Social Determinants of Health Inequalities: Roadmap for Health Equity

Social Determinants of Health Inequalities:
Roadmap for Health Equity

Social Housing and Homelessness
Conference
Bob Gardner
September 23, 2009

Outline

1. provide data and analysis of the social and economic
determinants of health and health inequalities
2. show that none of this is inevitable – that the adverse
impact of social determinants of health can be changed
through policy
3. will set out a roadmap for building health equity through
policy change and community mobilization
4. talk about how these lines of action intersect with social
housing, municipal services and local planning

© The Wellesley Institute 2
www.wellesleyinstitute.com

Systemic Health Disparities

• in Ontario and Toronto :
– people with lower income, education or other indicators of social
conditions and position tend to have poorer health
– major differences between women and men
– the gap between the health status of the best off and most
disadvantaged can be huge – and damaging

• the foundations of these inequalities lie far beyond the
health system in wider social and economic inequalities


Why Health Disparities?

• health inequalities are of wide interest for two reasons:

1. overall health of population and inequalities in health are telling
indicators of the state of a society
2. opportunities for good health – in the broadest sense of overall
well-being – affects us all

• the scale of differences between the best and worst off =
indictment of the health of Cdn society and current social
policy
• more specifically: close link between homelessness,
poor housing and poor health

Lower Income: Poorer Self-rated
Health

% Reporting Poor or Fair Health,
Toronto Central LHIN, 2001 CCHS
40
34
35
30
25
20
15 11
10
5
0
Low Income High Income

Three fold difference in self-rated health among lowest and
highest income neighbourhoods.
Canadian Community Health Survey 2001
Glazier et al. Primary Care among Disadvantaged Populations. Primary Care.
ICES Atlas, 2006. www.ices.on.ca/intool

Inequality by Race and
Ethno-Cultural Background

• solid data on racialization of poverty and inequality, and
racism and social exclusion are critical overall
determinants of health
• research on ‘healthy immigrant’ effect – people coming
in with better health than average and then deteriorating
• but Cdn jurisdictions don’t keep statistics by race, so
have limited comprehensive data
• stark differences for Aboriginal people:
– life expectancy at birth, on average, is 5 to 10 years less for First
Nations and Inuit peoples than for all Canadians
– self-reported health in Ontario is over twice as bad as for white
– seeing greater vulnerability of First Nations communities around
H1N1 © The Wellesley Institute 9

Lower Income: Higher Diabetes Rate

Diabetes Incidence, TC LHIN 2004/05
16
14 13.3
12
New Cases/1,000

10
8
5.8
6

4
2
0

Low Income High Income
Two fold difference in diabetes incidence between lowest and
highest neighbourhoods.

Age Standardized Rates. Data Source: Ontario Diabetes Database, 2004/05
www.ices.on.ca/intool www.wellesleyinstitute.com

Homeless Health

• 2007 Street Health Report – comprehensive survey of
homeless people in downtown Toronto
• self-reported health: 4X as many rated only fair or poor
vs. general pop’n in Toronto
• oral health: 62% rated fair or poor – 4X general pop’n
• 14% are usually in severe pain
• 74% had at least one serious condition
• 59% do not have a family doctor – vs. 9% for general
pop’n


Foundations of Health Disparities
Lie in Social Determinants of
Health

• clear research consensus that
roots of health disparities lie in
broader social and economic
inequality and exclusion
• impact on health outcomes of
inadequate childcare, poverty,
precarious employment, unequal
income distribution, social
exclusion, and inadequate
housing 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


Health Equity = Reducing
Unfair Differences
• health equity is the absence of socially structured inequalities and
differential outcomes
• the goal is to reduce those differences in health outcomes that are
avoidable, unfair and systematically related to social inequality
and disadvantage
• this concept is:
– 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
• a positive and forward-looking definition = equal opportunities for
good health


Think Big, But Get Going

• one problem is that health disparities can seem so
overwhelming and their underlying social determinants
so intractable
→ can be paralyzing

• think big and think strategically, but start somewhere

– make best judgment from evidence and experience
– experiment and innovate
– learn lessons and adjust
– gradually build coherent sets of policy and program actions

• set out 12 point roadmap for health equity

Wellesley Institute Roadmap for
Health Equity 1:
Learn from Leading Countries
• there is always much to be learned from policies, programs and
initiatives in other jurisdictions
• 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
• also increasing international and high-level attention:
– WHO Commission on Social Determinants of Health
– European Union, with its Closing the Gap project to tackle health
disparities
• look broadly for policy solutions, and adapt flexibly to
local/provincial circumstances


Commitment to Equity:
Sweden

• coordinated national policy to reduce health disparities
by reducing the number of people at risk of social and
economic vulnerability
• national public health strategy has 12 key objectives –
five of which, defined as fundamental to all the others,
are about improving social and economic determinants
– also 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


Local Ideas and Innovation

• not just from other jurisdictions – but good ideas from
here as well
• increasing emphasis in research literature and in service
planning on place-based analysis
• recognition of healthy communities as a foundation of
overall good health
– Toronto and Canada were early leaders in healthy cities
movement
• the importance of social resilience and social capital as
enablers of good health
• and of community mobilization and involvement as a
driver of community-based health and social action

Roadmap for Health Equity 2
It’s All About Policy
• reducing overall social and economic inequality may be
the most significant single way to reduce health
disparities → requires a significant commitment and re-
orientation of social and economic policy
• need to build health equity into all macro social and
economic policy:
– not just as one factor among many to be balanced, but as core
priority
– some jurisdictions have built equity consideration into their policy
processes – e.g. a change in tax policy or new environmental
policy would be assessed for its health equity impacts
– Canadian Index of Wellbeing = idea that how well a country is
doing cannot be captured by GDP or stock market indexes, but
should include social, cultural and other facets of wellbeing

Split Action Into Achievable
Chunks
• everything can’t be tackled at once:
– need to split strategy into actionable components and phase them in
• but coordinate through a cohesive overall framework
• fundamental policy action on equity takes time – need
patience
• pick issues and levers that will show progress and build
momentum for action on equity
– look for collaborations on issues with broad consensus – e.g. child
poverty
– and initiatives that will show results and build momentum – linking
schools, local health and social services to enhance early years
services for high-need children, families and communities
– re-frame issues from spending – esp. in this tight climate – to
investments that build social cohesion and enhance human capital


Work Across Silos

• significant improvements in health disparities require
broad cross-sectoral coordination of public policy
• your member depts often deliver services for various
levels of govt:
– prov: child care, social assistance
– feds: settlement, training
• great potential for integrating all this for both efficient
provision and seamless service to clients
– idea of ‘wrap-around’ services
– supportive housing is one of best examples -- proven impact and
cost-effectiveness
• but policies of various governments often have
contradictory objectives and structures

‘Joined Up’ Government

• more coordinated horizontal and cross-cutting way of developing
and implementing policy are often called ‘whole of government’
approaches or ‘joined-up’ government
• 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.
– also regional coordination bodies across agencies
– which in turn provides space/encouragement for interesting local
integration in areas such as Saskatoon

Better Policy Coordination II

• over the last decade in 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 on new
legislation or regulations that could impact health
– regional health plans are required to develop integrated pans with social
services
– local health authorities must coordinate with non-health services
• Ontario:
– Premier’s Councils of early 1990s emphasized coordinated policy
across ministries and spheres
– current project to develop cross-Ministry policy coordination on health
equity

Acting Across Silos for
Housing

• need to act across silos is very clear in housing
– all levels of govt have part of housing pie
– need for federal-prov cooperation and coordination for effective
and progressive housing policy
– vital role of municipalities and their local/community partners in
determining what is needed and delivering vital services
• so how could this work?
– commitment of sufficient funds from senior levels – with less
squabbling
– local and community-driven needs assessment and planning
– range of flexible services geared to local needs, but within
consistent overall objectives
– means to learn from all these local innovations

Promising Local Initiatives

• Seaton House in Toronto
– has a primary clinic on site
– interesting innovation grew out of providers and service users
there – CAISI integrated client record database
• Ottawa – palliative care in shelter
• Sherbourne Health Centre, Immigrant Women's Health Centre and
many others’ health buses
– break down barriers by going to where people are
– Sherbourne bus has integrated electronic health records
• psychiatrists and others out of downtown Toronto hospital provide
mental health services to homeless people wherever they are
• Street Health, harm reduction and other community workers in
shelters and streets

Targets and Incentives
• a vital part of comprehensive policy on health equity =
– setting targets or defining indicators – that build on available
reliable data and make the most sense in the particular policy
context
– closely monitoring progress against the indicators or targets
– disseminating the results widely for public scrutiny
• build these targets and objectives into routine
performance management
– in health, all hospitals and CHCs sign Service Accountability
Agreements with LHINs that govern flow of funds
– build in specific expectations:
• provide sufficient services in languages of community
• provide services that match their catchment profile
• provide outreach to specific disadvantaged populations – homeless,
isolated seniors, etc.


England

• UK Tackling Health Inequalities; A Programme for Action

– first published in 2003 and updated every two years
– committed to reducing inequalities in specific health outcomes by
10% by 2010
– argued that links across government are essential to sustaining
long-term change
– spelled out specific targets for reduced child poverty, more
affordable housing, early childhood development, employment,
building healthy communities, and broad national redistributive
and social policies
– Departments were responsible for meeting those targets


Build On What Is Working

• huge number of promising and innovative service
initiatives underway in every community
• rigorously evaluate the outcomes and potential of
program initiatives and investments – to build on
successes and scale up what is working
• needs a different form of evaluation:
– not just activity reports or even value for money
– not being swamped by reporting requirements to funders – who
never use the data
– but how does program or initiative affect health and related
inequalities?
– involve consumers and disadvantaged people directly in
determining what matters to them – what success looks like

Build Equity Within Health
System
• roots of health disparities lie in broader social and
economic factors
• but how the health system is organized and how
services and care are delivered are still crucial to
tackling health disparities
• transforming the health system is an indispensable
element of comprehensive health equity strategy,
including:
– reducing barriers to equitable access
– targeted interventions to improve the health of the poorest fastest –
generally as part of community/local initiatives
– primary care as a key enabler of health equity
– enhanced community participation and engagement in health care
planning
– more emphasis on health promotion, chronic care and preventive
programmes, especially for most disadvantaged

Action to Reduce Health
Disparities
• comprehensive strategy
developed in 2008 for Toronto
Central LHIN
• many of recommendations
have been acted on
• other LHINs also prioritizing
and moving to address health
disparities
• emphasized cross-sectoral
collaboration beyond the
LHINs on wider determinants


Reduce Access Barriers to
Good Healthcare

• identify and reduce barriers to access:
– within system architecture: considerable evidence that private
provision and payments -- such as user fees, prescription costs -
- create greater barriers for poorer people
– language and culture → ensure culturally competent care and
build anti-racism/oppression approach into service provision
• assess what models have best served the most
vulnerable communities and invest in them
– e.g. Community Health Centres, public health and other
community-based service providers have explicit mandates to
support the most under-served communities
→ expand their coverage and impact


Invest for Equity Impact
• target services to specific areas or populations:
– those facing the harshest disparities – to raise the worst off fastest
– or most in need of specific services
– or 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.
– which requires good local research and detailed information – speaks to
great potential of community-based research to provide rich local needs
assessments and evaluation data
– involvement of local communities and stakeholders in planning and
priority setting is critical to understanding the real local problems
• and invest in those levers and spheres that have the most impact on
health disparities

Enhance Equity Focused
Primary Care

• considerable international evidence that expanding
primary care can reduce health disparities
• major reforms are underway across Canada to
restructure primary care
– these system-level reform initiatives are an opportunity to build
equity in by concentrating increased primary care in areas with
poorest access or health status
– think of practice innovations as well -- e.g. nurse practitioner and
nurse-based clinics have been very effective in delivering
primary care and managing chronic conditions
– silos: CHCs in LHINs, Family Health Teams established by
MOHLTC, private practice docs essentially independent
– in terms of policy levers, it has been easier to establish CHCs
and other clinics, than to reform private medical practice


Collaboration Again

• can also see primary care reform as a catalyst for wider
changes:
– many countries have clinics that provide both health and wider
social services in one place
– new satellite CHCs are being developed in designated high-need
areas in Toronto — and some will involve the CHCs delivering
primary and preventive care and other agencies providing
complementary social services out of the same location
• think back to earlier eras with public health nurses in
schools
– key role in identifying problems early, providing routine care and
health promotion
– begin by putting public health nurses or associated workers in
schools in most disadvantaged areas
– link them into a network of services they can refer kids onto
when needed www.wellesleyinstitute.com

Act Locally

• action on equity cannot just come from senior
governments
• many of the most innovative and insightful programmes
addressing health disparities have come from local
authorities or community providers
– emerging evidence that neighbourhood has an independent or
reinforcing impact on health disparities
– lived experience of health problems and opportunity structures
always takes place in a local context
– this requires that equity-driven interventions be locally focussed
• regional health authorities (LHINs in Ont) have been an
important enabler and forum for planning and promoting
local initiatives

Act Locally And Systematically

• to implement equity locally LHINs can:
– use planning tools such as diversity lenses and health equity
impact assessments
– concentrate key programs in disadvantaged neighbourhoods
• build the voices and interests of the whole community –
including marginalized and traditionally excluded – into
their governance and planning
• enable innovation:
– fund or pilot new ways of addressing barriers or supporting hard-
to-serve communities
– encourage on-the-ground collaborations and partnerships
among health care providers and beyond
– establish and support cross-sectoral planning tables


Cross-sectoral Collaboration
at Local and Regional Levels

• back to British example – Health Action Zones and other
models were designed to combine community
development with targeted healthcare and social service
improvements
• and in Canada, some Regional Health Authorities have
developed operational and planning links with local
social services or emphasized community capacity
building:
– Saskatoon is developing cross-sectoral action on health equity:
• began from local research documenting shocking disparities among
neighbourhoods
• focussing 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

Looking for Innovation: Hub
Models of Integrated Care
• hub-style multi-service centres in which a range of health and
employment, child care, language, literacy, training and social
services are provided out of single locations.
• Winnipeg Regional Health Authority and Manitoba Family Services
and Housing have been partnering 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
• Ontario provincial associations representing CHCs, mental health
and community service agencies have been promoting idea
• federal and provincial governments could fund demonstration
projects and investments in hub-type integrated social and health
service centres

10: 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
– a very interesting primer has been developed by the Ontario Prevention
Clearinghouse (Health Nexus), Ontario Chronic Disease Prevention
Alliance and other partners to help incorporate social determinants into
chronic care management and support
http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20Fin
al.pdf
• up-stream initiatives need to be planned and implemented through
an equity lens
– 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
– move to see ‘healthy communities’ as vital to overall health
promotion
– implies wider community development and capacity building
approaches © The Wellesley Institute 42

11: Support Community-
Based Innovation
• themes so far:
– ‘chunking out’ actionable projects
– experimenting , but strategically
– relying on local community-based and other front-line innovations
• to realize this potential, senior governments need to
develop a framework to support experimentation and
innovation:
– common data and information platforms
– funding for pilot projects – available to CHCs, different practice models
and community-based providers
– 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 are
flexible and not too bureaucratic


12: Build On This Innovation

• 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.
• then need a provincial or national 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 on equity

Key Messages

1. health inequalities are pervasive and damaging – and
that’s not just a health system issue
2. the roots of health disparities lie in wider social and
economic inequality and exclusion
3. but none of this is inevitable – the adverse impact of
social determinants of health can be changed through
policy
4. have set out a roadmap for building health equity
through policy change and community mobilization
5. these lines of action intersect with your spheres of
social housing, municipal services and local planning

Moving Forward

• there isn’t a magic plan that can be applied in every country or
region to reduce disparities, but we broadly know what is needed
• but knowing policy directions that will work doesn’t mean
governments will adopt them:
– its unfortunately not just solid research or clear evidence from other
countries that drives government action
– its politics
• challenge is to mobilize community support/action and shift public
opinion:
• we need to find ways that governments, providers, community
groups, unions, and others can support each others’ campaigns
and coalesce around a few ‘big ideas’


Health Equity

• could be one of those ‘big’ unifying ideas..
– if we see opportunities for good health and wellbeing as a basic
right of all
– if we see these pervasive health disparities as not only incredibly
damaging to so many, but also as an indictment of an unequal
society
– if we recognize that coming together to address the social
determinants that underlie health inequalities will benefit many
other spheres – from better early child development to
community supports to live independently when we need it
– if we see that addressing the roots of so many of our social
problems requires broad collaboration and mobilization


Wellesley Roadmap for
Action on the Social
Determinants of Health
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 programme action;


Wellesley Roadmap II

6 rigorously evaluate the outcomes and potential of programme 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;

Wellesley Roadmap III

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


Contact Us

• 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


Social Determinants of Health Inequalities: Roadmap for Health Equity

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