This presentation outlines effective ways to create change within your community. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Health Equity Strategy,
Interpretation and Other Levers
for Driving Change
Waterloo Region Immigration Partnership
May 11, 2012
Bob Gardner

2. One Critical Quality Barrier
• from a resident participating in Wellesley
community-based research in St James Town
“Language is a big barrier to us whenever we
use any services. When our doctor is on
leave then we are unable to visit a different
one due to language problem. So we may
have to go to a walk-in clinic or emergency.
There were no interpreter services. I do not
know if they arrange them in hospitals. I
couldn’t follow what the doctor said.”
2

3. The Big Picture 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
3

4. Three Cumulative and Inter-Dependent Levels
Shape Health Inequities
1. because of inequitable access to 1. gradient of health in which more
wealth, income, education and other disadvantaged communities have
fundamental determinants of health poorer overall health and are at
→ greater risk of many conditions
2. also because of broader social and 2. some communities and populations
economic inequality and exclusion→ have fewer capacities, resources and
resilience to cope with the impact of
poor health
3. because of all this, disadvantaged 3. these disadvantaged and vulnerable
and vulnerable populations have communities tend to have
more complex needs, but face inequitable access to services and
systemic barriers within the health support they need
and other systems →
4

5. Key Message
• health disparities are pervasive and damaging
• will set out how these disparities can be addressed through
comprehensive health equity strategy
• equitable access to high quality interpretation is:
• crucial to breaking down barriers to good health care for newcomers
• an indispensable pre-condition for achieving equal opportunities for
good healthcare for all-- especially in an increasingly diverse society
• vital to other key components of an effective health system – from
ensuring good quality, patient-centred care, to enhancing access to
primary care, and preventing and managing chronic conditions
• building high quality interpretation services is a crucial
element of an effective overall health equity strategy
5

6. 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

7. 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 and
Equity Health Indicator
Framework
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8. Equity Into Health System: Why
• 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
8

9. Building Equity Into the Health System: How
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 improvement, chronic disease prevention and management, wait
times
• none of these directions can succeed without taking equity barriers,
social determinants of health and differential risks and needs into
account
• aligning with key priorities also enhances chance for success and
sustainability of equity focus
3. identifying those levers that will have the greatest impact on reducing health
inequities and driving system change
• enhanced primary care
• here = how access to interpretation can advance quality and equity
priorities
May-14-12 9

10. Building Equity Into the Health System: How II
4. embedding equity in provider organizations’
deliverables, incentives and performance management
5. targeting some resources or programs specifically:
• looking for investments and interventions that will have the
highest impact on reducing health disparities or improving the
health of most disadvantaged, fastest
• key access barriers – language, culture, availability
• addressing disadvantaged populations – poor, isolated,
racialized, homeless
6. while investing up-stream in health promotion and
addressing the underlying determinants of health
10

11. Equity Into Health System: How III
comprehensive strategy
developed in 2008 for Toronto
Central LHIN
many recommendations have
been acted on:
• LHIN-wide interpretation
resources
• equity-relevant patient data
• needs of non-insured
• enhancing coordination of
services in disadvantaged
neighbourhoods
other LHINs are also prioritizing
and moving to address health
disparities
11

12. Start From Communities
• 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
12

13. And Start From a Solid Strategic
Commitment
• need to make equity one of driving priorities for health
system and reform
• equity and a population health focus are among key principles enshrined in
new Excellent Care for All Act = opening and context
• need clear provincial strategy for equity:
• implicit from MOHLTC, but promised ten year strategy has not been released
• equity and population health are in public health standards
• need strategic coherence across health system in approach to equity
• LHINs, CCACs, and other coordinating agencies need to
prioritize equity – and many have
• cascading down to all providers prioritizing equity in their
overall strategic plans and then into service delivery and
resource allocation
13

14. Align Equity With Health System Drivers
• Excellent Care For All Act and quality agenda
• providers have to develop Quality Improvement Plans
• hospitals first reported April 2011
• other providers will report in subsequent years
• equity should be developed as one of dimensions to report on – but
wasn’t really in first hospital plans
• patient-centred care → means taking the full range of
people’s specific needs into account → customizing delivery
and quality for more health disadvantaged populations with
greater/more complex needs
• improving quality and outcomes also requires addressing
equity barriers such as language
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15. Align Equity With Health System Drivers:
Interpretation as a Key Quality Lever
• key things that worry health care EDs and CEOs:
• delivering high-quality care efficiently
• reducing risk and enhancing safety
• meeting provincial priorities – wait times, re-admissions, ALCs
• access to interpretation underlies all of these system drivers –
consistent evidence that:
• poor communication between provider and patient due to language or cultural
barriers can contribute to misdiagnoses and inappropriate prescriptions
• inability to read or understand instructions can lead to medication errors → safety,
cost and re-admission implications
• promising indications that good interpretation helps keep people out of hospital
and gets them out sooner
• aligning to such drivers and incentives = crucial to build support
for interpretation strategy
15

16. 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
• requires an array of effective and practical equity-focused planning tools
• Health Equity Impact Assessment analyzes potential impact of program or
policy change on health disparities and/or health disadvantaged populations
• intended to be relatively easy-to-use tool
• essentially prospective, helping plan forward
• HEIA was first piloted in 2009 and is being used by LHINs and providers
across the province
• Toronto Central has required HEIA within recent funding application
processes, and refreshing hospital equity plans → many hospitals are
extending its use
16

17. Success Condition: Equity-Focussed Data
• driving change through better planning and
performance management will require better
social determinants type data
• in addition to language needs, clients’ socio-economic and
cultural background → contributes to building up better
picture of community needs
• pilot project underway in 3 Toronto hospitals
• need to analyze impact of interpretation services
• comparing re-admission rates, satisfaction, post-hospital
recovery, infection, etc.
→ builds case for investing in interpretation
17

18. 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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19. Success Condition: Effective Equity Targets
• innovative work underway to develop equity
indicators – but don’t need to wait
• build equity into existing targets:
• reducing avoidable hospitalization and/or readmissions
→ equity target = reduce differences in rates of
hospitalization between populations or areas
• many 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, etc.
• NRC Picker has been translated into several languages
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20. Getting Specific: Building Language and
Interpretation Into Performance Management
• need to define clear equity-focussed expectations:
• all providers will deliver sufficient high-quality interpretation
services to meet the needs of the people, communities and
catchment areas they serve
• WWLHIN could make that a clear expectation across the system
• then build requirements to meet these expectations – and
targets and indicators to measure progress -- into
performance management systems:
• Quality Improvement Plans = major opportunity
• Service Accountability Agreements between LHINs and
providers
• accreditation requirements and processes
• professional Colleges and other regulatory mechanisms
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21. Connecting the Dots and Driving Change: Building
Interpretation Into Performance Management
• for providers to meet these requirements, they will need
to:
• know the language needs of the communities they serve
• this is far more than just the languages of those who come to them
for services
• also need to know who is not coming in because of language and
other barriers = unmet need
• and it doesn't mean just basic demographic data on languages
spoken
• it means what language people are most comfortable receiving care
in
• so building interpretation into performance mgmt →
providers assessing community needs far better, and
integrating that richer knowledge into their planning
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22. Use Available Levers: Equity Plans
• a promising direction several LHINs have taken up is to require providers to
develop equity plans
• hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation
in TC
• and other providers in Central
• CHCs have developed a sector-wide plan in GTA
• 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
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23. Toronto Central LHIN Equity Plans
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24. Build on Available Opportunities and
Resources
• identify key levers or locations for change where better
interpretation can have a major impact =
• discharge planning
• communications around medications
• draw on lessons learned in other LHINs and jurisdictions:
• Toronto Central is creating a system-wide phone interpretation
system for hospitals and community providers
• specific innovations – ‘phone-on-a-pole’ in UHN hospitals
• adapt resources already developed
• several Toronto hospitals have translated material that is
available to others
• data collection processes, indicators, etc.
• need to ensure interpretation practitioners and experts are at
planning tables
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25. Never Just Equitable Access, But Quality:
Customize Service Delivery
• taking adverse social context and living conditions into account is part of
good service delivery
→ 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
• focus in acute sectors and ECFAA on patient-centred care → good
communications and provider-patient relationship means taking the full range
of people’s specific needs into account → more intensive case management,
referral planning and post-discharge follow-up
• in an increasingly diverse society, high quality care = culturally competent care
• beyond acute
• health promotion has to be delivered in languages and cultures of particular
population/community
• well-baby care has to be more intensive for poor or homeless women
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26. Not Just at Individual Care 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
• 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
• CHCs, public health and many community providers have established
‘peer health ambassadors’ to provide system navigation, outreach and
health promotion services to communities facing particular barriers
• innovative coordinating bodies – Hospital Collaborative on Marginalized
Populations in Toronto
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27. Extend That → Address Roots of Health
Inequities in Communities
• look beyond vulnerable individuals to the communities in which they live
• have to take Social Determinants of Health into account in planning
and program design
• WWLHIN roundtables
• cross-sectoral coordination and planning are key means to address wider
SDoH
• 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
• explicit SDoH/equity planning networks such as SETo in Toronto
• providing and partnering to provide related services/support such as
settlement, language, child care, literacy, employment training, youth
support, etc.
• healthy communities strategic approach developed by the former
Ministry of Health Promotion and Sport (now in MOHLTC)
• focus on community development as part of mandate for many CHCs,
public health and others
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28. Extending Collaboration →Look for Policy Windows to
Intervene to Advance Health Equity
A broad collaborative of leading
Toronto health sector
institutions and experts came
together to:
• ensure that health and
health equity were taken
into account by the current
Commission on the Reform
of Social Assistance in
Ontario
• define a vision of a health-
enabling social assistance
system; and
• identify practical actions to
implement such a system
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29. Look Widely for Community Innovation
MiVIA (my Way)
• personal electronic health record originally developed for
mostly Hispanic seasonal farm workers in California – and
then extended to other vulnerable populations
• supports continuity and efficiency – highlighting the potential
of eHealth for even the most marginalized
• the web-based portal and records are in Spanish as well →
helping to reduce language barriers
• a vital element of success has been ‘promotores’ --
community/peer health promoters – who recruit people into
the program, train them on the tools and support them in
their own health management
• all services are free
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30. Look Widely for Community Innovation II
Edmonton Multi-Cultural Health Brokers Cooperative --
http://www.mchb.org/
• provides navigation, counselling and other support to people, who
because of language or cultural barriers have trouble making their way
through the health system
• they work in some 30 languages and also provide perinatal outreach,
home visits, family and seniors support, services for multi-cultural children
with disabilities and cultural competence training
• arose from a grass-roots recognition that these barriers were increasingly
important but not being addressed
• jointly developed by the local regional health authority, public health and
other stakeholders
• many of the brokers were internationally trained providers -- doing this
work allowed them to use their skills and become familiar with the
provincial system as they waited for recognition of their qualifications
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31. Conclusions: Driving Equity-Focused Health
Care Reform
• driving health care innovation and reform to enhance equitable access
and quality is possible:
• through solid integrated strategy
• systematically implemented – highlighted mechanisms and levers
• many innovations underway to draw lessons and inspiration from
• ensuring equitable access to high-quality interpretation will contribute
to creating an equitable healthcare system by:
• addressing critical barriers -- language and culture are among most important
barriers to equitable access and quality of care
• supporting key system drivers – linking interpretation to system priorities like
safety, quality, managing ER, ALC and other bottlenecks, risk management,
mental health, chronic conditions
• enhancing impact of innovation – new ways to reduce barriers such as
language and culture are necessarily part of wider quality improvement
• making connections – where building interpretation services intersects with –
and underpins – an overall equity strategy
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32. Further Resources
amongst a wide literature, two useful starting points are:
• the Disparities Solutions Center:
• out of Massachusetts General Hospital, Harvard and other
leading Boston institutions
• range of evidence-based resources for embedding equity in
service delivery and organizational best practices, including a
guide for hospital leaders
http://www2.massgeneral.org/disparitiessolutions/resources.html
#imqual
• Access Alliance Multicultural Health and Community
Services :
• a range of research reviews and resources on newcomer health
• literature review on the risks and costs of not providing health
care interpretation
http://accessalliance.ca/sites/accessalliance/files/documents/Lit_
Review_Cost_of_Not_Providing_Interpretation.pdf
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