Almost all LHINs have identified the need to map their local population health. Part of this needs to be identifying key barriers to equitable access, those population facing the greatest health disparities and gaps in services.
The Right Tools for the Right Purposes
There is no single ‘magic bullet’ tool that can be used for all purposes. Gender-based analysis is essential for ensuring organizational priorities and program plans take women’s’ needs into account and Health Equity Impact Assessment can effectively build equity into service planning. But neither are designed to drive needs assessments or equity-focused evaluation; different tools are needed for these purposes.
Health Equity Impact Assessment
An HEIA tool and accompanying resources has been developed by the Ministry of Health and Long-Term Care and piloted and implemented in a number of LHINs.
Wellesley has a page with links to workshops, tips and other resources to realize the potential of HEIA for equity-focused planning. These notes provide starting points.
Key to consistent and comprehensive action on health equity is starting from clear Board and organizational commitments and a powerful shared vision.
These resources set out some starting points.
Planning and Delivering Equity in Tough Times
A pressing immediate challenge is how LHINs can maintain and drive their equity agendas in the context of budget restraints, increasing pressure from providers for limited resources, and a conservative fiscal climate. Wellesley has prepared a policy briefing on meeting this challenge.
Jurisdictions around the world have developed comprehensive multi-level strategies to address health inequalities and their underlying social determinants:
- The World Health Organization’s Special Commission on Social Determinants of Health has attracted a great deal of attention. Not only did it publish a massive report, but it created various knowledge networks on various aspects of social determinants and policy to address.
- WHO Europe, the European Union and other bodies have developed strategies, undertaken extensive research and created clearinghouses where promising practices address health inequalities are assessed and shared.
- Many European, Australian and other jurisdictions have created national or stale level strategies. Several of these have been well established for years and have undertaken evaluations of their impact and lessons learned.
- A number of leading cites such as London and New York have created city-level strategies to address health inequalities and population health.
Closer to home, Toronto Central LHIN has developed the most comprehensive health equity strategy – Wellesley developed a strategic framework the LHIN built on. Local conditions and priorities will vary and strategies developed for particular contexts – such as this for Toronto Central – will not be applicable in other LHINs. Nor does every LHIN need such a comprehensive strategy. But there is also no need to totally ‘reinvent the wheel’ and this strategy could be a useful starting point for others.
These notes provide an overview to build from.
Definitions
There are tremendous advantages if all LHINs were to work within a similar understanding of health equity – at best, a clear definition from the Province. The slides below contain a consensus definition of health equity that has proven practical and actionable.
Equity and Population Health
There are also links to further material on the social determinants of health that underlie health disparities. Material is also provided on systemic barriers and inequities within health care and why it is so important to build equity into health system planning and delivery.
Building From Solid Evidence
To make progress on health equity we need to embed equity into ongoing service planning and system performance management. And to do that we need solid actionable data. The POWER project provides this crucial data on health conditions, outcomes and service utilization by gender, socio-economic variables, region, language, ethno-cultural background, etc. – it’s an essential tool to operationalizing health equity and social determinants of health.
Bob Gardner spoke at a panel launching the chapter on access to services.
Making a Case for Equity
One critical challenge is boiling complex issues like health equity and social determinants down into plain language and inspiring ideas. Here is one attempt at an ‘elevator speech’ on health equity, and a speech outlining the need for social and provider mobilization to drive equity.
We have also developed workshops on related issues; for example on developing health promotion strategies and arguments with policy impact
This provides basic data and links to further evidence on the nature of existing health disparities in Ontario. A great deal of data from the excellent POWER reports is broken down by individual LHIN.
How To Analyze the Social Determinants of Health Inequality
The roots of health disparities lie in wider structures of social and economic inequality – in the underlying social determinants of health. Understanding this wider context is vital to grounding action within the health care system. Wellesley has published a range of policy papers and research reports on this.
These social determinants do not operate in isolation but are very much inter-connected in individuals’ lives and in their system impacts. Similarly, they interact with each other and with wider social, economic and cultural forces in a constantly changing and dynamic way.
Nowhere is this inter-dependence – sometimes called inter-sectionality — clearer than for gender. While women face systemic differences in the underlying determinants of health, access to services and overall health status, all women are not the same. Low-income and/or racialized women face specific additional cumulative and interdependent inequalities. The women’s’ health movement, researchers and public agencies have developed gender-based analsysis and other essential tools to help address these disparities. ECHO: Improving Women’s’ Health In Ontario is a key starting point.
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Ontario continues to undertake a massive transformation of its health system: the 2010 Excellent Care for All act enshrines quality and performance management; provincial priorities such as reducing wait times for key procedures, chronic disease prevention and management, mental health, e health and other system-wide issues are driving change across the system; the expansion of Community Health Centres, Family Health Teams and other new models have enhanced primary care; Read the rest of this entry »
I’ve been working on pulling together various tools and resources to help policy makers and planners put health equity into practice — stay tuned here. One lever several LHINs have used is to have their partner hospitals do health equity plans. I looked again at this really useful analysis led by Sanjeev Sridharan of the hospital plans done within Toronto Central LHIN. This process proved very successful at mobilizing discussion and coordination within their organizations, and sharing experience across the system. The hospitals are now developing their second generation plans.
UBC health economist Bob Evans famously called arguments that Medicare is unsustainable or that we therefore need privatization zombies: meaning that these ideas are constantly refuted by all the evidence, yet they keep being raised again and again. Of course, that is because there are powerful interests driving these ideas. Economist Hugh Mackenzie and health policy consultant Dr Michael Rachlis have done an excellent analysis of how Medicare and a universal health system is sustainable and how the real answers to the pressures facing the system are better policy and management. They highlight that this debate is essentially political; that the fiscal pressures on health and other sectors come from government decisions to cut taxes and services, as opposed to inherent trends within the health system. They point the way forward: improved planning and management of care will control costs; service and organizational reforms can drive better quality care; enhanced primary care, health promotion and prevention can keep people well; and seeing all this as part of a comprehensive and integrated Second Stage of Medicare will underlie a vision of good health and well-being for all.
The American-based Prevention Institute made a presentation to recent National Research Council deliberations on HIA. They argued that HIA aligns well with primary prevention or upstream action on the roots of ill health and health disparities, and with healthy community planning approaches to addressing the underlying determinants of health. Read the rest of this entry »
Evidence from around the world shows that enhancing access to high quality comprehensive primary care for disadvantaged people and communities is one of them most important directions for addressing health inequalities. Community health centres are a vital part of this direction in Canada and many other countries, and the recent AOHC conference on Health Equity: Pushing the Boundaries highlighted how to drive this into action on the ground (I spoke on how do this). Read the rest of this entry »
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