health equity into action: building on partnerships and collaborations

Health Equity into Action: Building on Partnerships and

Collaborations

Forum: Toronto's Northwestern NeighbourhoodsSeptember 28, 2011

Bob Gardner

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Outline: Two Challenges and One Opportunity

1. getting the right balance:• identifying and prioritizing the right issues/levers that will make the most

difference and build momentum for change• do need comprehensive overall health equity strategy to guide and ground

action, but need to drive action on local/community level2. providing best services to health disadvantaged communities/neighbourhoods:

• means building Social Determinants of Health into planning, coordination and collaboration

• and into service design, mix and delivery 3. potential of local networks has been demonstrated

• SETo, WEUHA, Women’s College Hospital Network on the Non-insured• will set out success conditions• and steps to establish

April 9, 2023 | www.wellesleyinstitute.com

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The Local Community Challenge

• stark health inequities in Northwest Toronto neighbourhoods:• disadvantaged on social determinants of health:

• higher % of low income• higher % visible minority• poorer education

• inequitable health outcomes:• higher chronic conditions, LBW, infant mortality

• poorer access to primary care and other health and social services

• + possible dislocation of service patterns with shift of hospital


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And The Community Potential

• considerable experience/resources on the ground• lots of innovative programs underway• leadership/commitment for action on health equity• Central LHIN has prioritized equity and community-driven

action

→ opportunities to build local coordination and networks


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Think Big, But Get Going

• the point of SDoH analysis is to be able to identify policy and program changes needed to reduce health disparities

• but health inequities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing

• think big and think strategically, but get going• make best judgment from evidence and experience• identify actionable and manageable initiatives that can make a difference• experiment and innovate --- learn lessons and adjust• gradually build up coherent sets of policy and program actions – and

keep evaluating

• need to start somewhere – and focus today is on building local coordinated action to address health inequities and challenges in serving health disadvantaged communities

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

• can do this through a multi-pronged strategy:1. building health equity into all health care planning and delivery

• doesn’t mean all programs are all about equity• but all take equity into account in planning their services and outreach

2. aligning equity with system drivers and priorities• quality, chronic prevention/care, effective use of resources

3. embedding equity in provider organizations’ deliverables, incentives and performance management

4. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers

• looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable

5. while thinking up-stream to health promotion and addressing the underlying determinants of health

Health Equity Strategy Into Action

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Start From a Clear Strategy• need to develop clear overall strategy – whether at prov, LHIN or local level:

• clear vision of success – of what health equity or equitable climate change adaptation strategy looks like

• identify key levers or drivers for change + coherent and coordinated set of programs and activities

• grounded in a clear ‘theory of change’ -- the principles, assumptions, ambitions and activities that will lead to the changes we want

• within health, important changes can and have been made:• provincially, population health and equity are important principles of Excellent

Care for All Act and public health standards• locally, equity is a major priority of Central LHIN and Toronto Public Health --

they have both built this priority into their overall planning and operations, and both have led or enabled many promising equity service or collaboration initiatives

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Build Into Practice Through Equity-Focused Planning

• addressing health inequities requires a solid understanding of:• the specific needs of health-disadvantaged populations• key barriers to equitable access to high quality care• gaps in available services for these populations

• this requires sophisticated analyses of the bases of disparities:• i.e. is the main problem language barriers, lack of coordination among providers, sheer

lack of services in particular neighbourhoods, etc.• which requires good local research and detailed information – speaks to great potential

of community-based research• involvement of local communities and stakeholders in planning and priority setting is

critical to understanding the real local problems

• and understanding of local community strengths, resources and challenges• and this requires an array of effective and practical equity-focused planning

tools• Health Equity Impact Assessment is a practical tool that is being used throughout the

City and province

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Planning For Complexity of SDoH

POWER StudyGender andEquityHealth IndicatorFramework

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Build SDoH Into Planning:Cross-Sectoral Planning Through an Equity Lens

• 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 → Prov should make this an explicit expectation

• Local Immigration Partnerships , Social Planning Councils;• the Central LHIN initiative on cross-sectoral planning for newcomers

• 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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And into Service Design and Delivery

• Excellent Care for All and patient-centred care means taking the full range of people’s specific needs into account – taking SDoH 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

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Build Equity-Driven Service Models

• Community Health Centre model of care• explicitly geared to supporting people from marginalized communities • comprehensive multi-disciplinary services covering full range of needs

• many other sectors as well – mental health, immigrant and other community-driven organizations

• + joint delivery and service partnerships→ meeting full range of needs means moving beyond healthcare

• providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth support, etc.

→ look beyond vulnerable individuals to the communities in which they live• partnerships to build community capacities and resources

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Building on Potential of Community-Based Service Initiatives and Innovation

• huge number of community and front-line health initiatives addressing equity across province• Community Health Centres, community mental health, community

organizations based out of specific ethno-cultural communities• e.g. many community providers have established ‘peer health ambassadors’ to

provide system navigation, outreach and health promotion services to particular communities

• not being systemically shared or built upon → need to create forums and infrastructure to identify, assess and adapt this potential

• this progressive service delivery = beacon of inspiration for other sectors + constant living demonstration that action is possible

• look for insight and inspiration from ‘out of angle’ sources:• e.g. community gardens and kitchens can contribute to food security to some

degree, and sports programs contribute to health, but they can also help build social connectedness and cohesion

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Equity-Driven Innovation: Hub Models of Integrated Care

• hub-style multi-service centres in which a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations• many countries have clinics that provide both health and wider social

services in one place• some new satellite CHCs are being developed in designated high-need areas

in Toronto will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location

• opportunity to think big about what FHTs could be?• not just health -- idea of schools as service hubs is being developed

• think back to earlier eras with public health nurses in schools • start by putting hubs in schools in most disadvantaged areas• concentrated and integrated services for most disadvantaged kids have

proven to be effective investment

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Extend That Further→ Build on/from Community-Driven Action

• 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• collaborative cross-sectoral efforts – for poverty reduction,

community development, health disparities• 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 other complex social

problems• local mobilization → into policy advocacy

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http://www.wellesleyinstitute.com/research/comprehensive-community-initiatives-lessons-learned-potential-and-opportunities-moving-forward/

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Potential of Local Community-Based Networks

One of key ways to drive all of this into action is through local networks• SETo in Southeast Toronto• WEUHA in west end

• broader• a little more focus on service coordination, but still

SDoH• INCG (the Inter Network Coordinating Group of four

downtown and mid-town networks) works closely with Toronto Central LHIN


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SEToOrigins• arose out of local access concerns – possible closure of Wellesley

Hospital• ground up response to access challenges• highlighted that local hospitals were not focussing on marginalized

Accomplishments• began from local health profiles• ongoing collaboration and idea sharing – which supported 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


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SETo IISuccess Conditions• senior leadership• regular meetings to keep momentum going• sharing resources• collaborative approaches• admin support:

• never had stable funding, and don't need much• but some institution(s) is key to providing modest and stable base

resourcesfor an overview of SETo’s development see

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




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Other Networks• similar patterns, but several different lessons learned• WEUHA is a bigger/broader table

• one way it keeps interest alive is by devoting parts of most meetings to specific focused discussion of key local issues

• they also create small working groups to tackle particular issues• Women’s College Hospital Network on Non-Insured:

• grew out of front-line and grass roots recognition of critical access problem

• serves several key functions:• has sponsored research and held research conferences• advocates with institutions and governments to improve access• provides a forum – and builds the key personal connections – to

solve immediate consumer problems


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Provider Networks• in addition to range of mental health, ethno-cultural and other provider

networks, key sectors have developed coordinating forums• Hospitals Collaborative on Marginalized Populations:

• forum for initiating and coordinating equity efforts and programs• became cortically important as the place where hospitals discussed and

shared the equity plans required by the LHIN• for analyses of these plans see

http://www.torontoevaluation.ca/tclhinrefresh/ • Greater Toronto Community Health Centres

• forum for sharing information, identifying common problems and acting on common initiatives

• e.g. assessing challenges and solutions for improving access for non-insured people

• one innovative direction was rather than doing individual equity plans for Toronto Central LHIN, they collectively developed a common sector-wide equity plan


http://www.torontoevaluation.ca/tclhinrefresh/

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Collective Impact

• this broad base of community support and activism was a critical part of getting/keeping equity on agenda • part of building LHIN support• supported and built equity champions within provider institutions• all part of embedding equity in hospitals and other providers

• the local networks also began to coordinate with each other → magnifying strength and impact and enhancing/deepening working relationships

• all pay close attention to staying grounded in their community bases


Back to Community Again: Build Momentum and Mobilization

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

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

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

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

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

• health equity could be one

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health equity into action: building on partnerships and collaborations

Health & Medicine