1. Driving Local Action on Health
Equity
Bob Gardner
North Hamilton Community Health Centre
June 19, 2013

2. 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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3. And Locally
Code 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
emergency department
visits in downtown core
• 2X for psychiatric
emergencies
• less access to primary care
3July 2, 2013 | www.wellesleyinstitute.com

4. Today
• these health disparities are deep-seated and complex
• but they can be tackled addressed through comprehensive health
equity strategy and concerted action
• means acting on health equity within the health system
• will set out elements of a roadmap to build equity into health
planning and delivery
• CHC have long played a crucial role in driving equity into action
• also have to act well beyond health care -- tackling the underlying
social determinants of health
• through community-based innovation, cross-sectoral
collaborations and fundamental social and policy change to
reduce inequality
• again, with examples and opportunities for CHCs
4

5. Planning For Complexity
even though roots of health
disparities lie in social and
economic inequality
need 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
5July 2, 2013 | www.wellesleyinstitute.com

6. 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
• Health Equity Imapct Assessment is one tool
2. aligning equity with system drivers and priorities
• quality improvement, chronic disease prevention and management,
wait times, Health Links
• none of these directions can succeed without taking equity barriers,
social determinants of health and differential risks and needs into
account
• action idea = all Hamilton hospitals and CHCs to include equity
indicators in their QIPs
• aligning with key priorities also enhances chance for success and
sustainability of equity focus
6July 2, 2013

7. Building Equity Into the Health System: II
3. identifying those levers that will have the greatest impact on reducing
health inequities and driving system change
• solid interntional evidence that enhanced primary care is one of key
means to improve inequitable health care and health for
disadvantaged populations
• improving primary care is a major Ministry priority
• Family Health Teams, Health Links and many other initiatives are part
of this
• Community Health Centre model of care is the only sector
• explicitly geared to supporting people from marginalized
communities
• with comprehensive multi-disciplinary services covering full
range of needs
7July 2, 2013 | www.wellesleyinstitute.com

8. Building Equity Into the Health System: III
4. embedding equity in provider organizations’ deliverables,
accountabilities and performance management – in the incentives and
pressures that really drive the system
• a big problem for primary care is the doctor-driven incentives of
other models
• CHCs are working to develop a comprehensive performance
measurement and management system
5. targeting some resources or programs to reducing health disparities or
improving the health of the most disadvantaged, fastest
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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9. 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 clients
+ through an equity lens:
• not all clients are the same – diverse cultures, backgrounds and
perspectives, and unequal social and economic conditions
• how to involve all types of clients?
• specifically, how to involve and empower those not normally included
• adapt different and innovative methods – e.g. principles of inclusion
research
+ thinking about the communities in which they live and the social
determinants that shape their opportunities for health
9July 2, 2013 | www.wellesleyinstitute.com

10. Ensure Planning Is Community
Driven
• many hospitals and other
providers have community
advisory committees
• LHINs do a great deal of
community engagement
• CHCs have community boards
• CHCs demonstrate how to really
build community interests/voices
into planning and delivery →
lessons for other sectors
make this community engagement
real
• for all providers:
• community committees’
recommendations must be
responded to by mgmt
• committees make decisions
over a proportion of
discretionary budget
• for LHINs:
• build local health and well-
being councils, with
information and other
resources so they can work
effectively
• give these local councils
control over a proportion of
discretionary budget
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11. Collaborative Equity Planning
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• to meet accountability
requirements from Toronto
Central LHIN
• developed common equity
principles
• identified common priorities to
work on together:
• interpretation
• building equity into CHC
performance management
system
• uninsured
• action idea: similar joint equity
plan for local CHCs (+ others?)
• action idea = Hamilton health
equity plan, building on
Roundtable in spring

12. Never Just Equitable Access, But Quality:
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
→ customizing care mix to meet those needs
→ 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 crucial
• all of this is CHC model of care = constant demonstration about how to
deliver comprehensive equity-driven care
• pre-condition = need to know social context/conditions of
community/clients
• language, income, immigration history
• project in Toronto Central to collect such data directly
• as electronic health records are being developed, ensure equity and
social determinants data is built in
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13. Extend Equity-Driven Service → Address Roots of
Health Inequities in Communities
build on equity-orientated models
• 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
• hub-style multi-service centres →
• coordinated services -- a range of health and employment, child care,
language, literacy, training and social services are provided out of single
‘one stop' locations
• based solidly in local communities and responding to local needs and
priorities → can become important community ‘space’ and support
community capacity building
look beyond vulnerable individuals to the communities in which they live
→ meeting full range of needs means moving beyond health care
• focus on community development as part of mandate for CHCs
• providing and partnering to provide comprehensive services/support such as
settlement, language, child care, literacy, employment training, youth
programs, etc.
14July 2, 2013 | www.wellesleyinstitute.com

14. • vulnerable populations will vary in different places:
• poor neighbourhoods with high % of racialized population in many big
cities
• newcomers = major theme of earlier Roundtable
• highlights importance of community health profiles
• identifying ‘priority populations’ is key public health strategy
and mandate of CHCs is to serve most vulnerable
• action idea = create local primary care coordinating tables to
bring CHCs, Health Links, Family Health Teams, public health
and other providers together
• action idea = HNHB primary care initiatives to apply HEIA to
plans and adopt explicit equity objectives and targets
Invest in Health Disadvantaged
Populations or Communities
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15. Target Systemic 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
•action idea = create local network or
initiatives to improve access for uninsured
and/or refugees
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16. Addressing Systemic Barriers: Interpretation as
a Key Quality and Equity Lever
precondition for equity
• ensuring that adequate
interpretation is available
wherever needed → improves
quality and equity
• LHINs using available levers →
formal requirement on all
providers
+ alignment
• access to interpretation also
underlies wait times, safety and
other system priorities
•action idea = Hamilton providers
consider centralized/coordinated
interpretation services
17July 2, 2013 | www.wellesleyinstitute.com

17. Canadians With Chronic Conditions
Who Also Report Food Insecurity
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18. Health Promotion Through an Equity Lens
• programs have to take account of inequitable resources of vulnerable
individuals and communities
• advice to manage diabetes or heart problems by exercising depends
upon affording a gym or being close to safe park
• if not customized, generic health promotion programs can widen
disparities as better off take them up disproportionately
• 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
• action idea = Immigrant Women's’ Health Centre, Aboriginal
communities and other vans
• CHCs lead/demonstrate how equity-driven health pomrotion can be
done
19July 2, 2013 | www.wellesleyinstitute.com

19. Pulling it All Together: 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
• CHCs have long played a key role in developing and
connecting these resources and partnerships
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20. Equity and Community-Driven Local Planning
pre-condition for this kind of
coordinated action = creating an
effective cross-sectoral planning
forum
action idea = create local health
equity forum with concrete planning
mandate
can build on earlier roundtable
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/pr
ojects/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
22July 2, 2013 | www.wellesleyinstitute.com

21. 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 just 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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22. © The Wellesley Institute
www.wellesleyinstitute.com
Shifting the Frame
Sudbury & other public health
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23. 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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24. 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 where you are
• have set out a roadmap – of strategies, tools and ideas -- to drive equity
into action through policy change and community mobilization
where CHCs come in:
• demonstrating every day that something can be done about systemic
inequities -- by delivering the best possible health care to disadvantaged
communities
• working in partnerships and collaborations well beyond health care to
address the underlying determinants of health
• I see CHCs as a beacon and inspiration – showing change is possible and
how to move towards a more equitable health future
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