This presentation provides insight on the importance of a planning strategy to address complex social determinants of health. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Driving Health Equity Into Action: Planning and Strategy to Address Complex Social Determinants of Health Bob Gardner Climate Change Adaptation and Health Equity Workshop May 24, 2011

3. + major differences between women and men

4. the gap between the health of the best off and most disadvantaged can be huge – and damaging

5. in addition, there are systemic disparities in access to and quality of care within the healthcare system2

7. from the prov Ministry of Health and Long-Term Care, through LHINs and PHUs to many providers

8. some promising equity strategy, planning and operationalization

9. will draw out some parallels and lessons learned from health system reform

10. but overall health is shaped by factors well beyond health care – income inequality, the jobs we do, racism, housing and living conditions, social connectedness – the social determinants of health

11. and reducing health disparities involves far more than health reform

12. will focus on how equity needs to be considered in health care, climate change policy and many other spheres and some tools and principles on how to build equity into strategy across the determinants of healthBuilding Solutions -> Comprehensive Health Equity Strategy 3

14. 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

16. so climate change and its effects on air, water, disasters and other environmental trends is very much a health issue

17. but the inequitable distribution and impact of these underlying determinants also means:

18. some health disadvantaged populations are far more vulnerable to the effects of climate change and other environmentally driven problems

19. some populations have fewer resources and less capacity to cope with the impact of climate change and other emerging challenges

20. so climate change and clean air are very much a health equity issue5

22. In constantly changing and dynamic system

23. In fact, through multiple interacting and inter-dependent economic, social and health systems

24. Determinants have a reinforcing and cumulative effect on individual and population health

25. Figuring out effective policy and community responses to these complex and inter-dependent determinants is a crucial problem across all the spheres in which we work6

26. Three Cumulative and Inter-Dependent Levels Shape Health Inequities because of inequitable access to wealth, income, education and other fundamental determinants of health -> also because of broader social and economic inequality and exclusion-> because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the health and other systems -> gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions some communities and populations have fewer capacities, resources and resilience to cope with the impact of poor health these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need 7

28. shaped by many inter-related and inter-dependent factors

29. in constantly changing social, economic, community and policy environments

30. action has to be taken at multiple levels, by many governments, service providers, other stakeholders and communities

31. solutions are not always clear and policy agreement can be difficult to achieve

32. effect takes years to show up – far beyond any electoral cycle

33. need comprehensive strategy to tackle the underlying roots of health inequality in the wider social determinants of health

34. from high-level national social and policy change to reduce inequality through community-based innovation, cross-sectoral collaborations and mobilization

35. that can identify the lines of connection between all these factors and identify the crucial leverage points for change8

37. will weave in and out in this talk:

38. some lessons learned from working to develop equity strategy, planning and implementation within the health system

39. links between environmental and climate issues as determinants of health – fleshed out in your Backgrounder

40. benefits of thinking of these issues in inter-connected ways, so:

41. climate change is defined as a critical health equity issue – and this is built into strategy and planning

42. health reform is always connected to bigger picture of addressing underlying determinants of health, including environmental factors

43. those addressing complex issues can learn from each other and build momentum to address the root issues9

44. SDoH -> Gradient of Health-> Inequitable Risks and Vulnerabilities 10

45. Asthma = Sensitive to Air Quality neighbourhood patterns parallel distribution of poverty, income inequality and other social determinants 11

47. because of the health burden of these conditions – and their inequitable distribution -- some are more vulnerable than others to adverse impact of climate change

48. also because of overall inequality these more vulnerable populations tend to have less capacity and resources to cope with adverse effects

49. this has to be built into public policy around climate change adaptation12

51. can do this through a multi-pronged strategy: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 aligning equity with system drivers and priorities embedding equity in provider organizations’ deliverables, incentives and performance management 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 while thinking up-stream to health promotion and addressing the underlying determinants of health Lessons Learned from One Sector: Health Equity Strategy Into Action 13

52. Powerful Starting Point Equity Is a Fundamental Priority Within Public Health and SDoH are Understood 14

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

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

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

57. within health, important changes can and have been made:

58. provincially, population health and equity are important principles of Excellent Care for All Act and public health standards

59. locally, equity is a major priority of Toronto 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

60. parallel for climate change?

61. aligning climate change with population health and health equity priorities may be useful direction15

63. has to take dynamic and complex nature of social determinants of health into account

64. for health planners:

65. can’t just be demographic, technological and medical forecasting

66. has to also include broader environmental trends and threats

67. similarly, long-term planning within environmental policy has to:

68. take account of health impact of climate change and other trends/threats

69. undertake equity analyses to assess inequitable risks and vulnerabilities of different populations

70. build this equity analysis into development of strategy on how to adapt to climate change16

72. links between air quality and asthma, lung disease and other chronic conditions

74. idea: environmental and planning agencies to collect equity-relevant data17

76. the specific needs of health-disadvantaged populations

77. key barriers to equitable access to high quality care

78. gaps in available services for these populations

80. Equity-Focused Planning Tools: For Climate Change Adaptation Policy ensure health impact and health equity are considered in development of client change adaptation policy and relevant environmental service delivery/planning assess implications for health disadvantaged populations of climate change adaptation policies and programs assess current state of climate change policy stakeholders re awareness of health and health equity impact determine needs of communities facing inequitable health impact of climate assess impact of programs/interventions on health disadvantaged populations simple equity lens OAHPP Equity Assessment Framework or MOHLTC Health Equity Impact Assessment policy and program audits and/or HEIA equity-focused needs assessment, place-based analysis, community health profiles, local CBR equity-focused evaluation 19

82. but concern that HIAs did not sufficiently focus on equity -> increasing attention to equity-focused impact assessment – from WHO, through most European strategies, PHAC, to MOHLTC and LHINs

83. planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populationscan help to plan new services, policy development or other initiatives can also be used to assess/realign existing programs intended to be relatively easy-to-use tool essentially prospective, helping plan forward 20

85. final version of template and workbook released by Ministry in 2011 see their page at http://www.health.gov.on.ca/en/pro/programs/heia/background.aspx

87. following workshop21

89. could use HEIA to analyze potential impacts of climate change on poorest and poorest serviced neighbourhoods – where will indoor temperature get unsafe? what options do people in those neighbourhoods have?

90. then analyze how to target program responses to those neighbourhoods and communities most in need/at risk – who benefits from home retrofitting?

91. could drill down to analyze specific issues such as heat islands, availability of safe open spaces and air conditioning, etc.

92. need resources to enable this use of HEIA:

93. leading jurisdictions have offices that work with various sectors to undertake HEIA

94. tools, resources and support are needed from Province

95. + teeth:

96. idea = any new environmental/climate change policy going to Cabinet or Council must have HEIA done before approval22

98. setting targets for reducing access barriers, improving health outcomes of particular populations, etc

99. into performance management through cascading expectations through the system -- Prov -> LHINs, agencies, etc.-> providers

100. developing realistic and actionable indicators for service delivery and outcomes

101. closely monitoring progress against the targets

102. disseminating the results widely for public scrutiny

103. tying funding and resource allocation to performance

104. how to adapt for climate change strategy?

105. target = reduce differences in prevalence of asthma by neighbourhood

106. monitor = ensure programs collect data by neighbourhood and other equity-related indices to ensure uptake and reach is equitable 23

108. LHINs have required providers to prepare equity plans

109. been effective at embedding equity within organizational planning and priorities and encouraging front-line equity initiatives

110. all providers will be doing Quality Improvement Plans under new Act

111. embed equity as one of dimensions of quality in these plans

112. PHUs have to meet key standards around population health and equity

113. align equity with system priorities such as chronic disease prevention and management

114. can’t address diabetes without addressing the social circumstances and conditions in which people have to manage their conditions

115. and for climate change adaptation?24

117. build equity into any scenario planning or environmental impact assessments

118. into building codes and other regulatory powers

119. targeted programs such as Tower Renewal have particular implications for low-income tenants who live in these areas

120. what system and organizational drivers?

121. within health, can tie equity to crucial system priorities of quality, efficiency and sustainability

122. what equivalents for climate change adaptation – reducing long-term costs, ensuring overall sustainability?25

124. public health departments and LHINs are pulling together or participating in cross-sectoral planning tables on health issues

125. Local Immigration Partnerships, Social Planning Councils, poverty reduction initiatives, etc on many other connected issues

126. the Ministry of Health Promotion and Sport is developing a healthy communities strategic approach

127. cross-sectoral planning to ground health promotion 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 especially for most disadvantaged if this isn’t done -> can unintentionally widen disparities as better off take up programs more 26

129. ensuring healthy environments with clear air can be part of planning and program changes to build healthier communities = get to those tables

130. highlighting community activism to address environmental issues as one powerful way to highlight SDoH

131. from climate change and environmental issue angles

132. need to bring health and equity organizations/issues to those tables

133. through showing the inequitable health impact of climate change and other environmental trends

134. identifying areas where most disadvantaged neighbourhoods and communities need enhanced services:

135. indoor air quality is crucial to health -> concentrate remedial and restorative programs to improve quality of living conditions where need is greatest

136. if parks and trees are seen to be one way of enhancing local environmental quality -> concentrate new investments in worst-off areas 27

138. more coordinated, cross-departmental and cross-government policy development and coordination

139. growing interest in a ‘health in all policies’ approach:

140. Quebec requires any laws or regulations that could have health implications to be reviewed by the Ministry

141. Ontario has done policy research on HIAP and developed several tools

142. policy forums have been created:

143. Saskatchewan has provincial and regional forums of all ministries involved in human and social services

144. innovative planning processes have been developed

145. in Peel, planners and public health staff work together to ensure health impact is considered in planning decisions28

147. Community Health Centres, community mental health, community organizations based out of specific ethno-cultural communities

148. e.g. many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities

149. not being systemically shared or built upon -> need to create forums and infrastructure to identify, assess and adapt this potential

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

151. what are clean air equivalent initiatives that could capture imagination and build initiative?

152. look for insight and inspiration from ‘out of angle’ sources:

153. e.g. community gardens and kitchens can contribute to food security to some degree, but they can also help build social connectedness and cohesion29

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

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

157. 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

158. 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’30 May 23, 2011

160. thinking of what needs to be done to create healthy and equitable communities is a way of imagining and forging a powerful vision of a progressive future

161. and showing that we can get there from here31

163. do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy

164. think big and think strategically – but get going

165. there is a solid base of evidence, provider experience, commitment and community connections to build on

166. poor quality air has an adverse impact on health

169. many within the health, environmental and other sectors have long experience and strong commitment to equity -> build on this to drive coordinated and coherent system-wide equity agenda into action

170. work in broad partnerships and collaborations to address the underlying determinants of health inequalities

171. clean air and environmental quality are critical parts of these overall determinants of health – can be one key site of mobilization

172. making connections between all the issues/determinants is needed to build healthy and equitable communities33

174. my email is bob@wellesleyinstitute.com

175. I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equityFollowing Up 34

176. Wellesley Roadmap for Action on the Social Determinants of Health look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long-term; develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; act across silos – inter-sectoral and cross-government collaboration and coordination are vital; set and monitor targets and incentives – cascading through all levels of government and programme action; 35

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

180. integrated health, child development, language, settlement, employment, and other community-based social services;36

181. Wellesley Roadmap III 9 act locally – through well-focussed regional, local or neighbourhood cross-sectoral collaborations and integrated initiatives; 10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities; 11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country; 12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective programme and policy instruments, and into a coherent and coordinated overall strategy for health equity. 37

182. © The Wellesley Institute www.wellesleyinstitute.com 38