Meeting Highlights Health Equity Plans

Bob Gardner
November 2009
Meetings of Community Providers on
Health Equity Plans

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• scale of health disparities
• concept of health equity
• bigger picture: health equity and social determinants
• acting on health equity within the health system
• building equity into all planning and delivery – highlighting some
frameworks and resources for equity-focused planning
• targeting some % of programs and resources for equity impact
• identifying key drivers and enablers to move an equity
agenda forward
• potential of community-based initiatives and cross-
sectoral collaborations

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• 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

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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


• 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
• Health equity is a broad concept that also prioritizes diversity:
• reflecting the increasing diversity of Ontario society and the fact that
racism and ethno-cultural differences are important determinants of
health disparities
• recognizing that services that reflect and speak to the diversity of
cultures -- cultural competence – are essential to an equitable system
• Impact of achieving health equity would
• extend far beyond enhancing individual and collective well being
• would also contribute to overall social cohesion, shared values
of fairness and equality, economic productivity, and community
strength and resilience


• To reduce the scale and severity of disparities
• Not only improving the health and health
opportunities of the most vulnerable and
disadvantaged
• But benefiting people along the gradient:
o the kinds of integrated comprehensive primary care needed by
those with the most pressing and complex needs – will benefit
all
o reducing language and cultural barriers will benefit many
newcomers and those who have difficulty receiving services in
English, not just those who face the harshest health disparities


• the point of all this analysis is to be able to identify
what policy and program changes are needed to
reduce health disparities
• 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 get going

• everything can’t be tackled at once:
o need to split strategy into actionable components and phase them in
o but coordinate through a cohesive overall framework


• timing is everything:
• need to recognize that fundamental policy action on equity takes time
– need patience and long view
• pick some ‘quick wins’ -- issues and levers that will show progress and
build momentum for action on equity
• pick issues and direct resources to areas that will have the
greatest equity impact
o either in terns of meeting the health needs of most disadvantaged
populations
o or addressing most important barriers to health equity

• need to start somewhere – and we’re in healthcare system


• even though roots of health disparities lie in far wider social
and economic inequality
• this doesn’t mean that how the health system is organized
and how services and care are delivered are not crucial to
tackling health disparities
• many countries have been developing comprehensive multi-
sectoral strategies to reduce health disparities
• in all of them, transforming the health system is an
indispensable element, including:
o reducing barriers to equitable access to high quality care
o targeted interventions to improve the health of the poorest fastest –
often as part of community/local initiatives


1. its in the health system that the most disadvantaged
in SDoH terms end up sicker and needing care
• equitable healthcare 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 redressed
• people lower down the social hierarchy tend to have poorer access
to health services, even though they may have more complex needs
and require more care
• unless we address inequitable access and quality, healthcare could
make overall disparities even worse
• at the least, the goal is to ensure equitable access to care for all who
need it, regardless of their social position


Toronto Central: Lower Income,
More Physician Visits For
Arthritis
% With Physician Visits for Arthritis,
Age 45-64, TC LHIN 2001-03
25
20
20
14
15 13
11
10

5

0
Low Income High Income
Males Females

Proportion of Residents with physician visits for Arthritis is higher in Lower
Income neighbourhoods, especially females.
Neighbourhood Income Quintiles
Toronto Community Health Profiles Partnership, www.torontohealthprofiles.ca
The Wellesley Institute 23

Toronto Central:

Hip Replacement Rate, TC LHIN, 2004/05

144
150
#/100,000

100
68

50

0
Lowest Income Highest Income
Despite poorer health and greater need/potential to benefit from diagnosis and treatment in lower
income groups, the hip replacement rate is over twice as high in the highest income neighbourhoods.

Age Standardized Rates. Total Hip Replacements per 100,000 Population by Neighbourhood Income
Quintiles. .Source: Institute for Clinical Evaluative Sciences (ICES) November 2006

• broad social and healthcare provider consensus that
discrimination between women and men is no longer
acceptable
• but research has shown that women are less likely than
men to receive:
o standard heart medication
o dialysis treatment
o admission to intensive care units
o certain surgical procedures – cardiac catherization, kidney
transplants, knee arthroplasty (replacement)
• surgeons and referring physicians respond in surveys that
sex of patient has no effect on their clinical decisions
• so…..

• to see if there were differences by gender in clinical
practice
o standardized male and female patients went to family
physicians and orthopaedic surgeons
o presented with the same scripted clinical scenario
• found striking differences:
o orthopaedic surgeons were 22X more likely to recommend
male for total knee arthroplasty than female
o family physicians were 2X more likely for male

Source: Borkhoff et al, CMAJ, March 11, 2008


• goal is to ensure equitable access to high quality
healthcare regardless of social position and that all
individuals and communities get the care they need
• can do this through a two pronged strategy :
1. building health equity into all health planning and delivery
• doesn’t mean all programs are all about equity
• but all take equity into account in planning their services and outreach
2. targeting some resources or programs specifically to
addressing disadvantaged populations or key access barriers
• looking for investments and interventions that will have the highest
impact on reducing health disparities or enhancing the opportunities for
good health of the most vulnerable


• addressing health disparities in service delivery and
planning requires a solid understanding of:
o key barriers to equitable access to high quality care
o the specific needs of health-disadvantaged populations
o gaps in available services for these populations
• this requires good information
• and 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. Health Equity Impact
2. take account of disadvantaged
Assessment – has been piloted in
populations, access barriers and
Toronto and MOHLTC is
related equity issues in program
considering wider roll-out
planning and service delivery
3. assess current state of provider
organization 3. equity audits and/or HEIA
4. determine needs of communities
facing health disparities 4. equity-focused needs
5. assess impact of assessment
programs/interventions on
health disparities and 5. equity-focused evaluation
disadvantaged populations

© The© The Wellesley Institute 29 29

• a promising direction is to have providers undertake specific equity
planning exercises designed to:
• identify access barriers, disadvantaged populations, service gaps and
opportunities in their catchement areas and spheres
• develop programs and services to address those gaps and better meet
healthcare needs of disadvantaged communities
• these provider plans have the potential to:
• raise awareness of equity within the organizations
• more effectively build equity into planning, resource allocation and routine
delivery
• pull their many existing initiatives together into a coherent overall equity
strategy
• build connections amongst providers for addressing common equity issues
• hospitals in Toronto Central and Central LHINs developed equity plans
broadly meeting those objectives


http://www.torontoevaluation.ca/tclhin/index.html


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


• 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 context
• closely monitoring progress against the indicators or
targets
• disseminating the results widely for public scrutiny
• need to build these equity targets and objectives
into routine performance management and routine
provider planning


• we know there will be clear targets for priorities such as
diabetes and mental health → build equity into targets:
• Central has identified areas where diabetes incidence is highest
→ equity target = reduce differences in incidence, complications
and rates of hospitalization among areas across Central
• similarly, systemic inequities in depression → equity target =
reduce those differences by gender, income, region
• many providers assess their services through consumer
satisfaction surveys and similar methods
• providers look for high and improving satisfaction → equity target =
reduce any differences in satisfaction by gender, income, ethno-
cultural background, etc.


• assessing the potential equity impact of initiatives on
particular populations requires solid understanding of that
population's health situation, needs and context
o this can benefit from ongoing community 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:
o research and input from the affected population on impact
o health outcome data stratified by population and determinants


• underlying all this planning, monitoring of indicators and assessing
progress against objectives and targets = data on:
• service use patterns, differentiated by population and by determinants of
health-type data
• health outcomes data, also stratified
• how well service use reflects catchment and community make-up
• trends in all of this – to monitor impact and progress
• when hospitals in Toronto Central began working on their
equity plans it became very clear that they simply did not
have the necessary data to do equity-driven planning
• a workshop was held on what kinds of data on equity and diversity are
available, how the existing data sets can be effectively used, and what further
types of data are needed


• theme of presentations and resources was that a great deal can be
done now with existing sources of data
→ don’t need to wait for better data or consensus definitions before
beginning to act
• but also recognized need for common and coordinated system
level solutions and directions
→ need to begin these wider discussions within LHIN and beyond
o tremendous potential if this is done on coordinated prov basis
• presentations and resources from the day and report from
working group to Collaborative were published
o distributed to hospitals, other providers and stakeholders, and LHIN
o all available on partner sites including
http://www.healthequitycouncil.ca/dev

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• equity is essential to provincial priorities
• e.g. diabetes is particularly sensitive to social conditions
• prevention and management programs cannot be successful
unless they take account of social conditions and constraints
• equity also supports other system drivers
• better access to primary care is key to reducing pressure on ER
wait times and ALC
• reducing language barriers to good care through better
interpretation can reduce mis-diagnoses and over-prescriptions
→ enhanced quality and cost effectiveness
• reducing higher expenditures on vulnerable populations due to
health disparities → can contribute to overall and sustainability


• target services to specific areas or populations:
o those facing the harshest disparities – to raise the worst off fastest
o or most in need of specific services
o or the worst barriers to equitable access to high-quality services
• this requires sophisticated analyses of the bases of disparities:
o i.e. is the main problem language barriers, lack of coordination among
providers, sheer lack of services in particular neighbourhoods, etc.
o 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
o involvement of local communities and stakeholders in planning and priority
setting is critical to understanding the real local problems


• North York West region has been identified as
high need – diverse population, high % of
racialized population, high risk factors, lack of
access to primary care
• problems include concentrated poverty and
inadequate services and infrastructure
• highlights the need for local cross-sectoral planning
and collaboration beyond boundaries
• need to link up with local social services, community
service agencies, residents, public health, other LHINs
in area

• one of identified equity challenges for North York General
hospital was language:
• identified as critical issue in hospital equity plans and other Toronto
Central planning → major project to develop more systematic
coordinated approach to interpretation in downtown hospitals
• could hook up to this – or at least keep it on horizon
• could also link into Healthcare Interpreters Network
• another critical barrier to equitable access in parts of Central
– and other LHINs – is remoteness and transportation
• have been innovative community-based and volunteer transportation
• highlights key role of LHINs in enabling such critical supports for health


• LHINs are all about integration and coordination:
• will be experimenting and innovating with enhanced
coordination and partnerships
• with different kinds of community-based service delivery and
on-the-ground coordination
→ locate in high-need areas
• solid evidence that enhancing primary care is one of key
ways to improve care of disadvantaged
• lack of access to primary care has been identified as a key issue
in priority areas within Central
• concentrate new investments or coordination initiatives in those
areas
• recognizing that most of primary care levers are outside LHIN
mandate

• hub-style multi-service centres in which a range of health and
employment, child care, language, literacy, training and social services are
provided out of single ‘one stop' locations
• Winnipeg Regional Health Authority and Manitoba Family Services and
Housing have 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 -- including to
LHIN CEO provincial planning table
• more immediately, many CHCs offer expanded services or co-located
partnerships with other providers


• Central has identified this as a key direction
• public health are key players in addressing health disparities
on the ground
• a number of public health units have been pioneering social
determinants approaches -- Sudbury, Waterloo, Toronto
• working with public health -- even though outside the LHINs and with
different boundaries – is vital
• Social Planning Councils are developing cross-sectoral
planning forums and processes in many communities around
poverty and inequality – clear implications for health
• a key lesson of LHIN experience to date is that existing
networks and partnerships are a huge resource to build on
• → identify key networks to enhance equity coordination and delivery
in priority areas and support them


• investing in better chronic care prevention and management
are vital elements of health reform
• up-stream initiatives need to be planned and implemented
through an equity lens
• very clear gradient in incidence – and impact – of chronic conditions
• some populations and communities need greater support to prevent
and manage chronic conditions
• need to build these specific needs into CDPM planning and resource
allocation
• a very interesting primer has been developed by 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%20F
inal.pdf


• more emphasis on health promotion is vital to long-term
sustainability of system and individual health
• consistent data on variations of risk factors along the social gradient
• anti-smoking, exercise and other health promotion programmes need
to explicitly foreground the particular social, cultural and economic
factors that shape risky behaviour in poorer communities– not just the
usual focus on individual behaviour and lifestyle
• need to customize and concentrate health promotion programs
especially for most disadvantaged
• if this isn’t done → can unintentionally widen disparities as better off
take up programs more
• thinking bigger, the Ministry of Health Promotion is starting
to take a healthy communities approach to planning health
promotion -- implies wider community development and
capacity building approaches

• huge number of community and front-line initiatives already addressing
equity – across this LHIN and province
• + equity focused planning – through provider equity plans, HEIA or other
tools -- will yield useful information on existing system barriers and the
needs of disadvantaged populations, and on promising and successful
programme interventions
• we need to be able to:
o collate and analyze all the useful intelligence gained from provider equity-
focused planning
o capture and share information on local initiatives, and build on local front-line
insights
o share the resulting knowledge across the LHIN – and beyond
o assess most promising initiatives or directions
o scale up promising initiatives across the province where appropriate

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• health disparities are pervasive and damaging → high
public policy priority
• the roots of these disparities lie in far wider social
and economic inequality, but much can be done
within the health system
• a great deal of equity-focused planning and delivery is
already going on
• there is a solid base of healthcare provider
experience, commitment and community connections
to build on
• with the right strategy, tools and commitment,
progress can be made in enhancing health equity

• back to bigger picture
• following is a roadmap for comprehensive
integrated policy action on determinants of
health and health inequality


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;


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:
o making equity a core objective and driver of health system reform – every bit
as important as quality and sustainability;
o eliminating unfair and inefficient barriers to access to the care people need;
o 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:
o enhanced primary care for the most under-served or disadvantaged
populations;
o 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 programme and policy instruments, and into a
coherent and coordinated overall strategy for health equity.


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


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Meeting Highlights Health Equity Plans

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