driving health equity into action at a community level

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Driving Health Equity Into Action at a Community Level

Bob GardnerCentral LHIN

Health Equity Advisory Network RoundtableMay 19, 2011


The Challenge = 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 status of the best off and

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

and quality of care within the health care system• these inequities can be concentrated in particular

communities, neighbourhoods and areas

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Context• focus today is on concentrated equity initiatives in three communities:

• Chippewas of Georgina Island First Nation (Northern York)• Rural area of South Simcoe• Diverse urban communities in North York West

• focusing on particular communities or populations is a critical component of an overall equity strategy• will talk about the constant need to align and balance local/specific

initiatives with wider system changes and strategies• LHINs can effectively use the levers they control:

• allocating resources and influencing health care providers• can also enable partnerships, collaborations and other change initiatives

• shown to be effective way to drive quality improvement and system reforms

• especially important when levers of change are outside LHINs’ formal mandates and resources

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Percentage of Adults Who Reported Their Health as Fair or Poor:

Ontario and Central LHIN

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Hospitalization Rates for Diabetes: Ontario and Central LHIN


Impact of Disparities

inequality in how long people live• difference btwn life expectancy of top and bottom

income decile = 7.4 years for men and 4.5 for women• more sophisticated analyses add the pronounced

gradient in morbidity to mortality → taking account of quality of life and developing data on health adjusted life expectancy

• even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women

Statistics Canada Health Reports Dec 09

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Foundations of Health Disparities Roots Lie in Social Determinants of Health

•clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion

•impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally

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

Planning For Complexity of SDoH

POWER StudyGender andEquityHealth IndicatorFramework

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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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Think Big, But Get Going• 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• gradually build up coherent sets of policy and program actions

– and keep evaluating, learning and adapting

• need to start somewhere – and focus today is on 1. building equity into health system2. by focusing on concentrated action in three communities


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

• can do this through a three 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. aligning equity with system drivers and embedding it in provider organizations and performance management

3. 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

Equity Into Health System

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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• 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• idea = develop innovative community engagement and partnerships to ground and

drive action in these two communities

• need good local data on needs, gaps and opportunities• community-based research, needs assessment and evaluation• build on data from Toronto Health Profiles, public health, etc.

• idea = identify information needs and build actionable profile of community health needs

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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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Equity-Focused Planning Tools1. 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

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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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, final versions released by Ministry in 2011• Toronto Central has required HEIA within recent funding application processes

for Aging at Home, and refreshing hospital equity plans

• idea = LHIN and providers to undertake HEIA for any service or program changes that could affect these communities

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Beyond Planning: Embed Equity in Targets and Incentives

• 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• closely monitoring progress against the targets and indicators• disseminating the results widely for public scrutiny• tying funding and resource allocation to performance

• innovative work underway to develop equity indicators – but don’t need to wait

• idea = what are appropriate equity targets for these communities?• simplest could be to build on indicators already being collected → equity angle is to reduce differences between these communities and others

or LHIN as a whole on these indicators

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Building Effective Equity Targets For Central Priorities

• reducing diabetes incidence is prov and LHIN priority, and pressing issue in these communities

→ 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

→ equity target = reduce differences by gender, income, ethno-cultural background, neighbourhood

• 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 providers and 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, neighbourhood, etc.

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• where targets and indicators get tied to deliverables and incentives• key lever = all hospitals, CHCs and other providers sign Service

Accountability Agreements with LHINs that govern flow of funds• → can build specific expectations and deliverables into those

agreements• will vary by community and provider -- but could include:

• undertaking appropriate equity-focused planning to identify areas where access to services is inequitable and developing plans to address barriers and gaps

• stratifying quality indicators by equity – e.g. reducing hospital readmission rates is common objective

→equity angle is to reduce any inequitable differences in readmission rates by language ability or neighbourhood

• idea = identify the most relevant issues for the two communities – readmissions, primary care, clinic or specialist visits re diabetes – and include appropriate expectations in provider accountability agreements

Embed Equity In Performance Management

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• all this planning, monitoring indicators, and assessing progress against objectives and targets needs reliable data on:• ethno-cultural background, language, income, sexual orientation• service use and health outcomes, differentiated by these equity and determinants

of health variables• 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• three hospitals = Toronto Public Health are collaborating on how to collect and

incorporate equity data at service level• Central hospitals could link into this

• but don’t wait for perfect data• hospitals have been using postal code data as proxy for socio-economic conditions

• idea = any project that arises out of this equity planning to collect relevant SDoH data

Precondition: Equity-Relevant 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 have refreshed 2nd generation• hospitals and other providers in Central have completed progress reports for 10/11• CHCs are developing sector-wide plan in Toronto Central

• 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

• idea = ask providers to address specific issue arising out of this equity planning for the two communities in refreshed plans or as appendices to their plans

Use Effective Tools: Equity Plans

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Target Investment for Equity Impact

• target services to:• those communities or populations 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, social exclusion, etc.

• which requires good local research and detailed information –profile idea• involvement of local communities and stakeholders in planning and priority

setting is critical to understanding the real local problems


• equity planning/policy challenge = • what are the key drivers or levers for change within the health system?• how to build equity into those drivers and effectively use those levers to advance health

equity?• 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 –

and for these communities→ concentrate new FHTs or other initiatives in particular regions or neighbourhoods, or in

particular populations such as refugees or uninsured• challenge for LHIN = most of levers for transforming primary care are outside their

mandate → need cross-sectoral coordinated planning• idea = local projects to coordinate and enhance access to high quality primary

care in the two communities• also a chance to be innovative around new ways of community-driven coordination and

multi-disciplinary service integration

Use Effective Levers to Drive Change: Primary Care

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Up-Stream Through an Equity Lens: Chronic Conditions

• improving chronic care prevention and management are key Provincial and LHIN priorities→ align community equity initiatives

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

• very clear gradient in incidence – and impact – of chronic conditions• poor, Aboriginal and other vulnerable communities face greater incidence• at the same, time these communities tend to have less access to good food, safe

open space and recreational facilities to encourage exercise, and other resources to manage their conditions.

• the Toronto diabetes atlas produced by ICES found that only 25% of people in low-income neighbourhoods participated in weekly sports – versus 75% from high-income

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

• up-stream initiatives need to be planned and implemented through an equity lens• some populations and communities need greater support to prevent and manage

chronic conditions• idea = adapt innovative diabetes prevention and management models to these

communities


Gradient in Adult Smoking: Ontario and Central LHIN

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Up Stream Through an Equity Lens: Health Promotion

• more emphasis on health promotion is vital to long-term sustainability of system and individual health• consistent data on variations of risk factors along the social gradient• anti-smoking, exercise, harm reduction and other health promotion

programs 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 for particular community contexts and needs

• if this isn’t done → can unintentionally widen disparities as better off take up programs more

• here again, challenge = programs and levers are outside LHIN scope → partner across sectors

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Cross-Sectoral Planning Through an Equity Lens

• 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 Ont a number of public health units have been pioneering broad community collaborations -- Sudbury, Waterloo, Toronto, Peterborough

• Local Immigration Partnerships , Social Planning Councils• the Ministry of Health Promotion and Sport is developing a healthy communities

strategic approach and community partnerships• idea = sponsor or partner cross-sectoral planning with public health, health

promotion, social services, settlement, education, etc. in the two communities

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Back to Service Delivery and Excellent Care: Take SDoH Into Account

• all of this equity planning loops back to quality• patient-centred care means taking the full range of people’s specific needs

into account• social context and living conditions are part of this

• when people face adverse social determinants of health → can increase risk of mental and physical health challenges and 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 needs and contexts

• more intensive case management, referral planning and post-discharge follow-up

• idea = multi-disciplinary planning tables and projects to adapt quality of care to the specific social and cultural context of these two communities

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Not Just at Individual Level: Build Equity-Driven Service Models

• hub-style multi-service centres in which a range of health and employment, child care, language, settlement, 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• idea = explore potential of hub principles or model in these areas• important to realize that lessons learned from innovation in these two

communities will benefit others as well

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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• Vibrant Communities – communities across the country to build

individual and community capacities to reduce poverty

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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

• collaborative action to find local health equity solutions is part of that community mobilization + is critical to driving immediate action on pressing problems

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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 ,tools and options-- to drive equity into action through health system 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

→and locally, work in partnerships and collaborations to address the health inequalities in these specific communities

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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 [email protected]• 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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