This presentation offers ways to leverage a health equity strategy in order to inspire public action. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Health Equity Strategy Into
Public Health Action
alPHa-OPHA Health Equity Working Group
April 5, 2012
Bob Gardner

2. 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
2

3. Foundations of Health Disparities Roots 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
• real problem is differential
access to these determinants –
many analysts are focusing
more specifically on social
determinants of health
inequalities
3

4. Canadians With Chronic Conditions
Who Also Report Food Insecurity
4

5. 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, environmental and health
systems
Determinants have a reinforcing and
cumulative effect on:
• individuals throughout their lives
• and on communities and
population health
5

6. 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 →
6

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
7

8. 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.
April 9, 2012 8

9. 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
9

10. Powerful Starting Point = Equity As a Driving
Priority Within Public Health
10

11. 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 outreach
2. aligning equity with system drivers and priorities – such as chronic disease
prevention and management, quality – to enhance chance for success
3. identifying those levers that will have the greatest impact on reducing health
inequities and driving system change – enhanced primary care
4. 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
April 9, 2012 11

12. 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
12

13. 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
13

14. 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?
14

15. 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?
15

16. 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
16

17. 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
17

18. 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
18

19. 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
19

20. 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
20

21. 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
21

22. Toronto Central LHIN Equity Plans
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23. 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
23

24. 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
24

25. 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
25

26. 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
26

27. 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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28. 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
28

29. 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
29

30. 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
30

31. 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?
31

32. 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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33. 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?
33

34. 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
34

35. 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
35

36. 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
36

37. Look for Policy Windows to Intervene to Advance
Health Equity
Commission on the Reform of
Social Assistance in Ontario
A 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
37

38. 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’
38

39. 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
39