This presentation offers critical insights on thinking and acting on health equity. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Thinking About Health Equity/
Acting on Health Equity
Bob Gardner
Medical and Health Sciences Forum
University of Toronto
January 26, 2012

2. Key Messages
• health disparities are pervasive and damaging
• will set out how these disparities can be addressed through
comprehensive health equity strategy
• acting on health equity within the health system
• building equity into all planning and delivery
• targeting some programs and resources for equity impact
• aligning equity with key system drivers
• embedding equity in performance management and service delivery
• and well beyond healthcare -- 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
• community and political mobilization to demand and drive the necessary
policy changes
2

3. 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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4. Gradient of Health Across Many
Conditions
4

5. Impact of Health Inequities
5

6. Impact of Health Inequities II
• 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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7. 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
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8. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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9. 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
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10. 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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11. 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 will drive change in these
pathways and in population health as a whole
• analyze the policy changes needed to act on these levers
• specify the short, intermediate and long-term outcomes expected and the
preconditions for achieving them.
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12. Think Big, But Get Going
• challenge = health inequities 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 providing services and
support to meet needs of priority populations
• which & where depends on analysis of needs, resources, gaps
and opportunities, and community resources and structures
12

13. Health Equity = Reducing Unfair
Differences
• Health disparities or inequities are differences in health outcomes that
are avoidable, unfair and systematically related to social inequality and
disadvantage
• This concept:
• is clear, understandable and actionable
• identifies the problem that policies will try to solve
• is also tied to widely accepted notions of fairness and social justice
• The goal of health equity strategy is to reduce or eliminate socially and
institutionally structured health inequalities and differential outcomes
• A positive and forward-looking definition = equal opportunities for good
health
• Equity is a broad goal, including diversity in background, culture, race
and identity

14. Planning For
Complexity of SDoH
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 impt
POWER Study: Gender and
Equity Health Indicator Framework
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15. Equity Into Health System: Why
• even though roots of health disparities lie in far wider social
and economic inequality
• how the health system is organized and how services and
care are delivered is still crucial to tackling health disparities
• consistent theme in WHO, EU and all the major international
reports and in the many countries that have developed
comprehensive multi-sectoral strategies to reduce health
disparities
• in all of them, transforming the health system is an
indispensable element, including:
• reducing barriers to equitable access to high quality care
• targeted interventions to improve the health of the poorest, fastest
• up-stream investments in primary and preventative care directed to
most vulnerable
• delivering a full continuum of services in coordinated way at
community/local level
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16. Equity Into Health System: Why II
1. it’s in the health system that the most
disadvantaged in SDoH terms end up sicker and
needing care
• equitable healthcare and support can help to mediate the
harshest impact of the wider social determinants of health on
health disadvantaged populations and communities
2. in addition, there are systemic disparities in access
and quality of healthcare that need to be
addressed
• people lower down the social hierarchy can have poorer
access to health services, even though they may have more
complex needs and require more care
• unless we address inequitable access and quality, healthcare
and community support services could make overall
disparities even worse
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17. Equity Into Health System: How
• goal is to ensure equitable health regardless of social
position
• can do this through a multi-pronged strategy:
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
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
5. while thinking up-stream to health promotion and addressing the
underlying determinants of health
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18. Equity Into Health System: How II
while health disparities are
pervasive and deep-rooted, they
can be changed through policy and
program action
comprehensive strategy developed
in 2008 for Toronto Central LHIN
many recommendations have been
acted on
other LHINs are also prioritizing and
moving to address health disparities
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19. Start From The Community
• goal is to reduce health disparities and speak to needs of
most vulnerable communities – who will define?
• can’t just be ‘experts’, planners or professionals
• have to build community into core planning and priority setting
• not as occasional community engagement
• but to identify equity needs and priorities
• and to evaluate how we are doing
• how:
• many hospital have community advisory panels
• CHCs have community members on their boards
• innovative methods of engagement – e.g. citizens’ assemblies or
juries in many countries
• community-based research, needs assessment and evaluation
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20. And Start From a Solid Strategic
Commitment
• need to make equity one of driving priorities for health
system and reform
• equity and a population health focus are among key principles enshrined in
new Excellent Care for All Act = opening and context
• need clear provincial strategy for equity:
• implicit from MOHLTC, but promised ten year strategy has not been released
• equity and population health are in public health standards
• need strategic coherence across health system in approach to equity
• LHINs, CCACs, and other coordinating agencies need to
prioritize equity – and many have
• cascading down to all providers prioritizing equity in their
overall strategic plans and then into service delivery and
resource allocation
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21. Align Equity With Health System Drivers
• Excellent Care For All Act and quality agenda
• providers have to develop Quality Improvement Plans
• hospitals first reported April 2011
• other providers will report in subsequent years
• equity should be developed as one of dimensions to report on – but
wasn’t really in frost hospital plans
• patient-centred care → means taking the full range of people’s specific
needs into account → customizing delivery and quality for more health
disadvantaged populations with greater/more complex needs
• improving safety requires addressing equity barriers
• inadequate interpretation services can lead to mis-diagnoses, people not
being able to follow medication, etc.
• provincial priorities – e.g. diabetes, wait times, mental health, ALCs are all
much affected by inequitable health and access – and will not be achieved
unless planning/delivery takes equity into account
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22. Into Practice Through Equity-Focused Planning
• addressing health disparities in service delivery and planning
requires a solid understanding of:
• key barriers to equitable access to high quality care
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• need to understand roots of disparities:
• i.e. is the main problem language barriers, lack of coordination among
providers, sheer lack of services in particular neighbourhoods, etc.
• which requires good local research and detailed information – speaks
to great potential of community-based research
• involvement of local communities and stakeholders in planning and
priority setting is critical to understanding the real local problems
• requires an array of effective and practical equity-focused
planning tools
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23. Health Equity Impact Assessment
• increasing attention to potential – from WHO, through most European
strategies, PHAC, to MOHLTC and LHINs
• planning tool that analyzes potential impact of program or policy change
on health disparities and/or health disadvantaged populations
• can 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
• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI
• HEIA is being used in Toronto Central and other LHINs and providers across the
province
• Toronto Central has required HEIA within recent funding application processes
for Aging at Home, and refreshing hospital equity plans
• required in last generation of TC hospital equity plans and many hospitals are
extending its use
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24. 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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25. Success Condition: Effective Equity Targets
• innovative work underway to develop equity indicators – but don’t need
to wait
• build equity into existing targets:
• reducing diabetes incidence is prov and LHIN priority
→ equity target = reduce differences in incidence, complications and rates of
hospitalization between populations or areas
• a good service target has been proposed for diabetes = high/increasing % of
people who get best standard care
→ reduce differences by gender, income, ethno-cultural background
• need to drill down in specific areas that have high equity impact:
→ ensuring access and use of primary health care does not vary inequitably by
income level, immigration status, neigbourhood, gender, race, etc.
• many programs assess their services through client satisfaction surveys
and look for high and improving satisfaction
→ reduce any differences in satisfaction by gender, income, ethno-cultural
background, etc.
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26. Challenges: Equity Targets That Work
• 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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27. 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
•key direction = explore potential of
equity/SDoH data for Ontario
•pilot project in 3 Toronto academic
hospitals to collect equity data
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28. Use Available Levers: Equity Plans
• a promising direction several LHINs have taken up is to require providers
to develop equity plans
• hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation
in TC
• and other providers in Central
• CHCs have developed a sector-wide plan in GTA
• these plans are designed to:
• identify access barriers, disadvantaged populations, service gaps and
opportunities in their catchement areas and spheres
• develop programs and services to address those gaps and better meet
healthcare needs of disadvantaged communities
• these provider plans have the potential to:
• raise awareness of equity within the organizations
• build equity into planning, resource allocation and routine delivery
• pull their many existing initiatives together into a coherent overall equity
strategy
• build connections among providers for addressing common equity issues
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29. Toronto Central LHIN Hospital Equity Plans
http://www.torontoevaluation.ca/tclhinrefresh
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30. Target Investment for Equity Impact
• 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 resources
• lever = certain % of LHIN budgets to be equity targeted
• this requires sophisticated analyses of the bases of disparities:
• i.e. is the main problem language barriers, lack of coordination among
providers, sheer lack of services in particular neighbourhoods, etc.
• which requires good local research and detailed information – speaks to great
potential of community-based research to provide rich local needs
assessments and evaluation data
• involvement of local communities and stakeholders in planning and priority
setting is critical to understanding the real local problems
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31. Target Populations
• vulnerable populations will vary:
• poor neighbourhoods with high % of racialized population in many big cities
• Aboriginal communities across the prov
• isolated rural areas
• solid evidence that enhancing primary care is one of key ways to improve care of
disadvantaged
• lack of access to primary care has been identified as a key issue for Prov and
LHINs
→ concentrate new FHTs or other initiatives in particular regions or
neighbourhoods, or in particular populations such as refugees or uninsured
• need to drill down with good research:
• South Asian immigrants had 3X and Caribbean and Latin American 2X risk of
diabetes than immigrants from Western Europe or North America
• greater risk for women
• risk increases with time since immigration
Creatore et al CMAJ Aril 19, 2010
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32. Target Barriers
• one of critical equity challenges for many LHINs, hospitals and other providers in
diverse communities is language
• LHINs need to specifically require hospitals to ensure interpretation is
available in languages of their community
• need to fund centralized interpretation services to support smaller agencies
• in some other areas, distance and isolation are the critical determinants
• in Toronto and other cities: people without health insurance – primarily
immigrants/refugees:
• many community initiatives to provide access
• Women’s College Hospital Network on Noninsured is forum for coordination
• research conference showing critical barriers to access and good care and
resulting adverse health outcomes for vulnerable people
• equity is complex – ‘wicked’ policy problems
• but not all of it = avoidable disparities and workable solution
• eliminate the three month wait for OHIP for new immigrants
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33. System Coordination
• where complex care has been organized in provincial or
regional networks and resources devoted to coordination
and creating a continuum of care:
• cancer, cardiac
→ less inequitable access
• still access barriers can persist:
• e.g. lower levels of screening in some ethno-cultural
communities or areas
• peer health ambassadors and other community-based solutions
are promising
• lesson = combine comprehensive system-wide
coordination and local/grass-roots initiatives for specific
populations
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34. Never Just Equitable Access, But Quality:
Customize Service Delivery
• 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
• 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
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35. 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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36. Extend That → 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
healthcare
• 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.
• build local service partnerships -- many PHUs partner with CHCs,
ethno-cultural, neighbourhood specific and other community
providers and groups to support particular population
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37. Equity-Driven Innovation: Hub Models of
Integrated 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
• many countries have clinics that provide both health and wider social services
in one place
• 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 -- idea of schools as service hubs is being
developed
• think back to earlier eras with public health nurses in schools
• start by putting hubs in schools in most disadvantaged areas
• concentrated and integrated services for most disadvantaged kids have proven
to be effective investment
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38. Build Equity Upstream: 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 → if
not, will widen inequities
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39. Build SDoH In:
Cross-Sectoral Planning Through an Equity Lens
• cross-sectoral coordination and planning are much
emphasized in public health and health policy circles
• but what sectors? for what purposes?
• addressing wider SDoH is the glue for collaboration into
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 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
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40. Equity-Driven Collaboration and
Coordination
• across Canada, leading Regional Health Authorities have
developed operational and planning links with local social
services or emphasized community capacity building:
• Saskatoon is developing cross-sectoral action on health equity:
• began from local research documenting shocking disparities among
neighbourhoods
• focusing interventions in the poorest neighbourhoods – locating services
in schools, relying on First Nations elders to guide programming, etc.
• wide collaboration among public health, municipality, business,
community, Aboriginal and other leaders
• in Ontario public health are key players in addressing health
disparities on the ground
• a number of public health units have been pioneering social determinants
approaches -- Sudbury, Waterloo, Toronto, Peterborough
• generally through broad community collaborations
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41. Extend That → Build on/from Local and
Regional Initiatives
• there is always much to be learned from policies, programs
and initiatives in other jurisdictions
• all leading jurisdictions with comprehensive equity
strategies combine:
• national level macro strategies to reduce social health
inequalities
• with local or regional implementation and adaptation
• concentrated local investment and coordination
• British example: Health Action Zones and other models were
designed to combine community economic development with
targeted healthcare and social service improvements
• that is the potential of LHINs and RHAs
→ build equity into regional planning and coordination
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42. Extend That → Build On/From
Community-Level Action
• 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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43. 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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44. 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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45. 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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46. Key Messages
• health disparities are pervasive and deep-seated – but can’t let that
paralyze us
• do need a comprehensive and coherent health equity strategy – but
don’t wait for perfect strategy
• think big and think strategically – but get going
• there is a solid base of evidence, provider experience, commitment and
community connections to build on
• have set out a roadmap – of strategies, principles and tools -- to drive
equity into action through policy change and community mobilization
• many within the health system and beyond have long experience and
strong commitment to equity → build on this to drive coordinated and
coherent system-wide equity agenda into action
• work in partnerships and collaborations well beyond the health care
system to address the underlying determinants of health inequalities
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47. 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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48. 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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49. 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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50. 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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