Driving Health Equity into Action: Strategy, Ideas, and Tools for Midwifery Movement

Bob Gardner
Association of Ontario Midwives
March 22, 2011

© The Wellesley Institute
www.wellesleyinstitute.com

1. health disparities in Ontario and Canada are pervasive and
damaging
2. but these disparities can be addressed through comprehensive
health equity strategy
3. acting on health equity within the health system
• building equity into all planning and delivery
• targeting some programs and resources for equity impact
• aligning equity with key system drivers
• embedding equity in performance management and service delivery
4. and well beyond healthcare -- tackling the underlying roots of
health inequality in the wider social determinants of health
5. focus today is on principles and tools for equity-focused
planning, delivery and advocacy for Ontario midwives

www.wellesleyinstitute.com 2

• there is a clear gradient in health in which people with lower
income or socio-economic status, or facing discrimination,
racism or other lines of social exclusion, tend to have poorer
health
• plus major differences between women and men
• in addition, there are systemic disparities in access to and
quality of care within the healthcare system
• not just unfair and unjust, but health disparities make it more
difficult to achieve provincial priorities such as ALCs, ER,
diabetes, etc, and contribute to avoidable costs
• enhancing health equity has become a clear priority – from the
Province to LHINs to many providers
• that’s why we need strategies, tools and best practices to build
equity into effective system and service planning


inequality in how long people live
• difference btwn life expectancy of top and bottom income
decile = 7.4 years for men and 4.5 for women
+ inequality in how well people live:
• more sophisticated analyses add the pronounced gradient
in morbidity to mortality → taking account of quality of
life and developing data on health adjusted life
expectancy
• even higher disparities btwn top and bottom = 11.4 years
for men and 9.7 for women

Statistics Canada Health Reports Dec 09


• clear research consensus that roots
of health disparities lie in broader
social and economic inequality and
exclusion
• impact of inadequate early
childhood development, poverty,
precarious employment, social
exclusion, inadequate housing and
decaying social safety nets on health
outcomes is well established here
and internationally
• real problem is differential access to
these determinants – many analysts
are focusing more specifically on
social determinants of health
inequalities

www.welleseyinstitute.com
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•Determinants interact and
intersect with each other
•In 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


POWER Study
Gender and
Equity
Health Indicator
Framework

Highlights
1. how the structure,
resources and
resilience of
communities
mediate the
impact of SDoH
2. why we need to
take SDoH into
account in health
service planning
and delivery

11

• Health disparities or inequities are differences in health outcomes that
are avoidable, unfair and systematically related to social inequality and
disadvantage

• This concept:
• is clear, understandable and actionable
• identifies the problem that policies will try to solve
• is also tied to widely accepted notions of fairness and social justice

• The goal of health equity strategy is to reduce or eliminate socially and
institutionally structured health inequalities and differential outcomes

• A positive and forward-looking definition = equal opportunities for good
health
• Equity is a broad goal, including diversity in background, culture, race
and identity


• health disparities can seem so overwhelming and their
underlying social determinants so intractable → can be
paralyzing
• think big and think strategically, but get going
• make best judgment from evidence and experience
• identify actionable and manageable initiatives that can
make a difference
• experiment and innovate
• learn lessons and adjust – why evaluation is so crucial
• gradually build up coherent sets of policy and program
actions – and keep evaluating
• need to start somewhere – and focus here is on building
equity into best midwifery care

© The Wellesley Institute 13

• even though roots of health disparities lie in far wider social
and economic inequality
• how the health system is organized and how care is
delivered is still crucial to tackling health disparities
1. it’s in the health system that the most disadvantaged in
SDoH terms end up sicker and needing care
• equitable healthcare and support can help to mediate the harshest
impact of the wider social determinants of health on health
disadvantaged populations and communities
2. in addition, there are systemic disparities in access and
quality of healthcare that need to be addressed
• people lower down the social hierarchy can have poorer access to
health services, even though they may have more complex needs
and require more care
• unless we address inequitable access and quality, healthcare and
community support services could make overall disparities even
worse


• goal is to ensure equitable access to high quality
healthcare regardless of social position
• can do this through a three pronged strategy:
1. building health equity into all health planning and delivery
• doesn’t mean all programs are all about equity
• but all take equity into account in planning their services and outreach
2. aligning equity with system drivers and embedding it in
planning, service delivery and performance management
3. 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


• goal is to reduce health disparities and speak to needs of
most vulnerable communities – who will define?
• 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
• how:
• many hospital have community advisory panels
• CHCs have community members on their boards
• innovative methods of engagement – e.g. citizens’ assemblies or
juries in many countries
• community-based research, needs assessment and evaluation


• Quality Improvement Plans
• hospitals just developed first generation and will be reporting every year
• opportunity = equity can be built in as one of dimensions to report on
• where do midwives fit in hospital maternal health quality planning? = opportunity
to push equity
• other provider institutions will be reporting in future
• quality and patient-centred care:
• taking lived conditions/experience into account – meaning equity and diversity →
essential to high quality patient-centred care for all
• chronic disease prevention and management is major prov priority
• context for you – many clients?
• case= comprehensive midwifery care is better for clients with chronic conditions
• equity as contributing to cost-effectiveness and safety:
• e.g. reducing language barriers to good care through better interpretation can
reduce mis-diagnoses and over-prescriptions → enhanced quality and cost
effectiveness


• addressing health disparities in service delivery requires a
solid understanding of:
• key barriers to equitable access to high quality care
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• need to understand roots of disparities:
• i.e. is the main problem language barriers, lack of coordination among
providers, sheer lack of services in particular neighbourhoods, etc.
• which requires good local research and detailed information – speaks
to great potential of community-based research
• involvement of local communities and stakeholders in planning and
priority setting is critical to understanding the real local problems
• requires an array of effective and practical equity-focused
planning tools


1. quick check to ensure equity is 1. simple equity lens
considered in all service
delivery/planning
2. take account of disadvantaged
populations, access barriers and 2. Health Equity Impact
related equity issues in program Assessment
planning and service delivery
3. assess current state of provider 3. equity audits and/or HEIA
organization
4. determine needs of communities 4. equity-focused needs
facing health disparities assessment
5. assess impact of
programs/interventions on 5. equity-focused evaluation
health disparities and
disadvantaged populations


• The AOM is developing a consumer advocacy strategy that will be an
integral part of the Birth Centre provincial election campaign 2011.
• It is our hope that consumers will help the AOM develop and further the
campaign in many ways, including generating interest and support for
the campaign in their communities , attending all-candidate meetings,
and collecting feedback from other consumers as to how the campaign
can best reflect the needs of midwifery clients and potential clients of
birth centres.

Questions:
• How would we best reach out to clients from different communities?

• How do we ensure that the voices of consumers from different
geographical, class, ethno-cultural, linguistic, and sexual communities
are reflected as much as possible?


you will have started from basic then identify success conditions:
questions: •processes/forums for involving
•who you need to get involved consumers in planning campaign
•specifying your particular purposes: • innovative use of social
media?
• building support in their • deliberative dialogue
communities processes?
• taking message into electoral • just immediate consumers or
arena others in community?
• gathering community feedback •sharing information effectively on
and intelligence campaign and on opportunities (all
+ basic community engagement
candidates meetings, etc.)
questions •providing resources to get involved
(talking points, messaging, etc.)
• how much involvement and
•central support/planning from
influence? Association
• how will you incorporate input?

• simple equity lens that can be broadly applied =
• could the policy or initiative have a differential or
inequitable impact on different groups?
• adapted for this question:
• could this community engagement work differently and
inequitably in different communities and contexts?
• could some voices be excluded?
• do we need to adapt processes to ensure equitable voice
and participation?


•processes/forums for involving •are forums and meetings accessible?
consumers in planning campaign • drilling down to specific barriers
• distance, cost, physical, language,
• innovative use of social cultural (professional ‘speak’)
media? • inclusionary facilitating
• deliberative dialogue •who is involved:
processes? • breadth of outreach
• just immediate consumers or • making it easy – times, subsidizing
child care, transportation, etc.
others in community?
•access to means of communication:
•sharing information effectively on • computer
campaign • not just machines but speed
•providing resources to get involved • literacy and comfort
(talking points, messaging, etc.) •usability of resources
• both literal and culture/literacy level
• translation into key languages

• assessing the potential equity impact of initiatives on particular
populations requires solid understanding of that population's
health situation, needs and context → need ongoing engagement
with the population and/or specific community-based research or
needs assessment
• analyzing how to design services to meet specific barriers or
population needs will also benefit from engaging the affected
population
• similarly, monitoring and assessing the impact of service
initiatives also needs:
• research and input from the affected population
• as well as health outcome data stratified by population and social
determinants
• back to this advocacy challenge


• analyzes potential impact of program or policy change on health
disparities and/or health disadvantaged populations
• generally designed for planning forward – as easy-to-use tool to
ensure equity factors are taken into account in planning new services,
policy development or other initiatives
• but experience here and in other jurisdictions identified other uses:
• for strategic and operational planning
• for assessing whether programs should be re-aligned or continued
• more generally, discussions around HEIA provide a way to ensure
equity is incorporated into routine planning throughout an
organization
• increasing attention to potential – from WHO, through most
European strategies, PHAC, to Ontario


• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN
and Wellesley Institute
• refined the one-page template
• and developed a new workbook
• HEIA is being used in Toronto Central and other LHINs
• Toronto Central has required HEIA within recent funding application
processes for Aging at Home, and refreshing hospital equity plans
• been used in many settings :
• all programs within one Toronto hospital are undertaking HEIA
• also in some community-based programs
• so, it’s worth being aware of and considering for midwives


preliminary stage = scoping
• could the policy or initiative have a differential or inequitable impact
on different groups?
• if yes →

1. analyze how the planned program or initiative affects health equity for
particular populations
• list of health disadvantaged populations – not exhaustive
• potential impact on social determinants of health
2. assess potential positive and negative impacts of the initiative on the
population(s)
3. develop strategies to build on positive and mitigate negative impacts
4. plan how implementation of the initiative will be monitored to assess its
impact

27

Case Study 2:

• The Diversity Work Group is planning a session for the AOM annual
conference in May 2011. The session will focus on how to best serve
clients who do not communicate most effectively in English or in the
languages spoken by their midwives.
• The session will be in the form of a workshop where small groups of
midwives will discuss different case scenarios and share their
experiences and expertise in dealing with these situations.

Question:

How do we ensure that this workshop can best serve the needs of midwives
and clients in different geographical, class, ethno-cultural communities?


• friendly amendment to the question =
• how can midwives best serve clients facing language and related
barriers of social inequality and exclusion?
• how can this workshop empower midwives to effectively consider
these issues and build them into their practice?
• start from evidence and practice:
• are there inequitable variations in quality and experience of
midwifery care by social and economic situation, race, ethno-cultural
or immigration status; and/or comfort/facility with English?
• are there inequitable variations in access to midwifery care?
• this is initial scoping stage of HEIA – or any good planning = what is
problem we need to solve

March 27, 2011 www.wellesleyinstitute.com 30

• whether there are inequitable differences is a research
question:
• so, first action item from HEIA scoping = if we don’t know →
find out
• if midwives can’t answer → highlights importance of collecting better
equity-relevant data as priority
• can use proxy data from postal code = neighbourhood characteristics
from census data
• can use case studies and small-scale interview/chart review studies
• if evidence is yes – or if practitioners’ experience leads them
to conclude that there are or could be inequitable variations
• → then can drill down using HEIA template to analyze how to better
serve women who do not speak or understand English (or French) well


in terms of dimensions of good issues to look for:
midwifery care: • who of client groups needs care in
1. access – are language and culture which languages?
important barriers to getting care • are there communities of women
women want? who are excluded because of
language or cultural barriers – who
2. quality – how to ensure high- and why?
quality care for all despite • how does impact of
language barriers language/cultural barriers intersect
with poverty, precarious jobs,
3. expand to mean cultural racism or other social factors?
competence and • what practical difficulties do
appropriate/sensitive care women face?
• e.g. might not be able to
talk fully to midwife
• might not understand
appointment or care
information


what impact on quality if provision of care through a
midwife and woman have cultural competence lens
• interpretation at all stages of
difficulty communicating or treatment
woman doesn’t understand • translation of all material
information provided? • partnerships with community
groups to facilitate
→ poorer experience • equitable care = more
intensive pre-natal and post-
→ greater risk of partum planning and support
complications or poor for those most in need
outcomes • look for innovations with
potential -- peer health
ambassadors, links to CHCs
and other community
services


• language and cultural barriers don’t work in isolation
• drill down = does the impact of language barriers vary within
non English or French-speaking women and families?
• what other challenges could these women face?
• more unequal or precarious position in labour market
• racism
• living in poor or under-served neighbourhoods
• plus effects of immigration status, social exclusion
• worst for non-insured and undocumented


•population health and •special outreach to under-served or
epidemiological data indicate that most marginalized communities
disadvantaged women may have
poorer overall health •not much midwives can directly do
about social conditions?
• → greater risk of →can take poorer situations/higher
complications or poor risks into account:
outcomes • more intensive pre-admission
• + less capacity to cope well planning and support for
those most in need
with problems should they • even broader =taking SDoH
arise into account by including
•are some populations not accessing child care, transportation,
services equitably? nutritional and other support,
more intensive follow-up
• peer health ambassadors


language barriers continued = cultural competence lens
•may not understand how to take meds or • interpretation for discharge planning
follow-up care • translation of all post-treatment materials
•may not be able to contact providers for • more intensive follow up in
advice language/culture
• potential of peer health ambassadors
•will be dealing with many other providers
and institutions – primary care, public health
– who may not have language capacities can take poorer situations/higher risks into account:
• equitable care = more intensive post-
partum planning, case mgmt and
+ wider SDoH: assessment
•poor living conditions, food, anxiety • send home with more supplies, meds, etc.
•can’t take as much time off work • more intensive follow-up to those in
greatest need – socially as well as
•can’t afford meds medically defined
•don’t have equitable access to home and
community-based support

→ less able to cope → poorer recovery


• demonstrated value of equity lens and tools such as
HEIA on these issues – and most?
• can identify inequitable constraints and barriers:
• some seem outside of midwives control → but can take into
account in care planning and delivery
• can identify mediating actions that can be taken and
make recommendations:
• then need to monitor impact:
• indicators and outcomes
• client satisfaction – by these equity variables
• can assess lessons learned → incorporate into ongoing
quality improvement


• 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
• closely monitoring progress against the targets and
indicators
• disseminating the results widely for public scrutiny
• tying funding and resource allocation to performance
• what would equity-focused performance indicators,
measurement and management look like for midwifery?


• have emphasized taking SDoH into account in service del very and
planning
• more broadly, cross-sectoral coordination and planning are much
emphasized in public health and health policy circles
• addressing wider SDoH is the glue for collaboration into action
• public health departments and LHINs are pulling together or
participating in cross-sectoral planning tables
• Local Immigration Partnerships , Social Planning Councils
• comprehensive community initiatives to address poverty and other
complex local problems
• the Ministry of Health Promotion and Sport is developing a healthy
communities strategic approach
• cross-sectoral planning to ground health promotion
• at best, this implies wider community development and capacity
building approaches


• health disparities are pervasive and deep-seated – but
can’t let that paralyze us
• do need a comprehensive and coherent health equity
strategy – but don’t wait for perfect strategy
• think big and think strategically – but get going
• build equity into strategic priorities, align with quality
agenda and system priorities, embed in routine
planning and performance management
• and build equity into front-line planning and delivery
where you practice
• no magic blueprint -- experiment and innovate -- and
build on learnings and success


• nesting equity-focused planning in big
picture:
• clarifying assumptions and starting points – theory
of change underlying equity-focused planning
• data as success condition for all this
• complexities of equity-orientated performance
management
• overall health equity roadmap


• one critical component of this strategic approach is good planning
• addressing health disparities in service delivery and planning requires a
solid understanding of:
• key barriers to equitable access to high quality care
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• to develop effective planning, we need:
• clear strategy
• a coherent approach
• a repertoire of effective tools and techniques
• support for planners and practitioners to effectively use them
• good actionable information
• and then drilling down: what is our ‘theory’ of how equity-focused
planning works?


a ‘realist’ evaluation and/or synthesis approach has great promise
• not just to plan specific evaluation or research projects
• but to ground and guide overall planning and project development
• various other ‘theory of change’ approaches are similar
key premise is to identify the ‘program theory’ – in this case:
• how we think efficient and sustainable transfer and incorporation of equity-
focused planning tools and resources into health service practice takes place,
in different practice and other contexts
• what we think are the key drivers, facilitators and barriers of the necessary
professional and organizational changes
• how we think this will lead to more equitable healthcare and health
outcomes/opportunities
then build these assumptions and premises into planning and
operationalization:
• we test this ‘theory’ against literature, research and evaluation, and
experience
• and adjust these assumptions and principles in a constantly iterative process


not just
taking individual
account of programs but
social coordination,
constraints & partnerships &
conditions collaboration


enhanced access up-stream heath
to primary care conditions &
& health opportunities
promotion for improve fastest
most for those in
disadvantaged greatest need


• precondition for all this planning, monitoring indicators, and
assessing progress against objectives and targets is reliable
data on:
• ethno-cultural background, language, income, sexual orientation
• service use and health outcomes, differentiated by these equity
and determinants of health variables
• hospitals have been using postal code data as proxy
• begin collecting this data
• be aware of and try to align with provincial, LHIN and professional
initiatives
• project in Toronto Central LHIN where three hospitals are
collaborating on developing plans on how to collect and
incorporate equity data


• quality standards are especially important to most disadvantaged
populations
• how to forge quality standards that reflect individuals’ and communities’
diverse perspectives and needs
• e.g. what does quality reproductive care look like from point of view of poor
older recent immigrant?
• highlights the need for more community-based forms of research and needs
assessment, and critical importance of community engagement and
connections
• one danger of overall quality agenda and performance management is:
• guidelines could be too clinical or academic, or monitoring too quantitative
• not so easy to apply to complex interventions such as ongoing support for
health disadvantaged populations with complex health needs


• 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’


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 building a non-racist
society
• if we see that addressing the roots of so many of our social problems
requires broad collaboration and mobilization
• 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


• these speaking notes and further resources on
policy directions to enhance health equity, health
reform and the social determinants of health are
available on our site at
http://wellesleyinstitute.com
• my email is bob@wellesleyinstitute.com
• I would be interested in any comments on the ideas
in this presentation and any information or analysis
on initiatives or experience that address health
equity


1. look widely for ideas and inspiration from jurisdictions with comprehensive
health equity policies, and adapt flexibly to Canadian, provincial and local needs
and opportunities;
2. address the fundamental social determinants of health inequality – macro policy
is crucial, reducing overall social and economic inequality and enhancing social
mobility are the pre-conditions for reducing health disparities over the long-
term;
3. develop a coherent overall strategy, but split it into actionable and manageable
components that can be moved on;
4. act across silos – inter-sectoral and cross-government collaboration and
coordination are vital;
5. set and monitor targets and incentives – cascading through all levels of
government and program action;


6 rigorously evaluate the outcomes and potential of program initiatives and
investments – to build on successes and scale up what is working;
7 act on equity within the health system:
• making equity a core objective and driver of health system reform – every bit
as important as quality and sustainability;
• eliminating unfair and inefficient barriers to access to the care people need;
• targeting interventions and enhanced services to the most health
disadvantaged populations;
8 invest in those levers and spheres that have the most impact on health
disparities such as:
• enhanced primary care for the most under-served or disadvantaged
populations;
• integrated health, child development, language, settlement, employment, and
other community-based social services;


9 act locally – through well-focussed regional, local or neighbourhood cross-
sectoral collaborations and integrated initiatives;
10 invest up-stream through an equity lens – in health promotion, chronic care
prevention and management, and tackling the roots of health disparities;
11 build on the enormous amount of local imagination and innovation going on
among service providers and communities across the country;
12 pull all this innovation, experience and learning together into a continually
evolving repertoire of effective program and policy instruments, and into a
coherent and coordinated overall strategy for health equity.


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


Driving Health Equity into Action: Strategy, Ideas, and Tools for Midwifery Movement

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