This presentation offers health solutions that will help create a more equitable system. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. A Health Equity Toolkit:
Towards Health Care Solutions
For All
Bob Gardner
Solutions: East Toronto’s Health Collaborative
January, 2014

2. Problem to Solve:
Systemic Health Inequities in Ontario
clear gradient in health in
which people with lower
income, education or other
indicators of social inequality
and exclusion tend to have
poorer health
the gap between the best off
and most disadvantaged can
be huge – and damaging
however measured -- by
particular conditions, quality
of life, life expectancy
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3. Gradient of Health Across Many
Conditions
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4. Inequitable Quality
• from a resident participating in Wellesley communitybased research in St James Town
“Language is a big barrier to us whenever we use
any services. When our doctor is on leave then
we are unable to visit a different one due to
language problem. So we may have to go to a
walk-in clinic or emergency. There were no
interpreter services. I do not know if they arrange
them in hospitals. I couldn’t follow what the
doctor said.”
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5. Health Equity
•
•
•
goal of health equity strategy is to reduce or eliminate socially and
institutionally structured health inequalities and differential outcomes
positive and forward-looking definition = equal opportunities for good
health
operationalizing equity in health care = providing care to meet different
needs of different patients and populations, in ways that reduce inequitable
differences in outcomes:
•
understanding and addressing barriers to good care such as language and
misunderstanding/discrimination
•
recent immigrants need care that respects their cultures and
preferences and adjusts to their often more precarious economic
situation
•
understanding and addressing living conditions and social context of
patients
•
poorer people face greater burdens and constraints on opportunities
for good health = need to take into account in care planning
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6. Towards Health Equity Solutions
will set out a toolkit of ideas, directions
and techniques to build equity into
healthcare planning and delivery
• solidly based in research evidence
and years of best practice
• action-orientated and manageable
• measureable – so can monitor and
assess progress
• adaptable to specific organizational
and local contexts
• and can use to act well beyond
health system -- tackling the
underlying roots of health inequality
in the wider social determinants of
health
the particularly good news = don’t need
to start from scratch
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7. Today
equity toolkit
• most ideas/initiatives will be familiar
• but the great potential of networks like this is to identify communitylevel challenges and opportunities, and to pull initiatives and elements
together into a coherent overall equity strategy
was thinking of toolkit in three ways for Solutions:
1. some parts of the toolkit can be adapted in your organization and
sector – where you’re a champion at organizational level
2. some can help plan collaborative actions – potential of connected local
initiatives
3. some are about identifying broader systemic and policy issues -- adding
your collective voice to efforts to shift policy or framing of equity at
system level
will speculate on a few ideas and directions Solutions could consider
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8. 1. Start from Solid Foundations
•
high-performing healthcare systems build equity into all planning
and service delivery
•
•
•
need clear strategic commitment to build equity into system as a
whole
•
•
•
•
doesn’t mean all programs are all about equity
does mean all programs and planning need to take equity into
account
LHIN, Ministry
cascading throughout all providers and programs so that equity
becomes part of working culture across the system
commitment has to be backed up by resources for equity planning
and operationalization
role for Solutions? – mbrs promoting this goal of embedding
across all their organizations and work
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9. 2. Into Practice Through Equity-Focused
Planning
• addressing disparities in access to or quality of health care
requires a solid understanding of:
• the contours and scale of inequitable outcomes
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• key barriers to equitable access to high quality care along
patient journey
• at delivery level = considering equity in all program planning
• e.g. given importance of communications and understanding to
quality care → need to ensure cultural competence, access to
interpretation wherever needed, etc.
• need effective and practical equity-focused planning tools
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10. Tools: Always Plan through a Health Equity Lens
Could this program or policy have a
differential and inequitable impact on
some populations or communities?
How do we need to take the specific
needs of disadvantaged individuals and
communities into account in planning
and delivering this service?
Role for Solutions? Advocate that all
their member organizations use this
type of basic equity lens routinely –
from strategic to service planning
if this basic equity lens indicates there
could be inequitable impact → then
could drill down using fuller HEIA
Role for Solutions? Promote/enable
use of HEIA within its organizations
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11. • analyzes potential impact of program or policy change on health
disparities and/or health disadvantaged populations
• using HEIA can help
•
uncover unintended consequences or nuances easily missed in program
planning
• embed equity into routine planning processes and working culture
• ensure that projects not specifically about equity or particular populations,
will take language, diversity, local community conditions, etc. into account
• especially important for health service providers who are not
experienced with equity and for non-health organizations to take the
population health impact of their policies into account
• growing, if uneven, use:
• across LHINs -- Toronto Central has required HEIA within recent funding
application processes, and refreshing hospital equity plans → some hospitals
have built HEIA into their routine planning processes
• adaptation geared to public health settings and standards been developed
and promoted by Public Health Ontario
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12. 3. Success Condition = Collect Equity Data
need solid equity-orientated data
• to identify gaps and needs of
disadvantaged patients
• to measure and monitor progress
pilot project in 3 Toronto hospitals (and
Toronto Public Health) to collect patient
SDoH type data
scaled up to all hospitals in Toronto Central
LHIN
valuable website of resources on how to
collect and use this data
role for Solutions: all members to adapt data
collection model to their situations, as
standardized as possible → building pool of
SDoH data
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13. 4. Build Knowledge We Can Act On
base includes:
•
epidemiological research – scale of
disparities, disadvantaged
communities/groups, community
health profiles
•
community-based research =
especially unique understanding of
needs and interests of marginalized
or excluded populations
•
evaluation –what works, for which
populations, in varying contexts
•
need forums to share lessons
learned, emerging practices
systematic data collection + ability to
measure/monitor /evaluate + broad
research evidence = knowledge to
guide/ground action
role for Solutions? advocate for this
broad understanding and bring solid
community knowledge into planning

14. 5. Beyond Planning: Embed Equity Into Targets,
Deliverables and Performance Management
• clear consensus from research and policy literature, and
consistent feature in comprehensive health equity policies
and practice from other jurisdictions:
• developing realistic and actionable indicators for more equitable
service delivery and outcomes
• setting targets for reducing access differentials, improving health
outcomes of particular populations, etc
• monitoring progress against the targets and indicators
• disseminating the results widely for public scrutiny
• aligning performance with funding incentives and resource allocation
• principle here = build equity into system drivers and trends
• performance measurement and management are here to stay
• emerging challenge = building equity/population health into
performance-based funding models
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15. Success Condition = Effective Equity Targets
• innovative work underway to develop comprehensive equity
indicators – but don’t need to wait
• pick what is most relevant to your context:
• do rates of post-treatment recovery and hospital re-admission
vary inequitably – by geography, ethno-cultural background,
socio-economic status?
→ equity target = reduce inequitable differences
• build equity into existing targets:
• e.g. reducing hospital admission rates for ambulatory sensitive
conditions and diabetes are system goals
→ equity target = reduce inequitable differences in rates between
different populations or areas
• role for Solutions? advocate within own organizations to build
equity into scorecards and other performance measurement
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16. 6. Embed Equity Into Organizational and
System Drivers
• quality improvement is major provincial and system priority → embed
equity
• patient-centred care + QI + equity = customized care to meet differing
needs
• social determinants disadvantaged populations face greater barriers
beyond the hospital and clinic walls
• availability/cost of transportation, childcare, poor living conditions,
inequitable access to community services, discrimination, being able to
afford medication
→ need more intensive case management, referral planning and postdischarge follow-up for those in more challenging/isolated conditions
→ effective continuum of care and effective navigation/transitions is
especially important for marginalized
• role for networks like Solutions? identifying what good linkages and
comprehensive community support looks like for marginalized
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17. Use Proven Tools: Equity Standards
Canadian Health Equity Standards Working
Group
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18. 7. Use Available Levers To Embed Equity
• key priority for Ministry (therefore LHIN) and great potential to
transform system = Health Links
• considerable debate about whether starting assumptions of heavy
service users, etc., are right
• but regardless of Min directions lots of innovative approaches on
how to build SDoH in
• role for Solutions? explore project on how these and other ideas could
be developed into a comprehensive health equity toolkit for your Health
Links
• e.g. all HL to do community health mapping, identify priority and
under-served populations, adapt tools for customized care for
marginalized, develop explicit equity indicators, etc.
• Solutions mbrs could take lead in promoting these tools and ideas in
their HLs
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19. 8. Target Access and Quality Barriers
improving equity requires identifying and addressing specific
equity barriers
• within delivery – language, lack of understanding of different cultures,
differential treatment, prejudice and discrimination, accessibility
• beyond the clinical – e.g. sent home with follow-up prescriptions, but
don’t have a drug plan; can’t come into clinic for follow-up because of
family responsibilities
• most important barriers will vary → back to importance of data and
understanding health needs of community
another Solutions’ focus for Health Links?
• population health profiles, health equity audits, community engagement
→ to identify most important local barriers and gaps
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20. 9. Barrier = Under-Served Populations
Solution = Focused Community Partnerships
given often higher care needs and
less access to personal, family or
community resources facing most
marginalized:
• effective follow-up and
referrals and good continuity
of care, navigation and
transitions are even more
impt for the most vulnerable
• requires dense and connected
web of community support
role for Solutions? fulcrum to
strengthen collaboration among
community agencies through an
equity lens
• focused on particular
populations or barriers

21. 10. Shifting the Policy Frame:
Health = Healthy and Equitable Communities
what if hospital leaders said: we’re
not the most important drivers of
good health and we’re going to
work with others to build healthier
communities.
role for
Solutions?
policy advocacy
for key local
issues, adding
voice to wider
campaigns,
system issues
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22. Pull All This
Together into a Strategic
Roadmap
is there value in Solutions
developing an equity plan?
• what mbrs will do to promote
equity in their home orgs
• what network can do to
identify most pressing
common equity challenges
and collaborative
opportunities for change
can’t be a rigid blueprint, needs
to be adapted and implemented
flexibly to contexts and
circumstances
• but thinking of equity
roadmap helps to pull
various initiatives into a
coherent and connected plan