This presentation talks about the importance of health equity during difficult times. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Driving Health Equity in Tough
Times
Presentation to the Hospital Collaborative on
Marginalized Populations
April 2012
Bob Gardner

2. Social Determinants
of Health + Complex
Systems
Need to look at how these
other systems shape the
impact of SDoH:
•access to health
services can mediate
harshest impact of
SDoH to some degree
•community resources
and resilience are
important
POWER Study: Gender and
Equity Health Indicator
Framework
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3. Three Cumulative and Inter-Dependent Levels
Shape Health Inequities
1. because of inequitable access to 1. gradient of health in which more
wealth, income, education and other disadvantaged communities have
fundamental determinants of health poorer overall health and are at
→ greater risk of many conditions
2. also because of broader social and 2. some communities and populations
economic inequality and exclusion have fewer capacities, resources and
→ resilience to cope with the impact of
poor health
3. because of all this, disadvantaged 3. these disadvantaged and vulnerable
and vulnerable populations have communities tend to have
greater/more complex needs, but inequitable access to services and
face systemic barriers within the support they need
health and other systems →
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4. Towards Solutions:
Building Equity Into the Health System
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:
• such as chronic disease prevention and management, quality – won’t
succeed without building equity into planning/delivery
• also to enhance chance for success of equity agenda
3. identifying those levers that will have the greatest impact on
reducing health inequities and driving system change:
• enhanced primary care
April 20, 2012 4

5. Towards Solutions:
Building Equity Into the Health System II
4. embedding equity in provider organizations’
deliverables, incentives and performance management
5. 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 looking to
improve the health of most vulnerable, fastest
6. while investing up-stream:
• in health promotion and prevention – crucial to long-term
sustainability and pop’n health
• addressing the underlying determinants of health – crucial to
reducing health inequities
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6. Drummond on Health
• The Drummond Report’s emphasis on reform and innovation
in the way health care is organized and delivered is vital:
• focus on quality and patient-centred care
• emphasis on value, efficiency and innovation
• integration of health services
• long-term planning – call for 20 year plan with coherent
principles (ironically – has been draft within MOHLTC for
years)
• a shift to home and community care
• prevention
• argues that there are many opportunities for reform – and
that many are underway across the system
• But….
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7. Huge element is missing: equity
• equity is not included in his key principles of an ideal system
• which contradicts ECFFA
• equitable access to services, equitable outcomes and improved
population health must also be fundamental goals of reform.
• without taking equity into account:
• reforms being contemplated could make access to health care
less equitable
• good idea of more home and community-based care – but what of
poor home and living conditions of so many?
• or worsen the health of marginalized populations
• good idea of self-care and better information to promote one’s own
health – won’t work for poor, marginalized or those facing
language/literacy barriers
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8. Drummond on Health: Misdiagnosis
• Drummond highlights that a small proportion of patients
with complex needs account for a high proportion of
overall health system costs
• but this isn’t just elderly or end-of-life, or complex mental
health
• consistent inequitable gradient of health = higher
needs/utilization of disadvantaged
• that can be avoided with more equitable strategy and
outcomes
• emphasizes that preventing ill health and controlling
chronic diseases is crucial moving forward
• again, can only work if we take inequitable risk and burden
of chronic diseases into account
• and if we address social and economic inequality that
underlie these health inequities
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9. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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10. Drummond on Health: Primary Care
• The report also highlights the importance of primary care.
• emphasizes Family Health Teams, with their more integrated model of
care than sole practices
• but without addressing their inequitable distribution, incentives and
outcomes
• and ignoring Community Health Centres, who have explicit mandate and
solid record in addressing needs of health disadvantaged populations and
community building
• An equity approach would ensure that expanded family health
teams, community health centres and other key reforms are
concentrated in under-served and higher need areas
• highlighting that his good idea of integration needs to be clarified –
integrated for what?
• not just efficiency but to reduce inequitable access and improve health of
most disadvantaged
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11. Drummond on Health: System
Drivers
• pays remarkably little attention to how fundamental
transformation could actually be driven
• pay attention to incentives:
• e.g. of Family Health Teams – when OMA negotiations drive policy
• dangers of performance or activity-based funding to come – avoid the
complex and challenging
• and performance measurement:
• success conditions – equity-relevant data
• embed equity in provider and LHIN level indicators and targets:
• not just reduce overall hospital readmission rates or incidence of
diabetes
• reduce differentials by gender, income, language, neighbourhood
• provider equity plans
• building equity deliverables into Quality Improvement Plans
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12. Drummond on Health: Integration
• the report rightly points to the need for coordination and
integration of services
• essential to major provincial priorities such as reducing hospital
readmissions
• discharging a patient into overcrowded or unsafe housing means that
they are likely to end up back in the hospital → undermining the
savings and efficiencies the Commission is looking for
• it highlights that the LHINs are most appropriate vehicle for this
integration, but limited by MOHLTC policy/admin
• importance of building solid equity strategy and action at LHIN level
• also speaks to the importance of coordination beyond health care to
social services, housing and other determinants-related spheres
• could be positive role for LHINs moving forward
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13. Drummond on Health: Neglected Social
Determinants
• Drummond did recognize – although unevenly – that not
investing in the social/community foundations of a healthy
society will lead to higher costs down the road
• but didn’t recognize in its health analysis how inequitable
social determinants of health will undermine efforts at
reform and continue to create poorer health
• health providers and institutions have considerable
credibility and influence → use as platform to highlight these
wider connections
• e.g. power of hospital CEOs saying that welfare cuts will
increase pressure on ER and strain health care delivery
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14. Look for Areas to Intervene
•Commission on the Reform
of Social Assistance in
Ontario
•A broad collaborative of
leading Toronto health
sector institutions and
experts came together to:
• Define a vision of health-
enabling social assistance
system; and
• Practical actions to
implement such a system
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15. Public Policy Post-Drummond
• an enormous range of specific recommendations and welcome
recognition of need for govt and public services to be more innovative
and responsive
• but most important influence may be in shaping the tenor/parameters of
public policy
• it justifies and ushers in an era of austerity, restraint and limited public
investment
• this poses a real danger to health
• reducing vital support for affordable housing, safe communities,
transportation, and other community infrastructure will undermine
the foundations of strong and healthy communities
• will have an adverse impact on overall health and will increase health
inequities — in turn, putting more pressure on the health care system
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