This presentation examines the ways in which to advance health and health equity for children and youth during difficult times. Bob Gardner, Director of Policy Steve Barnes, Policy Analyst www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Advancing Health, Health Equity
and Opportunities for Children
and Youth in Tough Times
Presentation to the Provincial Advocate for
Children and Youth
April 2012
Bob Gardner & Steve Barnes

2. Outline
Pervasive and damaging health Rooted in underlying social
inequities determinants of health = parallels in
problems you address
Strategy and action to address health Some parallel lessons learned for
inequities your challenges
Addressing underlying determinants Parallels are close
of health
Post-Drummond era of austerity Policy context shapes all of our issues
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3. One 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
3

4. Impact of Inequities
• from the start: while infant mortality rates have been
declining overall, rates in Canada’s poorest
neighbourhoods remain two-thirds higher than those of
the richest neighbourhoods
• to the end: 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
• + inequality in how well people live:
• 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)
4

5. 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
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6. Health Equity and Social Justice
• this view builds upon Amartyn Sen -- a leading voice in
highlighting that what has to be equitable here is the capacity to
secure good health
• More broadly, he sees the capability for good health as “a central
feature of the justice of social arrangements in general”
• a recent book on Health Justice by Sridahr Venkatapuram
emphasizes:
• “the recognition of every human being’s moral entitlement to a
capability to be healthy”
• and links this to social determinants of health
• “.. and, more specifically, the entitlement is to the social bases” of
the capability to be healthy
• in these ways health equity can be seen as a fundamental
component of social justice
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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
• real problem is differential
access to these determinants –
many analysts are focusing
more specifically on social
determinants of health
inequalities
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8. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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9. Drilling Down: Diabetes
• Best way to prevent/manage diabetes is through
a healthy diet of lots of fruit & veggies
• But not all communities have easy access to grocery
stores
• And not all families can afford healthy food
• And not all families can afford the transport costs to
get to and from stores
• And not everyone has good access to primary health
care that helps manage diabetes in the first place
• All this leads to ongoing health problems over a
lifetime
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10. 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 individuals
throughout their lives and on
overall population health
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11. SDoH Over the Life Course
• important elaboration in SDoH analysis – recognizing that:
• the effect of determinants varies across people’s lives – so
need to analyze impact on children and youth specifically
• and that impact of inequalities is cumulative
• for children, research shows that:
• pre-natal and early years are especially sensitive to social
conditions and can have a major impact on future health
• intervening in early years to counteract adverse effects of
wider social and economic inequalities has great potential
• growing up in inadequate and inequitable social and family
circumstances can store up a life-time of health problems
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12. 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 disadvantaged communities have
other fundamental determinants of poorer overall health and are at
health → greater risk of many conditions
1. also because of broader social and 1. some communities and populations
economic inequality and exclusion→ have fewer capacities, resources and
resilience to cope with the impact of
poor health
1. because of all this, disadvantaged 1. 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 →
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13. Social Determinants
of Health +
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
13

14. 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 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 4, 2012 14

15. 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
• 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
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• need to start somewhere – and focus here is on children’s health and

16. Equity Into Health System: Why
if the foundations of health inequities lie in underlying
social determinants, why worry about health care?
3. 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
4. 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
16

17. Towards Solutions:
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
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
April 4, 2012 17

18. Equity-Focused Planning
• all of that 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 other services
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 – 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
HiAP
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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 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
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20. Extend That → Build Community-Level
Action
• all leading jurisdictions with comprehensive equity strategies combine
national policy with local adaptation and concentrated investment
• 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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21. Public Policy Post-Drummond
• An enormous range of specific
recommendations and welcome recognition of
need for govt and public services to be more
innovative and responsive
• But most important influence may be in shaping
the tenor/parameters of public policy
• It justifies and ushers in an era of austerity,
restraint and limited public investment – with
implications for all our fields
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22. Drummond on Health
• The Drummond Report’s emphasis on reform and innovation in
the way health care is organized and delivered is vital.
• Huge element is missing: equity.
• Equitable access to services, equitable outcomes and improved
population health must also be fundamental goals of reform.
• we need to ensure that that the reforms being contemplated do
not make access to health care less equitable or worsen the
health of marginalized populations.
• Drummond highlights that a small proportion of patients with
complex needs account for a high proportion of overall health
system costs and emphasizes that preventing ill health and
controlling chronic diseases is crucial moving forward
• but the distribution of ill-health is not random
• consistent inequitable gradient of health
22

23. Drummond on Health II
• The report also highlights the importance of primary care.
• An equity approach would ensure that expanded family
health teams, community health centres and other key
reforms are concentrated in under-served and higher need
areas to reduce inequitable disparities in access.
• The report rightly points to the need for coordination and
integration of services.
• Discharging a patient into overcrowded or unsafe housing
means that they are likely to end up back in the hospital,
thereby undermining the savings and efficiencies the
Commission is looking for.
23

24. Post-Drummond Social Policy
• Drummond did recognize – although unevenly – that
not investing in the social/community foundations of
a healthy society will lead to higher costs down the
road
• But it didn’t recognize in its health analysis how
inequitable social determinants of health will
undermine efforts at reform and continue to underlay
poorer health
• the same point – of not seeing the systemic roots of so
many social problems and policy challenges in structured
inequality weakens the Report throughout
• so there is no coherent vision of investing in the social
foundations of a healthy and equitable society
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25. Look for Areas to Intervene
•Commission on the Reform
of Social Assistance in
Ontario
•A broad collaborative of
leading Toronto health
sector institutions and
experts came together to:
• Define a vision of health-
enabling social assistance
system; and
• Practical actions to
implement such a system
25

26. Social Assistance Reform
• Drummond recommended that social
spending be allowed to increase by 0.5%
• But social assistance rates are already
inadequate and people on social assistance
do not have the supports to help them into
work/training
• Children who grow up in poverty ‘store up’ a
lifetime of health problems
26

27. Social Assistance Reform II
• The budget froze social assistance rates and
cut funding for health-related expenses
• And it preempted the advice of its own
expert Commission
• BUT it increased spending on social and
children’s services by an average of 2.7
percent over the next three years, the
largest percentage increase of any sector
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28. Lessons for Advancing Equity in
Tough Times
• Watch for constant danger of austerity policy:
→ cuts to community foundations of health and opportunity
or to services for most vulnerable
→ make inequalities worse
• Always keep equity in the front of your mind
• Don’t let the scale of the problem or the harsh policy
environment stop you from making progress
• Austerity will pass and we need to be ready with
imaginative and achievable policy solutions
• Identify opportunities and the policy levers that you have
within your control
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29. 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’
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30. 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 showing that we can get there from here
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