This presentation provides insight on health equity, social determinants of health and social policy. Bob Gardner, Director of Policy Steve Barnes, Policy Analyst www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Drawing Out Links: Health Equity,
Social Determinants of Health and
Social Policy
Bob Gardner & Steve Barnes
Graduate Class on Research Methods, Social
Work, University of Toronto
January 23, 2012

2. Outline
• set out how the Wellesley Institute, as an independent
progressive research and policy think tank, supports research,
policy analysis and community mobilization to drive social change
in the foundations of health inequities;
• identify the potential and challenges of applied research across a
range of methodologies – from local community-based research,
through quantitative analysis of trends in income and health
inequalities, through comparative policy research;
• explore how to ‘translate’ solid research into policy impact
• draw parallels between the social determinants of health and
health equity strategy and contemporary social problems;
• discuss key challenges for social policy and community building in
the coming period of austerity.
January 24, 2012 |
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3. A Parallel: Health Equity Strategy Into
Action
• health inequities are pervasive and damaging
• but these inequities can be addressed through comprehensive health equity
strategy
• and by focusing policy, programs and resources on particularly health
disadvantaged populations by:
• identifying priority populations and systemic barriers
• plan the most effective mix of focused services and support to meet the priority
populations’ diverse needs
• embed equity into system performance management thorough population-specific
targets and incentives
• evaluate effectiveness and impact, and build these learnings into continuous
improvement
• and acting well beyond health -- tackling the underlying roots of health
inequality in the wider social determinants of health
• through community-based innovation, cross-sectoral collaborations and fundamental
social and policy change to reduce inequality
• and the community and political mobilization to demand and drive the necessary policy
changes
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4. The Problem to Solve = Health
Disparities 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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5. Gradient of Health Across Many
Conditions
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6. 6

7. Impact of Disparities
• not just a gradient of health and impact on quality
of life
• inequality in how long people live
• difference btwn life expectancy of top and bottom
income decile = 7.4 years for men and 4.5 for women
• more sophisticated analyses add the pronounced
gradient in morbidity to mortality → taking account of
quality of life and developing data on health adjusted
life expectancy
• even higher disparities btwn top and bottom = 11.4
years for men and 9.7 for women
Statistics Canada Health Reports Dec 09
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8. Foundations of Health Disparities (and Parallels to Other
Problems) Lie in Social Determinants of Health
•clear research consensus that roots
of health disparities lie in broader
social and economic inequality and
exclusion
•impact of inadequate early
childhood development, poverty,
precarious employment, social
exclusion, inadequate housing and
decaying social safety nets on health
outcomes is well established here
and internationally
•we need comprehensive strategy to
drive policy action and social change
across these determinants
•these same systemic factors shape
many other social problems
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9. Complexity: Canadians With Chronic Conditions
Who Also Report Food Insecurity
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10. SDoH As a Complex Problem
Determinants interact and
intersect with each other in a
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
Similar dynamic complexity in
other spheres of social policy
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11. Three Cumulative and Inter-Connecting Levels
in Which SDoH Shape Health Inequities
1. because of inequitable access to 1. gradient of health in which more
wealth, income, education and disadvantaged communities have
other fundamental determinants poorer overall health and are at
of health → greater risk of many conditions
2. also because of broader social and 2. some communities and
economic inequality and populations have fewer
exclusion→ capacities, resources and resilience
to cope with the impact of poor
health
3. because of all this, disadvantaged
and vulnerable populations have 3. these disadvantaged and
more complex needs, but face vulnerable communities tend to
systemic barriers within the health have inequitable access to the
and other service systems → services and support they need
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12. 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
Can apply similar lens to
systemic and community
factors that shape broader
social inequality:
•social services can
mediate
•structure and strengths
of communities shape
impact and dynamics of
inequalities
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13. Why Worry About Policy?
• We are all interested in tackling social and economic inequality, whether:
• developing strategies for government action
• advocating for particular program investments
• getting governments to act on evidence or research
• what is needed to ensure that vulnerable populations have good health?
• comprehensive health and related services
• information to enable individuals to better manage their health care
• investment in research and service/program development
• and many changes beyond health care and research:
• community capacity and resource building
• addressing underlying social determinants of health
• all of these changes flow through government policy in one way or
another
• maximizing the policy impact of research is one critical part of winning
the necessary progressive policy
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14. Starting Points: Research, Knowledge and
Policy Impact
Knowledge exchange involves:
• different forms of knowledge -- research, practice-based, lessons learned, community
experience
• different purposes -- making a case for investment, innovation or policy change
To turn knowledge, program proposals or research into policy action requires :
1. getting research findings or the policy case to the right people – in terms they can use
2. understanding the environment in which govt policy decisions are made
3. being able to identify the policy implications of your research or identified community
needs -- and to translate that into concrete policy options to solve the problems you
have found
4. assessing the most effective policy options – pros and cons, costs, risk management
5. being able to make an effective – and winning -- case for your policy recommendations
6. partnering with those with specific policy and knowledge exchange expertise and
experience
7. grounding your research and policy advocacy in wider campaigns and alliances for
social change will maximize its impact
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15. Maximizing Policy Impact
To have policy impact we need to:
• understand the political and policy environment and policy
process within governments
• analyze the problem(s) identified by research or community
needs, and develop potential policy solutions
• assess the pros and cons and cost benefits of various policy
options
• choose and promote policy options that can work
• make a convincing case for them -- at best, with concrete
recommendations that can be acted on
• develop a targeted knowledge exchange strategy to get the
analysis and options to those who can decide
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16. Identify the Policy Implications
Assess implications of research What can be done with this
findings or program – ‘so what” knowledge – ‘now what’
•new needs or gaps in existing •service providers adapt or expand
services identified services, govts fund
•community preferences or •programs and resource allocations
priorities determined reflect community priorities
•barriers to getting services or •program or policy changes to
support identified reduce barriers
•innovations or ‘best practices’ •other providers take them up
•evaluating what initiatives work – •adapt and generalize to drive
and how, for whom, and in what innovation
contexts
•systemic inequities uncovered •policy changes to address systemic
foundations of inequities
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17. Knowledge → ‘policy-ready’
• to get your findings or case to the intended decision makers
– in ways they can understand and use – always involves
translation
• into the very different languages and mind sets of govts
• into ‘policy speak’
• and very concrete – translating your findings into:
• specific actionable policy options and recommendations
• that will work in the existing policy environment
• couched in the formats – cabinet briefing notes – and frameworks –
cost-benefit analysis and risk management – that govts use
• the more ‘policy ready’ → the more chance for influence
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18. Know Your Policy Environment
• to be able to do policy relevant research and influence policy
change, you need to know:
• the policy framework for your particular issue
• e.g. which levels of govt, and which Ministries or depts govern your issue?
• what are the main formal policies that shape your area?
• just as impt – what are the unstated assumptions and constraints that
shape the sphere?
• what are trends in govt funding and policy in the area?
• how policy is developed:
• players, processes and tempo
• constraints -- risk averse, short-termism, crisis-driven
• and some specific aspects of the government of the day:
• how does your issue relate to its overall agenda?
• where is it in the electoral cycle?
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19. Think of Policy Development as Process
• a particular policy – or policy framework – is the result of
decisions made about how to address a particular objective
or problem
• sometimes this can be a deliberate decision not to address the
particular issue
• within the public service there is a generally a careful
process of:
• identifying objectives
• assessing a range of possible actions to achieve the result
• analyzing them against number of factors –
effectiveness, cost, risk, political context, public and community
support, etc.
• always trade-offs, compromise , different “publics” affected
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20. Analyzing Policy Options
• policy options are the different legislative, program, funding, and other
ways governments can act to meet defined objectives
• to identify the best options, think of a wide range of factors such as
• how complex and big a policy change you are looking for
• impact (balancing criteria such as equity, efficiency, stability)
• cost – be specific -- is it short-term, capital or operating, one-time or
continuing, etc.?
• versus benefits – specify here too – are the benefits short-term or
more long term -- such as eventual reduced health care expenditures
as a result of upstream investment in health promotion and
prevention?
• timing – how long to show an impact?
• for government, assessing pros-cons, risks and cost-benefits is a standard
part of policy process
• for you, posing recommendations/demands in terms used and
understood within the policy process increases your credibility and
usability
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21. Making the Case to Policy Makers
• know your audience -- and the policy environment and way of thinking within govts
• pick the right person/level to make pitch to – with the authority and levers to act
• be aware of their position and constraints
• think translation: from options to a winnable case
• framed in ways that resonate with policy makers
• making complex issues understandable and actionable
• with a human story for elected officials especially (and the media)
• customize reports for policy audiences
• separate/short policy implications summaries
• in terms they understand and with concrete recommendations they can act on
• use the forms they are used to – decks and briefing notes
• e.g. always address cost benefits, risk management, options and other factors that govt
policy makers think about
• all geared to different levels and functions within govt – e.g. different for Deputy
Minister than mid-level policy analyst
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22. Making the Case to Policy Makers II
• meeting is best, plus covering letter/brief
• consider your most effective ‘line-up’ to make the case
• not just one-time, but systematic outreach and follow up
with policy makers
• follow up meetings
• as part of long-term strategy to build relationships with key policy
makers in your spheres
• always a question of balance:
• need hard-nosed analysis
• always stay grounded in movement/community principles → limit on
room to compromise
• but also strategically opportunistic → maximize chance of winning
case
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23. Take the ‘Long View’
• significant policy change can take many years
• but also look for immediate winnable issues
• to build momentum and hope
• but be careful of co-optation and short-term reforms that deflect from
long-term goals
• Caledon Institute for Social Policy has term “relentless incrementalism”
• have good peripheral vision -- situate your issue in relation to
• other comparable issues → to build coalitions – the wider the better,
with ‘unusual suspects’ as well
• the overall govt policy agenda -- back to ‘fit’
• be prepared for set-backs:
• even the most compelling evidence and well crafted brief doesn't
always drive policy
• politics does
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24. It’s Also/All About Power
• driving policy change on complex/contentious issues is not
just about presenting the best evidence and case
• governments and politicians have to have the political will to
act
• long history of HIV/AIDS movement = have to be forced
• critical importance of political and community mobilization:
• building and staying grounded in community movements
• building/sustaining broad coalitions for change
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25. Get Some Help
• policy analysis is a specialized trade and the policy world is a
complex and difficult environment
• community organizations, service providers and researchers
can’t drop everything and become policy analysts and
advocates
• so draw on specialized expertise in knowledge exchange
• partner with organizations with policy expertise
• back to need for systematic strategy:
• partner with govts early in policy or research process
• build relationships
• see knowledge exchange as dynamic and iterative process
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26. Parallel: Health Inequities = ‘Wicked’
Problem
• health inequities and their underlying social determinants of health are classic
‘wicked’ policy problems:
• 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.
• same for other spheres of social policy
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27. Think Big, But Get Going
• challenge = health inequities and social inequalities 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:
• focus today is on engaging with and understanding social
services and support to meet needs of disadvantaged
populations and understand the structural roots, of
poverty, exclusion and other social problems
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28. Parallel: Start 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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29. And With Equity-Focused Planning
• Public Health Ontario has developed an equity assessment framework
for public health units.
• a number of Public Health Units 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
• MOHLTC and many LHINs have used Health Equity Impact Assessment
• advantage of using the similar tools = build up comparable experience
and data
• lever = could enable/require LHINs, PHUs and service providers to
undertake HEIA or other equity planning processes
• for all new programs and those focusing on particular populations
• to be eligible for particular funding
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30. Parallel 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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31. Building Equity Targets
• build equity into indicators already being collected → equity angle is to
reduce differences between these populations/communities and others
or PHU as a whole on these indicators
• also drill down – e.g. a number of PHUs and LHINs have identified areas
or populations where diabetes prevalence is highest
• equity target = reduce differences in incidence, complications and
rates of hospitalization by income, ethno-cultural backgrounds, etc.
and among neighbourhoods or regions
• 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 facilities and proactive empowerment of kids – and
ensuring equitable access to resources, space and programs
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32. Parallel 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 – Saskatoon
•national project to develop health
disparity indicators and data
•Toronto PH is addressing complexities
of collecting and using race-based data
•key direction = explore potential of
equity/SDoH data for Ontario
•in addition, innovative thinking
emerging around dynamic systems
modeling meeting population health
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33. Build Equity Into Priority Issues: Chronic
Disease Prevention and Management
•very clear gradient in incidence and
impact of chronic conditions
•chronic disease prevention and
management programs cannot be
successful unless they take health
disparities and wider social conditions
into account
•some populations and communities
need greater support to prevent and
manage chronic conditions
•anti-smoking, exercise and other health
promotion programmes need to
explicitly foreground the particular
social, cultural and economic factors
that shape risky behaviour in poorer
communities– not just the usual focus
on individual behaviour and lifestyle
•need to customize and concentrate
health promotion programs to be
effective for most disadvantaged
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34. 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
• public health and many community providers have established ‘peer health
ambassadors’ to provide system navigation, outreach and health promotion
services to particular communities
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35. Extend That → Address Roots of Health
Inequities in Communities
• look beyond vulnerable individuals to the communities in which they live
• 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.
• across Canada, leading Regional Health Authorities have developed operational
and planning links with local social services or emphasized community capacity
building:
• Saskatoon began from local research documenting shocking disparities among
neighbourhoods
• focused interventions in the poorest neighbourhoods – e.g. differences in
immunization rates between poor and other neighbourhoods decreased
• beyond health – locating services in schools, relying on First Nations elders to
guide programming, etc.
• wide collaboration among public health, municipality, business, community
leaders
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36. Through Cross-Sectoral Planning
• cross-sectoral coordination and planning are the glue that
binds together coordinated action on SDoH
• public health departments and LHINs are pulling together
or participating in cross-sectoral planning tables on health
issues – can get beyond institutional silos
• Local Immigration Partnerships, Social Planning Councils,
poverty reduction initiatives, etc
• healthy communities initiatives funded by the Ministry of
Health Promotion and Sport
• 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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37. Equity-Driven Innovation: Integrated
Community-Based 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
• Quebec has long had such comprehensive integrated
community centres
• some new satellite CHCs are being developed in designated
high-need areas in Toronto will involve the CHCs delivering
primary and preventive care and other agencies providing
complementary social services out of the same location
• not just health -- schools as service hubs is being developed --
think back to earlier eras with public health nurses in schools
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38. Extend That → Build Community-Level
Action
• all leading jurisdictions with comprehensive equity strategies combine
national policy with local adaptation and concentrated investment
• many cities have developed neighbourhood revitalization strategies
• Toronto’s priority neighbourhoods, Regent’s Park
• promising direction = comprehensive community initiatives:
• broad partnerships of local residents, community organizations,
governments, business, labour and other stakeholders coming
together to address deep-rooted local problems – poverty,
neighbourhood deterioration, health disparities
• collaborative cross-sectoral efforts – employment opportunities, skills
building, access to health and social services, community development
• 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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39. Parallel: Evaluating Complex Equity
Interventions
• how do we know what works = crucial importance of evaluation
• far too complex to pick apart all the causal relations and patterns of influence:
• very difficult to attribute particular changes to particular components of the overall
initiative
• will never meet RCT gold standard of proof – that approach can’t capture complexity
• but that doesn't mean particular initiative is ineffective
• impact can take many years to show up
• but that doesn’t mean nothing is happening
• traditional evaluation of one program in isolation or of a particular population
among many will not capture this complexity
• potential of more ‘realist’ approach – M + C = O
• evaluating impact of interventions – but always in particular contexts
• and sometimes we look at what works in particular population or social contexts rather
than form of intervention
• and we evaluate our framework of theory of change
• we identified levers in our strategy – did they prove to be important in practice?
• looking for indications that the change mechanisms unfold as we expected, that the
direction of causal influence and impact is as we expected ,etc
• looking for evidence that outcomes anticipated are being achieved
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40. Complexities: Building Equity Targets
• can’t just measure activity:
• number or % of priority pop’n that participated in program
• need to measure health outcomes – even when impact only shows up in long-
term
• so if theory of change for health program begins with enabling more exercise
or healthier eating – then we measure 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
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41. Parallel: Watch for Unintended
Consequences
• 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 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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42. 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’
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43. Health Equity
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 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 showing that we can get there from here
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44. Following Up
• 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
• email at bob@wellesleyinstitute.com
• we 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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