This presentation provides critical insights on how build equity and healthy communities. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Bob Gardner
Heart Health Resource Centre Think Tank
on Community Planning
Nov 30, 2009
© The Wellesley Institute
www.wellesleyinstitute.com

2. • 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
2

3. 1. scale and nature of health disparities
2. define starting points and goals: health equity, social
determinants of health
3. 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
3

4. • 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
4

5. 5

6. 6

7. 7

8. 8

9. • 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
© The Wellesley Institute
9
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10. 10

11. 11

12. 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
12

13. • 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
13

14. • 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
14

15. 15

16. • 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
16

17. • 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
17

18. 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
18

19. 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
19

20. • 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
20

21. • 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
21

22. • 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?
22

23. not just
taking account individual
of social programs but
constraints & coordination,
conditions partnerships &
collaboration
23

24. enhanced up-stream heath
access to conditions &
health opportunities
promotion for improve fastest
most for those in
disadvantaged greatest need
24

25. • 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
25

26. 1. quick check to ensure equity is 1. simple equity lens
considered in all service
delivery/planning
2. Health Equity Impact
2. take account of disadvantaged
Assessment – has been piloted in
populations, access barriers and
Toronto and MOHLTC is
related equity issues in program
considering wider roll-out
planning and service delivery
3. assess current state of provider
organization 3. equity audits and/or HEIA
4. determine needs of communities
facing health disparities 4. equity-focused needs
5. assess impact of assessment
programs/interventions on
health disparities and 5. equity-focused evaluation
disadvantaged populations
26

27. • 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
27

28. 1. screening – projects where while HEIA is sometimes
HEIA would be useful promoted as easy-to-use
2. scoping – which pop’n and ‘first-pass’ planning tool
health effects to consider
3. assessing potential equity risks does not mean it is only about
and benefits – specifying 1 -- 3
particular pop’n experts argue core of HEIA is
4. developing recommendations – in fact 4 – assessing &
to promote positive or mitigate developing recommendations
negative effects
to address equity implications
5. report results to decision
makers
6. monitoring and evaluation – of
effectiveness of
recommendations
28

29. • 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
29

30. • 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
30

31. • 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
31

32. • 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.
32

33. • 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
33

34. http://www.torontoevaluation.ca/tclhin/index.html
34

35. • 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
35

36. • 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.
36

37. • 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
37

38. • 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
38

39. • 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
39

40. • 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
40

41. • 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
41

42. • 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
42

43. Diabetes Incidence, TC LHIN 2004/05
16
14 13.3
12
New Cases/1,000
10
8
5.8
6
4
2
0
Low Income High Income
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 43

44. • 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
44

45. 45

46. • 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
46

47. • 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
47

48. 48

49. • 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
49

50. • 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
50

51. • 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
51

52. • 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
52

53. • 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
53

54. • 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
54

55. • 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
55

56. • 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
56

57. • back to bigger picture
• following is a roadmap for comprehensive
integrated policy action on determinants of
health and health inequality
57

58. 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;
58

59. 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;
59

60. 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.
60

61. • 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
61

62. The Wellesley Institute advances urban health through rigorous research,
pragmatic policy solutions, social innovation, and community action.
62