This presentations offers critical insights on how to advance health equity for priority populations. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Building on the Evidence:
Advancing Health Equity for
Priority Populations
Bob Gardner
OPHA/HPO Fall Forum
October 5, 2011

2. Powerful Starting Point = Equity As a Driving
Priority Within Public Health
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3. Key Messages
• health inequities are pervasive and damaging
• but these inequities can be addressed through comprehensive health equity
strategy
• and by focusing policy, programs and resources on particularly health
disadvantaged populations by:
• identifying priority populations and systemic barriers
• plan the most effective mix of focused services and support to meet the priority
populations’ diverse needs
• embed equity into system performance management thorough population-specific
targets and incentives
• evaluate effectiveness and impact, and build these learnings into continuous
improvement
• and acting well beyond health -- 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
• and the community and political mobilization to demand and drive the necessary policy
changes
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4. 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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5. Gradient of Health Across Many
Conditions
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6. 6

7. Impact of Disparities
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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8. 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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9. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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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 individual and
population health
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11. 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
exclusion→ capacities, resources and resilience
to cope with the impact of poor
health
3. because of all this, disadvantaged
and vulnerable populations have 3. these disadvantaged and
more complex needs, but face vulnerable communities tend to
systemic barriers within the health have inequitable access to services
and other systems → and support they need
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12. 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
POWER Study: Gender and
Equity Health Indicator Framework
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13. 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.
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14. Nothing So Practical As A Good Theory
• English evaluation leader Ray Pawson quoting German sociologist Kurt
Lewin
• Pawson isn’t arguing for abstract theory, but for ensuring we are always
clear about
• the assumptions we are making that underpin our work – whether planning a
specific service initiative or developing a broad multi-sectoral strategy
• the pathways and factors that we assume will lead from the planning through
service delivery to the hoped-for impact
• how we think all of this will vary depending upon the organizational, social or
policy context
• there are many approaches and as many terms – theory of
change, program theory, framework for change
• but the basic idea is to be really clear about starting points and premises
when planning any initiative
• and it’s this set of assumptions, pathways and objectives in our theory of
change that we subsequently measure, monitor and evaluate
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15. Framework for Change for ‘Wicked’ Problem:
Health Inequities
complex multi-level strategies to tackle framework of change = all about
health gaps: reducing structured inequality :
• international frameworks such as WHO • health inequities arise out of wider social
Commission on Social Determents
determinants of health = won’t solve
• European Union and other international
initiatives through health reform alone
• many individual countries • underlying structures of social and
key features in all: economic inequality need to be addressed
• focus on inclusive labour by new policies
market, childcare, affordable • policies need to be aligned with the
housing, social security and other macro incentives and processes that drive
policies
government
• targets and deliverables for relevant
programs and departments • key levers will vary – e.g. could be reducing
• equitable access to quality health care is prevalence of precarious employment
just one part of this broader package • has to involve collaboration and
• emphasized partnerships with community coordination across governments and with
service providers and organizations – in
both policy development and service many community and non-government
delivery stakeholders
• national strategies are implemented and • need effective balance of high-level and
adapted to local conditions macro with population-focused strategies
• emphasis on addressing needs and and local and community mobilization
inequitable barriers facing particular
populations
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16. 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
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17. High-Level: Health Equity Strategy Into
Action
• 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. Drilling Down: Why Focus on Particular
Populations
1. equity rationale:
• certain groups within society are most adversely affected by systemic health inequities
• goal of many strategies is to raise the worst off, fastest
• not just a social justice argument, but improving adverse health of worst off can
contribute to more effective use of scarce healthcare resources, positively affect social
productivity and cohesion, enhance overall population health, etc.
2. health and underlying social disadvantage can be inter-generational
• will persist –if not worsen – if not addressed
3. access
• most disadvantaged populations have greater and more complex needs
• universal programs can leave vulnerable groups out – and behind
4. specific at-risk groups need specific interventions
• universal programs will not be effective unless adapted to specific needs, constraints
and dynamics of vulnerable populations
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19. Drilling Down: How to Focus on Particular
Populations
• part of this is clarifying scope and terrain upon which we work
• defining priority populations
• not just a general or statistical category – bottom 20 %, all immigrants
• but social groups who face particularly poor health or inequitable
determinants of health
• these populations could occupy particular positions – precarious
workers, recent immigrants – or may share common
backgrounds, identities or other community interests – Aboriginal
people, LGBTQ, homeless
• could be people who live in particularly disadvantaged
neighbourhoods
• however defined, no population or community is ever homogeneous
• need to drill down – e.g. youth vs. seniors within Francophone African
immigrants -- to identify needs and plan interventions
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20. Drilling Down: To Do What?
• really talking about focussed interventions and activities
• scope of these interventions can vary
• policy interventions that could improver the social determinants of
health that underlie the population’s inequitable health
• decisions to allocate more resources or develop programs specific to
particular populations or problems
• designing services for particular populations or customized to their
particular contexts
• so we need to always specify the focus
• also need to specify goals of interventions
• what are the problems we are trying to solve?
• what will success look like?
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21. Drilling Down: Finding Specific Solutions for
Specific Problems
•identifying the specific needs of the •will generally need to drill down further
population/community → determining • e.g. problem may be that those how
best mix of services and support to meet most need health promotion
those needs programs are not accessing them
• need to specifically design to reach
the most vulnerable and enable them
to stay in programs
•addressing key barriers the population •policy, program or resource changes to
may face to getting the services and reduce those barriers
support they need • may be general – peer health
ambassadors
• or specific -- if transportation is the
barrier – then subsidies to get people
to services or locating services where
•more deep-seated community and people live
structural factors that underlie their •poverty reduction initiatives
health inequalities
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22. Starting Points for Focussed Interventions
• addressing health inequities requires a solid understanding of:
• key barriers to equitable access to high quality care and support -- i.e. is the main
problem language barriers, lack of coordination among providers, sheer lack of services
in particular neighbourhoods, etc.
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• identifying the right populations
• most in need? highest risk?
• and/or where interventions have potential to make the most health difference?
• identifying what those populations need
• and want -- are ready to accept -- and will really benefit from
• clear consensus – and in Ontario public health standards:
• use multiple data sources – epi, admin, from community health profiles
• and methods – program evaluations, intervention research, community-based and
qualitative research
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23. 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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24. And With Equity-Focused Planning
• Public Health Ontario has developed an equity assessment framework
for public health units.
• a number of PHUs have developed and use equity lens:
• Toronto has a simple 3 question lens -- not just for public health, but
other departments
• Sudbury has used an equity planning tool for several years
• MOHLTC and many LHINs have used Health Equity Impact Assessment
• advantage of using the similar tools = build up comparable experience
and data
• lever = could enable/require PHUs to undertake HEIA or other equity
planning processes
• for all new programs and those focusing on particular populations
• as part of overall standards/expectations or to be eligible for particular
funding
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25. 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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26. Building Equity Targets
• build equity into indicators already being collected → equity angle is to
reduce differences between these populations/communities and others
or PHU as a whole on these indicators
• also drill down – e.g. a number of PHUs and LHINs have identified areas
or populations where diabetes prevalence is highest
• equity target = reduce differences in incidence, complications and
rates of hospitalization by income, ethno-cultural backgrounds, etc.
and among neighbourhoods or regions
• similarly, common goal is reducing childhood obesity → if goal is to
increase the % of kids who exercise regularly
• equity target = reduce the differentials in % of kids who exercise by
neighbourhood, gender, ethno-cultural background, etc.
• and achieving that won’t be just a question of education and
awareness, but facilities and proactive empowerment of kids – and
ensuring equitable access to resources, space and programs
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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 – Saskatoon
•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
•in addition, innovative thinking
emerging around dynamic systems
modeling meeting population health
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28. Levers for Action: Equity Plans
• lesson from health care sector = building equity into
provider plans
• ECFAA requires hospitals and then other providers to develop
quality improvement plans → need to build equity in as key
dimension
• several LHINs have required providers to develop equity plans
• equity priorities will/can be built into accountability agreements
• for public health, provincial standards offer a key lever
• PHU could develop health equity plans showing how they are
putting population health standards and requirements into
practice
• detailing how equity and population-specific expectations and
targets are being built into routine PHU performance
management and accountabilities
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29. Build Equity Into Priority Issues: 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
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30. Never Just Access: 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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31. 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
• 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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32. Extend That → Address Roots of Health
Inequities in Communities
• look beyond vulnerable individuals to the communities in which they live
• 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.
• across Canada, leading 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
• focused interventions in the poorest neighbourhoods – e.g. differences in
immunization rates between poor and other neighbourhoods decreased
• beyond health – locating services in schools, relying on First Nations elders to
guide programming, etc.
• wide collaboration among public health, municipality, business, community
leaders
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33. Through Cross-Sectoral Planning
• cross-sectoral coordination and planning are the glue that
binds together coordinated action on SDoH
• public health departments and LHINs are pulling together
or participating in cross-sectoral planning tables on health
issues – can get beyond institutional silos
• Local Immigration Partnerships, Social Planning
Councils, poverty reduction initiatives, etc
• healthy communities initiatives funded by the Ministry of
Health Promotion and Sport
• 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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34. Equity-Driven Innovation: Integrated
Community-Based 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
• Winnipeg Regional Health Authority and Manitoba Family Services and
Housing have partnered on a new model to integrate health and social
service delivery – one-stop access models in various communities to
deliver a broad range of health and social services directly and to refer on
to other agencies when services aren’t available
• Quebec has long had such comprehensive integrated community centres
• 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 -- schools as service hubs is being developed -- think back
to earlier eras with public health nurses in schools
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35. 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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36. 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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37. Challenges Moving Forward In Improving
Health Equity for Disadvantaged Populations
• always a question of balance
• never just this population or that
• never focusing all programs on priority population or a comprehensive
strategy
• need focused interventions nested in a comprehensive strategy
• how do we ensure we’re not just focusing on symptoms
• services to the worst off
• but without addressing the social determinants and inequalities that
underpin their health inequities
• timing is everything
• deep-seated problems = require long-term policy/political
commitment and sustained investment
• knowing when to initiate interventions can be critical
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38. Evaluating Complex Equity Interventions
• how do we know what works = crucial importance of evaluation
• far too complex to pick apart all the causal relations and patterns of influence:
• very difficult to attribute particular changes to particular components of the overall
initiative
• will never meet RCT gold standard of proof – that approach can’t capture complexity
• but that doesn't mean particular initiative is ineffective
• impact can take many years to show up
• but that doesn’t mean nothing is happening
• traditional evaluation of one program in isolation or of a particular population
among many will not capture this complexity
• potential of more ‘realist’ approach – M + C = O
• evaluating impact of interventions – but always in particular contexts
• and sometimes we look at what works in particular population or social contexts rather
than form of intervention
• and we evaluate our framework of theory of change
• we identified levers in our strategy – did they prove to be important in practice?
• looking for indications that the change mechanisms unfold as we expected, that the
direction of causal influence and impact is as we expected ,etc
• looking for evidence that outcomes anticipated are being achieved
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39. Complexities: Building Equity Targets
• 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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40. Watch for Pitfalls: Unintended
Consequences
• health promotion that emphasizes individual health behaviour or risks
without setting it in wider social context
• can lead to ‘blame the victim’ portrayals of disadvantaged who practice ‘risky’
behaviour
• focus on individual lifestyle in isolation without understanding wider social
forces that shape choices and opportunities won’t succeed
• universal programs that don’t target and/or customize to particular
disadvantaged communities
• inequality gap can widen as more affluent/educated take advantage of
programs
• programs that focus on most disadvantaged populations without
considering gradients of health and need
• the quintile or group just up the hierarchy may be almost as much in need
• e.g. access to medication, dental care, child care and other services for which
poorest on social assistance are eligible do not benefit working poor
• supporting the very worst off, while not affecting the ‘almost as worse off’ is
unlikely to be effective overall
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41. Watch for Pitfalls: Don’t Create More Silos
• MHPS’s healthy communities strategy is far more comprehensive and
integrated than previous approaches
• but the improved cross-sectoral planning it envisions will still operate
within separate risk behaviours or health conditions –
• and health system is fragmented – LHINs, primary care, provincial programs,
acute and up-stream, two ministries, public health – let along beyond health
• these conditions and challenges are very much inter-dependent and
cumulative in individuals’ lives and community dynamics
• avoid ‘risk’ silos in ‘healthy communities’ by:
• enabling a community to define its own health priorities
• e.g. better providing better access to good food, exercise facilities and
information/support to manage own health → will benefit all these priority
areas
• developing health promotion programs that address a neighborhood's full
range of challenges in a comprehensive way
• so the more effective focus will often be at neighbourhood level
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42. 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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43. 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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44. 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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