driving health equity into action: strategy, ideas, and tools for midwifery movement

© The Wellesley Institutewww.wellesleyinstitute.com

Bob Gardner

Association of Ontario Midwives

March 22, 2011


1. health disparities in Ontario and Canada are pervasive and damaging

2. but these disparities can be addressed through comprehensive health equity strategy

3. 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

4. and well beyond healthcare -- tackling the underlying roots of health inequality in the wider social determinants of health

5. focus today is on principles and tools for equity-focused planning, delivery and advocacy for Ontario midwives

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• there is a clear gradient in health in which people with lower income or socio-economic status, or facing discrimination, racism or other lines of social exclusion, tend to have poorer health

• plus major differences between women and men• in addition, there are systemic disparities in access to and

quality of care within the healthcare system• not just unfair and unjust, but health disparities make it more

difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs

• enhancing health equity has become a clear priority – from the Province to LHINs to many providers

• that’s why we need strategies, tools and best practices to build equity into effective system and service planning

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

decile = 7.4 years for men and 4.5 for women

+ inequality in how well people live:• more sophisticated analyses add the pronounced gradient

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

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

Statistics Canada Health Reports Dec 09

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8www.welleseyinstitute.com

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

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

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


•Determinants interact and intersect with each other•In constantly changing and dynamic system•In fact, through multiple interacting and inter-dependent economic, social and health systems•Determinants have a reinforcing and cumulative effect on individual and population health

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POWER StudyGender andEquityHealth IndicatorFramework

Highlights1. how the structure,

resources and resilience of communities mediate the impact of SDoH

2. why we need to take SDoH into account in health service planning and delivery

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• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage

• This concept:• is clear, understandable and actionable• identifies the problem that policies will try to solve• is 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 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 building equity into best midwifery care


• even though roots of health disparities lie in far wider social and economic inequality

• how the health system is organized and how care is delivered is still crucial to tackling health disparities

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

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• 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 planning, service delivery 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

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• 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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• Quality Improvement Plans• hospitals just developed first generation and will be reporting every year • opportunity = equity can be built in as one of dimensions to report on• where do midwives fit in hospital maternal health quality planning? = opportunity

to push equity• other provider institutions will be reporting in future

• quality and patient-centred care:• taking lived conditions/experience into account – meaning equity and diversity →

essential to high quality patient-centred care for all

• chronic disease prevention and management is major prov priority• context for you – many clients?• case= comprehensive midwifery care is better for clients with chronic conditions

• equity as contributing to cost-effectiveness and safety:• e.g. reducing language barriers to good care through better interpretation can

reduce mis-diagnoses and over-prescriptions → enhanced quality and cost effectiveness

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• addressing health disparities in service delivery 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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1. quick check to ensure equity is considered in all service delivery/planning

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

3. assess current state of provider organization

4. determine needs of communities facing health disparities

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

1. simple equity lens

2. Health Equity Impact Assessment

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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• The AOM is developing a consumer advocacy strategy that will be an integral part of the Birth Centre provincial election campaign 2011.

• It is our hope that consumers will help the AOM develop and further the campaign in many ways, including generating interest and support for the campaign in their communities , attending all-candidate meetings, and collecting feedback from other consumers as to how the campaign can best reflect the needs of midwifery clients and potential clients of birth centres.

Questions: • How would we best reach out to clients from different communities?

• How do we ensure that the voices of consumers from different geographical, class, ethno-cultural, linguistic, and sexual communities are reflected as much as possible?

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you will have started from basic questions:

•who you need to get involved

•specifying your particular purposes:

• building support in their communities

• taking message into electoral arena

• gathering community feedback and intelligence

+ basic community engagement questions

• how much involvement and influence?

• how will you incorporate input?

then identify success conditions:•processes/forums for involving consumers in planning campaign

• innovative use of social media?

• deliberative dialogue processes?

• just immediate consumers or others in community?

•sharing information effectively on campaign and on opportunities (all candidates meetings, etc.)•providing resources to get involved (talking points, messaging, etc.)•central support/planning from Association

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• simple equity lens that can be broadly applied =

• could the policy or initiative have a differential or inequitable impact on different groups?

• adapted for this question:

• could this community engagement work differently and inequitably in different communities and contexts?

• could some voices be excluded?

• do we need to adapt processes to ensure equitable voice and participation?

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•processes/forums for involving consumers in planning campaign

• innovative use of social media?

• deliberative dialogue processes?

• just immediate consumers or others in community?

•sharing information effectively on campaign

•providing resources to get involved (talking points, messaging, etc.)

•are forums and meetings accessible?

• drilling down to specific barriers

• distance, cost, physical, language, cultural (professional ‘speak’)

• inclusionary facilitating

•who is involved:

• breadth of outreach

• making it easy – times, subsidizing child care, transportation, etc.

•access to means of communication:

• computer

• not just machines but speed

• literacy and comfort

•usability of resources

• both literal and culture/literacy level

• translation into key languages

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• assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context → need ongoing engagement with the population and/or specific community-based research or needs assessment

• analyzing how to design services to meet specific barriers or population needs will also benefit from engaging the affected population

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

• as well as health outcome data stratified by population and social determinants

• back to this advocacy challenge

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• analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations• generally designed for planning forward – as easy-to-use tool to

ensure equity factors are taken into account in planning new services, policy development or other initiatives

• but experience here and in other jurisdictions identified other uses:

• for strategic and operational planning

• for assessing whether programs should be re-aligned or continued

• more generally, discussions around HEIA provide a way to ensure equity is incorporated into routine planning throughout an organization

• increasing attention to potential – from WHO, through most European strategies, PHAC, to Ontario

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• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and Wellesley Institute• refined the one-page template

• and developed a new workbook

• HEIA is being used in Toronto Central and other LHINs

• Toronto Central has required HEIA within recent funding application processes for Aging at Home, and refreshing hospital equity plans

• been used in many settings :• all programs within one Toronto hospital are undertaking HEIA

• also in some community-based programs

• so, it’s worth being aware of and considering for midwives

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preliminary stage = scoping

• could the policy or initiative have a differential or inequitable impact on different groups?

• if yes →

1. analyze how the planned program or initiative affects health equity for particular populations

• list of health disadvantaged populations – not exhaustive

• potential impact on social determinants of health

2. assess potential positive and negative impacts of the initiative on the population(s)

3. develop strategies to build on positive and mitigate negative impacts

4. plan how implementation of the initiative will be monitored to assess its impact

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Case Study 2:

• The Diversity Work Group is planning a session for the AOM annual conference in May 2011. The session will focus on how to best serve clients who do not communicate most effectively in English or in the languages spoken by their midwives.

• The session will be in the form of a workshop where small groups of midwives will discuss different case scenarios and share their experiences and expertise in dealing with these situations.

Question:

How do we ensure that this workshop can best serve the needs of midwives and clients in different geographical, class, ethno-cultural communities?

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• friendly amendment to the question =

• how can midwives best serve clients facing language and related barriers of social inequality and exclusion?

• how can this workshop empower midwives to effectively consider these issues and build them into their practice?

• start from evidence and practice:

• are there inequitable variations in quality and experience of midwifery care by social and economic situation, race, ethno-cultural or immigration status; and/or comfort/facility with English?

• are there inequitable variations in access to midwifery care?

• this is initial scoping stage of HEIA – or any good planning = what is problem we need to solve

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• whether there are inequitable differences is a research question:

• so, first action item from HEIA scoping = if we don’t know → find out• if midwives can’t answer → highlights importance of collecting better

equity-relevant data as priority• can use proxy data from postal code = neighbourhood characteristics

from census data• can use case studies and small-scale interview/chart review studies

• if evidence is yes – or if practitioners’ experience leads them to conclude that there are or could be inequitable variations• → then can drill down using HEIA template to analyze how to better

serve women who do not speak or understand English (or French) well

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in terms of dimensions of good midwifery care:1. access – are language and culture

important barriers to getting care women want?

2. quality – how to ensure high-quality care for all despite language barriers

3. expand to mean cultural competence and appropriate/sensitive care

issues to look for:• who of client groups needs care in

which languages? • are there communities of women

who are excluded because of language or cultural barriers – who and why?

• how does impact of language/cultural barriers intersect with poverty, precarious jobs, racism or other social factors?

• what practical difficulties do women face?

• e.g. might not be able to talk fully to midwife

• might not understand appointment or care information

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what impact on quality if midwife and woman have difficulty communicating or woman doesn’t understand information provided?

→ poorer experience

→ greater risk of complications or poor outcomes

provision of care through a cultural competence lens

• interpretation at all stages of treatment

• translation of all material• partnerships with community

groups to facilitate• equitable care = more

intensive pre-natal and post-partum planning and support for those most in need

• look for innovations with potential -- peer health ambassadors, links to CHCs and other community services

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• language and cultural barriers don’t work in isolation

• drill down = does the impact of language barriers vary withinnon English or French-speaking women and families?

• what other challenges could these women face?

• more unequal or precarious position in labour market

• racism

• living in poor or under-served neighbourhoods

• plus effects of immigration status, social exclusion

• worst for non-insured and undocumented

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•population health and epidemiological data indicate that disadvantaged women may have poorer overall health

• → greater risk of complications or poor outcomes

• + less capacity to cope well with problems should they arise

•are some populations not accessing services equitably?

•special outreach to under-served or most marginalized communities

•not much midwives can directly do about social conditions? →can take poorer situations/higher risks into account:

• more intensive pre-admission planning and support for those most in need

• even broader =taking SDoH into account by including child care, transportation, nutritional and other support, more intensive follow-up

• peer health ambassadors

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language barriers continued = •may not understand how to take meds or follow-up care•may not be able to contact providers for advice•will be dealing with many other providers and institutions – primary care, public health – who may not have language capacities

+ wider SDoH:•poor living conditions, food, anxiety•can’t take as much time off work•can’t afford meds•don’t have equitable access to home and community-based support

→ less able to cope → poorer recovery

cultural competence lens• interpretation for discharge planning• translation of all post-treatment materials• more intensive follow up in

language/culture• potential of peer health ambassadors

can take poorer situations/higher risks into account:• equitable care = more intensive post-

partum planning, case mgmt and assessment

• send home with more supplies, meds, etc.• more intensive follow-up to those in

greatest need – socially as well as medically defined

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• demonstrated value of equity lens and tools such as HEIA on these issues – and most?

• can identify inequitable constraints and barriers:• some seem outside of midwives control → but can take into

account in care planning and delivery

• can identify mediating actions that can be taken and make recommendations:

• then need to monitor impact:• indicators and outcomes• client satisfaction – by these equity variables

• can assess lessons learned → incorporate into ongoing quality improvement

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• 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

• what would equity-focused performance indicators, measurement and management look like for midwifery?

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• have emphasized taking SDoH into account in service del very and planning

• more broadly, cross-sectoral coordination and planning are much emphasized in public health and health policy circles

• 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• Local Immigration Partnerships , Social Planning Councils• comprehensive community initiatives to address poverty and other

complex local problems• the Ministry of Health Promotion and Sport is developing 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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• 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• build equity into strategic priorities, align with quality

agenda and system priorities, embed in routine planning and performance management

• and build equity into front-line planning and delivery where you practice

• no magic blueprint -- experiment and innovate -- and build on learnings and success

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• nesting equity-focused planning in big picture:

• clarifying assumptions and starting points – theory of change underlying equity-focused planning

• data as success condition for all this

• complexities of equity-orientated performance management

• overall health equity roadmap

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• one critical component of this strategic approach is good 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

• to develop effective planning, we need:• clear strategy• a coherent approach• a repertoire of effective tools and techniques• support for planners and practitioners to effectively use them• good actionable information

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

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a ‘realist’ evaluation and/or synthesis approach has great promise• not just to plan specific evaluation or research projects• but to ground and guide overall planning and project development• various other ‘theory of change’ approaches are similar

key premise is to identify the ‘program theory’ – in this case:• how we think efficient and sustainable transfer and incorporation of equity-

focused planning tools and resources into health service practice takes place, in different practice and other contexts

• what we think are the key drivers, facilitators and barriers of the necessary professional and organizational changes

• how we think this will lead to more equitable healthcare and health outcomes/opportunities

then build these assumptions and premises into planning and operationalization:• we test this ‘theory’ against literature, research and evaluation, and

experience • and adjust these assumptions and principles in a constantly iterative process

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taking account of

social constraints &

conditions

not just individual

programs but coordination,

partnerships & collaboration

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enhanced access to primary care

& health promotion for

most disadvantaged

up-stream heath conditions & opportunities

improve fastest for those in

greatest need

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• precondition for all this planning, monitoring indicators, and assessing progress against objectives and targets is reliable data on:• ethno-cultural background, language, income, sexual orientation

• service use and health outcomes, differentiated by these equity and determinants of health variables

• hospitals have been using postal code data as proxy

• begin collecting this data• be aware of and try to align with provincial, LHIN and professional

initiatives

• project in Toronto Central LHIN where three hospitals are collaborating on developing plans on how to collect and incorporate equity data

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• quality standards are especially important to most disadvantaged populations

• how to forge quality standards that reflect individuals’ and communities’ diverse perspectives and needs

• e.g. what does quality reproductive care look like from point of view of poor older recent immigrant?

• highlights the need for more community-based forms of research and needs assessment, and critical importance of community engagement and connections

• one danger of overall quality agenda and performance management is:

• guidelines could be too clinical or academic, or monitoring too quantitative

• not so easy to apply to complex interventions such as ongoing support for health disadvantaged populations with complex health needs

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• sophisticated strategy, solid equity-focused research, planning and innovation, and well-targeted investments and services are key

• but in the long run, also need fundamental changes in over-arching state social policy and underlying structures of economic and social inequality

• these kinds of huge changes come about not 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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could 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 these pervasive health disparities as not only incredibly

damaging to so many, but also as an indictment of an unequal society• if we recognize that coming together to address the social

determinants that underlie health inequalities will benefit many other spheres – from better early child development to building a non-racist society

• if we see that addressing the roots of so many of our social problems requires broad collaboration and mobilization

• 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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• 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

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http://wellesleyinstitute.com/

mailto:[email protected]


1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities;

2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long-term;

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

4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital;

5. set and monitor targets and incentives – cascading through all levels of government and program action;

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6 rigorously evaluate the outcomes and potential of program initiatives and investments – to build on successes and scale up what is working;

7 act on equity within the health system:

• making equity a core objective and driver of health system reform – every bit as important as quality and sustainability;

• eliminating unfair and inefficient barriers to access to the care people need;

• targeting interventions and enhanced services to the most health disadvantaged populations;

8 invest in those levers and spheres that have the most impact on health disparities such as:

• enhanced primary care for the most under-served or disadvantaged populations;

• integrated health, child development, language, settlement, employment, and other community-based social services;

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9 act locally – through well-focussed regional, local or neighbourhood cross-sectoral collaborations and integrated initiatives;

10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities;

11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country;

12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective program and policy instruments, and into a coherent and coordinated overall strategy for health equity.

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driving health equity into action: strategy, ideas, and tools for midwifery movement

Health & Medicine