Driving Local Action on Health Equity

Driving Local Action on Health Equity Bob Gardner

North Hamilton Community Health CentreJune 19, 2013

Problem to Solve: Systemic Health Inequities 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 and neighbourhoods

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And LocallyCode Red series on health inequities by neighbourhoods:

• 21 years difference in age at death

• major differences in health outcomes across many measures

plus inequitable access to health care in poorest areas

• 50% higher rates of emergency department visits in downtown core

• 2X for psychiatric emergencies

• less access to primary care

April 12, 2023 | www.wellesleyinstitute.com

Today• these health disparities are deep-seated and complex• but they can be tackled addressed through comprehensive health

equity strategy and concerted action• means acting on health equity within the health system

• will set out elements of a roadmap to build equity into health planning and delivery

• CHC have long played a crucial role in driving equity into action• also have to act well beyond health care -- tackling the underlying

social determinants of health• through community-based innovation, cross-sectoral collaborations

and fundamental social and policy change to reduce inequality• again, with examples and opportunities for CHCs

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Planning For Complexity

even though roots of health disparities lie in social and economic inequalityneed to also look at how these other systems shape the impact of SDoH:

•access to health services can mediate harshest impact of SDoH to some degree•so too can responsive social services•structure, resources and resilience of communities shape impact and dynamics of inequalities


Building Equity Into the Health System: How

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• Health Equity Imapct Assessment is one tool

2. aligning equity with system drivers and priorities• quality improvement, chronic disease prevention and management,

wait times, Health Links• none of these directions can succeed without taking equity barriers,

social determinants of health and differential risks and needs into account

• action idea = all Hamilton hospitals and CHCs to include equity indicators in their QIPs

• aligning with key priorities also enhances chance for success and sustainability of equity focus

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Building Equity Into the Health System: II

3. identifying those levers that will have the greatest impact on reducing health inequities and driving system change • solid interntional evidence that enhanced primary care is one of key

means to improve inequitable health care and health for disadvantaged populations

• improving primary care is a major Ministry priority• Family Health Teams, Health Links and many other initiatives are part

of this• Community Health Centre model of care is the only sector

• explicitly geared to supporting people from marginalized communities

• with comprehensive multi-disciplinary services covering full range of needs


Building Equity Into the Health System: III

4. embedding equity in provider organizations’ deliverables, accountabilities and performance management – in the incentives and pressures that really drive the system• a big problem for primary care is the doctor-driven incentives of other models • CHCs are working to develop a comprehensive performance measurement and

management system5. targeting some resources or programs to reducing health disparities or improving

the health of the most disadvantaged, fastest6. investing up-stream in health promotion and addressing the underlying determinants

of health7. enabling equity-focused innovation

• a huge range of promising and innovative programs have been developed by Community Health Centres, hospitals, networks and other providers to address the needs of disadvantaged communities.

• we need to share lessons learned, evaluate and identify what is working, and build on the enormous amount of local imagination and innovation going on

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Where to Start?

• can’t just be ‘experts’, planners or professionals who define issues and drive system transformation• have to build diverse voices and community needs into planning• not just as occasional community engagement• but to identify fundamental needs and priorities• and to evaluate how we are doing

→ need to start from communities and clients+ through an equity lens:

• not all clients are the same – diverse cultures, backgrounds and perspectives, and unequal social and economic conditions

• how to involve all types of clients?• specifically, how to involve and empower those not normally included• adapt different and innovative methods – e.g. principles of inclusion research

+ thinking about the communities in which they live and the social determinants that shape their opportunities for health


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Ensure Planning Is Community Driven

• many hospitals and other providers have community advisory committees

• LHINs do a great deal of community engagement

• CHCs have community boards• CHCs demonstrate how to

really build community interests/voices into planning and delivery → lessons for other sectors

make this community engagement real• for all providers:

• community committees’ recommendations must be responded to by mgmt

• committees make decisions over a proportion of discretionary budget

• for LHINs:• build local health and well-

being councils, with information and other resources so they can work effectively

• give these local councils control over a proportion of discretionary budget


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Collaborative Equity Planning


• to meet accountability requirements from Toronto Central LHIN

• developed common equity principles

• identified common priorities to work on together:• interpretation• building equity into CHC

performance management system• uninsured

• action idea: similar joint equity plan for local CHCs (+ others?)

• action idea = Hamilton health equity plan, building on Roundtable in spring

Never Just Equitable Access, But Quality: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 → customizing care mix to meet those needs→ continuum of care especially important

• also face greater access barriers – e.g.. availability/cost of transportation, childcare, language, discrimination

→ facilitated access and effective navigation/transitions is crucial• all of this is CHC model of care = constant demonstration about how to deliver

comprehensive equity-driven care

• pre-condition = need to know social context/conditions of community/clients• language, income, immigration history• project in Toronto Central to collect such data directly• as electronic health records are being developed, ensure equity and social

determinants data is built in

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Extend Equity-Driven Service → Address Roots of Health Inequities in Communities

build on equity-orientated models• CHCs, public health and many community providers have established ‘peer health

ambassadors’ to provide system navigation, outreach and health promotion services to communities facing particular barriers

• hub-style multi-service centres →• coordinated services -- a range of health and employment, child care, language,

literacy, training and social services are provided out of single ‘one stop' locations• based solidly in local communities and responding to local needs and priorities →

can become important community ‘space’ and support community capacity building

look beyond vulnerable individuals to the communities in which they live→ meeting full range of needs means moving beyond health care

• focus on community development as part of mandate for CHCs • providing and partnering to provide comprehensive services/support such as

settlement, language, child care, literacy, employment training, youth programs, etc.


• vulnerable populations will vary in different places:• poor neighbourhoods with high % of racialized population in many big

cities• newcomers = major theme of earlier Roundtable• highlights importance of community health profiles

• identifying ‘priority populations’ is key public health strategy and mandate of CHCs is to serve most vulnerable

• action idea = create local primary care coordinating tables to bring CHCs, Health Links, Family Health Teams, public health and other providers together

• action idea = HNHB primary care initiatives to apply HEIA to plans and adopt explicit equity objectives and targets

Invest in Health Disadvantaged Populations or Communities

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Target Systemic Barriers

•in Toronto and other cities: people without health insurance

• immigrants in 3 month wait time, refugees

• inequitable access → delayed care and worse outcomes

• CHCs and community clinics provide some access

• Women’s College Hospital Network on Noninsured is forum for coordination

•federal cuts to refugee healthcare→ adverse impact on particularly

vulnerable people→ increased healthcare costs/demands at

prov and provider levels•action idea = create local network or initiatives to improve access for uninsured and/or refugees

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Addressing Systemic Barriers: Interpretation as a Key Quality and Equity Lever

precondition for equity• ensuring that adequate

interpretation is available wherever needed → improves quality and equity

• LHINs using available levers → formal requirement on all providers

+ alignment• access to interpretation also

underlies wait times, safety and other system priorities

•action idea = Hamilton providers consider centralized/coordinated interpretation services


Canadians With Chronic Conditions Who Also Report Food Insecurity

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Health Promotion Through an Equity Lens

• programs have to take account of inequitable resources of vulnerable individuals and communities• advice to manage diabetes or heart problems by exercising depends upon

affording a gym or being close to safe park• if not customized, generic health promotion programs can widen disparities as

better off take them up disproportionately• adjust programs to inequitable risks and specific barriers

• South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America (Creatore et al CMAJ Aril 19, 2010)

• deliver in languages and cultures of particular population/community• go where people are -- e.g. CHCs/promoters into malls• action idea = Immigrant Women's’ Health Centre, Aboriginal communities and

other vans• CHCs lead/demonstrate how equity-driven health pomrotion can be done


Pulling it All Together: Local Cross-Sectoral Planning

• cross-sectoral coordination and planning can identify community health needs, access barriers, fragmentation, service gaps, and how to address them• public health departments and LHINs are pulling together

or participating in cross-sectoral planning tables• Local Immigration Partnerships, Social Planning Councils• such broad collaboration will be particularly important to

Health Links and other system integration initiatives• and coordinated services are particularly important in less

advantaged communities with less resources• also key means to address deep-seated health inequities and

wider SDoH at community level• CHCs have long played a key role in developing and

connecting these resources and partnerships

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Equity and Community-Driven Local Planning

pre-condition for this kind of coordinated action = creating an effective cross-sectoral planning forum

action idea = create local health equity forum with concrete planning mandate

can build on earlier roundtable

Looking for Ideas : SETO

•arose out of community concern re access•brings together public health, CHCs, shelters, researchers and service providers serving marginalized communities in south-east Toronto•for an overview of SETo’s development see http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx •ongoing collaboration and idea sharing → supports service coordination and problem solving•emphasized concrete demonstration projects → many with lasting impact•advocacy with institutions and governments around results of projects and key issues such as harm reduction, dental care and access for non-insured people


http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx

http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx

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 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 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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Shifting the Frame

Sudbury & other public health


Health Equity

• could be one of those ‘big’ unifying ideas..• if we see opportunities for good health and well-being as a

basic right for all• if we see the damaged health of disadvantaged and

marginalized populations as an indictment of an unequal society – but that focused initiatives can make a difference

• if we recognize that coming together to address the social determinants that underlie health inequalities will also address the roots of so many other social problems

• thinking of what needs to be done to create health equity is a way of imagining and forging a powerful vision of a progressive future

• and showing that we can get there from here

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Key Messages• health inequities 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 where you are• have set out a roadmap – of strategies, tools and ideas -- to drive equity into

action through policy change and community mobilization

where CHCs come in:• demonstrating every day that something can be done about systemic

inequities -- by delivering the best possible health care to disadvantaged communities

• working in partnerships and collaborations well beyond health care to address the underlying determinants of health

• I see CHCs as a beacon and inspiration – showing change is possible and how to move towards a more equitable health future

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Healthcare

Driving Local Action on Health Equity