This presentation provides insight on how to drive health equity into action at a community level. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Driving Health Equity Into Action at a Community Level Bob Gardner Central LHIN Health Equity Advisory Network Roundtable May 19, 2011

3. + major differences between women and men

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

5. in addition, there are systemic inequities in access to and quality of care within the health care system

6. these inequities can be concentrated in particular communities, neighbourhoods and areas2

8. Chippewas of Georgina Island First Nation (Northern York)

9. Rural area of South Simcoe

10. Diverse urban communities in North York West

11. focusing on particular communities or populations is a critical component of an overall equity strategy

12. will talk about the constant need to align and balance local/specific initiatives with wider system changes and strategies

13. LHINs can effectively use the levers they control:

14. allocating resources and influencing health care providers

15. can also enable partnerships, collaborations and other change initiatives

16. shown to be effective way to drive quality improvement and system reforms

17. especially important when levers of change are outside LHINs’ formal mandates and resources3

18. Percentage of Adults Who Reported Their Health as Fair or Poor: Ontario and Central LHIN 4

19. 5

20. August 4, 2011 Hospitalization Rates for Diabetes: Ontario and Central LHIN

21. 7

23. 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

24. even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women Statistics Canada Health Reports Dec 09 8

26. 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

29. This concept:

30. is clear, understandable and actionable

31. identifies the problem that policies will try to solve

32. is also tied to widely accepted notions of fairness and social justice

33. The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes

34. A positive and forward-looking definition = equal opportunities for good health

38. can do this through a three pronged strategy:building health equity into all health 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 embedding it in provider organizations 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 Equity Into Health System 13

40. can’t just be ‘experts’, planners or professionals

41. have to build community into core planning and priority setting

42. not as occasional community engagement, but to identify equity needs and priorities, and to evaluate how we are doing

43. many providers have community advisory panels or community members on their boards

44. can also build on innovative methods of engagement – e.g. citizens’ assemblies or juries in many jurisdictions

45. idea = develop innovative community engagement and partnerships to ground and drive action in these two communities

46. need good local data on needs, gaps and opportunities

47. community-based research, needs assessment and evaluation

48. build on data from Toronto Health Profiles, public health, etc.

49. idea = identify information needs and build actionable profile of community health needs14

51. key barriers to equitable access to high quality care

52. the specific needs of health-disadvantaged populations

53. gaps in available services for these populations

54. need to understand roots of disparities:

55. i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc.

56. which requires good local research and detailed information – speaks to great potential of community-based research

57. involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems

58. requires an array of effective and practical equity-focused planning tools15

59. Equity-Focused Planning Tools quick check to ensure equity is considered in all service delivery/planning take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery assess current state of provider organization determine needs of communities facing health disparities assess impact of programs/interventions on health disparities and disadvantaged populations simple equity lens Health Equity Impact Assessment equity audits and/or HEIA equity-focused needs assessment equity-focused evaluation 16

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

64. developing realistic and actionable indicators for service delivery

65. closely monitoring progress against the targets and indicators

66. disseminating the results widely for public scrutiny

67. tying funding and resource allocation to performance

68. innovative work underway to develop equity indicators – but don’t need to wait

69. idea = what are appropriate equity targets for these communities?

70. simplest could be to build on indicators already being collected -> equity angle is to reduce differences between these communities and others or LHIN as a whole on these indicators 18

74. undertaking appropriate equity-focused planning to identify areas where access to services is inequitable and developing plans to address barriers and gaps

78. three hospitals = Toronto Public Health are collaborating on how to collect and incorporate equity data at service level

79. Central hospitals could link into this

80. but don’t wait for perfect data

81. hospitals have been using postal code data as proxy for socio-economic conditions

82. idea = any project that arises out of this equity planning to collect relevant SDoH dataPrecondition: Equity-Relevant Data 21

84. identify access barriers, disadvantaged populations, service gaps and opportunities in their catchement areas and spheres

85. develop programs and services to address those gaps and better meet healthcare needs of disadvantaged communities

86. these provider plans have the potential to:

87. raise awareness of equity within the organizations

88. build equity into planning, resource allocation and routine delivery

89. pull their many existing initiatives together into a coherent overall equity strategy

90. build connections among providers for addressing common equity issues

91. idea = ask providers to address specific issue arising out of this equity planning for the two communities in refreshed plans or as appendices to their plansUse Effective Tools: Equity Plans 22

94. what are the key drivers or levers for change within the health system?

95. how to build equity into those drivers and effectively use those levers to advance health equity?

96. solid evidence that enhancing primary care is one of key ways to improve care of disadvantaged

98. also a chance to be innovative around new ways of community-driven coordination and multi-disciplinary service integrationUse Effective Levers to Drive Change: Primary Care 24

100. chronic disease prevention and management programs cannot be successful unless they take health disparities and wider social conditions into accountvery clear gradient in incidence – and impact – of chronic conditions poor, Aboriginal and other vulnerable communities face greater incidence at the same, time these communities tend to have less access to good food, safe open space and recreational facilities to encourage exercise, and other resources to manage their conditions. the Toronto diabetes atlas produced by ICES found that only 25% of people in low-income neighbourhoods participated in weekly sports – versus 75% from high-income built environment is also key -- the atlas found that people in low-income areas walked more for transportation purposes but less for exercise up-stream initiatives need to be planned and implemented through an equity lens some populations and communities need greater support to prevent and manage chronic conditions idea = adapt innovative diabetes prevention and management models to these communities

101. Gradient in Adult Smoking: Ontario and Central LHIN 26

104. Local Immigration Partnerships , Social Planning Councils

105. the Ministry of Health Promotion and Sport is developing a healthy communities strategic approach and community partnerships

106. idea = sponsor or partner cross-sectoral planning with public health, health promotion, social services, settlement, education, etc. in the two communities28

110. important to realize that lessons learned from innovation in these two communities will benefit others as well30

112. many cities have developed neighbourhood revitalization strategies

113. Toronto’s priority neighbourhoods

114. Regent’s Park

115. promising direction = comprehensive community initiatives:

116. broad partnerships of local residents, community organizations, governments, business, labour and other stakeholders

117. coming together to address deep-rooted local problems – poverty, neighbourhood deterioration , health disparities

118. collaborative cross-sectoral efforts – employment opportunities, skills building, access to health and social services, community development

119. Vibrant Communities – communities across the country to build individual and community capacities to reduce poverty31

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

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

123. 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

124. collaborative action to find local health equity solutions is part of that community mobilization + is critical to driving immediate action on pressing problems32 August 4, 2011

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

127. think big and think strategically – but get going

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

129. have set out a roadmap – of strategies, principles ,tools and options-- to drive equity into action through health system change and community mobilization

130. 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 ->and locally, work in partnerships and collaborations to address the health inequalities in these specific communities 33

132. my email is bob@wellesleyinstitute.com

133. 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

134. 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

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

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

139. 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

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