Health Equity into Policy Action: A Policy Conversation at MOHLTC

Health Equity Into Policy Action:
A Policy Conversation at MOHLTC

Bob Gardner
Director of Public Policy
February 12, 2007

© The Wellesley Institute
www.wellesleyinstitute.com

Wellesley Institute

• funds community-based research on the relationships
between housing, poverty and income distribution, social
exclusion and other social and economic inequalities and
health
• provides workshops, training and other capacity building
support to non-profit community groups
• works to identify and advance policy alternatives and
solutions to pressing issues of urban health
• works in diverse collaborations and partnerships for
progressive social change
• all of this is geared to addressing the pervasive impact of
the social determinants of health


Unique Hybrid

• lots of policy institutes and think tanks – but few focus on
SDoH and urban health
• many provide training and capacity building – but not all
have an explicit goal of rebuilding community capacity
lost in funding cuts and constraints
• few focus on funding CBR or have an extensive
community training programme in methods
• no other institute brings all three strands together – all
focused on SDoH


Introduction

• health disparities are pervasive, persistent and solidly rooted in
overall social and economic inequality
• but, action is possible:
– many jurisdictions have developed comprehensive policies and
programs to address health inequity – and there are enough
indications of how these policies can be effective
– there are huge numbers of on-the-ground initiatives addressing both
the underlying social foundations and the effects of health disparities –
including very many in Ontario
– there is much we can learn from, and adapt to Ontario situation
– there is real potential for innovation and experimentation
• my goal today is to highlight some promising pointers and
directions that can address health inequities, and ways to think
about connecting up these initiatives in a coherent and integrated
way


Starting Points: Pre-Conditions
for Success

• clear strategic vision of equity
– has been considerable discussion of what a well-performing
health system looks like
– need to be just as clear on defining features of health equity and
an equitable health system
• clear understanding of the roots of health disparities both
within the health system and in wider social inequalities
→ to guide policy and interventions
• a coherent and integrated policy framework to make
connections between sectors and initiatives and to
ground investments and programmes


Pre-Conditions II

• identifying the key places and levers where policy
change can most effectively be made to happen – and
will make the most difference to health equity
• incentives and enablers to support system change and
programme/delivery action
• long-term commitment – one of clearest lessons from
abroad is that tackling health disparities takes time
• but combined with a willingness and capacity to
experiment and innovate
• workable indicators to guide/monitor implementation
and an infrastructure and working culture to learn from
and build on success and innovation


Defining Health Equity:
Reducing Unfair Differences

• the most common sense of health equity is working to
reduce differences in health outcomes that are
avoidable, unfair and systematically related to social
inequality and disadvantage
– clear, understandable & actionable
– it identifies the problem that policies will try to solve
– it’s also tied to widely accepted notions of fairness and social
justice
• this definition sees health equity as the absence of
socially structured inequalities and differential outcomes
• but also need a more forward-looking vision to guide and
inspire action


A Positive Vision of Health
Equity

• as equal opportunities for good health
• nested in a society in which poverty, inequality and
social exclusion – and their impacts on ill health – have
been reduced
• consumer driven care and delivery, with individual and
community needs at the heart of planning
• culturally appropriate care – crucial in diverse society
• equitable access to a full and seamless continuum of
health and social services
• health and human services systems that focus on the
most disadvantaged
• investing ‘up-stream’ in preventive and health promotion

Health Disparities Are Well
Documented
• the Ontario Health Quality Council used risk-adjusted rates of death
in hospital following a stroke as an indicator of health equity in its
first 2006 report – mortality in the LHIN with the worst rates was
36% higher than in the best
• Canada-wide disparities have been equally well documented
– life expectancy at birth, on average, is five to 10 years less for First
Nations and Inuit peoples than for all Canadians
– while infant mortality rates have been declining overall, infant mortality
rates in Canada’s poorest neighbourhoods remain two-thirds higher
than those of the richest neighbourhoods
• all advanced countries – even those with best overall health – have
significant disparities in health outcomes
– considerable evidence that health disparities have increased in many
countries → often the immediate challenge is seen to be preventing
health disparities from continuing to worsen


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 key determinants such
as early childhood development,
education, employment, working
conditions, income distribution,
social exclusion, housing and
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 disparities


International Policy
Responses

• increasing international and high-level attention:
– international organizations such as the World Health
Organization, especially its Commission on SDOH, and the
European Union
• coordinated national policies are being highlighted in
many European and other rich countries:
– for many this is still at the high-level policy stage
– few have implemented comprehensive policies
– but a clear consensus that integrated cross-sector policy
frameworks are needed
• and a clear consensus that supporting a wide range of
regional, local and community initiatives is also essential

Lines of Policy Approaches

• common formulation sees three levels of policy action on health disparities
– with different objectives:
1. addressing the needs of the most disadvantaged populations and communities
– to reduce the harsh impact of health disparities
2. narrowing the gap between the most disadvantaged and wealthiest groups –
which means raising the health of the most disadvantaged faster
3. reducing the overall gradient of health disparities – making health outcomes
less unequal
• the latter is seen to be the most inclusive – but few governments have
taken this most comprehensive approach
– most analysts see that action on these three levels can be complementary –
certainly not contradictory
– I think policy addressing all these levels will be key – and will try to illustrate how
this can be thought of in a coordinated way
• there is also debate about the best ‘entry-points’ – where in the inter-
dependent system of social determinants should policy intervene:
– I'll be arguing that policy addressing different issues simultaneously – but in a
connected way – is key


Equity Policy Frameworks in
Other Countries

• a number of countries have made lessening health
disparities a high national priority and have developed
cross-sectoral policy frameworks and/or action plans
• focus here on macro social and economic policy – will
return to health
• not meant to be a comprehensive survey -- will only
highlight three among many interesting possibilities
• these examples can provide:
– ideas that could be adapted to Ontario situation
– lessons learned on how to develop an integrated policy
framework and cross-sector collaboration
– inspiration that cross-sector policy collaboration and action is
possible – and can have an impact

Sweden

• social welfare policy was seen to be key to reducing
health disparities
• coordinated national policy to reduce the number of
people at risk of social and economic vulnerability
– focus on inclusive labour market, anti-discrimination, childcare,
affordable housing and other policies
– equitable access to improved health care was seen to be just
one part of this broader package
• emphasized partnerships with community service
providers and organizations – in both policy development
and service delivery
• arose out of a very different political culture with strong
consensus on social solidarity

United Kingdom

• key things came together:
– New Labour government identified inequality as a crucial issue
– Reducing Health Inequalities: an Agenda for Action 1999
– 2003 Programme for Action with concrete targets by 2010
– UK Presidency of EU in 2005 focused on health disparities
• Programme for Action goals focused on raising living
standards, early childhood development, employment,
building healthy communities, and broad national
redistributive and social policies
• it also emphasized delivering action at the local level
through effective partnerships and collaborations and
targeting the most deprived areas


UK II: Multi-Level Action

• local initiatives in disadvantaged communities to improve living conditions
and address social exclusion are central:
– Health Action Zones, designed to combine community development with targeted
health care access and service improvements
– combined social support and health care in deprived areas – the Citizen’s Advice
Bureau in Blackpool
– “Fit to Work” partnership of local government, health authority and non-profit
social entrepreneur agency to link neighbourhood regeneration to health in inner-
city London
– Engaging Communities Learning Network to share information on what is
working locally – part of Programme strategy to ‘mainstream’ equity initiatives
and learning into public service
• while there was a significant focus on social and economic policy, that didn’t
mean that changes within the health system were not also crucial:
– targeted interventions to improve the health of the poorest fastest – generally as
part of community/local initiatives as above
– equitable access as a key goal
– mandated community participation in health care planning
– more emphasis on preventive programmes


UK III: Possible Lessons

• some pointers for ‘political/structural success conditions:
– the Programme argued that links across government are essential to
sustaining long-term change and spelled out specific targets for key
Departments
– a 2005 status report assessed how each Department was doing against
the targets – most were on target
– concrete targets and public scrutiny were certainly part of that progress
– so too was high level attention and support – e.g. social exclusion unit in
Cabinet Office, clear commitments from Prime Minister
• the Programme of Action included inter-related activities and
expectations from national, regional and local authorities
• it emphasized multi-sector government/community partnerships and
collaborations


Netherlands

• health disparities were recognized as a major issue through the 1980s and
the Ministry of Health launched multi-year research-based approaches in
90s
• unique in systematically assessing the effectiveness of targeted
interventions directed to addressing socio-economic disadvantage,
mediating the effects of wider inequality, community-based health
promotion, access to care, etc.
• results were built into overall national strategy to address health disparities
• some lessons:
– planning and progress meetings of researchers, officials and political leaders
were important to building broad support and maintaining momentum
– one obstacle was relative weakness of Ministry of Health in relation to other
spheres
– other Ministries didn’t see reducing health inequalities as their responsibility until
re-framed – e.g. providing access to affordable housing was understandable
rather than better health through better housing
– progress is always shaped by political/electoral vagaries – adoption of provisions
was frequently delayed


Better Policy Coordination:
Saskatchewan

• coordinating table of ADMs -- Human Services
Integration Forum
– to promote inter-agency collaboration and integrated planning
and service delivery
– current priorities include strengthening families’ capacities, early
childhood support, increased opportunities for youth, increase
well-being and employment situations, improve coordination and
integration of services, etc.
• broader effects may be even more important:
– also developed regional coordination bodies to link wide range of
agencies and activities
– which in turn provides space/encouragement for interesting local
integration in areas such as Saskatoon


Better Policy Coordination II:
Quebec
• provincial strategy coordinates health and related social spheres –
in one Ministry
• Health and Wellbeing Council encourages inter-sectoral action
• widespread consultation and involvement of community sector in
policy development
• comprehensive 10 year plan to address social determinants and
wellbeing
• all Ministries are required to consult the Ministry of Health and Social
Services on new legislation or regulations that could impact health
• regional health authorities are required to develop integrated plans
with social services
• local health authorities must coordinate with non-health services


Lessons Learned in Other
Jurisdictions
• one vital key to health equity lies outside health system -- building equity
into all macro social and economic policy:
– not just as one factor among many to be balanced, but as core priority
– always a political question
• cross-cutting collaborations across government is essential – and that
requires high-level commitment and champions
• creating as integrated and broad a policy framework as possible to ground
and guide this collaboration/coordination is also key:
– very difficult – few countries’ policies appear to be truly integrated
– but clear that the more integrated → more chance of success
• political and governmental structures are important
– one factor in success of UK in developing an overall strategy is centralization of
power at national level
– we know that constitutional and jurisdictional barriers are critical in Canada –
regardless of FPT Task Forces


Comparative Lessons
Learned II
• there is no magic blueprint but a range of directions and approaches
that can be adapted
• everything can’t be tackled at once:
– split strategy into actionable components – phase them in
– but coordinate though a cohesive overall framework
• some technical lessons from other countries:
– build equity considerations into policy at design stage
– use tools such as Health Equity Impact Assessments
– clear targets/indicators and public reporting of progress against them
• and some quandaries as to who and how:
– Health leads in most jurisdictions
– how that was smoothed out in the face of inevitable departmental
rivalries and differences is a key question


Cross-Sectoral Multi-Level
Collaboration

• clear conclusion from experience of other jurisdictions is that action on equity cannot
just come from senior governments
• de-centralization and regionalization are seen to be crucial:
– not just in the sense of regional health care planning, governance and delivery, but cross-
sector collaborations among local governments, health authorities, community-based
service providers and other stakeholders
– MESH process arising out of Aboriginal health centres in Australia begins from community
involvement in defining local needs to allocate resources to most disadvantaged
• collaborations and partnerships were emphasized and local and community
initiatives were seen to be a vital source of innovation
• in many countries regional health authorities can be an important enabler and lever
for creating these collaborations
– e.g. a number of leading Regional Health Authorities across Canada have identified
addressing health disparities and social determinants of health as a top priority


Regional Cross-Sector
Collaboration in Practice: LHINs

• can see LHINs reform as another opportunity for acting on equity in
a comprehensive and coordinated way
• the primary role of LHINs is to integrate health care planning and
provision to better reflect and serve local needs
• many have recognized importance of social determinants, but how
to implement?
• LHINs will need to collaborate/coordinate beyond health → chance
to be innovative from the start
– the Province could mandate -- and fund – that each LHIN will establish
cross-sectoral planning tables to foster policy and programme
collaboration to address health disparities and to address the underlying
social and economic determinants of health
– would need to build incentives and expectations to ensure LHIN
participation in such collaborative planning tables and processes


Within Health System

• have seen statistics and analyses that health care system has less
impact on health than social and economic factors
• but that doesn’t mean that how the health system is organized and
how services and care are delivered are not crucial to tackling health
disparities
• all countries see the health system as an indispensable element of
comprehensive strategy around health equity, including:
– overall system architecture that supports equity
– reducing barriers to equitable access
– primary care as a key enabler of health equity
– targeted services for the most disadvantaged areas or populations
– culturally competent and appropriate high-quality care that reflects the
full diversity of population
– regionalization and supporting local initiatives


Starting With Equity as Core
Health System Priority

• tremendous window of opportunity as the new provincial
strategy is being developed
• should incorporate equity as a core priority:
– as an over-arching commitment to equal opportunities for good
health for all
– plus a clear recognition that additional resources and
investment will be focussed on most disadvantaged
– with concrete objectives, indicators, and resources and
incentives to reach them
– not just at the Ministry level, but cascading expectations for
LHINs and all programmes and providers


Health System Architecture

• financing can have an important effect on equity:
– the balance between public and private provision/funding:
• considerable evidence that greater private share can have adverse impact on equitable
access to health care
• for example, the more services that involve user fees → greater barriers for poorer
people
– equitable allocation – meaning more funds to areas with greater need
• so too can the balance between hospital and other institutional versus
community-based delivery – latter can more easily be targeted to
disadvantaged populations
• what is sometimes called ‘connecting tissue’ of IT, the culture/infrastructure
to support innovation, linking research into policy/practice
– ensure this includes community-based research and innovation, and doesn’t
create digital or other access barriers
– collect the kind of systematic and comparable data needed for equity and
diversity planning – income, race, ethno-cultural, sexual orientation, etc.
• Ontario is going through a comprehensive transformation of system →
chance to build equity into the basic architecture and fabric of new system


Reduce Barriers to Access
to Care
• critical part of health equity strategy is to identify and reduce barriers to
access:
– affordability
– availability – considerable variation in access to specialist, primary and other
care by region and neighbourhood → need targeted remedial plans
– language and culture → put most positively, ensure culturally competent care
and build anti-racism/oppression approach into service provision
• key mechanisms are CHCs, public health and other community-based
service providers that focus on under-served communities
• many of the best of these local programmes involve collaboration beyond
health:
– CHCs, child care and other partners working together on early years
programmes
– the development of the new satellite CHCs in designated areas in Toronto —
with primary care and social and other services out of the same facilities – is one
among many examples of complementary services from different agencies being
provided together in community locations;


LHINs and Equity

• the LHINs have all recognized health disparities – to some degree – in the
first Integrated Health Service Plans
• implementing equity will require in each LHIN:
– planning tools such as diversity lenses and health equity impact assessments
– targeted investment and programmes in disadvantaged neighbourhoods
– governance that builds in the voices and interests of whole community –
including marginalized and traditionally excluded
– willingness and capacity to pilot new ways of addressing barriers or supporting
hard-to-serve communities
– encouraging on-the-ground collaborations and partnerships among health care
providers and beyond
• and provincial enabling policy and resources:
– consistency and sustainability will only be assured if the Ministry sets equity
standards that all LHINs must implement and provides the necessary funds
– plus targets and expectations – reduce health disparity in region by X%, ensure
utilization patterns reflect diversity and needs of local population
– plus provincial infrastructure to help share best practices across LHINs


Looking to other Provinces

• Interior Health in BC has developed a social determinants-based plan –
Beyond Health Services and Lifestyle
• several Alberta RHAs have developed operational and planning links with
local social services and one has emphasized community capacity building
as key to addressing health
• non-health agencies in Alberta are also creating cross-sectoral planning and
action forums around housing, poverty and other determinants
• Saskatoon is developing cross-sectoral action on health equity:
– began from local research documenting shocking disparities among
neighbourhoods
– will focus interventions in the poorest neighbourhoods – locating services and
links in schools, relying on First Nations elders to guide programming
• 18 big city Medical Officers of Health are working together on strategies to
address urban health disparities
• the Centre Lea Roback provides determinants focussed research and
planning support to Montreal’s public health department and other cross-
sector forums


Primary Care: Equity Focused

• considerable international evidence that expanding primary care can
reduce health disparities
• major reforms underway in Ontario – how to build equity in?
– focus increased primary care in areas with poorest access or health
status
– in terms of policy levers: it may be easiest to establish CHCs, but can
also try to encourage location of other practice forms in poorer areas
• can also see primary care reform as a lever for wider changes –
– many CHCs now see working beyond health and linking to agencies
working on wider determinants of health as part of their mandate
– can this be built into other forms of enhanced primary care – social
workers, brokers, health educators in FHTs?
– how could local community governance shape primary care – enhanced
FHTs with community boards?


Targeted Intervention/Investment
To Most Disadvantaged

• a defining principle of health equity strategies is that everyone does
not need or receive the same kind of services:
– to address and ameliorate the worst effects of health disparities requires
targeting resources and services to specific areas or populations
– this requires sophisticated analyses of particular disparities and
inequities – i.e. is the main problem language barriers to access, lack of
coordination among providers, sheer lack of services in particular
neighbourhoods, etc.
– also requires detailed information and good local research
– an involvement of local communities and stakeholders with local
knowledge is critical to understanding the real problems
• community-based and community-driven service development has
tremendous potential to be innovative and responsive
– will give a few examples and then discuss how this community-driven
innovation can be built upon to drive wider reforms


Multicultural Health Brokers
Cooperative from Edmonton
• arose out of a small project initiated by public health to support the
growing – and often isolated -- immigrant and refugee communities
in early 90s
• provides intensive pre-natal and infant support to women and
families facing language and cultural barriers within health care and
overall social exclusion
• saw that they needed to extend beyond point of service delivery →
idea of broker:
– connect people to full range of health and social services they need and
advocate for clients
– provide continuity in a fragmented system
– support innovative self-help initiatives organized by clients themselves
• and beyond even further:
– have developed collaborations with schools, social services and other
agencies to address access gaps and barriers
– provide multicultural training to agencies and service development
assistance to public health and regional health authorities

Street Health

• nursing and other primary care for homeless people in downtown
Toronto
• as needs became clear → expanded programmes – harm reduction,
referrals to housing and other services, support in working through
eligibility maze of social assistance programmes
• and beyond the health care system:
– ID Project – to help homeless people apply for documents needed to
secure eligibility for programmes and provide secure places to store ID
– community-based research to:
• identify eligibility barriers to ODSP for homeless people with disabilities and
pilot effective support programme to help people secure assistance for which
they are eligible
• survey the service needs/barriers of homeless people


Up Stream Through an
Equity Lens
• investing in better chronic care management, preventive care and
health promotion are seen to be vital elements of health reform
• needs to be planned and implemented through an equity lens
– anti-smoking, exercise and other health promotion programmes need to
take account of the particular social, cultural and economic factors that
shape risky behaviour in poorer communities
– specific efforts need to be made to address language, cultural and other
barriers to disadvantaged communities getting the health promotion
information and support they need:
• a great deal of valuable culturally appropriate and translated health
promotion work is going on through ethno-cultural and other specific
community groups
• which highlights one direction to building the necessary community
capacities to be able to take action on health promotion
– the Ontario Prevention Clearinghouse is a key resource


Equitable Access to Health
Promotion for Most
Disadvantaged
• equity-driven health promotion would ensure preventive, dental care,
sexual and reproductive health, immunization and related services
are provided equitably in disadvantaged communities:
– it is vital that such services be located directly in the neighbourhoods
that need them most
– e.g. public health workers in every school and multi-service
neighbourhood agency in poor or under-served areas
– increasing public health capacity to provide services in the languages of
local communities
– great potential of community-based research to provide rich local needs
assessments and evaluation data
• current revisions of mandatory health program standards should
include addressing inequitable health and underlying social and
economic determinants
– a model to build determinants and equity into public health programming
has been developed by the Sudbury & District Health Unit


Count Us In

• a Wellesley funded project with Ontario Women’s Health Network,
Ontario Prevention Clearinghouse, Toronto Public Health and other
partners
• project was on the barriers homeless and marginalized women face
in access to crucial health and social services → key insights to
program planning and improvement (an example of kind of CBR
needed to drive equity interventions)
• but also developed a new way of doing research
• inclusion research trains, supports and involves homeless and other
marginalized women in doing the research themselves
• a form of peer-driven research that yields richer, more nuanced and
deeper understanding
• a circle of investigation with inclusion researchers from the
community being researched and professionals to create new policy
approaches

Inclusion Research Brings
Equity Into Health Promotion
• original project went on to conduct inclusion research focus groups
in three Ontario cities to develop a new strategy for preventing
stroke among women
• it found that marginalized women have a clear understanding of the
social determinants of health and highly value inclusion; prefer
learning in intimate group settings; and knew little of the risks of
stroke
• a new health promotion strategy emerged from the research --
targeted awareness campaigns to marginalized women, and
innovative outreach led by lay educators
• clinics were held in one city as a result of the research and a
partnership was created in another to deliver a pilot project with
inclusion researchers as co-facilitators
• in addition, this research provided the necessary ‘Canadian’
experience so that some inclusion researchers were able to get jobs
in the social service sector


Policy Framework for
Innovation
• have been arguing that the way to proceed on massive challenge of health
disparities is by ‘chunking out’ actionable projects, by experimenting and by
relying on community-based and other front-line innovations
• first of all, will need a framework to support experimentation and innovation:
– common data and information platforms
– funding for pilot projects
– dedicated funding lines to LHINs for pilots, and expectations that each LHIN will
undertake innovations
– looking for results and value, but also need funding regimes that don’t over-
burden
• then need a provincial infrastructure to:
– systematically trawl for and identify interesting local innovations and experiments
– evaluate and assess potential beyond the local circumstances
– share info widely on lessons learned
– scale up or implement widely where appropriate
• all to create a permanent cycle and culture of front-line driven innovation


Community Engagement

• clear conclusion from other countries and RHAs in other provinces
is that community involvement is vital to implementing equity
• this means ensuring that the widest range of priorities, needs,
preferences and perspectives are incorporated into health
planning:
– new forums and mechanisms to bring the voices of disadvantaged and
vulnerable communities in
– specific targeted outreach strategies
• it also means means extending representation and accountability to
all:
– including communities traditionally excluded
– some of the tools are diversity and equity planning checklists to ensure
LHIN, agency and other boards and planning bodies are representative


LHINs as Window of Opportunity
for Community Engagement

• community engagement is part of legislated mandate, and the LHINs have
made a good start with extensive consultations for their first IHSPs
• but chance to think bigger:
– to embed responsive and effective new forms of involving people in planning and
priority setting from the start
– e.g. neighborhood forums sending priorities up to LHIN-wide community-
consumer forums to assess, balance and advise LHIN boards
– particular and sustained efforts to involve marginalized communities – the
innovations needed will vary by region, but will include partnering with agencies
or community organizations marginalized people trust, linking with grass-roots
organizations, going where poor people are rather than making them come to
you, translation, providing child care and honoraria, etc.
• and, as always, to make this happen will require:
– clear provincial direction and expectations
– adequate funding and support to the LHINs
• and to make it happen most effectively – an infrastructure to share
community engagement best practices widely


Conclusion: Directions for
Policy Action
• dramatic improvements in health disparities require broad cross-
sectoral changes in public policy that will reduce social and
economic inequality:
– start by building better coordination across Ministries
– look for collaborations on issues with broad consensus – child poverty
– and initiatives that will show results and build momentum – joined up
schools, local health and social services to enhance early years
services for high-need families and communities
– re-frame issues from what other Ministries should do to reduce health
disparities to common goals – investments that build social cohesion
and enhance human capital
• local and community collaborations will be crucial
– LHINs must support partnerships and innovation in addressing roots of
health disparities


Directions II

• make equity a core objective in new overall health strategy
– and cascade down concrete equity expectations to LHINs and local
providers
• ensure the basic architecture of the health system supports equity –
financing, allocation, information management, planning structures,
etc.
• and develop a systematic and carefully linked suite of initiatives:
– tackle structural barriers to equitable access
– target increased resources and programmes to areas/communities
facing worst disparities and/or who could benefit the most
– support innovative forms of community-based provision that address
disparities on the ground – CHCs, public health, community agencies
– expand access to primary care, especially in under-served areas


Directions III

• all of this will need to be sensitive to varying local
circumstances and community needs
– vital role for new LHINs
– with appropriate central support and direction from Ministry
– looking for best balance between enough local flexibility for
innovation and meeting specific needs, and provincial standards
and resources to ensure equity is effectively addressed across
the province
• there isn’t a precise blueprint → experiment and pilot
– but always systematically – to be able to assess what is working
(and build on it) and what isn’t (to learn lessons and move on)
– create a constant cycle of innovation, evaluation, adjustment and
learning


Further Resources

• the European Union has been focusing on health inequalities
– its Closing the Gap project seeks to promote action in individual member
countries and share information on national policies, best practices and new
initiatives across Europe http://www.health-inequalities.eu/
• the World Health Organization’s European office has established a Special
Commission on the Social Determinants of Health
http://www.euro.who.int/socialdeterminants
– useful source of data, comparative and analytical work, country profiles, new and
emerging initiatives and shared best practices
– I also particularly like the Commission’s series of Knowledge Networks on health
systems, social exclusion, gender and other key areas
• these sites will link to country and departmental sites in Sweden, the UK
and other countries cited here
– but one that is particularly relevant here is Tackling Health Inequalities: Status
Report on the Programme of Action a 2005 Department of Health report
assessing progress on the action plan and health inequality targets in each
Ministry
• the International Journal for Equity in Health has interesting comparative
research, analytical pieces and issue surveys


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