© The Wellesley Institutewww.wellesleyinstitute.com

Bob Gardner, PhD

WZB Berlin

March 25, 2010

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1. scale and nature of health inequalities in Ontario and Canada + background on health and social systems

2. how health disparities can be addressed through comprehensive health equity strategy

3. then how this strategy can be driven into action • through breaking it up into manageable and coordinated

policy directions and program interventions• equity-focused planning, promising practices in services,

evaluation, and other enablers for innovation

4. identify key enablers for building successful action on health equity

5. draw out some interesting comparisons between Canadian and European situations

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• 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

• concentrated disadvantage and poor health in particular communities – Aboriginal, poor, immigrant

• major differences between women and men• the gap between the health status of the best off and

most disadvantaged can be huge – and damaging• in addition, there are systemic disparities in access to

and quality of care within the healthcare system

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5

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Diabetes Incidence, TC LHIN 2004/05

5.8

13.3

0

2

4

6

8

10

12

14

16

Low Income High Income

New

Cases/1

,000

Two fold difference in diabetes incidence between lowest and highest neighbourhoods.

Age Standardized Rates. Data Source: Ontario Diabetes Database, 2004/05 www.ices.on.ca/intool

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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

+ inequality in how well people live:• 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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10© The Wellesley Institute

www.welleseyinstitute.com

• 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

• real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities

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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

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• 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 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

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• there is always much to be learned from policies, programs and initiatives in other jurisdictions

• a number of countries have made lessening health disparities a top national priority and have developed cross-sectoral policy frameworks and/or action plans:• England, Scotland, Australia, New Zealand

• many European countries, especially Nordic

• also increasing international and high-level attention:• WHO Commission on Social Determinants of Health

• European Union, with its Closing the Gap and Determine projects to tackle health disparities

• look broadly for policy solutions, and adapt flexibly to local/provincial circumstances

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• focus and balance of national strategies varies but a key theme:• addressing roots of inequality through macro social and economic

policy

• key components include:• integrated policy geared to reducing overall social and economic

inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long-term;

• early child investment is common theme• as is poverty reduction• reducing social exclusion and inequalities in labour market are key

• develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on

• act across silos – cross-sectoral and cross-government collaboration and coordination are vital• local and community-level coordination and interventions are key

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• the point of all this analysis is to be able to identify policy and program changes needed to reduce health disparities

• but health disparities 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 – and focus here is on population health and health system

• 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

• many countries 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 these services in coordinated way at community/local level

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1. it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care

• equitable healthcare and proactive health promotion 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 tend to 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 health promotion could make overall disparities even worse

• at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social position

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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 –50+ recommendations

many recommendations have been acted on

other LHINs are also prioritizing and moving to address health disparities

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• goal is to ensure equitable access to high quality healthcare regardless of social position

• can do this through a two pronged strategy:1. building health equity into all health planning and delivery

• doesn’t mean all programs are all about equity

• but all take equity into account in planning their services and outreach

2. 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

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• align equity with system drivers:• equity is pre-condition to quality and efficiency agendas

• essential part of high-performing health system -- OHQC

• align with system priorities:• can’t solve wait times or chronic conditions without

addressing equity

• build equity into priority setting and service planning

• build into performance management:• targets and incentives

• cascading through the system -- Prov → LHINs, agencies, etc.→ providers

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• need to make equity one of driving priorities for health system and reform

• need national leadership – not the case in Canada• need clear provincial strategy for equity:

• implicit in Ontario• but promised MOHLTC ten year strategy has not been released• Ministry of Health Promotion is moving towards a healthy community

planning approach – potentially more equity-orientated• uneven – within Ont govt and public health, let alone in wider health

system• need strategic coherence across public health system in approach to

equity

• LHINs and other coordinating agencies need to prioritize equity• cascading down to clear prioritization from providers for their

service delivery and resource allocation

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• greater chance of success for equity strategy if aligned with provincial priorities:

• diabetes, wait times, mental health

• mental health and diabetes are particularly sensitive to social conditions

• chronic disease prevention and management programs cannot be successful unless they take account of social conditions and constraints

• critical to enabling people with mental health challenges to live in the community are a continuum of community supports that take into account the social exclusion, poverty and other challenges people face

• Wellesley and Canadian Mental Health Association–Ontario partnered on input to current discussions about mental health strategy:

• stressed that programs had to take account of SDoH in design and delivery

• highlighted healthy communities approach

• highlighted the potential of specific planning tools such as Mental Health Impact Assessment

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• comprehensive policies on health equity from other countries include:• setting targets or defining indicators – that build on

available reliable data and make the most sense in the particular context

• closely monitoring progress against the indicators or targets

• disseminating the results widely for public scrutiny

• and, at the same time, need to build equity targets and objectives into routine performance management and provider planning

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• there are broad targets for priorities such as diabetes or empowering healthy behaviours → build equity into these targets:• a number of PHUs and LHINs have identified areas where diabetes incidence is

highest → equity target = reduce differences in incidence, complications and rates of hospitalization among populations or areas

• a good service target has been proposed for diabetes = high % of people who get high standard care → equity target = reduce differences by gender, income, region

• 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, neigbourhood, gender, race, etc. • in fact, concentrate services in most disadvantaged communities with greatest

needs• many programs assess their services through client satisfaction surveys and

similar methods • providers look for high and improving satisfaction → equity target = reduce

any differences in satisfaction by gender, income, ethno-cultural background, etc.

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• 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

• this starts from a 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• involvement of local communities and stakeholders in planning and

priority setting is critical to understanding the real local problems

• and then requires an array of effective and practical equity-focused planning tools

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1. quick check to ensure equity is considered in all service delivery/planning

2. take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery

3. assess current state of provider organization

4. determine needs of communities facing health disparities

5. assess impact of programs/interventions on health disparities and disadvantaged populations

1. simple equity lens

2. Health Equity Impact Assessment – has been piloted in Toronto and MOHLTC is considering wider roll-out

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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• 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

• essentially prospective

• arose out of broader health impact assessments, which have been increasingly used in many jurisdictions in last 15 years• HIA is commonly understood in municipal and community planning circles

• one reason for HEIA was increasing policy attention to SDoH and health disparities → need explicit equity focus

• increasing attention to potential – from WHO, through most European strategies to MOHLTC and LHINs

• HEIA is seen to be relatively easy-to-use tool

• Wellesley partnered to pilot and refine, and HEIA is now being implemented in Ontario

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• precondition for all this planning, monitoring indicators, and assessing progress against objectives and targets is reliable data on:• health outcomes and behaviour, differentiated by population, neighbourhood and

income, education, ethno-cultural background and other determinants of health

• service use patterns, also stratified

• how well service use reflects catchment and community make-up

• trends in all of this – to monitor impact and progress

• when hospitals in Toronto Central began working on their equity plans it became very clear that they simply did not have the necessary data to do equity-driven planning• recognized as key issue in MOHLTC and LHINs

• similar challenges for public health?

• and why not coordinate development of best equity-relevant data?

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• looking abroad for promising practices = Public Health Observatories in UK• consistent and coherent collection and analysis of pop’n health

data• division of specialization among the Observatories – London

focuses on equity issues

• interest/development in Western Canada:• Saskatoon has developed a comprehensive local health equity

strategy• including sophisticated research and created a public health

observatory to collect data and build into monitoring an continuous improvement

• more generally, innovative thinking emerging around dynamic systems modeling meeting population health

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• all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds

• can build in specific expectations – will vary by community and provider -- but could include:• undertaking appropriate equity-focused planning• ensuring service utilization matches appropriately with demography

and needs of their catchment profile• providing sufficient services in languages of community and

appropriate interpretation• identifying areas where access to services is inequitable and

developing plans to address barriers and gaps• developing specific services or outreach to particular disadvantaged

populations – homeless, isolated seniors, etc.

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• a promising direction several LHINs have taken up is to have providers undertake specific equity planning exercises 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

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http://www.torontoevaluation.ca/tclhin/index.html

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• provincial standards offer a possible lever• do include responsibility to assess and act on population health• many innovative and comprehensive initiatives from PHUs

• require each PHU to develop a health equity plan showing how it was putting population health standards into practice

• and then:• call a province-wide roundtable to share, debate and learn from all the

individual plans• build on these into a coherent overall strategy• build this into specific expectations and targets and build these into

routine PHU performance management and accountabilities

• more specifically, could require PHUs or other providers to undertake HEIA to be eligible for particular programs or funding

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• second theme of overall strategic framework is to target services to specific areas or populations:

• those facing the harshest disparities – to improve the health of the worst off fastest

• or those most in need of specific services

• or to the worst barriers to equitable access to high-quality services

• 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.

• highlighted data

• also requires good local research and detailed information – speaks to great potential of community-based research to provide rich local needs assessments and evaluation data

• language is key barrier to access → cross-sectoral project analyzing how to enhance and streamline interpretation services

• many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities

• for homeless people:• CAISI database so records are accessible from many providers• travelling psychiatrists, nurses and other providers• Baby and Me passport• Street Health report as CBR into action

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• assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context

• and this requires ongoing community engagement with the population in planning and priority setting

• also means engaging the affected population on how to design services to meet their specific needs

• similarly, monitoring and assessing the impact of service initiatives also needs research and input from the affected population on impact

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• investing in better chronic care prevention and management are vital elements of health reform

• chronic disease prevention and management programs cannot be successful unless they take health disparities and wider social conditions into account

• up-stream initiatives need to be planned and implemented through an equity lens• very clear gradient in incidence – and impact – of chronic conditions• some populations and communities need greater support to prevent and

manage chronic conditions– poor, Aboriginal and other vulnerable communities face greater incidence and

greater challenges in managing diabetes– at the same, time these communities tend to have less access to good food,

safe open space and recreational facilities to encourage exercise, etc.– the Toronto diabetes atlas produced by ICES found that only 25% of in low-

income neighbourhoods participated in weekly sports – versus 75% form high-income

– built environment is also key -- Atlas found that people in low-income areas walked more for transportation purposes but less for exercise

• a very interesting example is the integrated diabetes program developed out of the London InterCommunity Health Centre:– began from far greater incidence and impact in local Hispanic

community – originated in local CHCs’ community engagement

– CHC, community groups and others worked closely together

– language specific and culturally sensitive services

– preventative and promotion services offered where people went –e.g. shopping malls

– also saw that social conditions had to be addressed → referrals to social service support, cross-sectoral planning, advocacy around employment and other problems

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• health promotion initiatives need to be planned and implemented through an equity lens• very clear gradient in incidence of smoking, over-weight, lack of

exercise

• healthy behaviour targets can’t just be increasing exercise rates and decreasing smoking overall → equity target = reduce differences by gender, income, region

• a valuable primer has been developed by Health Nexus, Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support –– meant to be a virtual resource for health promotion workers in the

field– http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20

Final.pdf

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• can’t just measure activity:• number of people or % of pop’n that participated in health promotion

program• need to measure health outcomes – even when impact only shows up in

long-term

• need to assess reach• who isn’t signing up? who needs program/support most?

• and assess impact through equity lens• need to know who stuck with program and what impact it had on their

health – and how this varies by population• need to differentiate those with greatest need = who programs most need

to enroll and keep to have an impact• → develop funding and evaluation weighting that recognizes more

complex needs and challenges of most disadvantaged, and builds this into incentive system

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• cross-sectoral coordination and planning are seen to be key ways to put wider SDoH into action

• key to British and European strategies are local investments in community economic development and targeted healthcare and social service improvements

• 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• Social Planning Councils are developing cross-sectoral

planning forums and processes in many communities around poverty and inequality – with clear implications for health

• at best, MHP’s healthy communities approach to planning health promotion implies wider community development and capacity building

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• idea of comprehensive community initiatives• British example of Health Action Zones and other models

were designed to combine community economic development with targeted healthcare and social service improvements

• in Canada, some 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

• 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

• 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

• Ontario provincial associations representing CHCs, mental health and community service agencies have been promoting idea -- including to LHIN CEO provincial planning table

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• a key lesson of LHIN experience to date is that existing networks and partnerships are a huge resource to build on

• principle = identify key networks to enhance equity coordination and delivery in priority areas and support them build on them

• there are well-established provider coordinating networks across the province

• i.e. for mental health priority, can build on:• local networks of community-based providers• Canadian Mental Health Association's local divisions• LHINs and the planning tables they have established for this priority

• and the network of health promotion networks and resource centres – build on existing infrastructure – don't totally re-invent

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• potential:• huge number of community and front-line initiatives already

addressing equity across province

• + equity focused planning through provider equity plans, 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 promising and successful program interventions

• but• these initiatives and interventions are not being rigorously assessed

• experience and lessons learned are not being shared systematically

• potential of promising interventions is not being realized

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• to drive equity-focused innovation and effective interventions, we need to be able to:• collate and analyze all the useful intelligence gained from equity-focused

planning• capture and share information on local initiatives, and build on local front-

line insights• share the resulting knowledge across regions – and beyond • assess the most promising initiatives or directions• scale up promising initiatives across the province where appropriate

• creating a forum and infrastructure for this innovation knowledge management is crucial

• but who takes it up?• innovation doesn’t fit nicely into Ministry and other institutional

boundaries• whatever the form, needs to be collaboration with Ministries, Prov

associations, other stakeholders?

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• build equity-focused innovation into incentives and drivers

• cascading from Prov to LHINs to providers• expectation that X% of budget will be devoted to equity-

orientated innovation• ear-marked funds for equity innovation

• + government funding of cross-sectoral action addressing wider determinants • Public Health Agency of Canada and provincial counterparts

should fund/support cross-sectoral collaborations and initiatives – getting beyond most programs that can’t fund beyond their narrow jurisdictional boundaries

• these agencies can become centres of expertise on equity and SDoH-orientated collaboration

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• figuring our what interventions and approaches work, in what contexts and why

• to drive investment in policy directions and program interventions that will have the strongest equity impact

• increasing international, Cdn and Ont interest in more strategic and realist evaluation• International Collaboration on Evaluation and Health Inequalities

• I have argued elsewhere for a role for various Canadian public health agencies• becoming centres of expertise in evaluation applied to public health

strategy and delivery• vital link between public health and other players in health system

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• 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 just because of good analysis but through widespread community mobilization and social pressure

• key to equity-driven reform will also be empowering communities to imagine their alternative health futures and to organize to achieve them

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• 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• we have enormous resources of knowledge of promising practices

and on-the-ground experience – challenge is to build on this potential

• have set out overall strategic approaches, principles and tools to drive equity into action → experiment and innovate

• many within the public health system have long experience and strong commitment to equity → build on this to drive coordinated and coherent system-wide equity agenda into action

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• 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

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The Wellesley Institute advances urban health through rigorous research,

pragmatic policy solutions, social innovation, and community action.

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• back to bigger picture

• following is a roadmap for comprehensive integrated policy action on determinants of health and health inequality

• plus options for further discussion:• avoiding unintended consequences

• barriers to collaboration

• importance of social policy

• complexities of planning

• inequitable access to health services

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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 program action;

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6 rigorously evaluate the outcomes and potential of program 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;

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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 program and policy instruments, and into a coherent and coordinated overall strategy for health equity.

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• 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 and promotion that doesn’t target and/or customize to particular disadvantaged communities• inequality gap can widen as more affluent/educated take

advantage of programs

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• have been emphasizing the potential of collaboration and cross-sectoral planning:• but health system is fragmented – LHINs, primary care, provincial

programs, acute and up-stream, two ministries, public health

• need to find ways to work beyond jurisdictional boundaries

• let alone developing cross-sectoral collaborations beyond health

• local issue-orientated and community-based planning is most likely to succeed in breaking silos down

• let alone competing professional interests – organized medicine as the ‘elephant n the room’ for health reform

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• BC is healthiest province overall (Quebec is 3rd healthiest)• most social and behavioural risk factors for chronic diseases (i.e.

smoking, physical inactivity, poor education, unemployment and lack of home ownership)) are significantly more prevalent among low-income residents of Quebec than BC

• but Quebec’s low-income residents are at the least risk for major chronic diseases among Canadian provinces

• the percentage of low-income individuals with an unmet medical need was significantly lower in Quebec (9.5%) -- higher (16.5%) in BC • 31.5% of BC residents with an unmet medical need reported cost as a

factor compared with only 6.4% of QC residents who reported cost• Quebec’s anti-poverty strategy (2002) and other comprehensive social

policies appear to give its low-income residents advantages in chronic disease prevention

• Source: Fang, R. et al Disparities in chronic disease among Canada’s low-income populations. Prev Chronic Dis 2009;6(4).

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• need clear strategy and theory of what ‘healthy community’ looks like →what success looks like:• equitable health promotion and outcomes

• supported and sustained by healthy communities

• effective and responsive kinds of planning to get there

• all within a clear understanding of the wider context and constraints of social determinants of health

• and then drilling down: what is our ‘theory’ of how equity-focused planning works?

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taking account

of social constraints &

conditions

not just individual

programs but coordination,

partnerships & collaboration

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enhanced access to

health promotion for

most disadvantaged

up-stream heath conditions & opportunities

improve fastest for those in

greatest need

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• processes and constraints are complex, and outcomes uncertain and unpredictable, at each of these junctures

• and all of this varies by context:• particular communities or neighbourhoods – with their different

health challenges and needs• particular population health and service landscape – further

specified by health condition or concern (e.g. mental health)• existing municipal and local polices and traditions• community resilience, connectedness, organizing and traditions

• we don’t really know what works best at each these junctures (let alone cumulatively) or in varying contexts → need to build evaluation in from the start to learn

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% With Physician Visits for Arthritis, Age 45-64, TC LHIN 2001-03

1311

20

14

0

5

10

15

20

25

Low Income High Income

Males Females

Proportion of Residents with physician visits for Arthritis is higher in Lower Income neighbourhoods, especially females.

Neighbourhood Income Quintiles

Toronto Community Health Profiles Partnership, www.torontohealthprofiles.ca

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Hip Replacement Rate, TC LHIN, 2004/05

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144

0

50

100

150

Lowest Income Highest Income

#/1

00

,00

0

Despite poorer health and greater need/potential to benefit from diagnosis and treatment in lower income groups, the hip replacement rate is over twice as high in the highest income neighbourhoods.

Age Standardized Rates. Total Hip Replacements per 100,000 Population by Neighbourhood Income Quintiles. .Source: Institute for Clinical Evaluative Sciences (ICES) November 2006

• broad social and healthcare provider consensus that discrimination between women and men is no longer acceptable

• but research has shown that women are less likely than men to receive:• standard heart medication• dialysis treatment• admission to intensive care units• certain surgical procedures – cardiac catherization, kidney

transplants, knee arthroplasty (replacement)

• surgeons and referring physicians respond in surveys that sex of patient has no effect on their clinical decisions

• so…..

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• to see if there were differences by gender in clinical practice• standardized male and female patients went to family

physicians and orthopaedic surgeons • presented with the same scripted clinical scenario

• found striking differences:• orthopaedic surgeons were 22X more likely to recommend

male for total knee arthroplasty than female• family physicians were 2X more likely for male

Source: Borkhoff et al, CMAJ, March 11, 2008

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