Health Equity Roadmap: Driving Local Action

Health Equity Roadmap Driving Local Action

Bob GardnerHamilton Health Equity Roundtable

Feb 27, 2013

Problem to Solve: Systemic Health Inequities in Ontario

•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 •+ major differences between women and men•the gap between the health of the best off and most disadvantaged can be huge – and damaging•impact and severity of these inequities can be concentrated in particular populations and neighbourhoods

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And LocallyCode Red series on health inequities by neighbourhoods:

• 21 years difference in age at death

• major differences in health outcomes across many measures

plus inequitable access to health care in poorest areas

• 50% higher rates of emergence departments visits in downtown core

• 2X for psychiatric emergencies

• less access to primary care

April 12, 2023 | www.wellesleyinstitute.com

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Three Cumulative and Inter-Dependent Levels Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health

→ gradient of health in which more disadvantaged individuals and communities have poorer overall health and are at greater risk of many conditions

2. also because of broader social and economic inequality and exclusion

→ some communities and populations have less infrastructure, resources and resilience to cope with the impact of poor health

3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the health care and other systems

→ these disadvantaged and vulnerable populations and communities tend to have inequitable access to services and support they need

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Planning For Complexity

even though roots of health disparities lie in social and economic inequalityneed to also look at how these other systems shape the impact of SDoH:

•access to health services can mediate harshest impact of SDoH to some degree•so too can responsive social services•structure, resources and resilience of communities shape impact and dynamics of inequalities


• as a result of the social gradient of health, 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

• 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

Equity Into Health System: Why

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Building Equity Into the Health System: How

1. building health equity into all health care 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 priorities• quality improvement, chronic disease prevention and management,

wait times• none of these directions can succeed without taking equity barriers,

social determinants of health and differential risks and needs into account

• aligning with key priorities also enhances chance for success and sustainability of equity focus

3. identifying those levers that will have the greatest impact on reducing health inequities and driving system change • e.g.. enhanced primary care

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Building Equity Into the Health System: II

4. embedding equity in provider organizations’ deliverables, incentives and performance management – in the incentives and pressures that really drive the system

5. targeting some resources or programs specifically:• looking for investments and interventions that will have the highest impact on

reducing health disparities or improving the health of most disadvantaged, fastest• key access barriers – language, culture, availability• addressing disadvantaged populations – poor, isolated, racialized, homeless

6. investing up-stream in health promotion and addressing the underlying determinants of health

7. enabling equity-focused innovation• a huge range of promising and innovative programs have been developed by

Community Health Centres, hospitals, networks and other providers to address the needs of disadvantaged communities.

• we need to share lessons learned, evaluate and identify what is working, and build on the enormous amount of local imagination and innovation going on

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Where to Start?

• can’t just be ‘experts’, planners or professionals who define issues and drive system transformation• have to build diverse voices and community needs into planning• not just as occasional community engagement• but to identify fundamental needs and priorities• and to evaluate how we are doing

→ need to start from communities and patients + through an equity lens:

• not all patients are the same – diverse cultures, backgrounds and perspectives, and unequal social and economic conditions

• how to involve all types of patients?• specifically, how to involve and empower those not normally included• adapt different and innovative methods – e.g. principles of inclusion research

+ thinking also about the communities in which they live and the social determinants that shape their opportunities for health


And Start From a Solid Strategic Commitment

• need to make equity one of driving priorities for health system and its transformation• equity and a population health focus are among key principles enshrined in new

Excellent Care for All Act = opening and context

• need clear provincial strategy for equity: • implicit from MOHLTC, but not in Action Plan• equity and population health are in public health standards

• LHINs, CCACs, and other coordinating agencies need to prioritize equity – and many have

• cascading down to all providers prioritizing equity in their overall strategic plans and then into service delivery and resource allocation

• action idea = Hamilton providers to make explicit strategic commitment to acting on equity

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Into Practice Through Equity-Focused Planning

• at system level = 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

• at practice level = considering equity in all program and service planning• obvious – given gradient of prevalence and impact of chronic diseases + impact of

living conditions → CDPM programs have to take social determents and community conditions into account

• not so obvious – surgery seems purely clinical• but concern about reducing re-admission rates → need to understand living and social conditions into

which people are being discharged

• requires an array of effective and practical equity-focused planning tools

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Always Plan through a Health Equity Lens

Could this program or direction 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 service planning/delivery?

if we don’t know → find out• highlights importance of collecting better

equity-relevant data across the system and by every provider

• can use proxy data from postal code = neighbourhood characteristics from census data

• can use case studies and small-scale interview/chart review studies

• can draw on provider experience and community perceptions

•if evidence is yes → then drill down using fuller HEIAApril 12, 2023 | www.wellesleyinstitute.com

Providers should apply this type of equity lens routinely – from strategic to service planning

Health Equity Impact Assessment• analyzes potential impact of program or policy change on health

disparities and/or health disadvantaged populations• can help us identify key barriers to equitable access, specific needs

of health-disadvantaged populations and service gaps• can help uncover unintended consequences or nuances easily

missed in program planning• it can help ensure that projects not specifically about equity or

particular populations, will take equity into account• e.g. planning diabetes awareness and outreach – helps take

language, diversity, local community conditions, etc• 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

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• first piloted and refined in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI, further piloted in other LHINs, and rolled out to all

• template, workbook and other resources from Ministry at http://www.health.gov.on.ca/en/pro/programs/heia

• growing, if uneven, use across all 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 piloted by Public Health Ontario

• primers on HEIA and a variant Mental Health Wellbeing Impact Assessment, many Wellesley workshops and other resources can be found at http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment

• action idea= all providers in Hamilton to pilot HEIA

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http://www.health.gov.on.ca/en/pro/programs/heia

http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment

http://www.wellesleyinstitute.com/policy-fields/healthcare-reform/roadmap-for-health-equity/heath-equity-impact-assessment

Align Equity With Health System Drivers

• Excellent Care For All Act and quality improvement agenda • providers have to develop Quality Improvement Plans

• hospitals first reported April 2011• other providers beginning to report• equity should be developed as one of dimensions to report on – but

wasn’t really in hospital plans

• action idea = all Hamilton hospitals and CHCs to include equity indicators in their QIPs

• will return to other drivers such as chronic disease prevention and management, patient-centred care

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Embed Equity in Targets, Deliverables, Performance Management and other System Drivers

• 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 more

equitable service delivery and health outcomes• tying funding and resource allocation to performance• closely monitoring progress against the targets and

indicators• disseminating the results widely for public scrutiny

• all this needs to be integrated into comprehensive performance measurement and management strategy

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Success Condition: Effective Equity Targets

• innovative work underway to develop equity indicators – but don’t need to wait

• build equity into existing targets:• reducing avoidable hospitalization and/or readmissions is key prov

priority – and clearly good for patients → equity target = reduce inequitable differences in rates between

different populations or areas• action idea = Hamilton hospitals to monitor differences in avoidable

admissions and re-admissions by neighbourhood • and the same for person-centred care:

• satisfaction is widely used indicator of meeting patient needs and perspectives

→ equity target = reduce differences in satisfaction by gender, neighbourhood, language, etc.

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Success Condition = Better Data

•CHCs collect good data•pilot project in 3 Toronto academic hospitals to collect equity data – scaled up to all hospitals in Toronto Central •action idea = Hamilton hospitals to develop appropriate model

•looking abroad for promising practices = Public Health Observatories in UK

• consistent and coherent collection and analysis of pop’n health data

• interest/development in Western Canada

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• a promising direction several LHINs have taken up is to require providers to develop equity plans• hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TC• and other providers in Central• CHCs have developed a sector-wide plan in GTA

• these plans are 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

Use Available Accountability Levers: Equity Plans

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Toronto Central LHIN Equity Plans


Never Just Equitable Access, But Quality:Equity Into Quality Service Delivery

• adverse social context and living conditions→ can increase risk of mental and physical illness + fewer resources to cope (from supportive social networks, to good food

and being able to afford medications)• for high quality person-centred care

→ providers and programs need to customize and adapt care to population needs and contexts

→ good communications and provider-patient relationship means taking the full range of people’s needs/situations into account

• e.g.. more intensive case management, referral planning and post-discharge follow-up for health disadvantaged

• in an increasingly diverse society, high quality care = culturally competent care:• requires organizational resources, commitment and operationalization

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Not Just Responsive Individual Care: Build Equity-Driven Service Models

• drill down to further specify needs and barriers:• health disadvantaged populations have more complex and greater

needs for services and support • → continuum of care especially important• also face greater access barriers – e.g.. availability/cost of

transportation, childcare, language, discrimination • → facilitated access and effective navigation/transitions is especially

important → locate some Health Links initiatives in most vulnerable communities

and ensure equity is built into planning all initiatives

• action idea = apply HEIA and develop equity plan for the Hamilton Central Health Link initiative out of McMaster Family Health Team

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Extend Equity-Driven Service → Address Roots of Health Inequities in Communities

• build on equity-orientated models• e.g.. Community Health Centre model of care is explicitly geared to supporting

people from marginalized communities with comprehensive multi-disciplinary services covering full range of needs

• CHCs, public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to communities facing particular barriers

• look beyond vulnerable individuals to the communities in which they live

→ meeting full range of needs means moving beyond healthcare• focus on community development as part of mandate for many PHUs and CHCs • providing and partnering to provide related services/support such as settlement,

language, child care, literacy, employment training, youth programs, etc.


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Potential of Hub Models

hub-style multi-service centres around the world and across the country• a range of health and employment, child care, language, literacy, training and

social services are provided out of single ‘one stop' locations• can provide more ‘wrap-around’ integrated services from person’s point of view• based solidly in local communities and responding to local needs and priorities →

can become important community ‘space’ and support community capacity building

• from provider and funder points of view = more efficient use of scarce resources• can enable synergies among providers and better overall coordination

• emerging forms:• CHCs as hubs of primary care, health promotion and related social services• network of neighbourhood multi-service centres• schools with health and social services acting as hubs for their local communities


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Target Investment for Equity Impact

• target services to:• those facing the harshest disparities – to raise the worst off fastest• or most in need of specific services• or the worst barriers to equitable access to high-quality services

• this requires resources• lever = certain % of LHIN budgets to be equity targeted

• this requires sophisticated analyses of the bases of disparities:• i.e. is the main problem language barriers, lack of coordination among

providers, sheer lack of services in particular neighbourhoods, etc.• which requires good local research and detailed information – speaks to great

potential of community-based research• involvement of local communities and stakeholders in planning and priority

setting is critical to understanding the real local problems

• vulnerable populations will vary in different places:• poor neighbourhoods with high % of racialized population in many

big cities• Aboriginal communities across the prov

• identifying ‘priority populations’ is key public health strategy• mandate of CHCs is to serve most vulnerable• solid evidence that enhancing primary care is one of key ways to

improve care of disadvantaged• equity target = ensuring access and use of primary health care does

not vary inequitably by income level, immigration status, neigbourhood, gender, race, etc.

• action idea = HNHB primary care initiative to apply HEIA to its plan and adopt explicit equity objectives and targets

Target Health Disadvantaged Populations or Communities

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Target Barriers•in Toronto and other cities: people without health insurance

• immigrants in 3 month wait time, refugees

• inequitable access → delayed care and worse outcomes

• CHCs and community clinics provide some access

• Women’s College Hospital Network on Noninsured is forum for coordination

•federal cuts to refugee healthcare→ adverse impact on particularly vulnerable

people→ increased healthcare costs/demands at

prov and provider levels•equity is ‘wicked’ policy problem, but not all of it = predictable and avoidable results of bad policy•action idea = create local network or initiatives to improve access for uninsured and/or refugees

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Addressing Systemic Barriers: Interpretation as a Key Quality and Equity Lever

•access to interpretation underlies wait times, safety and other system priorities – consistent evidence that:

• poor communication due to language or cultural can contribute to misdiagnoses and inappropriate prescriptions

• inability to read or understand instructions can lead to medication errors → safety, cost and re-admission implications

• promising indications that good interpretation helps keep people out of hospital and get them out sooner

•requirement that adequate interpretation be available wherever needed → improves quality and equity•action idea = Hamilton providers consider centralized/coordinated interpretation services


Canadians With Chronic Conditions Who Also Report Food Insecurity

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Health Promotion Through an Equity Lens

• programs have to take account of inequitable resources of vulnerable individuals and communities• advice to manage heart problems by exercising depends upon affording a

gym or being close to safe park• adjust programs to inequitable risks and specific barriers

• South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America (Creatore et al CMAJ Aril 19, 2010)

• deliver in languages and cultures of particular population/community• go where people are -- e.g. CHCs/promoters into malls• idea = Immigrant Women's’ Health Centre, Aboriginal communities and

other vans• if not customized, generic health promotion programs can widen disparities

as better off take them up disproportionately


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Pulling it All Together: Acting on Patient and Community Priorities

• one goal of LHIN and provider engagement should be building significant community participation and influence into priority setting

• draw on experience at provider level:• many hospitals have community advisory panels• CHCs and many community-based providers have residents on their boards • some forms of FHTs also have community governance

• build on insights from other countries – idea of participatory planning -- various health councils or forums • give the councils all the information they need → make recommendations on

promising initiatives and allocation of resources, and address tricky trade-off issues• make this real = allocate a % of LHIN discretionary budget to priorities or initiatives

identified by local planning forums or other means of engagement• action idea = embed community/patient participation in provider expectations:

• providers determine most appropriate mechanism/forum for their context• but all need to institutionalize some form of direct community/patient forums


Pulling it All Together II: Local Cross-Sectoral Planning

• cross-sectoral coordination and planning can identify community health needs, access barriers, fragmentation, service gaps, and how to address them• public health departments and LHINs are pulling together

or participating in cross-sectoral planning tables• Local Immigration Partnerships, Social Planning Councils• such broad collaboration will be particularly important to

Health Links and other system integration initiatives• and coordinated services are particularly important in less

advantaged communities with less resources• also key means to address deep-seated health inequities and

wider SDoH at community level:• role of LHINs = connect and support these resources and

partnerships

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Pulling it All Together III: Potential of Local Equity Plan?

strategy developed in 2008 for Toronto Central LHIN -- many recommendations have been acted onyour and other LHINs have very different community structures and population health needsbut is there value in a Hamilton equity plan within HNHB LHIN?

• could bring together healthcare providers within the LHIN, but also public health, non-healthcare community organizations, business, residents and other stakeholders

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Or, At Least, Local Equity Planning

Hamilton plan may not need to be so comprehensive?

regardless -- pre-condition is creating an effective cross-sectoral planning forum

action idea = create local health equity forum with concrete planning mandate

Looking for Ideas : SETO

•arose out of community concern re access•brings together public health, CHCs, shelters, researchers and service providers serving marginalized communities in south-east Toronto•for an overview of SETo’s development see http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx •ongoing collaboration and idea sharing → supports service coordination and problem solving•emphasized concrete demonstration projects → many with lasting impact•advocacy with institutions and governments around results of projects and key issues such as harm reduction, dental care and access for non-insured people


http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx

http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx

Building on the Potential of Community-Based Innovation and Initiatives

potential:• huge number of community and front-line

initiatives already addressing equity across province

• + equity focused planning will yield useful information on existing system barriers and the needs of disadvantaged populations

• and we’ll be seeing more and more population-specific program interventions

but• these initiatives and interventions are not

being rigorously assessed• experience and lessons learned are not being

shared systematically• so potential of promising interventions is not

being realizedneed forums to share and build innovation• another advantage of local equity forum – like

this roundtable

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© The Wellesley Institutewww.wellesleyinstitute.com 45

Shifting the Frame

Sudbury & other public health


Back to Community Again: Build Momentum and Mobilization

• 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 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’

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Health Equity

• could be one of those ‘big’ unifying ideas..• if we see opportunities for good health and well-being as a

basic right for all• if we see the damaged health of disadvantaged and

marginalized populations as an indictment of an unequal society – but that focused initiatives can make a difference

• if we recognize that coming together to address the social determinants that underlie health inequalities will also address the roots of so many other social problems

• 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

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Key Messages• health inequities 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• there is a solid base of evidence, provider experience, commitment and

community connections to build on

• have set out a roadmap – of strategies, principles and tools -- to drive equity into action through policy change and community mobilization

• many within the health care system have long experience and strong commitment to equity → build on this to drive coordinated and coherent system-wide equity agenda into action

• work in partnerships and collaborations well beyond health care to address the underlying determinants of health inequalities

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Health & Medicine

Health Equity Roadmap: Driving Local Action