© The Wellesley Institutewww.wellesleyinstitute.com

Bob Gardner

Heart Health Resource Centre Think Tank

on Community Planning

Nov 30, 2009

• understanding the scale, impact and roots of existing health disparities in Ontario

• to build insights from social determinants of health data and analysis into healthy communities planning

• learning how to develop and adapt specific health equity-focused health impact and planning tools and approaches

• identifying the most promising collaborations and initiatives to build on

• all geared to the priority areas identified within the Healthy Communities Ontario (HCO) strategy

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1. scale and nature of health disparities2. define starting points and goals: health equity, social

determinants of health3. how to build this into healthy community planning

framework – approaches, tools, data and success conditions

4. social determinants of health into planning:• within health system• upstream into CDPM and health promotion• beyond health systems into cross-sectoral collaboration• building on the potential of local initiatives and

connections

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• 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 status of the best off and most disadvantaged can be huge – and damaging• difference btwn life expectancy of top and bottom income decile = 7.4

years for men and 4.5 for women• 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)

• in addition, there are systemic disparities in access to and quality of care within the healthcare system

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www.welleseyinstitute.com

• 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 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

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• 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

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• 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

• and can encompass equity-focused health promotion• recognizing that vulnerable populations face more complex and

serious barriers to good health• recognizing that programs and plans need to always take this social

context and constraints into account

• achieving health equity would extend far beyond enhancing individual and collective well-being

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• 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

• need to start somewhere – and we’re in health systems

• 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

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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

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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

many recommendations have been acted on

other LHINs are also prioritizing and moving to address health disparities

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• 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

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• to develop effective planning need:

• clear strategy

• solid coherent approach

• repertoire of effective tools and techniques

• with support for planning authorities and practitioners to effectively use them

• good actionable information

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• more specifically, need clear strategy and theory of what ‘healthy community’ planning looks like

• including clear vision of 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?

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taking account

of social constraints &

conditions

not just individual

programs but coordination,

partnerships & collaboration

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enhanced access to

health promotion for

most disadvantaged

up-stream heath conditions & opportunities

improve fastest for those in

greatest need

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• 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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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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• 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

• at same time, need for shorter and more focused processes – sometimes called Rapid HIA -- had been recognized

• HEIA is seen to be relatively easy-to-use tool

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1. screening – projects where HEIA would be useful

2. scoping – which pop’n and health effects to consider

3. assessing potential equity risks and benefits – specifying particular pop’n

4. developing recommendations –to promote positive or mitigate negative effects

5. report results to decision makers

6. monitoring and evaluation – of effectiveness of recommendations

while HEIA is sometimes promoted as easy-to-use ‘first-pass’ planning tool

does not mean it is only about 1 -- 3

experts argue core of HEIA is in fact 4 – assessing & developing recommendations to address equity implications

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• WHO Commission emphasized need for such planning tools

• Senate Sub-Committee on Population Health recommended HIA be used to ground government decision-making and related equity data, research and planning mechanisms in its recent report

• PHAC has commissioned a review of HEIA in other jurisdictions and held consultations in Oct

• parallel workshop was held on how HEIA and social determinants outcome indicators can be adapted for Aboriginal health planning purposes

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• will use of HEIA and other tools be voluntary (and how strongly encouraged) or mandatory (and how strongly supported and enforced)?• international lesson = explicit requirements – or at least

significant incentives – are key to widespread implementation

• what kinds of incentives and levers should be used to encourage/drive use of HEIA?• special ear-marked funding or consultant support to begin to

use HEIA – especially at start• requiring proponents to demonstrate they have used HEIA in

planning out a potential project whenever they apply for HCO funds

• requirements within accountability agreements that providers use HEIA in appropriate circumstances

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• a premise of the draft Ontario HEIA – and many others – is that:• assessing the potential impact of initiatives on particular populations

requires solid understanding of that population's health status, needs and context

• this can benefit from ongoing community engagement with the population and/or specific needs assessment

• analyzing possible mitigation strategies will also benefit from engaging the affected population in designing the necessary service changes

• similarly, the stage of monitoring and assessing the impact of the initiative – and how HEIA contributed -- also needs:• research and input from the affected population on impact• outcome data stratified by population and determinants

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• MHP is funding various projects and centres under its healthy communities stream

• these agreements and funding programs provide an opportunity to build in specific equity expectations

• expectations will vary by community and provider, but could include:• undertaking appropriate equity-focused planning• 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• ensuring service utilization matches appropriately with demography

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

populations – homeless, isolated seniors, etc.

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• 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

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

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• comprehensive policies on health equity 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

• need to build equity targets and objectives into routine performance management and provider planning

• principle = every health promotion program should have equity targets

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• we know there will be broad targets for priorities such as diabetes and mental health → build equity into these targets:• several LHINs have 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

• looking up-stream: equity target = ensuring take-up of health promotion programs does not vary inequitably by income level, neigbourhood, gender, race, etc.

• 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.

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• underlying all this planning, monitoring of 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• 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

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• theme of presentations and resources was that a great deal can be done now with existing sources of data • e.g. POWER data cited earlier is available by LHIN

• public health departments also have equity-relevant 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

• tremendous potential if this is done on coordinated prov basis

• presentations and resources from the day and report from working group to Collaborative were published• available on partner sites including

http://www.healthequitycouncil.ca/dev

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• greater chance of success for equity strategy if aligned with provincial priorities

• in fact, equity is essential to MOHLTC and MHP priorities,• 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

• various supports designed to enable people with mental health challenges to live in the community also need to take into account their social conditions

• 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 ways discussed here• highlighted healthy communities approach • highlighted the potential of specific planning tools such as Mental Health

Impact Assessment

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• 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.

• 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

• involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems

• assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context• 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:• research and input from the affected population on impact

• health outcome data stratified by population and determinants

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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– 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 safe

open space and recreational facilities to encourage exercise– 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 -n low-income areas walked more for transportation purposes but less for exercise

• need to build these specific needs and constraints into CDPM planning and resource allocation

Diabetes Incidence, TC LHIN 2004/05

5.8

13.3

0

2

4

6

8

10

12

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Low Income High Income

New

Cases/1

,000

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

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• a very interesting example is the integrated diabetes program developed out of the London InterCommunity Health Centre:– far greater incidence and impact in local Hispanic community– 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, advocacy around employment and other problems

• 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 http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20Final.pdf

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• Waterloo public health has seen food insecurity as a key determinant of health inequalities in their region• developing a comprehensive strategy -- involving many health

and social service agencies • and involving community members directly in setting priorities

and driving community gardens and other local projects

• a number of Toronto CHCs developed peer community-based programs to provide outreach and health promotion to their specific ethno-cultural communities or neighbourhoods

• more generally, poverty reduction strategies – from the provincial down to the local – are a critical context for acting on SDoH

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• 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

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• 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 programs

need to explicitly consider 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 for most disadvantaged

• if this isn’t done → universal programs can unintentionally widen disparities as better off take up programs more

• need to also build local community needs and a priority for disadvantaged into decisions on where to locate new programs

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• 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

• thinking bigger, a healthy communities approach to planning health promotion implies wider community development and capacity building approaches

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• British example of comprehensive policy: 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

• 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

• Ontario provincial associations representing CHCs, mental health and community service agencies have been promoting idea -- including to LHIN CEO provincial planning table

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• link this innovative hub thinking/model to other key equity reforms such as enhanced primary care:• many countries have clinics that provide both health and wider social

services in one place• 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

• think back to earlier eras with public health nurses in schools• they played a key role in identifying problems early, providing routine

care and health promotion

• can begin by putting public health nurses or associated workers in schools in most disadvantaged areas

• then link them into a network of services they can refer kids onto when needed

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• have been emphasizing the potential of local 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 planning is most likely to succeed in breaking silos down

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• healthy communities is far more comprehensive and integrated than previous approaches

• but the improved cross-sectoral planning it envisions will still operate within separate risk behaviours or health conditions

• in individuals’ lives and community dynamics, these conditions and challenges are very much inter-dependent and often cumulative

• build these risks and challenges into ‘healthy communities’ planning from the outset:• enabling a community to define its own health priorities better,

providing better access to good food, exercise facilities and information/support to manage own health → will benefit all these priority areas

• developing health promotion programs that address a neighborhood's full range of challenges in a comprehensive way

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• huge number of community and front-line initiatives already addressing equity and health promotion 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 on promising and successful program 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

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• back to bigger picture

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

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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;

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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;

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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 program 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 bob@wellesleyinstitute.com

• I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity

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The Wellesley Institute advances urban health through rigorous research,

pragmatic policy solutions, social innovation, and community action.

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