Health Equity Strategy Into Public Health Action

alPHa-OPHA Health Equity Working Group

April 5, 2012

Bob Gardner

The 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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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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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, environmental and health systems

Determinants have a reinforcing and cumulative effect on:

• individuals throughout their lives • and on communities and

population health

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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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Planning For Complexity

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 = Classic ‘Wicked’ Problem

• health inequities and their underlying social determinants of health are:• 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• will never have full understanding of all pathways and causal links• don’t need to

• 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 public health system

Powerful Starting Point = Equity As a Driving Priority Within Public Health

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Ideas From the Acute Side: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, quality – to enhance chance for success3. identifying those levers that will have the greatest impact on reducing health

inequities and driving system change – enhanced primary care4. embedding equity in provider organizations’ deliverables, incentives and

performance management 5. 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 looking to improve the health of most vulnerable, fastest

6. while investing up-stream in health promotion and addressing the underlying determinants of health

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Start with Levers• key challenge is to identify those levers that can have the most effective equity

impact• both analytical and strategic question:

• evidence of effect on disadvantaged pop’n or structure of inequities• window of opportunity, readiness to drive change

• considerable international evidence that enhancing access to primary care is one of most effective ways to improve health of disadvantaged populations

• public health can also be a key lever for equity-driven change:• through enhancing screening, preventative care and health promotion for

populations facing the greatest health risks and burdens → laying foundations for more equitable opportunities for good health

• PH expertise in analyzing population health, complex systems and social determinants

• and leadership in cross-sectoral collaborations needed to concretely act on SDoH

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Equity-Focused Planning

• all of this 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 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 – building 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

-- Health in All Policies

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Equity-Focused Planning Tools Into Public Health

• a number of PHUs have developed and use equity lens:• Toronto has a simple 3 question lens -- not just for public health, but

other departments• Sudbury has used an equity planning tool for several years• but uneven use and impact

• one lever = could enable/require PHUs to undertake HEIA or other equity planning processes• for all new programs and those focusing on particular populations• to be eligible for particular programs or funding• as part of overall prov standards/expectations • advantage of using the same tool/processes = build up comparable

experience and data• role for OPHA or PHO in developing PH specific resources, training,

enabling?

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Aligning Equity in Public Health With Key System Priorities

• showing how equity will be critical to achieving system goals and linking equity into central priorities will enhance uptake and success

• one overarching system priority is sustainability:• powerful case to be made for preventative programs and health

promotion as key to reducing avoidable acute care use/costs • another priority is chronic disease prevention and management

• long been key focus of PH health promotion efforts• Health Quality Ontario looked for cross-cutting goals/projects that can

drive quality improvement and transform the acute system = reducing hospital readmission rates

• could reducing prevalence and impact of chronic disease be a common goal to integrate health promotion and chronic care efforts?

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Beyond Planning: Embed Equity in System Performance Management

• 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

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

• need comprehensive performance measurement and management strategy

• then choose appropriate equity targets and indicators for particular populations/communities

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Success Condition: Effective Equity Targets

• considerable international experience and innovative work underway to develop Canadian equity indicators→ look for synergies between PH national and prov indicator development

and initiatives in hospitals, CHCs and other areas of acute care• not just about reviewing the literature and evidence:

• strategy: clearly defining success – the structural and outcomes changes sought

• identify how best to measure progress towards this• practical context – won’t have perfect data, what indicators will work within

existing systems?• don’t need to wait -- an immediate direction is to build equity into indicators

already being collected → equity angle is to reduce differences between particular

populations/communities and others or PHU as a whole on these indicators

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Adapting Equity Targets• reducing diabetes incidence is prov priority

• equity target = reduce differences in incidence, complications and rates of hospitalization by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions

• also good reform driver = can only be achieved through coordinated action

• similarly, common goal is reducing childhood obesity → if goal is to increase the % of kids who exercise regularly• equity target = reduce the differentials in % of kids who exercise by

neighbourhood, gender, ethno-cultural background, etc.• and achieving that won’t be just a question of education and

awareness, but proactive empowerment of kids and ensuring equitable access to facilities, space and programs

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Challenges: Equity Indicators and Targets

• can’t just measure activity like number or % of priority pop’n that participated in program• if theory of change for particular health program begins with enabling more

exercise or healthier eating – then we measure change in that initial step• need to assess reach

• who isn’t signing up? who needs program/support most?• who stuck with program and what impact it had on their health – and how this

varies within the pop’n• and assess impact through equity lens

• need to differentiate those with greatest need = who programs most need to support and keep to have an impact

• then adapt incentives and drivers• develop weighting that recognizes more complex needs and challenges of

most disadvantaged, and builds this into incentive system• need to measure health outcomes – even when impact only shows up in long-

term

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Success Condition = Better Data

•looking abroad for promising practices = Public Health Observatories in UK

• consistent and coherent collection and analysis of pop’n health data

• specialization among the Observatories – London focuses on equity issues

•interest/development in Western Canada•national project to develop health disparity indicators and data•Toronto PH is addressing complexities of collecting and using race-based data•pilot project in 3 Toronto academic hospitals to collect equity data•key direction = explore potential of equity/SDoH data for Ontario

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Levers for Action: Equity Plans

• lesson from health care sector = building equity into provider requirements/ plans• ECFAA requires hospitals and then other providers to develop

quality improvement plans → need to build equity in as key dimension

• equity priorities will/can be built into accountability agreements with LHINs

• a promising direction several LHINs have taken up is to require providers to develop equity plans designed to:• identify access barriers, disadvantaged populations, service gaps

and opportunities in their catchment areas and spheres• develop programs and services to address those gaps and better

meet healthcare needs of disadvantaged communities

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Toronto Central LHIN Equity Plans

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Equity-Focused Planning In Public Health

• provincial standards offer a possible lever• building on current requirements, each PHU could be expected to develop an

explicit health equity plan showing how it was putting population health standards into practice

• does not need to be onerous – templates simplified the process within TC LHIN

• could be requiring and reviewing more explicit equity priorities, deliverables, targets and indicators in strategic plans

• and then:• call a province-wide roundtable to share, debate and learn from all the

individual plans• which can be build into a coherent overall strategy• and simultaneously develop specific expectations and targets and build these

into routine PHU performance management and accountabilities going forward

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Alignment Again: to Quality and Person-Centred Services

• taking social context and living conditions into account are part of good service delivery• when people face adverse social determinants of health → can increase risk of mental and physical health 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 SDoH and

population needs and contexts• e.g. well-baby care has to be more intensive for poor or homeless women• to get beyond barriers, screening and health promotion has to be delivered in

languages and cultures of particular population/community• focus in acute sectors and ECFAA on patient-centred care → means taking the full

range of people’s specific needs into account → more intensive case management, referral planning and post-discharge follow-up

• so focus on priority populations means different types of service mixes to take account of their specific context and needs

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

• drill down to further specify needs and barriers:• health disadvantaged populations have more complex and greater needs

for services and support → continuum of care especially important• poorer people also face greater barriers – e.g. availability/cost of

transportation, childcare, language, discrimination → facilitated access is especially important

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

• e.g. hub models of one-stop coordinated services• public health and many community providers have established ‘peer health

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

• PH is involved with many innovative local initiatives

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Target Investment for Equity Impact

• consistent tradition within PH has been to identify priority populations and target services to:• those 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 sophisticated analyses of the bases of disparities:• which requires good local research and detailed information

• community-based research to provide rich local needs assessments and evaluation data

• community health profiles• involvement of local communities and stakeholders in planning and

priority setting is critical to understanding the real local problems

• and requires incentives and resources• lever = certain % of PHU budgets to be targeted to priority populations

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Drilling Down: How to Focus on Particular Populations

• defining priority populations• not just a general or statistical category – bottom 20 %, all immigrants• but social groups who face particularly poor health or inequitable

determinants of health• these populations could occupy particular positions – precarious

workers, recent immigrants – or may share common backgrounds, identities or other community interests – Aboriginal people, LGBTQ, homeless

• could be people who live in particularly disadvantaged neighbourhoods

• however defined, no population or community is ever homogeneous• need to drill down – e.g. youth vs. seniors within Francophone African

immigrants -- to identify needs and plan interventions

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Build Equity Upstream: Chronic Disease Prevention and Management

•very clear gradient in incidence and impact of chronic conditions

•some populations and communities need greater support to prevent and manage chronic conditions

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

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Watch for Unintended Consequences: Health Promotion

• health promotion that emphasizes individual health behaviour or risks without setting it in wider social context• can lead to ‘blame the victim’ portrayals of disadvantaged who practice ‘risky’

behaviour• focus on individual lifestyle in isolation without understanding wider social forces that

shape choices and opportunities won’t succeed• universal programs that don’t target and/or customize to particular

disadvantaged communities• inequality gap can widen as more affluent/educated take advantage of programs

• programs that focus on most disadvantaged populations without considering gradients of health and specific need• the quintile or group just up the hierarchy may be almost as much in need• e.g. access to medication, dental care, child care and other services for which poorest

on social assistance are eligible do not benefit working poor• supporting the very worst off, while not affecting the ‘almost as worse off’ is unlikely

to be effective overall

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Build SDoH In:Cross-Sectoral Planning Through an Equity Lens• another part of overall strategy for public health = key role

as connector• back to levers = cross-sectoral coordination and planning are

key means to address wider SDoH in 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 former Ministry of Health Promotion and Sport

developed 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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Enabling Cross-Sectoral and Equity-Focused Innovation

• key lever = build equity-focused collaboration and innovation into incentives:• expectation that X% of budget will be devoted to equity-orientated

innovation, sustaining cross-sectoral initiatives or planning, etc.• ear-marked funds for equity innovation and collaboration efforts

• build on public health tradition = many have pioneered cross-sectoral action addressing wider determinants • could PHO fund/support cross-sectoral collaborations and initiatives –

getting beyond programs that can’t fund outside their narrow silos?• partner with other jurisdictions and agencies – PHAC, other provinces• PHO or OPHA to be centre of expertise on equity and SDoH-orientated

collaboration?

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Address Roots of Health Inequities in Communities

• look beyond vulnerable individuals to the communities in which they live• have to take SDoH into account in program design

→ meeting full range of needs means moving beyond health care• focus on community development as part of mandate for many PHUs and CHCs • providing and partnering to provide related services/support such as settlement,

language, child care, literacy, employment training, youth support, etc.• 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

• 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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Building on the Potential of Community-Based Innovation and Initiatives

• potential:• huge number of community and front-line

initiatives already addressing equity across province

• + equity focused planning through HEIA or other tools will yield useful information on existing system barriers and the needs of disadvantaged populations

• and we’ll be seeing more and more population-specific program interventions

• but• these initiatives and interventions are not

being rigorously assessed• experience and lessons learned are not

being shared systematically• so potential of promising interventions is

not being realized• role for PHO or OPHA?

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Build 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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Back Up to High-Level Strategy: Addressing Systemic Inequality

• reducing overall social and economic inequality → requires a significant commitment and re-orientation of social and economic policy

• need to build health and health equity into macro social and economic policy:• not just as one factor among many to be balanced, but as core priority• some jurisdictions have built equity consideration into their policy

processes – e.g. a change in tax policy or new environmental policy would be assessed for its health equity impacts

• which means more ‘joined-up’ policy processes:• using HEIA and HiAP approaches• built into cross-Ministry collaboration and incentives• led from central authorities• Saskatchewan, Quebec have been implementing such processes

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Add Voice: Policy Platforms and Opportunities

• long tradition of advocating for healthy public policies• Healthy Cities movement• linking pop’n health into wide ranging issues -- climate change,

city design• public health has unique position:

• part of local govt• protected by provincial mandates and responsibilities• long been solidly based in local communities and collaborations

• can use credible professional/evidence-based voice to intervene in public debates

• many PHUs have played a lead role in local poverty reduction, food security, environmental and other issues

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Look for Policy Windows to Intervene to Advance Health Equity

Commission on the Reform of Social Assistance in OntarioA broad collaborative of leading Toronto health sector institutions and experts came together to:

• ensure that health and health equity were taken into account

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

• identify practical actions to implement such a system

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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 public health is part of showing that we can get there from here

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