Advancing Health, Health Equity and Opportunities for Children

and Youth in Tough TimesPresentation to the Provincial Advocate for

Children and YouthApril 2012

Bob Gardner & Steve Barnes

OutlinePervasive and damaging health inequities

Rooted in underlying social determinants of health = parallels in problems you address

Strategy and action to address health inequities

Some parallel lessons learned for your challenges

Addressing underlying determinants of health

Parallels are close

Post-Drummond era of austerity Policy context shapes all of our issues

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One Problem to Solve: 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

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Impact of Inequities• from the start: while infant mortality rates have been

declining overall, rates in Canada’s poorest neighbourhoods remain two-thirds higher than those of the richest neighbourhoods

• to the end: 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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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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Health Equity and Social Justice• this view builds upon Amartyn Sen -- a leading voice in

highlighting that what has to be equitable here is the capacity to secure good health

• More broadly, he sees the capability for good health as “a central feature of the justice of social arrangements in general”

• a recent book on Health Justice by Sridahr Venkatapuram emphasizes:

• “the recognition of every human being’s moral entitlement to a capability to be healthy”

• and links this to social determinants of health• “.. and, more specifically, the entitlement is to the social bases” of

the capability to be healthy• in these ways health equity can be seen as a fundamental

component of social justice

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Foundations of Health Disparities Roots Lie in Social Determinants of Health

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• 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

Canadians With Chronic Conditions Who Also Report Food Insecurity

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Drilling Down: Diabetes• Best way to prevent/manage diabetes is through

a healthy diet of lots of fruit & veggies• But not all communities have easy access to grocery

stores• And not all families can afford healthy food• And not all families can afford the transport costs to

get to and from stores• And not everyone has good access to primary health

care that helps manage diabetes in the first place• All this leads to ongoing health problems over a

lifetime

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SDoH As a Complex ProblemDeterminants 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 individuals throughout their lives and on overall population health

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SDoH Over the Life Course• important elaboration in SDoH analysis – recognizing that:

• the effect of determinants varies across people’s lives – so need to analyze impact on children and youth specifically

• and that impact of inequalities is cumulative• for children, research shows that:

• pre-natal and early years are especially sensitive to social conditions and can have a major impact on future health

• intervening in early years to counteract adverse effects of wider social and economic inequalities has great potential

• growing up in inadequate and inequitable social and family circumstances can store up a life-time of health problems

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Three Cumulative and Inter-Dependent Levels Shape Health Inequities

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

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

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

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

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

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

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Social Determinants of Health +

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 important

POWER Study: Gender andEquity Health Indicator Framework

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Health Inequities = ‘Wicked’ Problem

• health inequities and their underlying social determinants of health are classic ‘wicked’ policy problems:• shaped by many inter-related and inter-dependent factors • in constantly changing social, economic, community and policy environments• action has to be taken at multiple levels -- by many levels of government,

service providers, other stakeholders and communities• solutions are not always clear and policy agreement can be difficult to achieve• effects take years to show up – far beyond any electoral cycle

• have to be able to understand and navigate this complexity to develop solutions • we need to be able to:

• identify the connections and causal pathways between multiple factors • articulate the mechanisms or leverage points that we assume drive change in

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

preconditions for achieving them.

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Think Big, But Get Going• 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 children’s health and health system

if the foundations of health inequities lie in underlying social determinants, why worry about health care?

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

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Towards Solutions:Building Equity Into the Health System

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

outreach2. aligning equity with system drivers and priorities – such as chronic

disease prevention and management, quality3. 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

• looking to improve the health of most disadvantaged, fastest5. while investing up-stream in health promotion and addressing the

underlying determinants of health

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Equity-Focused Planning

• all of that needs good planning• addressing health disparities in service delivery, planning and policy

development requires a solid understanding of:• key barriers to equitable access to high quality health care and other services and

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

• and need to understand the roots of disparities:• i.e. is the main problem language barriers, lack of coordination among providers,

sheer lack of services in particular neighbourhoods, racism, concentrated poverty, precarious work, etc.

• which requires good local research and detailed information – speaks to great potential of community-based research and involvement of local communities

• requires an array of effective and practical equity-focused planning tools:• for health care to ensure equitable access – equity into targets, deliverables and

performance management• other sectors to ensure implications for health are taken into account HEIA• all sectors to enhance policy and program coordination and coherent impact HiAP

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

communities – who will define those needs?• can’t just be ‘experts’, planners or professionals

• have to build community into core planning and priority setting• not as occasional community engagement, but to identify equity needs and

priorities, and to evaluate how we are doing• many providers have community advisory panels or community members on

their boards • can also build on innovative methods of engagement – e.g. citizens’

assemblies or juries in many jurisdictions• need to develop community engagement that will work for disadvantaged and

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

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Extend That → Build Community-Level Action

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

• many cities have developed neighbourhood revitalization strategies • Toronto’s priority neighbourhoods, Regent’s Park

• promising direction = comprehensive community initiatives:• broad partnerships of local residents, community organizations,

governments, business, labour and other stakeholders coming together to address deep-rooted local problems – poverty, neighbourhood deterioration, health disparities

• collaborative cross-sectoral efforts – employment opportunities, skills building, access to health and social services, community development

• e.g. of Vibrant Communities – 14 communities across the country to build individual and community capacities to reduce poverty

• Wellesley review of evidence = these initiatives have the potential to build individual opportunities, awareness of structural nature of poverty and local mobilization → into policy advocacy

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Public Policy Post-Drummond

• An enormous range of specific recommendations and welcome recognition of need for govt and public services to be more innovative and responsive

• But most important influence may be in shaping the tenor/parameters of public policy

• It justifies and ushers in an era of austerity, restraint and limited public investment – with implications for all our fields

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Drummond on Health• The Drummond Report’s emphasis on reform and innovation in

the way health care is organized and delivered is vital.• Huge element is missing: equity.

• Equitable access to services, equitable outcomes and improved population health must also be fundamental goals of reform.

• we need to ensure that that the reforms being contemplated do not make access to health care less equitable or worsen the health of marginalized populations.

• Drummond highlights that a small proportion of patients with complex needs account for a high proportion of overall health system costs and emphasizes that preventing ill health and controlling chronic diseases is crucial moving forward• but the distribution of ill-health is not random• consistent inequitable gradient of health

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Drummond on Health II

• The report also highlights the importance of primary care. • An equity approach would ensure that expanded family

health teams, community health centres and other key reforms are concentrated in under-served and higher need areas to reduce inequitable disparities in access.

• The report rightly points to the need for coordination and integration of services. • Discharging a patient into overcrowded or unsafe housing

means that they are likely to end up back in the hospital, thereby undermining the savings and efficiencies the Commission is looking for.

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Post-Drummond Social Policy• Drummond did recognize – although unevenly – that

not investing in the social/community foundations of a healthy society will lead to higher costs down the road

• But it didn’t recognize in its health analysis how inequitable social determinants of health will undermine efforts at reform and continue to underlay poorer health• the same point – of not seeing the systemic roots of so

many social problems and policy challenges in structured inequality weakens the Report throughout

• so there is no coherent vision of investing in the social foundations of a healthy and equitable society

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Look for Areas to Intervene•Commission on the Reform of Social Assistance in Ontario•A broad collaborative of leading Toronto health sector institutions and experts came together to:

• Define a vision of health-enabling social assistance system; and

• Practical actions to implement such a system

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Social Assistance Reform

• Drummond recommended that social spending be allowed to increase by 0.5%

• But social assistance rates are already inadequate and people on social assistance do not have the supports to help them into work/training

• Children who grow up in poverty ‘store up’ a lifetime of health problems

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Social Assistance Reform II

• The budget froze social assistance rates and cut funding for health-related expenses

• And it preempted the advice of its own expert Commission

• BUT it increased spending on social and children’s services by an average of 2.7 percent over the next three years, the largest percentage increase of any sector

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Lessons for Advancing Equity in Tough Times

• Watch for constant danger of austerity policy: → cuts to community foundations of health and opportunity

or to services for most vulnerable → make inequalities worse

• Always keep equity in the front of your mind• Don’t let the scale of the problem or the harsh policy

environment stop you from making progress• Austerity will pass and we need to be ready with

imaginative and achievable policy solutions• Identify opportunities and the policy levers that you have

within your control

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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 social policy and underlying structures of economic and social inequality

• these kinds of huge changes come about not because of good analysis, but through widespread community mobilization and public pressure

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

• we need to find ways that governments, providers, community groups, unions, and others can support each others’ campaigns and coalesce around a few ‘big ideas’

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Health Equity

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