Thinking About Health Equity/ Acting on Health Equity

Bob GardnerMedical and Health Sciences Forum

University of TorontoJanuary 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

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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 Health Inequities

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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

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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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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.

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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

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

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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 are impt

POWER Study: Gender andEquity Health Indicator Framework

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• 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

Equity Into Health System: Why

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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 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

Equity Into Health System: Why II

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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 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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Equity Into Health System: How IIwhile health disparities are pervasive and deep-rooted, they can be changed through policy and program actioncomprehensive strategy developed in 2008 for Toronto Central LHINmany recommendations have been acted onother LHINs are also prioritizing and moving to address health disparities

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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?

• 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

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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

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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

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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

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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

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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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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.

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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

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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•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

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• 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

Use Available Levers: Equity Plans

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

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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

• 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

Target Populations

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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

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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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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 Equitycould 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 here45

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

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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

Following Up

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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;

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Wellesley Roadmap II6 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;

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Wellesley Roadmap III9 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.

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