Social Determinants of Health and Healthy Public Policy

Social Determinants of Health and Healthy
Public Policy

Bob Gardner
Director, Public Policy
Conference Board Roundtable on Social Determinants
of Health
October 27, 2006

© The Wellesley Institute
www.wellesleyinstitute.com

Wellesley Institute

• funds community-based research on the relationships
between health and housing, poverty and income
distribution, social exclusion and other social and
economic inequalities
• provides workshops, training and other capacity building
support to non-profit community groups
• works to identify and advance policy alternatives and
solutions to pressing issues of urban health
• works in diverse collaborations and partnerships for
progressive social change
• all of this is geared to addressing the pervasive impact of
the social determinants of health


Unique Hybrid

• lots of policy institutes and think tanks – but few focus on
SDoH and urban health
• many provide training and capacity building – but not all
have an explicit goal of rebuilding community capacity
lost in funding cuts and constraints
• few focus on funding CBR or have an extensive
community training programme in methods
• no other institute brings all three strands together – all
focused on SDoH


Focus Today

1. flesh out concretely these various programmes and
activities at Wellesley – and how we are working to
support action on SDoH
2. at the same time, highlight some key challenges and
barriers – and some opportunities and potential
directions we could consider -- in getting policy action
on the SDoH


Key Messages

1. the problem isn’t lack of research and evidence on the impact of
the social determinants of health – it’s politics
2. some European and other governments have developed
comprehensive social policy that addresses determinants of health
– so policy action is possible
3. similarly, better inter-government coordination and integrated policy
is possible – and we can learn from examples in Canada and
aboard
4. community-based research can be an important tool in identifying
gaps, barriers and potential lines of action
5. front-line health and social service delivery have been building the
social determinants of health into their programming – that has
great potential


Evidence-based policy
making
• public administration is increasingly and incredibly complex – policy
in different spheres needs to be ‘joined up’
• reliable research is crucial to guide the development of effective
public policy
• research on the outcomes and impact of policies and programmes is
equally crucial to effective implementation and monitoring
• public policy and investment should be driven by what works – and
this needs to be demonstrated
• public policy needs to be flexible and responsive to new evidence
and research
• govts as learning organizations


The evidence on social
determinants is consistent and
solid

• wide and rich research literature in
Canada and aboard
• impact of key determinants such
as early childhood development,
education, employment, working
conditions, income distribution,
social exclusion, housing and
social safety nets on health
outcomes and disparities
• the Health Council of Canada’s
February 2006 report:
– “The biggest health problem in
Canada is inequality. The overall
improvement in our health status
masks the grim reality that health
inequalities among social classes
are growing…”


But

• Canadian govts recognize the importance of SDoH
– internationally regarded as policy leader since Ottawa Charter
for Health Promotion in 1986
• yet this has not translated into consistent policy change,
investment and change:
– homelessness remains a key indicator of a society in disarray
– far too many do not have affordable housing
– poverty remains high, and concentrated in particular populations
– access to childcare is limited and inequitable, etc., etc.
• why has there been so little action
• in many ways, that is the driving force for this
Roundtable


Powerful Institutional
Constraints

• we could analyze solidly established institutions and
structures that are crucial to fabric of contemporary
society:
– operation of labour, capital and other markets
– trends and impacts of globalization
– the interests of powerful individuals and associations who benefit
from existing social and economic arrangements
• these are the institutions and interests that underlie the
inequality of condition and opportunities that constitute
the SDoH
• arguably, the adverse impact of the SDoH will not be
fundamentally improved until these structures and
constraints are fundamentally changed

Political Barriers

• within govts and public admin:
– silo structures
– competition among Ministries and divisions for funds and power
– disconnect between cost and benefits – where expenditure in one
sphere may reduce spending and problems in another Ministry
– risk averse working cultures
– short-term framework of decision and policy making
• beyond
– electoral politics – that’s about what sells, not evidence
– and bigger debates about the role of govts in contemporary Cdn society
-- Conservative view of more limited role for state and wider spheres of
individual responsibility
– limited public awareness of importance of SDoH → so limited public
pressure on govts
– in context of pervasive health promotion around individual lifestyles


Policy Directions and Issues
with Potential

• but these long-term issues are beyond the focus of this
Roundtable
• this Roundtable assumes that more immediate changes
in social policy can make a big difference in ameliorating
the impact of the SDoH
• I set out possible directions where important progress
could be made in the short and mid-term to shift public
policy


Have to Understand Policy
Environment

• all of this doesn't mean that we can’t make the case for
comprehensive social policy that acts on the
determinants of health
• but to make that case, we need to understand the
barriers and challenges within the overall political and
policy environment
• we need to also understand the dynamics of govt policy
making
• we need to make the case in ways that govts can
understand and act on


Making the Investment Case
for SDoH
• govts are increasingly interested in outcomes and impacts
• key officials in Ontario’s MOHLTC think of investment portfolios
where their policies or funding can make a measurable difference to
an impt problem
• so what is the economic case for investment in childcare or
affordable housing or public policy that reduces inequality?
– Cdn manufacturing companies explicitly factor in the competitive
advantages of public health care – are there similar advantages from
other public investment?
– cost of doing nothing is far higher – shelters vs. new public housing
– will save expenditures on consequences (poorer health, less
employment, deteriorating social relations) in the mid to long-term
– will support a more productive and cohesive society – but can that be
demonstrated or quantified?


Support for SDoH
Investment

• many prominent business organizations – Toronto-
Dominion Bank, the Toronto Board of Trade, Toronto
City Summit Alliance – have highlighted housing, income
security and other preconditions of a healthy society and
a strong economy
• Wellesley released yesterday a Blueprint to End
Homelessness in Toronto
• it makes just such a case that investing in affordable
hosing will pay off
• and that the alternative – the cost of continuing to do
little about the homelessness crisis – cannot be
sustained


The Blueprint:
A two-part
action plan
Step one:
Move the
“sheltered”
homeless
into homes
Monthly cost of a
shelter bed: $1,932

Monthly cost of a rent
supplement: $701


The Blueprint:
A two-part
action plan

Step two:
Build new homes
7,800 new homes
2,000 supportive homes
8,600 renovated homes
9,750 rent supplements
emergency relief
eviction prevention
inclusive planning

25% set-aside for
Aboriginal housing

Prospects?

• SDoH into policy action
– proponents may not have been making as good a policy case
as we could have
– building an economic or longer-term investment case for SDoH
may be useful part of that
– but the environment for Cdn govts being open to even the best
case doesn't seem very favourable
• want to emphasize two directions that can give some
hope
1. European counties show that comprehensive policy and action
on SDoH is possible
2. Cdn and international experience shows that better cross-govt
coordination around determinants is possible – and can be
effective

European Initiatives

• The European Union has launched Closing the Gap
– focusing on health inequalities
– with the goal of promoting action in individual member countries
– and coordinating and sharing information on national policies,
best practices and new initiatives across Europe
– http://www.health-inequalities.eu/
• the World Health Organization’s European office has
established a special commission
http://www.euro.who.int/socialdeterminants
– useful source of data, new and emerging initiatives and shared
best practices


Two Examples

• Sweden:
– coordinated national policy to reduce the number of people at risk of
social and economic vulnerability
– focus on inclusive labour market, anti-discrimination, childcare,
affordable housing and other policies
– they emphasized partnerships with community service providers and
organizations
• United Kingdom:
– Reducing Health Inequalities: an Agenda for Action 1999
– goals focused on raising living standards, early childhood development,
employment and building health communities
– simultaneous focus on broad national redistributive and social polices
– plus supporting local initiatives in disadvantaged communities to
improve living conditions and address social exclusion – Health Action
Zones
– mandated community participation in health care planning
– high level attention – e.g. social exclusion unit in Cabinet Office


Moving Forward

• but Canada isn’t Sweden
• so comprehensive policy along these lines can be an
important mid-term goal, but immediate prospects of
those kinds of polices are not good
• what can governments do in the here and now?


Better Policy Coordination

• Saskatchewan:
– coordinating table of ADMs -- Human Services Integration Forum
– to promote inter-agency collaboration and integrated planning
and service delivery
– current priorities include strengthening families’ capacities, early
childhood support, increased opportunities for youth, increase
well-being and employment situations, improve coordination and
integration of services, etc.
– also regional coordination bodies across agencies
– which in turn provides space/encouragement for interesting local
integration in areas such as Saskatoon


Better Policy Coordination II

• Quebec:
– provincial strategy coordinates health and related social spheres – in
one Ministry
– Health and Wellbeing Council encourages inter-sectoral action
– widespread consultation and involvement of community sector in policy
development
– comprehensive 10 year plan to address social determinants and
wellbeing
– all Ministries are required to consult the Ministry of Health on new
legislation or regulations that could impact health
– regional health plans are required to develop integrated pans with social
services
– local health authorities must coordinate with non-health services
• Ontario:
– Premier’s Councils of early 1990s emphasized coordinated policy
across ministries and spheres


Regional Health Planning

• regional health authorities in many provinces highlight
SDoH:
– many see determinants and population health as crucial to
guiding appropriate programmes and initiatives
– some Alberta RHAs have developed operational and planning
links with local social services
– others have emphasized community capacity building as one
strategy in addressing health
– Alta, BC and other RHAs have developed comprehensive
community engagement processes and forums


LHINs in Ontario

• advocates have argued that SDoH and related issues of diversity
and disparities should be built into LHINs planning
– Toronto Central LHIN has explicitly emphasized social determinants and
equity as underlying principles
• similarly community engagement has been a major theme:
– all LHINs have undertaken extensive – if quite different and
uncoordinated – consultations with their communities when they were
developing their initial plans
– all are required to develop ongoing community engagement – again,
variable but forums and processes created across the province
– connection here is that issues important to local communities – access,
gaps, barriers, many related to SDoH – will be prioritized to the LHINs


Ontario: SDoH Driving a
Public Agency

• Ontario HIV/AIDS Treatment Network
• funded by Ont govt and well connected to its AIDS
Bureau
• its community-based, sociological and clinical research
is designed to yield practical knowledge
• its knowledge mobilization and outreach is designed to
support better programmes and public policy → better
health and lives for PHAs
• OHTN’s research program and overall strategy is
premised upon SDoH


Expected Outcomes

• Three year prospective research on impact of housing
and homelessness on PHS’s health:
– baseline, factors that affect housing status and available options
– peer and community-based research
– identify most effective housing options at different stages
• Specific outcomes for this initiative include:
– housing options that improve access to health care, treatment
and social services
– safe and stable housing situations for PHAs in communities
across Ontario
– the development of effective and appropriate housing policies
and supportive care models that support PHAs throughout their
life course.


Funders
Canadian Institutes of Health Research (CIHR)
- $300,000
Ontario HIV Treatment Network (OHTN) -
$170,000 + in-kind (office space,
teleconference calls etc)
Ontario Ministry of Health and Long-term
Care, AIDS Bureau - $35,000
Wellesley Institute - $18,750

Ontario AIDS Network (OAN) - $6,600

Total = $530,350 over 3 years

Potential of Community-
Based Research
• CBR – at best driven by direct community involvement in defining
issues and problems – can yield concrete, deep and rich
understanding of the SDoH
• this kind of evidence can be a powerful supplement to the type of
macro and statistical data that we have seen
• CBR can uncover the ways in which inequality or limited access to
services translates concretely into lived experience and impact on
people’s lives and opportunities
• it can help to identify the most important barriers and service gaps
communities face
• and it can also build on community networks, cultures and
understanding to identify promising directions for change


Examples of CBR into
Action

• we want to support CBR that will have programme or
policy impact – that can support social change
• two recent examples that Wellesley has worked with
concretely illustrate this potential
• can get links to their reports, press coverage and other
material on our site at
http://wellesleyinstitute.com/research


Street Health: CBR on
ODCSP

• Street Health has provided health and other support to
homeless people in Toronto for twenty years
• they were finding that large numbers of the homeless
people they worked with were disabled
• but they were not receiving ODSP – the prov assistance
programme for people with disabilities -- why not?
• this is vitally impt = being on ODSP would mean that
people could afford housing → health implications


Findings and Implications

• the research uncovered administrative, programme and
other systemic barriers to homeless people getting
benefits to which they are entitled
• and their analysis showed practical and cost-effective
ways that these barriers could be fixed
• including pioneering a model of support workers who
helped homeless people through the maze of applying
for ODSP – highly successful in securing access


Research Into Policy Action

• they worked with ODSP and other govt people from the
start
• they identified target govt and media audiences for their
findings
• they developed concrete and actionable policy options
and programme recommendations that could address
the barriers and gaps found
– including which govt bodies would need to act on what and how
– including cost benefit analyses
• they are undertaking sustained outreach to get their
recommendations taken up


Count Us In

• Ontario Women’s Health Network, Ontario Prevention
Clearinghouse, Toronto Public Health and other partners
• project was on barriers homeless and marginalized
women face in access to crucial health and social
services
• also developed a new way of doing research
• inclusion research trains, supports and involves
homeless and other marginalized women in doing the
research themselves
• a form of peer-driven research that yields richer, more
nuanced and deeper understanding

Research Into Policy Action

• this project also identified policy barriers and issues and
the govt agencies that needed to act on their findings,
and developed and promoted specific policy
recommendations
• but this research came at a particularly interesting time
in health reform in Ontario and illustrates two further vital
points for realizing the potential of CBR:
– need to be aware of the strategic environment surrounding the
particular issue and look for opportunities to promote the
research and overall perspective
– need to be ready to seize these opportunities when the arise


Look for Opportunities

• LHINs have all been emphasizing community
engagement in their initial planning and priority setting
• the province is also developing a new strategic plan for
health and extensive community engagement is crucial
to it
• both see including marginalized, poor and those diverse
voices who are seldom heard in policy deliberations as a
critical challenge
• inclusion research – and its underlying principles of
involving marginalized communities directly in defining
their own experience – can be an important tool in
meeting this challenge


Seize the Opportunities

• sustained and targeted outreach:
– the Inclusion Research Team met with Toronto Central LHIN and
prepared a backgrounder for them
– pushed backgrounder to other LHIN and MOHLTC officials
• increasing emphasis on community engagement has
opened space for pushing innovative community-driven
methods and perspectives


Wellesley Institute Role in
Ensuring CBR Has Policy Impact

• we work with these and other research partners to help them ensure
their research has policy impact:
– provide advice on policy implications and environment from design
stage onwards
– help in translating findings into policy ready analyses and
options/recommendations
– help to broker contact with appropriate officials and stakeholders
– promote the CBR in the wider policy circles in which we work
• our capacity building programme also organizes seminars and
forums, and a workshop series with a stream focusing on exactly
this problem of translating results into policy alternatives, knowledge
exchange, policy advocacy and effective presentation to policy
makers


Community-Based Research
and Capacity Building

• another defining feature of community-based research =
it works to leave something behind in the community
• community capacity building is part of goal:
– connections and networks are built as part of research – active
problem solving is normally part of projects
– bringing community perspectives and knowledge into view – and
hopefully into public policy debate – can enhance confidence
and build understanding
– peer researchers learn new and useful skills = small step to
enhancing their opportunities
– can be part of building up social capital of neighbourhoods and
communities


Social Capital

• some disadvantaged neighbourhoods have dense community
networks
– residents groups, ethno-cultural associations, voluntary service
providers
– informal networks for child care, recreation and other support
• does this kind of social capital make a difference to ameliorating the
worst impacts of poverty and unequal access to services?
• how important are these and other aspects of specific
neighbourhood capacity and cohesion to health?
– United Way, govts and other partners investment in capacity building in
disadvantaged neighbourhoods
– focus of coordinated research efforts – CRICH, academic/St
Christopher House and other projects


St Jamestown

• long-term Wellesley project to investigate social
determinants of immigrant health:
– densest immigrant receiving area in country
– immigrants come in with better than average health, but it
deteriorates relatively
– why – what social and other factors are important?
– and what different policies and service interventions could
prevent this disparity?
• will work with community groups to define and implement
research
• community capacity building will be crucial part of project


Front-line Service Delivery

• Community Health Centres:
– identify barriers → policy advocacy e.g. health care for non-
insured
– action research e.g. Access Alliance consultations on specific
needs & perspectives of refugee & immigrant communities to
feed into LHINs
– build linking to literacy, employment and other non-health
services into programming
• Wellesley project with Association of Ontario Health
Centres to collect and database CBR that individual
CHCs undertake
→ try to expand to collect and organize examples of innovations in
front-line service delivery that take SDoH into account


Front-line Service Delivery II

• public health:
– Sudbury discussion paper
– linking public health work into non-health services, taking social
inequality and community conditions into account in planning
and delivery
– identifying policy issues arising from their work and advocating
for programme and policy changes to address inequities
• Ontario Prevention Clearinghouse
– leader in community-based health promotion and prevention
programme
– grounded in SDoH analysis


What Next?

1. the problem isn’t lack of research and evidence on the
impact of the social determinants of health – its politics

– need to understand policy and political environment
– ‘insider’ research with top officials and political leaders: what
are barriers to avoid, what is best way to make the case, where
are quick wins or tipping points?
– need to develop actionable policy alternatives that are winnable
within existing environment
– build investment case for SDoH


What Next?

2. some European and other governments have
developed comprehensive social policy that addresses
determinants of health

– comparative research: most promising policy directions, lessons
learned on how to build policy and political momentum, on-the
ground innovations, etc.
– plus Cdn ‘insider’ research: could European and other initiatives
be adapted here, if not, why not?


What Next?

3. similarly, better inter-government coordination and
integrated policy is possible – and we can learn from
examples in Canada and aboard

– comparative analysis: coordinating processes and forums from
across the country, what works and what doesn't, impact?
– ‘insider’ research with senior officials involved and connected
– historical research: lessons from past Cdn experiments


What Next?

4. community-based research can be an important tool in
identifying gaps, barriers and potential lines of action

– a crucial barrier is that results are not well known or widely
distributed → clearinghouse function is needed
– inventory and assessment of CBR on SDoH related issues as
starting point


What Next?

5. front-line health and social service delivery have been
building the social determinants of health into their
programming – that has great potential

– similarly, need for databases, clearinghouses and forums to
share, assess and scale up promising innovations
– not just relevant for SDoH, but for health care reform and
innovations in general
– given attention to health reform and search for workable
solutions → good environment for community-based
innovations


Social Determinants of Health and Healthy Public Policy

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (20)

Semelhante a Social Determinants of Health and Healthy Public Policy

Semelhante a Social Determinants of Health and Healthy Public Policy (20)

Mais de Wellesley Institute

Mais de Wellesley Institute (20)

Último

Último (20)

Social Determinants of Health and Healthy Public Policy