Driving Health Equity for Kids: From the Earliest Years to Transforming the System

Achieving Health Equity for Kids: Whatever it Takes
Hospital for Sick Children Conference
Bob Gardner, PhD
March 30, 2010

© The Wellesley Institute
www.wellesleyinstitute.com

• Start with big picture – fundamental roots of inequality in children's
health lie in wider structures of social and economic inequality →
action needed at macro policy level
• But what happens in healthcare system is still vital
• Analyze how to embed equity in planning and service delivery
• strong strategic commitment from the top
• equity-focused planning and performance management
• And how to address particular health disadvantaged populations or
access barriers
• Circle back to social inequality – one way hospitals and providers can
address SDoH is through
• cross-sectoral collaborations and planning
• building understanding of SDoH and inequality into service delivery
• partnering with community providers and others to address roots of inequality

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• 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
• concentrated disadvantage and poor health in
particular communities – poor, immigrant, socially
excluded and isolated
• major differences between women and men
• the gap between the health status of the best off and
most disadvantaged can be huge – and damaging
• in addition, there are systemic disparities in access to
and quality of care within the healthcare system


• 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)


• 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

6
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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


• 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 showing that pre-natal and early years are especially
sensitive to social conditions and can have a major impact on
future health
• that 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


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

© The Wellesley Institute 9

1. it’s in the health system that the most disadvantaged
in SDoH terms end up sicker and needing care
• equitable healthcare and proactive health promotion can help to
mediate the harshest impact of the wider social determinants of
health
2. in addition, there are systemic disparities in access
and quality of healthcare that need to be addressed
• people lower down the social hierarchy tend to 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, health system
could make overall disparities even worse
• at the least, the goal is to ensure equitable access to care/support
for all who need it, regardless of their social position


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 –
50> recommendations

many recommendations have been
acted on
other LHINs are also prioritizing and
moving to address health disparities


• goal is to ensure equitable access to high quality healthcare
regardless of social position
• can do this through a two pronged strategy:
1. 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
2. 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


• need to start from clear vision of what high quality children's
healthcare looks like – and how crucial equity is to achieving
that vision
• then make equity one of driving priorities for health system
and reform
• define equity as an essential part of high-performing
health system – as Ontario Health Quality Council
• in fact, stronger argument that equity is pre-condition to
success on quality, efficiency and patient-centred priorities
• need clear provincial strategic commitment to health equity
• cascading down through LHINs’ strategic plans and policies
• and to expectations to all providers that equity is among
their central priorities


• a promising direction several LHINs have taken up is to have
providers undertake specific equity planning exercises 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 can:
• raise awareness of equity within the organizations
• build equity into planning, resource allocation and routine delivery
• pull existing initiatives together into a coherent overall equity strategy
• build connections among providers for addressing common equity
issues
• imagine the great potential if all specialized children's hospitals
and providers developed equity plans in integrated manner


• greater chance of success for equity strategy if aligned with provincial
priorities: diabetes, wait times, mental health
• all these priorities are particularly sensitive to social conditions
• e.g. chronic disease prevention and management programs cannot be
successful unless they take account of social conditions and
constraints
• risks people face and resources available to them vary over life course
--- need to analyze specifically for kids
• e.g. diabetes is also crucial for children’s health
• recognized to be an increasing threat to future generations
• illustrates the case for early investment -- preventing childhood
diabetes is crucial to avoiding a lifetime of health problems
• supporting resources and opportunities for healthy behaviours for kids
can help to prevent chronic conditions later on


• 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 and kids
• 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


• has been piloted and refined in Toronto and is being implemented in
LHINs across the province
• 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
• essentially a checklist to anticipate possible equity implications
• could adapt for specific dynamics of children and youth health and
service provision
• think of potential:
• if all children's hospital and other specialized children’s health services began
using HEIA
→ build up great deal of comparable evidence, insight and experience quickly


• all hospitals, agencies and CHCs sign Service Accountability
Agreements with LHINs that govern flow of funds
• can build in specific expectations – will vary by community
and provider -- but could include:
• undertaking appropriate equity-focused planning
• ensuring service utilization matches appropriately with demography
and needs of their catchment profile
• providing sufficient services in languages of community and
appropriate interpretation
• identifying areas where access to services is inequitable and
developing plans to address barriers and gaps
• developing specific services or outreach to particular disadvantaged
populations – homeless young moms, immigrant kids, racialized youth,
etc.


• second theme of overall strategic framework is to target services to:
• those kids facing the harshest disparities – to improve the health of
the worst off fastest
• or those most in need of specific services
• or to the worst barriers to equitable access to high-quality services
• 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.
• highlights need to collect equity-focused data and do HEIA-type
planning
• also requires good local research and detailed information – speaks to
great potential of community-based research to provide rich needs
assessments and evaluation data
+ incentives and funds to develop equity initiatives


• having identified key barriers to equitable access and outcomes
for kids
• if critical barrier is language → expand translation and
interpretation services
• if issues is differential treatment for racialized or new immigrants
→ cultural competence training and requirements
• if issue is poor conditions in which kids live – and to which they
will be discharged →
• financial and other support to parents
• support with costs not covered under OHIP – drugs, transportation,
childcare
• enhanced community support – likely working in partnership with
providers
• if issue is parents/kids don’t have health card →
• provide services to uninsured resident kids for free


• taking social inequalities into account when designing
children’s health services
• My Baby and Me Passport
• peer ambassador type support for well babies and mothers
• align health equity with other key priorities
• investing in children – and in health of most disadvantaged kids -
- has to be central to poverty reduction strategy
• cross-sectoral coordination and planning are vital ways to
act on wider SDoH
• every LHIN should support or establish cross-sectoral planning
tables
• with expectations that hospital and other providers undertake
cross-sectoral collaborations


• idea of comprehensive community initiatives – Vibrant
Communities, healthy city movements
• British Health Action Zones, German ‘social cities’ and other
models were designed to combine community economic
development with targeted healthcare and social service
improvements
• in Canada, some Regional Health Authorities have
developed operational and planning links with local social
services or emphasized community capacity building:
• Saskatoon 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


• has been increasing interest in 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
• some new satellite CHCs 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
• also considerable experience/evidence for potential of:
• early years centres
• investing in comprehensive and integrated services for children at
highest risk and with most complex problems
• earlier eras of public health nurses in schools
• idea of childcare centres also providing broader child development
and social support – both on-site and linking into community services


• there is always much to be learned from policies, programs and
initiatives in other jurisdictions
• proven success of ‘head start’ type programs
• a number of countries have made lessening health disparities a top
national priority and have developed cross-sectoral policy frameworks
and/or action plans:
• England, Scotland, Australia, New Zealand
• many European countries, especially Nordic
• also increasing international and high-level attention:
• WHO Commission on Social Determinants of Health -- and its
knowledge network on early child development
• European Union, with its Closing the Gap and Determine projects to
tackle health disparities
• reducing poverty and investing in comprehensive programs to address
health inequalities for children are central to all these strategies


• to drive equity-focused innovation and effective interventions, we need
to be able to:
• collate and analyze all the useful intelligence gained from equity-focused
planning
• capture and share information on local initiatives, and build on local front-line
insights
• share the resulting knowledge across regions – and beyond
• assess the most promising initiatives or directions
• scale up promising initiatives across the province where appropriate
• creating a forum and infrastructure for this innovation knowledge
management is crucial
• but who takes it up?
• innovation doesn’t fit nicely into Ministry and other institutional boundaries
• whatever the form, needs to be collaboration with Ministries, Prov associations, other
stakeholders?
• idea of collaborative of children's hospitals and other providers creating
forums to share and build innovation on children’s health equity


• health professionals, hospitals and other providers have
considerable prestige and influence with pubic and policy
makers
• plus there is general public support for improving the lives
and opportunities of children
• can use that standing to advocate for health equity for
children:
• think if Sick Kids and its counterparts were to make public
commitments that it is intolerable that some of its kids do worse than
others because of poverty and inequality, and they are going to make
sure their programs do something about it
• or that they will provide the best care to every kid regardless of where
they were born or whether they have an OHIP card
• think of the impact of leading providers and experts developing a
Charter or Manifesto for Children’s Health Equity


• 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


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 program action;


6 rigorously evaluate the outcomes and potential of program 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;


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 program and policy instruments, and into a
coherent and coordinated overall strategy for health equity.


The Wellesley Institute advances urban health through rigorous research,
pragmatic policy solutions, social innovation, and community action.


Driving Health Equity for Kids: From the Earliest Years to Transforming the System

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