This document discusses developing a comprehensive health equity strategy in Ontario. It begins by outlining the scale of health inequalities in Canada and how a strategy can address disparities through policy directions, programs, and other enablers. It then discusses comparing strategies in other countries and jurisdictions, and identifying key components like cross-sector collaboration and targeting interventions. The document emphasizes starting with actionable initiatives, evaluating lessons learned, and gradually building a coherent strategy over time to reduce health inequalities.

1. Bob Gardner, PhD
WZB Berlin
March 25, 2010
© The Wellesley Institute
www.wellesleyinstitute.com 1

2. 1. scale and nature of health inequalities in Ontario and
Canada + background on health and social systems
2. how health disparities can be addressed through
comprehensive health equity strategy
3. then how this strategy can be driven into action
• through breaking it up into manageable and coordinated
policy directions and program interventions
• equity-focused planning, promising practices in services,
evaluation, and other enablers for innovation
4. identify key enablers for building successful action on
health equity
5. draw out some interesting comparisons between
Canadian and European situations
2

3. • there is a clear gradient in health in which people with
lower income, education or other indicators of social
inequality and exclusion tend to have poorer health
• concentrated disadvantage and poor health in
particular communities – Aboriginal, poor, immigrant
• major differences between women and men
• the gap between the health status of the best off and
most disadvantaged can be huge – and damaging
• in addition, there are systemic disparities in access to
and quality of care within the healthcare system
3

4. 4

5. 5

6. 6

7. 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 7

8. 8

9. 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)
9

10. • 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
© The Wellesley Institute
10
www.welleseyinstitute.com

11. 11

12. Determinants interact and intersect
with each other in a 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
12

13. • 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 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
13

14. • 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, especially Nordic
• also increasing international and high-level attention:
• WHO Commission on Social Determinants of Health
• European Union, with its Closing the Gap and Determine projects to tackle
health disparities
• look broadly for policy solutions, and adapt flexibly to
local/provincial circumstances
14

15. • focus and balance of national strategies varies but a key theme:
• addressing roots of inequality through macro social and economic
policy
• key components include:
• integrated policy geared to reducing overall social and economic
inequality and enhancing social mobility are the pre-conditions for
reducing health disparities over the long-term;
• early child investment is common theme
• as is poverty reduction
• reducing social exclusion and inequalities in labour market are key
• develop a coherent overall strategy, but split it into actionable and
manageable components that can be moved on
• act across silos – cross-sectoral and cross-government
collaboration and coordination are vital
• local and community-level coordination and interventions are key
15

16. • the point of all this analysis is to be able to identify policy and
program changes needed to reduce health disparities
• but 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 population health
and health system
16

17. • even though roots of health disparities lie in far wider social
and economic inequality
• how the health system is organized and how services and
care are delivered is still crucial to tackling health disparities
• many countries have developed comprehensive multi-
sectoral strategies to reduce health disparities
• in all of them, transforming the health system is an
indispensable element, including:
• reducing barriers to equitable access to high quality care
• targeted interventions to improve the health of the poorest, fastest
• up-stream investments in primary and preventative care directed to
most vulnerable
• delivering these services in coordinated way at community/local level
17

18. 1. it’s in the health system that the most disadvantaged
in SDoH terms end up sicker and needing care
• equitable healthcare and proactive health promotion 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 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 and
health promotion could make overall disparities even worse
• at the least, the goal is to ensure equitable access to care/support
for all who need it, regardless of their social position
18

19. while health disparities are
pervasive and deep-rooted, they
can be changed through policy and
program action
comprehensive strategy developed
in 2008 for Toronto Central LHIN –
50+ recommendations
many recommendations have been
acted on
other LHINs are also prioritizing and
moving to address health disparities
19

20. • goal is to ensure equitable access to high quality
healthcare regardless of social position
• 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
20

21. • align equity with system drivers:
• equity is pre-condition to quality and efficiency agendas
• essential part of high-performing health system -- OHQC
• align with system priorities:
• can’t solve wait times or chronic conditions without
addressing equity
• build equity into priority setting and service planning
• build into performance management:
• targets and incentives
• cascading through the system -- Prov → LHINs, agencies,
etc.→ providers
21

22. • need to make equity one of driving priorities for health system
and reform
• need national leadership – not the case in Canada
• need clear provincial strategy for equity:
• implicit in Ontario
• but promised MOHLTC ten year strategy has not been released
• Ministry of Health Promotion is moving towards a healthy community
planning approach – potentially more equity-orientated
• uneven – within Ont govt and public health, let alone in wider health
system
• need strategic coherence across public health system in approach to
equity
• LHINs and other coordinating agencies need to prioritize equity
• cascading down to clear prioritization from providers for their
service delivery and resource allocation
22

23. • greater chance of success for equity strategy if aligned with provincial priorities:
• diabetes, wait times, mental health
• mental health and diabetes are particularly sensitive to social conditions
• chronic disease prevention and management programs cannot be successful
unless they take account of social conditions and constraints
• critical to enabling people with mental health challenges to live in the
community are a continuum of community supports that take into account the
social exclusion, poverty and other challenges people face
• Wellesley and Canadian Mental Health Association–Ontario partnered on input
to current discussions about mental health strategy:
• stressed that programs had to take account of SDoH in design and delivery
• highlighted healthy communities approach
• highlighted the potential of specific planning tools such as Mental Health
Impact Assessment
23

24. • comprehensive policies on health equity from other
countries include:
• 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
• and, at the same time, need to build equity targets
and objectives into routine performance
management and provider planning
24

25. • there are broad targets for priorities such as diabetes or empowering healthy
behaviours → build equity into these targets:
• a number of PHUs and LHINs have identified areas where diabetes incidence is
highest → equity target = reduce differences in incidence, complications and
rates of hospitalization among populations or areas
• a good service target has been proposed for diabetes = high % of people who
get high standard care → equity target = reduce differences by gender,
income, region
• need to drill down in specific areas that have high equity impact:
• ensuring access and use of primary health care does not vary inequitably by
income level, neigbourhood, gender, race, etc.
• in fact, concentrate services in most disadvantaged communities with greatest
needs
• many programs assess their services through client 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.
25

26. • 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
• this starts from a 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
• involvement of local communities and stakeholders in planning and
priority setting is critical to understanding the real local problems
• and then requires an array of effective and practical equity-
focused planning tools
26

27. 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
27

28. • planning tool that analyzes potential impact of program or policy change
on health disparities and/or health disadvantaged populations
• can help to plan new services, policy development or other initiatives
• can also be used to assess/realign existing programs
• essentially prospective
• arose out of broader health impact assessments, which have been
increasingly used in many jurisdictions in last 15 years
• HIA is commonly understood in municipal and community planning circles
• one reason for HEIA was increasing policy attention to SDoH and health
disparities → need explicit equity focus
• increasing attention to potential – from WHO, through most European
strategies to MOHLTC and LHINs
• HEIA is seen to be relatively easy-to-use tool
• Wellesley partnered to pilot and refine, and HEIA is now being implemented
in Ontario
28

29. • precondition for all this planning, monitoring indicators, and
assessing progress against objectives and targets is reliable data
on:
• health outcomes and behaviour, differentiated by population, neighbourhood and
income, education, ethno-cultural background and other determinants of health
• service use patterns, 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
• recognized as key issue in MOHLTC and LHINs
• similar challenges for public health?
• and why not coordinate development of best equity-relevant data?
29

30. • looking abroad for promising practices = Public Health
Observatories in UK
• consistent and coherent collection and analysis of pop’n health
data
• division of specialization among the Observatories – London
focuses on equity issues
• interest/development in Western Canada:
• Saskatoon has developed a comprehensive local health equity
strategy
• including sophisticated research and created a public health
observatory to collect data and build into monitoring an
continuous improvement
• more generally, innovative thinking emerging around
dynamic systems modeling meeting population health
30

31. • 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:
• undertaking appropriate equity-focused planning
• ensuring service utilization matches appropriately with demography
and needs of their catchment profile
• providing sufficient services in languages of community and
appropriate interpretation
• identifying areas where access to services is inequitable and
developing plans to address barriers and gaps
• developing specific services or outreach to particular disadvantaged
populations – homeless, isolated seniors, etc.
31

32. • a promising direction several LHINs have taken up 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
• build equity into planning, resource allocation and routine delivery
• pull their many existing initiatives together into a coherent overall
equity strategy
• build connections among providers for addressing common equity
issues
32

33. http://www.torontoevaluation.ca/tclhin/index.html
33

34. • provincial standards offer a possible lever
• do include responsibility to assess and act on population health
• many innovative and comprehensive initiatives from PHUs
• require each PHU to develop a health equity plan showing how it
was putting population health standards into practice
• and then:
• call a province-wide roundtable to share, debate and learn from all the
individual plans
• build on these into a coherent overall strategy
• build this into specific expectations and targets and build these into
routine PHU performance management and accountabilities
• more specifically, could require PHUs or other providers to
undertake HEIA to be eligible for particular programs or funding
34

35. • second theme of overall strategic framework is to target services to
specific areas or populations:
• those facing the harshest disparities – to improve the health of the worst off
fastest
• or those most in need of specific services
• or to 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.
• highlighted data
• also requires good local research and detailed information – speaks to great
potential of community-based research to provide rich local needs
assessments and evaluation data
35

36. • language is key barrier to access → cross-sectoral project
analyzing how to enhance and streamline interpretation
services
• many community providers have established ‘peer health
ambassadors’ to provide system navigation, outreach and
health promotion services to particular communities
• for homeless people:
• CAISI database so records are accessible from many providers
• travelling psychiatrists, nurses and other providers
• Baby and Me passport
• Street Health report as CBR into action
36

37. • assessing the potential equity impact of initiatives on
particular populations requires solid understanding of that
population's health situation, needs and context
• and this requires ongoing community engagement with the
population in planning and priority setting
• also means engaging the affected population on how to
design services to meet their specific needs
• similarly, monitoring and assessing the impact of service
initiatives also needs research and input from the affected
population on impact
37

38. • investing in better chronic care prevention and management are
vital elements of health reform
• chronic disease prevention and management programs cannot be
successful unless they take health disparities and wider social
conditions into account
• 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
– poor, Aboriginal and other vulnerable communities face greater incidence and
greater challenges in managing diabetes
– at the same, time these communities tend to have less access to good food,
safe open space and recreational facilities to encourage exercise, etc.
– the Toronto diabetes atlas produced by ICES found that only 25% of in low-
income neighbourhoods participated in weekly sports – versus 75% form
high-income
– built environment is also key -- Atlas found that people in low-income areas
walked more for transportation purposes but less for exercise
38

39. • a very interesting example is the integrated diabetes program
developed out of the London InterCommunity Health Centre:
– began from far greater incidence and impact in local Hispanic
community – originated in local CHCs’ community engagement
– CHC, community groups and others worked closely together
– language specific and culturally sensitive services
– preventative and promotion services offered where people went –
e.g. shopping malls
– also saw that social conditions had to be addressed → referrals to
social service support, cross-sectoral planning, advocacy around
employment and other problems
39

40. 40

41. • health promotion initiatives need to be planned and implemented
through an equity lens
• very clear gradient in incidence of smoking, over-weight, lack of
exercise
• healthy behaviour targets can’t just be increasing exercise rates
and decreasing smoking overall → equity target = reduce
differences by gender, income, region
• a valuable 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 –
– meant to be a virtual resource for health promotion workers in the
field
– http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20
Final.pdf
41

42. • can’t just measure activity:
• number of people or % of pop’n that participated in health promotion
program
• need to measure health outcomes – even when impact only shows up in
long-term
• need to assess reach
• who isn’t signing up? who needs program/support most?
• and assess impact through equity lens
• need to know who stuck with program and what impact it had on their
health – and how this varies by population
• need to differentiate those with greatest need = who programs most need
to enroll and keep to have an impact
• → develop funding and evaluation weighting that recognizes more
complex needs and challenges of most disadvantaged, and builds this into
incentive system
42

43. • cross-sectoral coordination and planning are seen to be key
ways to put wider SDoH into action
• key to British and European strategies are local investments
in community economic development and targeted
healthcare and social service improvements
• 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
• Social Planning Councils are developing cross-sectoral
planning forums and processes in many communities around
poverty and inequality – with clear implications for health
• at best, MHP’s healthy communities approach to planning
health promotion implies wider community development
and capacity building
43

44. • idea of comprehensive community initiatives
• British example of Health Action Zones and other models
were designed to combine community economic
development with targeted healthcare and social service
improvements
• 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
• focusing 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
44

45. • 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 partnered 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
• some new satellite CHCs are being developed in designated high-need
areas in Toronto will involve the CHCs delivering primary and preventive
care and other agencies providing complementary social services out of
the same location
• Ontario provincial associations representing CHCs, mental health and
community service agencies have been promoting idea -- including to
LHIN CEO provincial planning table
45

46. • a key lesson of LHIN experience to date is that existing
networks and partnerships are a huge resource to build on
• principle = identify key networks to enhance equity
coordination and delivery in priority areas and support them
build on them
• there are well-established provider coordinating networks
across the province
• i.e. for mental health priority, can build on:
• local networks of community-based providers
• Canadian Mental Health Association's local divisions
• LHINs and the planning tables they have established for this priority
• and the network of health promotion networks and resource
centres – build on existing infrastructure – don't totally re-
invent
46

47. • potential:
• huge number of community and front-line initiatives already
addressing equity across 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 we’ll be seeing more and more promising and successful program
interventions
• but
• these initiatives and interventions are not being rigorously assessed
• experience and lessons learned are not being shared systematically
• potential of promising interventions is not being realized
47

48. • to drive equity-focused innovation and effective interventions, we
need to be able to:
• collate and analyze all the useful intelligence gained from equity-focused
planning
• capture and share information on local initiatives, and build on local front-
line insights
• share the resulting knowledge across regions – and beyond
• assess the most promising initiatives or directions
• scale up promising initiatives across the province where appropriate
• creating a forum and infrastructure for this innovation knowledge
management is crucial
• but who takes it up?
• innovation doesn’t fit nicely into Ministry and other institutional
boundaries
• whatever the form, needs to be collaboration with Ministries, Prov
associations, other stakeholders?
48

49. • build equity-focused innovation into incentives and
drivers
• cascading from Prov to LHINs to providers
• expectation that X% of budget will be devoted to equity-
orientated innovation
• ear-marked funds for equity innovation
• + government funding of cross-sectoral action addressing
wider determinants
• Public Health Agency of Canada and provincial counterparts
should fund/support cross-sectoral collaborations and initiatives
– getting beyond most programs that can’t fund beyond their
narrow jurisdictional boundaries
• these agencies can become centres of expertise on equity and
SDoH-orientated collaboration
49

50. • figuring our what interventions and approaches work, in what
contexts and why
• to drive investment in policy directions and program interventions
that will have the strongest equity impact
• increasing international, Cdn and Ont interest in more strategic
and realist evaluation
• International Collaboration on Evaluation and Health Inequalities
• I have argued elsewhere for a role for various Canadian public
health agencies
• becoming centres of expertise in evaluation applied to public health
strategy and delivery
• vital link between public health and other players in health system
50

51. • 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 just
because of good analysis but through widespread
community mobilization and social pressure
• key to equity-driven reform will also be empowering
communities to imagine their alternative health
futures and to organize to achieve them
51

52. • 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
• we have enormous resources of knowledge of promising practices
and on-the-ground experience – challenge is to build on this
potential
• have set out overall strategic approaches, principles and tools to
drive equity into action → experiment and innovate
• many within the public health system have long experience and
strong commitment to equity → build on this to drive coordinated
and coherent system-wide equity agenda into action
52

53. • 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
53

54. The Wellesley Institute advances urban health through rigorous research,
pragmatic policy solutions, social innovation, and community action.
54

55. • back to bigger picture
• following is a roadmap for comprehensive
integrated policy action on determinants of
health and health inequality
• plus options for further discussion:
• avoiding unintended consequences
• barriers to collaboration
• importance of social policy
• complexities of planning
• inequitable access to health services
55

56. 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;
56

57. 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;
57

58. 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.
58

59. • health promotion that emphasizes individual health
behaviour or risks without setting it in wider social
context
• can lead to ‘blame the victim’ portrayals of disadvantaged
who practice ‘risky’ behaviour
• focus on individual lifestyle in isolation without
understanding wider social forces that shape choices and
opportunities won’t succeed
• universal programs and promotion that doesn’t target
and/or customize to particular disadvantaged
communities
• inequality gap can widen as more affluent/educated take
advantage of programs
59

60. • have been emphasizing the potential of collaboration and
cross-sectoral planning:
• but health system is fragmented – LHINs, primary care, provincial
programs, acute and up-stream, two ministries, public health
• need to find ways to work beyond jurisdictional boundaries
• let alone developing cross-sectoral collaborations beyond health
• local issue-orientated and community-based planning is most likely to
succeed in breaking silos down
• let alone competing professional interests – organized
medicine as the ‘elephant n the room’ for health reform
60

61. • BC is healthiest province overall (Quebec is 3rd healthiest)
• most social and behavioural risk factors for chronic diseases (i.e.
smoking, physical inactivity, poor education, unemployment and lack of
home ownership)) are significantly more prevalent among low-income
residents of Quebec than BC
• but Quebec’s low-income residents are at the least risk for major chronic
diseases among Canadian provinces
• the percentage of low-income individuals with an unmet medical need
was significantly lower in Quebec (9.5%) -- higher (16.5%) in BC
• 31.5% of BC residents with an unmet medical need reported cost as a
factor compared with only 6.4% of QC residents who reported cost
• Quebec’s anti-poverty strategy (2002) and other comprehensive social
policies appear to give its low-income residents advantages in chronic
disease prevention
• Source: Fang, R. et al Disparities in chronic disease among Canada’s low-income
populations. Prev Chronic Dis 2009;6(4).
61

62. • need clear strategy and theory of what ‘healthy
community’ looks like →what success looks like:
• equitable health promotion and outcomes
• supported and sustained by healthy communities
• effective and responsive kinds of planning to get there
• all within a clear understanding of the wider
context and constraints of social determinants
of health
• and then drilling down: what is our ‘theory’ of
how equity-focused planning works?
62

63. not just
taking account individual
of social programs but
constraints & coordination,
conditions partnerships &
collaboration
63

64. enhanced up-stream heath
access to conditions &
health opportunities
promotion for improve fastest
most for those in
disadvantaged greatest need
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65. • processes and constraints are complex, and outcomes
uncertain and unpredictable, at each of these junctures
• and all of this varies by context:
• particular communities or neighbourhoods – with their different
health challenges and needs
• particular population health and service landscape – further
specified by health condition or concern (e.g. mental health)
• existing municipal and local polices and traditions
• community resilience, connectedness, organizing and traditions
• we don’t really know what works best at each these
junctures (let alone cumulatively) or in varying contexts →
need to build evaluation in from the start to learn
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66. % 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
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67. 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
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68. • 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:
• standard heart medication
• dialysis treatment
• admission to intensive care units
• 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…..
68

69. • to see if there were differences by gender in clinical
practice
• standardized male and female patients went to family
physicians and orthopaedic surgeons
• presented with the same scripted clinical scenario
• found striking differences:
• orthopaedic surgeons were 22X more likely to recommend
male for total knee arthroplasty than female
• family physicians were 2X more likely for male
Source: Borkhoff et al, CMAJ, March 11, 2008
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