This presentation offers insight on how to put health equity into action by building on partnerships and collaborations. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Health Equity into Action:
Building on Partnerships and
Collaborations
Forum: Toronto's Northwestern Neighbourhoods
September 28, 2011
Bob Gardner

2. Outline: Two Challenges and One
Opportunity
1. getting the right balance:
• identifying and prioritizing the right issues/levers that will make the most
difference and build momentum for change
• do need comprehensive overall health equity strategy to guide and ground
action, but need to drive action on local/community level
2. providing best services to health disadvantaged communities/neighbourhoods:
• means building Social Determinants of Health into planning, coordination
and collaboration
• and into service design, mix and delivery
3. potential of local networks has been demonstrated
• SETo, WEUHA, Women’s College Hospital Network on the Non-insured
• will set out success conditions
• and steps to establish
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3. The Local Community Challenge
• stark health inequities in Northwest Toronto
neighbourhoods:
• disadvantaged on social determinants of health:
• higher % of low income
• higher % visible minority
• poorer education
• inequitable health outcomes:
• higher chronic conditions, LBW, infant mortality
• poorer access to primary care and other health and social services
• + possible dislocation of service patterns with shift of
hospital
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4. And The Community Potential
• considerable experience/resources on the ground
• lots of innovative programs underway
• leadership/commitment for action on health equity
• Central LHIN has prioritized equity and community-driven
action
→ opportunities to build local coordination and
networks
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5. Think Big, But Get Going
• the point of SDoH analysis is to be able to identify policy and
program changes needed to reduce health disparities
• but 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
• gradually build up coherent sets of policy and program actions –
and keep evaluating
• need to start somewhere – and focus today is on building local
coordinated action to address health inequities and challenges in
serving health disadvantaged communities
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6. Health Equity Strategy Into Action
• goal is to ensure equitable access to high quality healthcare
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
• quality, chronic prevention/care, effective use of resources
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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7. Start From a Clear Strategy
• need to develop clear overall strategy – whether at prov, LHIN or local level:
• clear vision of success – of what health equity or equitable climate change
adaptation strategy looks like
• identify key levers or drivers for change + coherent and coordinated set of
programs and activities
• grounded in a clear ‘theory of change’ -- the
principles, assumptions, ambitions and activities that will lead to the changes
we want
• within health, important changes can and have been made:
• provincially, population health and equity are important principles of Excellent
Care for All Act and public health standards
• locally, equity is a major priority of 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
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8. Build Into Practice Through Equity-Focused
Planning
• addressing health inequities requires a solid understanding of:
• the specific needs of health-disadvantaged populations
• key barriers to equitable access to high quality care
• gaps in available services for these populations
• 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
• involvement of local communities and stakeholders in planning and priority setting
is critical to understanding the real local problems
• and understanding of local community strengths, resources and
challenges
• and this requires an array of effective and practical equity-focused
planning tools
• Health Equity Impact Assessment is a practical tool that is being used throughout
the City and province
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9. Planning
For
Complexity
of SDoH
POWER Study
Gender and
Equity
Health Indicator
Framework
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10. Build SDoH Into Planning:
Cross-Sectoral Planning Through an Equity Lens
• cross-sectoral coordination and planning are much emphasized in public
health and health policy circles
• 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 Central LHIN initiative on cross-sectoral planning for newcomers
• the Ministry of Health Promotion and Sport is developing 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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11. And into Service Design and Delivery
• Excellent Care for All and patient-centred care means
taking the full range of people’s specific needs into
account – taking SDoH into account:
• social context and living conditions are part of this
• when people face adverse social determinants of health
→ can increase risk of mental and physical health challenges
and 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 needs and contexts
• more intensive case management, referral planning and
post-discharge follow-up
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12. Build Equity-Driven Service Models
• Community Health Centre model of care
• explicitly geared to supporting people from marginalized communities
• comprehensive multi-disciplinary services covering full range of needs
• many other sectors as well – mental health, immigrant and other
community-driven organizations
• + joint delivery and service partnerships
→ meeting full range of needs means moving beyond healthcare
• providing and partnering to provide related services/support such as
settlement, language, child care, literacy, employment training, youth
support, etc.
→ look beyond vulnerable individuals to the communities in which they live
• partnerships to build community capacities and resources
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13. Building on Potential of Community-Based Service
Initiatives and Innovation
• huge number of community and front-line health initiatives addressing
equity across province
• Community Health Centres, community mental health, community
organizations based out of specific ethno-cultural communities
• e.g. many community providers have established ‘peer health
ambassadors’ to provide system navigation, outreach and health
promotion services to particular communities
• not being systemically shared or built upon → need to create forums
and infrastructure to identify, assess and adapt this potential
• this progressive service delivery = beacon of inspiration for other sectors
+ constant living demonstration that action is possible
• look for insight and inspiration from ‘out of angle’ sources:
• e.g. community gardens and kitchens can contribute to food security
to some degree, and sports programs contribute to health, but they
can also help build social connectedness and cohesion
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14. 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
• opportunity to think big about what FHTs could be?
• 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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15. Extend That Further→ Build on/from
Community-Driven Action
• 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
• collaborative cross-sectoral efforts – for poverty
reduction, community development, health disparities
• 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 other complex social
problems
• local mobilization → into policy advocacy
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16. Potential of Local Community-
Based Networks
One of key ways to drive all of this into action is through local
networks
• SETo in Southeast Toronto
• WEUHA in west end
• broader
• a little more focus on service coordination, but still
SDoH
• INCG (the Inter Network Coordinating Group of four
downtown and mid-town networks) works closely with
Toronto Central LHIN
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17. SETo
Origins
• arose out of local access concerns – possible closure of Wellesley
Hospital
• ground up response to access challenges
• highlighted that local hospitals were not focussing on marginalized
Accomplishments
• began from local health profiles
• ongoing collaboration and idea sharing – which supported service
coordination and problem solving
• emphasized concrete demonstration projects → many with lasting
impact
• advocacy with institutions and governments around results of projects
and key issues such as harm reduction, dental care and access for non-
insured people
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18. SETo II
Success Conditions
• senior leadership
• regular meetings to keep momentum going
• sharing resources
• collaborative approaches
• admin support:
• never had stable funding, and don't need much
• but some institution(s) is key to providing modest and stable base
resources
for an overview of SETo’s development see
http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages
/seto.aspx
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19. Other Networks
• similar patterns, but several different lessons learned
• WEUHA is a bigger/broader table
• one way it keeps interest alive is by devoting parts of most meetings to
specific focused discussion of key local issues
• they also create small working groups to tackle particular issues
• Women’s College Hospital Network on Non-Insured:
• grew out of front-line and grass roots recognition of critical access
problem
• serves several key functions:
• has sponsored research and held research conferences
• advocates with institutions and governments to improve access
• provides a forum – and builds the key personal connections – to
solve immediate consumer problems
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20. Provider Networks
• in addition to range of mental health, ethno-cultural and other provider
networks, key sectors have developed coordinating forums
• Hospitals Collaborative on Marginalized Populations:
• forum for initiating and coordinating equity efforts and programs
• became cortically important as the place where hospitals discussed and
shared the equity plans required by the LHIN
• for analyses of these plans see
http://www.torontoevaluation.ca/tclhinrefresh/
• Greater Toronto Community Health Centres
• forum for sharing information, identifying common problems and acting on
common initiatives
• e.g. assessing challenges and solutions for improving access for non-insured
people
• one innovative direction was rather than doing individual equity plans for
Toronto Central LHIN, they collectively developed a common sector-wide
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2011 |
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21. Collective Impact
• this broad base of community support and activism was a
critical part of getting/keeping equity on agenda
• part of building LHIN support
• supported and built equity champions within provider institutions
• all part of embedding equity in hospitals and other providers
• the local networks also began to coordinate with each other
→ magnifying strength and impact and
enhancing/deepening working relationships
• all pay close attention to staying grounded in their
community bases
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22. 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’
• health equity could be one
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