Central LHIN Leaders’ Briefings: Building Health Equity into Action

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Bob GardnerNovember 2009

Meetings of Community Providers on Health Equity Plans


• 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

December 8, 2009

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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

December 8, 2009


• 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

December 8, 2009


• 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

December 8, 2009


• 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

December 8, 2009

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• 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 ino 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 impacto either in terns of meeting the health needs of most disadvantaged

populationso or addressing most important barriers to health equity

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

December 8, 2009


• 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 careo targeted interventions to improve the health of the poorest fastest –

often as part of community/local initiatives

December 8, 2009


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

December 8, 2009


% With Physician Visits for Arthritis, Age 45-64, TC LHIN 2001-03

1311

20

14

0

5

10

15

20

25

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

Toronto Central: Lower Income, More Physician Visits For Arthritis

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Toronto Central:

Hip Replacement Rate, TC LHIN, 2004/05

68

144

0

50

100

150

Lowest Income Highest Income

#/1

00

,00

0

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 medicationo dialysis treatmento admission to intensive care unitso 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…..

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• to see if there were differences by gender in clinical practiceo 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 femaleo family physicians were 2X more likely for male

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

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• 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

December 8, 2009


• 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

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1. quick check to ensure equity is considered in all service delivery/planning

2. take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery

3. assess current state of provider organization

4. determine needs of communities facing health disparities

5. assess impact of programs/interventions on health disparities and disadvantaged populations

1. simple equity lens

2. Health Equity Impact Assessment – has been piloted in Toronto and MOHLTC is considering wider roll-out

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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• 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

December 8, 2009


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

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 planningo providing sufficient services in languages of community and

appropriate interpretationo identifying areas where access to services is inequitable and

developing plans to address barriers and gapso ensuring service utilization matches appropriately with demography

and needs of their catchment profileo developing specific services or outreach to particular disadvantaged

populations – homeless, isolated seniors, etc.

December 8, 2009


• 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

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• 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.

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• assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and contexto 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


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• 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

December 8, 2009


• 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 publishedo 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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http://www.healthequitycouncil.ca/dev


• 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

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• 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

December 8, 2009


• 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

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• 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

December 8, 2009


• 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


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• 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

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• 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%20Final.pdf

http://www.ocdpa.on.ca/docs/Primer to Action SDOH Final.pdf

http://www.ocdpa.on.ca/docs/Primer to Action SDOH Final.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

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• 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

December 8, 2009


• back to bigger picture

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

December 8, 2009


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;


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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;


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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.


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• 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 [email protected]

• 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

December 8, 2009

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Central LHIN Leaders’ Briefings: Building Health Equity into Action

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