This presentation offers insights on how to advance health equity by building on community-based innovation. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Advancing Health Equity: Building
on Community-Based Innovation
Bob Gardner
Peel Cancer Screening Study: Knowledge
Exchange Forum
October 20, 2011

2. Key Messages
• health inequities are pervasive and damaging
• but these inequities can be addressed through
comprehensive health equity strategy
• part of this is focusing policy, programs and resources on
health disadvantaged populations by:
• identifying priority populations and key systemic access barriers
• planning the most effective mix of services and support to meet
priority populations’ diverse needs
• peer health ambassadors is one promising direction that can
address the specific needs and barriers faced by particular
populations
• this kind of community-based innovation on the ground is a
crucial part of advancing equity
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3. 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
+ inequitable access to health care
•impact and severity of these
inequities can be concentrated in
particular populations
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4. 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
•we need comprehensive strategy to
drive policy action and social change
across these determinants
October 27, 2011 |
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www.wellesleyinstitute.com

5. 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 capacities,
exclusion→ resources and resilience to cope
with the impact of poor health
3. because of all this, disadvantaged 3. these disadvantaged and
and vulnerable populations have vulnerable communities tend to
more complex needs, but face have inequitable access to services
systemic barriers within the health and support they need
and other systems →
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6. POWER Study
Gender and Equity
Health Indicator
Framework
Highlights
1. How better
access/care within
health system can
make a difference to
most vulnerable
2. Why we need to take
SDoH into account in
health service
planning and delivery
3. How the structure,
resources and
resilience of
communities mediate
the impact of SDoH 6

7. Think Big, But Get Going
• challenge = health inequities can seem so overwhelming and their
underlying social determinants so intractable → can be paralyzing
→ do need comprehensive social and economic strategy and action to
address the foundations and impact of health inequities
• think big and think strategically, but get going
• need to start somewhere:
• even though roots of health disparities lie in far wider social and
economic inequality, the health system is still crucial to tackling health
disparities
• it’s in the health system that the most disadvantaged in SDoH terms
end up sicker and needing care
• in addition, there are systemic disparities in access and quality of
healthcare that need to be addressed
• we want to ensure equitable access to high quality care
• focus today is on engaging with and providing key preventative services
and support to meet needs of particular populations
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8. Specific Problem to Solve: Inequitable Access to
Preventive Health Services
100
88.4
83.6
80 78.4
65.7 66.7
60
48.4
44.7 White
South Asian
40
29.2
20
0
General Practitioner Prostate-Specific Antigen Blood Test Mammogram Pap smear

9. High-Level: Health Equity Strategy Into Action
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
3. embedding equity in provider organizations’
deliverables, incentives and performance management
4. 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
• looking to improve the health of most disadvantaged, fastest
5. while investing up-stream in health promotion and addressing
the underlying determinants of health
October 27, 2011 9

10. Drilling Down: Solutions for Particular
Populations
• taking social context and living conditions into account are part of good service
delivery
• 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
• 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
population needs and social contexts:
• health promotion and care have to be delivered in languages and cultures of
particular population/community
• focus in 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 in acute side + targeted efforts to reach populations facing access barriers
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11. Part of the Solutions:
Community-Driven Innovation
public health and many community providers have established
‘peer health ambassadors’ to provide system
navigation, outreach and health promotion services to particular
communities
Peer Health Ambassadors
• Members of the community, from the community
• Working with established healthcare providers to improve access and
quality of care for targeted populations
• including improving access to preventative screening
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12. Wellesley Research Project
Purpose
• Survey the range and impact of Peer Health Ambassadors
• Assess their potential to meet needs of marginalized
populations
• Identify key success conditions and enablers to realize this
potential
Methods
• Review of literature
• Key informant interviews with 10 Toronto community
organizations currently working with peer-based models
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13. Findings:
Great Potential
• Peer Health Ambassadors are a promising model for
improving health equity through eliminating barriers to health
care and improving engagement
• considerable variation in role, level of expertise and “peerness”
• three broad areas -- navigating the system, health promotion, and as
integrated into comprehensive service provision
• Marginalized groups prefer healthcare providers who have
personal experience with their problems, who understand
their viewpoints, and who share key traits
(race, gender, religion, sexuality, cancer, drug use, etc.)
• When community impact is reported, the results are generally
very positive
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14. Findings:
Facilitators to Effectiveness and Impact
• Financial compensation
• Initial and ongoing training/support/mentoring for peers
• Clear roles and division of labour + flexibility to accommodate
dynamic needs of both peers and communities being served
• Participation of peers in program or service planning and
development
• Rigorous quality assurance at every stage
• Program evaluation to improve practices
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15. Findings: Barriers
• Peer life-stage, ability to adapt their own health and lifestyle to work
environment
• Breach of peers’ personal boundaries by clients and co-workers, because
of the highly personal nature of this work
• Organizational capacity to support peer needs, service demands and client
expectations
• Client preferences for credentialed professionals or specific delivery
settings
• Resistance from professionals or institutions to community-based delivery
• Unstable funding
• Challenges in scaling up
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16. Realizing the Potential of Peer Health
Ambassador Initiatives
• Enlist service users and community in planning and development
• Provide ongoing training and support, driven by peer and community needs
• Provide financial compensation, even during training
• Allow for adaptability and flexibility of training and program to suit the needs of
peer workers and clients
• Monitor quality
• Market the services using mediums that can reach the target population
• Link into coordinated continuum of services and support to communities facing
poorer access
• Actively pursue alternative funding sources – beyond rigid project funding from
government sources
• Evaluate to understand what ‘works’ – for which particular populations, in what
contexts – and build this learning into continuous improvement
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17. 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
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18. Key Messages
• Need comprehensive strategy to address health inequities
• Part of this is ensuring equitable access to high-quality care
for all
• Part of this is always addressing specific problems facing
specific populations – inequitable access to cancer screening
for particular communities
• Peer ambassador type initiatives have shown great potential
in being able to reach, support and involve marginalized
populations
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19. 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
• my email is bob@wellesleyinstitute.com
• 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
equity
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20. Wellesley Roadmap for Action on the
Social Determinants of Health
1. look widely for ideas and inspiration from jurisdictions with comprehensive
health equity policies, and adapt flexibly to Canadian, provincial and local needs
and opportunities;
2. 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;
3. develop a coherent overall strategy, but split it into actionable and manageable
components that can be moved on;
4. act across silos – inter-sectoral and cross-government collaboration and
coordination are vital;
5. set and monitor targets and incentives – cascading through all levels of
government and programme action;
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21. Wellesley Roadmap II
6 rigorously evaluate the outcomes and potential of programme initiatives and
investments – to build on successes and scale up what is working;
7 act on equity within the health system:
• making equity a core objective and driver of health system reform – every bit
as important as quality and sustainability;
• eliminating unfair and inefficient barriers to access to the care people need;
• targeting interventions and enhanced services to the most health
disadvantaged populations;
8 invest in those levers and spheres that have the most impact on health
disparities such as:
• enhanced primary care for the most under-served or disadvantaged
populations;
• integrated health, child development, language, settlement, employment, and
other community-based social services;
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22. 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.
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