This presentation provides critical insight on health equity. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Bob Gardner
Healthcare Interpretation Network
November 23, 2009
© The Wellesley Institute
www.wellesleyinstitute.com

2. • from a resident participating in Wellesley
community-based research in St James Town
“Language is a big barrier to us whenever we use
any services. When our doctor is on leave then
we are unable to visit a different one due to
language problem. So we may have to go to a
walk-in clinic or emergency. There were no
interpreter services. I do not know if they arrange
them in hospitals. I couldn’t follow what the
doctor said.”
2

3. • free and equitable access to high quality interpretation is:
• crucial to breaking down barriers to good health care for
disadvantaged and marginalized populations
• an indispensable pre-condition for achieving equal
opportunities for good healthcare for all-- especially in an
increasingly diverse society
• vital to other key components of an effective health system –
from enhancing access to primary care, to preventing and
managing chronic conditions and ensuring good quality, patient-
centred care
• building high quality interpretation services is a crucial
element of an overall progressive health equity strategy
3

4. • starting points:
• increasing diversity of population
• pervasive health disparities
• health equity strategy
• 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
• where interpretation and language fit as key enablers of
health equity
• relating interpretation to other key drivers and enablers to
move an equity agenda forward
4

5. • 41% of population in Toronto Central LHIN are immigrants
(28% in Ont)
• 8% of population in Toronto Central and 10% in Central
arrived in last five years
• more that half Central's population have a mother tongue
other than English
• digging down locally: 66% of residents in St James Town have a
mother tongue that is neither English nor French.
• 42% speak neither English nor French at home
• 5% of Toronto Central’s population have no knowledge of
English or French
• digging down by population: more than 17% of seniors in
Central do not understand English well or at all
5

6. • health disparities in Ontario – and in LHINs across the
province -- are pervasive
• 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
• plus major differences between women and men
• the gap between the health status of the best off and most
disadvantaged can be huge – and damaging
• in addition, there are systemic disparities in access to
and quality of care within the healthcare system
• those are the problems we are all trying to solve with
health equity strategy and action
6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 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 among lowest and highest
neighbourhoods.
Age Standardized Rates. Data Source: Ontario Diabetes Database, 2004/05
www.ices.on.ca/intool 12

13. 13

14. • 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 & 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
14

15. • 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
15

16. 16

17. • 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:
• the kinds of integrated comprehensive primary care
needed by those with the most pressing and complex
needs – will benefit all
• 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
17

18. clear research consensus
that roots of health
disparities lie in broader
social and economic
inequality and exclusion
real problem is
differential access to
these determinants –
many analysts are
focusing more specifically
on social determinants of
health inequalities
18

19. •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
19

20. 20

21. • everything can’t be tackled at once:
• need to split strategy into actionable components and phase them in
• 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 impact
• either in terns of meeting the health needs of most disadvantaged
populations
• or addressing most important barriers to health equity
• need to start somewhere – and we’re in healthcare system –
and you’re in one of most crucial equity areas
21

22. • 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:
• reducing barriers to equitable access to high quality care
• targeted interventions to improve the health of the
poorest fastest
22

23. • it is in the health system that the most
disadvantaged 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
• in addition, there are systemic disparities in access
and quality of healthcare that need to be redressed
• more vulnerable populations 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
23

24. 24

25. Lower Income: More Physician
Visits For Arthritis
% With Physicia n Visits for Arthritis,
Age 45-64, TC LHIN 2001-03
25
20
20
14
15 13
11
10
5
0
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
25

26. Hip Replacement Rate, TC LHIN, 2004/05
144
150
#/100,000
100
68
50
0
Lowest Income Highest Income
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
26

27. • 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:
• standard heart medication
• dialysis treatment
• admission to intensive care units
• 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…..
27

28. to see if there were differences by gender in clinical
practice
• standardized male and female patients went to family
physicians and orthopaedic surgeons
• presented with the same scripted clinical scenario
found striking differences:
• orthopaedic surgeons were 22X more likely to recommend
male for total knee arthroplasty than female
• family physicians were 2X more likely for male
Source: Borkhoff et al, CMAJ, March 11, 2008
28

29. • 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
29

30. • language is one of most crucial barriers to access to
care
• like most barriers it can be addressed through good
policy and services →
• need high-quality trained interpretation services available
to all who need them -- where and when they need them
• need flexible continuum of responsive and consumer-
centred interpretation services
• how to ensure interpretation services are available
and accessible = crucial challenge for equitable and
efficient system
• high on Toronto Central LHIN agenda and on province’s
30

31. • addressing health disparities in service delivery and
planning requires a solid understanding of:
• key barriers to equitable access to high quality care
• the specific needs of health-disadvantaged populations
• gaps in available services for these populations
• this requires good information
• and effective and practical equity-focused planning
tools
31

32. • 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
32

33. http://www.torontoevaluation.ca/tclhin/index.html
33

34. • a very consistent theme was need to improve interpretation
services and address language as a critical barrier
→ major project to develop more systematic coordinated
approach to interpretation in downtown hospitals
• this project initially arose out of Healthcare Interpreters Network
• not just Toronto Central: one of identified equity challenges
for North York General hospital in Central LHIN was
language:
• useful to hook up to Central on this – so many of these issues are at
least GTA-wide
• HIN could play a key role in this linking up
34

35. • e.g. for the language project
• some jurisdictions – Oslo, Sydney -- are seen to be
leaders in municipal-wide coordinated interpretation
services
• centralized services all providers can draw on
• sometimes cross-sectoral – not just health
• will see some other examples shortly of community-
based initiatives that provide services in various
languages as part of their core approach →
• need to link community and institutional services into a
coherent system or web of services
• need to learn from each other and share resources
35

36. • all hospitals, agencies and CHCs sign Service Accountability
Agreements with LHINs that govern flow of funds and
provision of services
• can build in specific equity 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 – newcomers who don’t speak English well, homeless,
isolated seniors, etc.
36

37. • need to define clear equity-focussed expectations:
• all providers will deliver sufficient high-quality
interpretation services to meet the needs of the people,
communities and catchment areas they serve
• then build requirements to meet these expectations –
and targets and indicators to measure progress -- into
performance management systems:
• not just Service Accountability Agreements between LHINs
and providers
• accreditation requirements and processes
• professional Colleges and other regulatory mechanisms
37

38. • for providers to meet these requirements, they will need to:
• know the language needs of the communities they serve
• this is far more than just the languages of those who come to them for
services
• also need to know who is not coming in because of language and
other barriers = unmet need
• and it doesn't mean just basic demographic data on languages spoken
• it means what language people are most comfortable receiving care in
• so demand/drive for accessible interpretation → built into
performance mgmt → providers assessing community needs
far better
38

39. • driving change through performance management will
require better data on language and other needs of
community
• need far better social determinants type data across the health system
• need to also collect data on service delivery
• in addition to language needs
• clients’ socio-economic and cultural background → contributes to
building up better picture of community needs
• impact of interpretation services – comparing re-admission rates,
satisfaction, post-hospital recovery, infection, etc. → builds case for
investing in interpretation
• need to ensure interpretation practitioners and experts are
at planning tables where equity-focused indicators and data
collection systems are being worked out
39

40. • target services to specific areas or populations:
• those facing the harshest disparities – to raise the worst off fastest
• or most in need of specific services
• or 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. • key things that worry EDs and CEOs:
• reducing risk and enhancing safety
• delivering high-quality care efficiently
• meeting provincial priorities – wait times, mental health or diabetes, ALCs
• access to interpretation underlies all of these system drivers:
• poor communication between provider and patient due to language or
cultural barriers can contribute to misdiagnoses and inappropriate
prescriptions
• inability to read or understand instructions can lead to medication errors →
safety and cost implications
• promising indications that good interpretation helps keep people out of
hospital and gets them out sooner
• aligning to such drivers and incentives = crucial to build
support for interpretation strategy
41

42. • the Ontario Health Quality Council has identified a
number of key features of a well-performing health
system
• equity and patient-centred high quality care are
crucial features
• communications and provider-patient relationship
are crucial to quality of care
• in an increasingly diverse society this means:
• high quality care = culturally competent care
• access to interpretation where, when and how needed is
an integral part of quality, as well as equity
42

43. • chronic conditions – especially diabetes -- mental health, reducing
ER wait times, etc. are all provincial priorities
• equity is essential to meeting these priorities
• e.g.. diabetes is particularly sensitive to social conditions and context
• prevention and management programs cannot be successful unless they
take account of social conditions and constraints – meaning SDoH in
general
• more specifically, support for self-management for diabetes and
other chronic conditions has to be delivered in languages of
communities to be effective
• educational and other material has to be translated
• simply so that medical issues are understood
• but also because so much of enabling people to manage their own health
is about culture and support – far more effective in language people are
comfortable with
43

44. • there will be clear targets for provincial priorities such as diabetes
and mental health → build equity into targets:
• need to identify populations/areas where diabetes incidence is
highest, and many of them are language or ethno-cultural
communities
→ equity target = reduce differences in incidence, complications and
rates of hospitalization between groups within a LHIN
• similarly, systemic inequities in depression and other mental health
problems
→ equity target = reduce those differences by language, ethno-cultural
background and other determinants
• 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 language spoken,
gender, income, ethno-cultural background, etc.
44

45. • 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
• and that includes addressing language barriers and
ensuing that all programs are culturally competent
• 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
45

46. • 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
to social conditions and constraints of particular communities
• and that includes addressing language barriers and ensuing that
all programs are culturally competent
• if this isn’t done → can unintentionally widen disparities as
better off take up programs more
46

47. • 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
47

48. • interpretation is never just about words, but culture
• skilled high-quality interpretation is one part of ensuring
culturally competent care
• all part of inter-related changes needed to ensure inclusive
health services and healthcare system
• cultural sensitivity and competence – just as equity overall –
need to be built into core fabric of daily service provision
• so cultural competence and interpretation must be central
to wider equity and diversity-focussed organizational and
system transformation
• and need to build on the many local community-based
initiatives and front-line innovations who are doing just
that
48

49. • peer ambassadors – local initiatives out of
Toronto CHCs:
• members of specific neighbourhoods or ethno-
cultural communities are trained and supported
• play roles such as helping others in their
community navigate through health system or
deliver health promotion programs
• ambassadors often work within the language of
the community/consumer
• need to be well trained and supported
49

50. • potential in other provincial priorities – e.g. cancer
screening:
• cancer systems are good at treating people equitably once
they get into programs
• but not so good at screening – systemic disparities
• generally its the more marginalized who are not screened –
and those facing access barriers such as language
→ potential here also of peer/community ambassador types to
enhance outreach and support to marginalized
• MOHLTC is considering incorporating such a program into
cancer screening initiative
50

51. • MiVIA (my Way)
• personal electronic health record originally developed for
mostly Hispanic seasonal farm workers in California – and
then extended to other vulnerable populations
• supports continuity and efficiency – highlighting the potential
of eHealth for even the most marginalized
• the web-based portal and records are in Spanish as well →
helping to reduce language barriers
• a vital element of success has been ‘promotores’ --
community/peer health promoters – who recruit people into
the program, train them on the tools and support them in
their own health management
• all services are free
51

52. • Edmonton Multi-Cultural Health Brokers Cooperative
• provides navigation, counselling and other support to people, who
because of language or cultural barriers have trouble making their way
through the health system
• arose from a grass-roots recognition that these barriers were
increasingly important but not being addressed
• jointly developed by the local regional health authority, public health
and other stakeholders
• many of the brokers were internationally trained providers -- doing
this work allowed them to use their skills and become familiar with
the provincial system as they waited for recognition of their
qualifications
52

53. • health brokers example highlights importance of advocates
for equitable interpretation to support other progressive
reform demands
• streamlining assessment and integration for internationally trained
providers could correct important injustice
• would also help to enhance the capacity of the system to deliver
professional care in more languages
• language barriers often intersect with other lines of
inequality:
• for example, many people who do not have access to OHIP and who
face terrible disparities as a result also face language barriers
• HIN and other advocates for addressing language barriers can join with
advocates working to ensure that lack of OHIP does not prevent
people from getting vital care
53

54. • 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:
• collate and analyze all the useful intelligence gained from provider equity-
focused planning
• capture and share information on local initiatives, and build on local front-line
insights
• share the resulting knowledge across the LHIN – and beyond
• assess most promising initiatives or directions
• scale up promising initiatives across the province where appropriate
54

55. • ensuring equitable access to high-quality interpretation
will help contribute to creating an equitable healthcare
system by:
• addressing barriers -- language and culture are among most
important barriers to equitable access and quality of care
• using available levers – how interpretation can be built into
health providers’ incentives, expectations and requirement
• aligning with system drivers – linking interpretation to system
priorities like safety, quality, managing ER, ALC and other
bottlenecks, risk management, mental health, chronic
conditions
• supporting opportunities for innovation
• making connections – where building interpretation services
intersects with – and underpins – an overall equity strategy
55

56. • back to bigger picture
• following is a roadmap for comprehensive
integrated policy action on determinants of
health and health inequality
56

57. 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;
57

58. 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:
• 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;
58

59. 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.
59

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