

• what are the problems we are trying to solve?• what will success look like?

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Drilling Down: Finding Specific Solutions for Specific Problems

•identifying the specific needs of the population/community → determining best mix of services and support to meet those needs

•addressing key barriers the population may face to getting the services and support they need

•more deep-seated community and structural factors that underlie their health inequalities

•will generally need to drill down further

• e.g. problem may be that those how most need health promotion programs are not accessing them

• need to specifically design to reach the most vulnerable and enable them to stay in programs

•policy, program or resource changes to reduce those barriers

• may be general – peer health ambassadors

• or specific -- if transportation is the barrier – then subsidies to get people to services or locating services where people live

•poverty reduction initiatives

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Starting Points for Focussed Interventions

• addressing health inequities requires a solid understanding of:• key barriers to equitable access to high quality care and support -- i.e. is the main

problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc.

• the specific needs of health-disadvantaged populations• gaps in available services for these populations

• identifying the right populations• most in need? highest risk?• and/or where interventions have potential to make the most health difference?

• identifying what those populations need• and want -- are ready to accept -- and will really benefit from

• clear consensus – and in Ontario public health standards:• use multiple data sources – epi, admin, from community health profiles• and methods – program evaluations, intervention research, community-based and

qualitative research

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Start From The Community• goal is to reduce health disparities and speak to needs of most vulnerable communities – who

will define those needs?• 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• many providers have community advisory panels or community members on their boards • can also build on innovative methods of engagement – e.g. citizens’ assemblies or juries in

many jurisdictions• need to develop community engagement that will work for disadvantaged and marginalized

communities:• in the language and culture of particular community• has to be collaborative• sustained over the long-term• has to show results – to build trust• need to go where people are• need to partner with trusted community groups

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And With Equity-Focused Planning

• Public Health Ontario has developed an equity assessment framework for public health units.

• a number of PHUs have developed and use equity lens:• Toronto has a simple 3 question lens -- not just for public health, but

other departments• Sudbury has used an equity planning tool for several years

• MOHLTC and many LHINs have used Health Equity Impact Assessment• advantage of using the similar tools = build up comparable experience and

data• lever = could enable/require PHUs to undertake HEIA or other equity

planning processes• for all new programs and those focusing on particular populations• as part of overall standards/expectations or to be eligible for particular

funding

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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

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Building Equity Targets

• build equity into indicators already being collected → equity angle is to reduce differences between these populations/communities and others or PHU as a whole on these indicators

• also drill down – e.g. a number of PHUs and LHINs have identified areas or populations where diabetes prevalence is highest • equity target = reduce differences in incidence, complications and

rates of hospitalization by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions

• similarly, 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 facilities and proactive empowerment of kids – and ensuring equitable access to resources, space and programs

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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 – Saskatoon•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 •in addition, innovative thinking emerging around dynamic systems modeling meeting population health

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Levers for Action: Equity Plans

• lesson from health care sector = building equity into provider plans• ECFAA requires hospitals and then other providers to develop quality

improvement plans → need to build equity in as key dimension• several LHINs have required providers to develop equity plans• equity priorities will/can be built into accountability agreements

• for public health, provincial standards offer a key lever• PHU could develop health equity plans showing how they are putting

population health standards and requirements into practice • detailing how equity and population-specific expectations and

targets are being built into routine PHU performance management and accountabilities

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Build Equity Into Priority Issues: 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

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Never Just Access: 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

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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

• build local service partnerships -- many PHUs partner with CHCs, ethno-cultural, neighbourhood specific and other community providers and groups to support particular population

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Extend That → Address Roots of Health Inequities in Communities

• look beyond vulnerable individuals to the communities in which they live• 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.

• across Canada, leading Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building:• Saskatoon began from local research documenting shocking disparities among

neighbourhoods• focused interventions in the poorest neighbourhoods – e.g. differences in

immunization rates between poor and other neighbourhoods decreased • beyond health – locating services in schools, relying on First Nations elders to

guide programming, etc.• wide collaboration among public health, municipality, business, community

leaders

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Through Cross-Sectoral Planning

• cross-sectoral coordination and planning are the glue that binds together coordinated action on SDoH• public health departments and LHINs are pulling together or

participating in cross-sectoral planning tables on health issues – can get beyond institutional silos

• Local Immigration Partnerships, Social Planning Councils, poverty reduction initiatives, etc

• healthy communities initiatives funded by the Ministry of Health Promotion and Sport

• look for insight and inspiration from ‘out of angle’ sources:• e.g. community gardens and kitchens can contribute to food

security to some degree, and sports programs contribute to health, but they can also help build social connectedness and cohesion

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Equity-Driven Innovation: Integrated Community-Based 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

• Winnipeg Regional Health Authority and Manitoba Family Services and Housing have partnered on a new model to integrate health and social service delivery – one-stop access models in various communities to deliver a broad range of health and social services directly and to refer on to other agencies when services aren’t available

• Quebec has long had such comprehensive integrated community centres• 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 -- schools as service hubs is being developed -- think back to earlier eras with public health nurses in schools

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Extend That → Build Community-Level Action

• all leading jurisdictions with comprehensive equity strategies combine national policy with local adaptation and concentrated investment

• 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

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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

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Challenges Moving Forward In Improving Health Equity for Disadvantaged Populations

• always a question of balance• never just this population or that• never focusing all programs on priority population or a comprehensive

strategy• need focused interventions nested in a comprehensive strategy

• how do we ensure we’re not just focusing on symptoms• services to the worst off• but without addressing the social determinants and inequalities that

underpin their health inequities

• timing is everything• deep-seated problems = require long-term policy/political

commitment and sustained investment• knowing when to initiate interventions can be critical

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Evaluating Complex Equity Interventions

• how do we know what works = crucial importance of evaluation• far too complex to pick apart all the causal relations and patterns of influence:

• very difficult to attribute particular changes to particular components of the overall initiative• will never meet RCT gold standard of proof – that approach can’t capture complexity• but that doesn't mean particular initiative is ineffective

• impact can take many years to show up• but that doesn’t mean nothing is happening

• traditional evaluation of one program in isolation or of a particular population among many will not capture this complexity

• potential of more ‘realist’ approach – M + C = O• evaluating impact of interventions – but always in particular contexts• and sometimes we look at what works in particular population or social contexts rather than form of

intervention• and we evaluate our framework of theory of change

• we identified levers in our strategy – did they prove to be important in practice?• looking for indications that the change mechanisms unfold as we expected, that the direction of causal

influence and impact is as we expected ,etc• looking for evidence that outcomes anticipated are being achieved

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Complexities: Building Equity Targets

• 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

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Watch for Pitfalls: Unintended Consequences

• 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 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

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Watch for Pitfalls: Don’t Create More Silos

• MHPS’s healthy communities strategy is far more comprehensive and integrated than previous approaches

• but the improved cross-sectoral planning it envisions will still operate within separate risk behaviours or health conditions – • and health system is fragmented – LHINs, primary care, provincial programs, acute

and up-stream, two ministries, public health – let along beyond health

• these conditions and challenges are very much inter-dependent and cumulative in individuals’ lives and community dynamics

• avoid ‘risk’ silos in ‘healthy communities’ by:• enabling a community to define its own health priorities • e.g. better providing better access to good food, exercise facilities and

information/support to manage own health → will benefit all these priority areas • developing health promotion programs that address a neighborhood's full range of

challenges in a comprehensive way• so the more effective focus will often be at neighbourhood level

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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’

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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 here43

• 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

Following Up

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