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On: Dec. 6, 2011 Wellesley Institute’s Deputation on the 2012 Toronto Budget

The Wellesley Institute has been working alongside countless inviduals and organizations over the past few months to inform budget-related decision-making at Toronto City Hall in our efforts to improve population health.  On Wednesday, December 7th, Wellesley Institute CEO, Rick Blickstead, will be delivering a deputation on the 2012 Toronto Budget to the City of Toronto’s Budget Committee.

Read the full submission here.

Budget decisions that result in the elimination of secure jobs, increase unemployment, reduce access to services that Torontonians rely on, and increase social and economic inequality will harm the health of all Torontonians.

But, there are alternatives:

The budget documents released on November 28th show that the city is not facing a fiscal crisis. This means that councillors have options: they can make choices other than the service reductions in the proposed 2012 budget. If councillors use only a part of the 2011 surplus and enact a normal property tax increase, they can balance the budget without service cuts and increases to user fees and still set aside funds for other purposes.

To illustrate what’s at stake, we outline some of the health implications of proposed service cuts in three critical public service delivery areas: public transit, student nutrition, and housing:

Public transit is a cornerstone of a healthy city. Reducing the quality of transit service has a number of critical health impacts, including:

  • Increased probability of obesity and related health outcomes, including respiratory ailments, coronary heart disease and diabetes through greater automobile dependency.
  • Increased social exclusion through increased isolation.
  • Increased stress and reduced well-being for drivers and transit users through increased traffic congestion.
  • Increased respiratory problems for children and seniors, and increased heart health problems and premature death for adults through increased air pollution from congestion due to single-passenger traffic.
  • Reduction in city’s economic health and lost job creation opportunities through reduced economic competitiveness.

Student nutrition programs benefit kids’ academic performance and help them develop good eating habits that benefit their health far into the future. Children in low-income families, where good nutrition is hard to afford, will be hurt the most by cuts to these programs.

Housing is one of the fundamental social determinants of health. There is already a desperate shortage of affordable housing in Toronto. Some of the health impacts of making cuts to new affordable housing development, reducing the number of bed nights available in shelters, and shutting down three homeless shelters, as proposed in the 2012 budget, are:

  • Increased likelihood of infectious diseases, particularly respiratory infections, through increased crowded housing conditions.
  • Increased risk of health problems or disability in childhood because of inadequate housing.
  • Increased illness and premature death through increase in homeless population.

An evaluation of the health impacts of these cuts illustrates how their implementation will create more problems for the city and its residents than they will solve. In the interest of protecting the health and well-being of Toronto and its residents, councillors must consider the health implications of each proposed service cut when evaluating options to balance the budget.

There are better, healthier options for balancing the 2012 budget. We urge councillors to consider the health impacts of each of the cuts being proposed in the 2012 budget and make choices that will support a city building budget: one that builds a more equitable, more prosperous and healthier city for us all.

Click here for more on the 2012 Toronto budget and the Wellesley Institute’s efforts. 

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On: Nov. 16, 2011 Measuring Equity – Lessons and Tools

Last week the Wellesley Institute shared a booth at the Health Achieve conference with MAgIC (Measuring and Managing Access Gaps in Care). MAgIC is a research collaboration focused on developing ways to measure inequities in access to the health care system, with a particular focus on gender. MAgIC was developed under a grant funded by the Canadian Institutes of Health Research, Institute of Gender and Health with the support of the University of Toronto, Faculty of Medicine, and is administered in collaboration with The Wellesley Institute.

The MAgIC performance measurement system has two steps: first, it uses a decision tree analysis to segment populations; then it uses the difference in rates of outcomes to generate a measurement of the inequity gap for policy and decision making now, and measurement over time.

This measure is important because health care providers often struggle to measure inequities in service delivery. The MAgIC system facilitates not only the initial identification of access gaps, but also provides a benchmark metric that can be incorporated into ongoing quality improvement. MAgIC has also blogged about our shared presence at Health Achieve.

Highlighting MAgIC’s work is particularly timely given that the Wellesley Institute is hosting Dr. Cory Neudorf, Chief Medical Officer of Health for the Saskatoon Health Region, in Toronto on November 23rd. Saskatoon is widely recognized as a leader in Canada in research and policy that addresses health inequities. Dr. Neudorf will be speaking about key directions and lessons learned in Saskatoon, which will lead to a discussion about how to address health equity in Toronto and Ontario. Details of the event are below.

Wednesday, November 23rd, 1:30-4:30pm

Medical Sciences Building, University of Toronto

1 King’s College Circle, Room: MS 3154 (3rd floor)

Room is fully accessible. Accessibility info: http://www.osm.utoronto.ca/osm/accessibility/building_data/ms.pdf

UofT campus map, building MS: http://rrs.osm.utoronto.ca/map/f?p=110:1:1417784470411340

No registration required for this event. 

For more information email: contact@wellesleyinstitute.com


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On: Nov. 14, 2011 Wellesley Institute Forum on Health Equity

with special guest Cory Neudorf

Tackling Health Inequities: Lessons Learned from A Leading Health Region

 
Cory Neudorf, Chief Medical Health Officer for  Saskatoon Health Region, will be making a special lecture and leading a discussion on addressing health inequities at a local community level.

Saskatoon has led the way in Canada in sophisticated research that identifies the nature and foundations of systemic health inequities between neighbourhoods in the city; developing comprehensive multi-pronged strategies to tackle those inequities; and driving these strategies into action through focussed programs engaging with local communities and building effective cross-sectoral collaborations.

Dr Neudorf is a widely recognized international expert on health inequalities, health indicators, monitoring and reporting, and population health research; has been Chair of the Canadian Public Health Association; and is a Clinical Associate Professor at the University of Saskatchewan medical college.  He will discuss the key directions Saskatoon has taken; some early successes in addressing inequities and health disadvantaged populations; lessons learned; and implications for  our efforts to address health equity in Toronto and Ontario.

NOVEMBER 23rd

Medical Sciences Building, University of Toronto

1 King’s College Circle

room: MS 3154

It is on the 3rd floor

1:30 p.m. – 4:30 p.m.

 

(The easiest access from the main entrance is to take stairs across from Tim Hortons)

Room is fully accessible

Accessibility page info:

http://www.osm.utoronto.ca/osm/accessibility/building_data/ms.pdf

 

UofT campus map, building MS: http://rrs.osm.utoronto.ca/map/f?p=110:1:1417784470411340

 

No registration required for this event. 

For more information email: contact@wellesleyinstitute.com

 

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On: Nov. 14, 2011 Living In Auspicious Times: health as a human right

World Conference on Social Determinants of Health

Rio de Janeiro, October 19-21, 2011

World Health Organization (WHO)

Margot Lettner

“We live in very auspicious times for participation. It sails the winds of history.”

Among the many papers I picked up at the Rio Conference is one authored by Bernardo Kliksberg, Honorary Professor, University of Buenos Aires. Reading it at Galeo Airport – one long wait for Delta Flight 60 and the wilting salgados have lost all savoury appeal – I came across his simple way of seeing how social participation can transform public policies that fight health inequities.

A world conference hosted by a United Nations agency such as the WHO, like the Rio Conference that just ended, is an event: 1,200 delegates (450 representing 60 Member States, 750 experts and civil society members); a big tent; a brand; star moderators in Zeinab Badawi and Riz Khan from BBC World News and Al Jazeera English, respectively; a president, assorted government ministers, a chorus of independent voices. Script, actors, audience and certainly patrons are decided far in advance and – in this particular theatre tradition – improvisation is limited.

Formal planning for the Rio Conference began at least a year in advance, with an advisory group of about 20 health policy experts drawn from WHO Member States who met on Wasan Island, Ontario in September 2010 to brainstorm themes. But its real genesis was even earlier. The Commission on Social Determinants of Health chaired by Sir Michael Marmot reported to the WHO in 2008, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Then in 2009, the World Health Assembly passed Resolution 62.14 requiring the WHO to follow up on the report’s recommendations.

By this spring, the draft conference Discussion Paper was open for comments. Member States began negotiating the text of the Rio Declaration this past summer. The conference agenda was set by September.

So by the time we all arrived in Rio, much of the writing was already on the page.

It’s important to keep this context in mind while being there, as well as when reflecting later on what happened. As a participant, your real opportunity to contribute is limited. Only one plenary session opened up for comments and questions from the floor; and this was the final plenary that presented the just-approved Rio Declaration to delegates. It was electric but cut short because some panelists had to leave. While the smaller breakout sessions that ran during the conference included some moderated discussion, the relatively large number of participants, over 100 in each group, limited meaningful conversation and learning.

The conversations with most meaning, then, that held the most provocative and novel ideas and experiences, that offered the most hope as well as the deepest disquiet, happened away from the podium. Here are the conversations I heard most often as I talked with people; and which also came to resonate the most with me.

We need to name and formalize the right to health as a human right. We need new forms of civil society and broader citizen participation in public policymaking, an activist agenda that not only reclaims and reconfigures the democratic, but also resists the public service’s chronic reluctance to change. We need to join up agendas: as the WHO’s Commission on Social Determinants of Health argued in Closing the Gap in a Generation, we must make common cause with people active in, and affected by, sustainable development, the environment and climate change, education from early childhood to learning across the lifecycle, employment and working conditions and anti-poverty campaigns.

We need a global health ethics that mandate protocols for health governance, given a pre-eminently market-driven global economic model weak on equity and accountability. We need to use the declarations tabled at Rio – both the official and the alternative ones – to develop local action plans based on local evidence and local mechanisms for policymaking, practice and monitoring. And we need to reconnect our priorities with frontline health: to resource and measure the basics of primary health and public health and the people who practice them. Building the “we” as the foundation to this work – an inclusive, participatory, and activist voice – is imperative.

“All for equity,” the Rio rally, faces immediate challenges within the UN itself. The WHO has committed to provide technical assistance to Member States on how to implement a determinants approach, on “what works, what doesn’t,” chiefly through its regional offices. It also raises its own capacity as an issue. First, the WHO and other UN agencies have not always worked collaboratively on determinants-based issues (as the conference closed on October 21, agency representatives met in Rio to explore a better way – a sign of change?)

Second, and of greater concern, some Member States continue to press the WHO hard to restructure its current governance, partnerships and operations, believing that their funding entitles them to greater say over WHO decisions and activities. What non-sovereign influences may also come through this back door; and how transparent will their identity and influence be? Health as a commodity, health care as a commercial transaction – whose values are valued, who is accountable? WHO is already experiencing financial pressures, in part from lagging Member contributions, that have resulted in staff reductions. The UN and its agencies are not only an expression of our international political will towards consensus or disagreement, they also embody our international public service.

In a post-Rio presentation hosted by The Wellesley Institute on December 6, I will be talking about these themes in greater detail, including my visit with the Fundação Oswaldo Cruz (FIOCRUZ), the public health foundation partnered with Brazil’s Ministry of Health. Most importantly, the session will be open for conversations about what concrete work can be done now to move determinants-based approaches into practice here, in Ontario; as well as where the political and social openings are that will build momentum, advocates and better outcomes across communities and policy sectors. Event details will be posted on the Wellesley Institute website shortly.

Here are some other significant ideas, achievements and events profiled at the conference that may spark new collaborations on December 6.

 

Provocations

1.     It’s the wealth distribution model, not necessarily the economic model, that influences health status – Luiz Odorico Monteiro de Andrade, National Secretary for Strategic Planning and Participation, Ministry of Health, Brazil
2.     A strategic plan is a social determinants of health plan. The ideal plan, of course, would place communities at the centre of the plan with services around them – Kevin Buckett, Director of Public Health, South Australian Department of Health

3.     Why don’t we report social indicators daily just as we do economic indicators? – David Sanders, University of the Western Cape

 

Tools

1.     WHO launched its new global community of practice tool for social determinants www.actionsdh.org (information at actionsdh@who.int). Membership is free and gives users access to downloadable content, conversation forums, opportunity to contribute evidence, examples, and resources and a newsletter.

2.     People’s Health Movement (PHM) launched its new global Right to Food and Nutrition Watch 2011 as a companion advocacy, accountability and research-into-practice tool to its just-released Global Health Watch 3: An Alternative World Health Report (www.rtfn-watch.org, www.ghwatch.org, www.phmovement.org).

 

Frontline health, Brazilian milestones

1.    In 1988, health care as a citizen’s right and corresponding duty of the state was added to the Brazilian Constitution.

2.    Over the past 40 years, Brazilian health sector reform has been driven by civil society rather than by governments, political parties or international organizations. Social participation in health sector strategies, policies, implementation and evaluation is constitutionally legislated through health councils and conferences at all three levels of government, with membership made up of 50% users, 25% health workers and 25% health managers/providers. A proportion of municipal or state health budgets is a participatory budget and decided by citizens through popular vote. ParticipaSUS, the national policy for strategic and participatory management, continues to integrate social participation in health decision making.

3.     Bolsa Família, Brazil’s social security system with an intersectoral policy focus, includes a conditional cash transfer program for families that supplements household income and is tied to school enrolment and use of primary health care services such as vaccinations. R$13 billion was distributed to 10.5 million families in 2008, with over 90% of payments going directly to mothers. (For six detailed papers that critically examine outcomes and opportunities in Brazil’s health policies, see The Lancet, “Health in Brazil,” May 2011.)

 

The case for evidence

1.  It’s radical to measure, and measuring the right thing is powerful. What gets measured, gets done – Michael Marmot, University College, London.

2.     The rub of inequities lies in their invisibility and their magnitude. For better data about determinants we need disaggregated measures that trend over time; that reflect increasingly real-time results; that capture outcomes beyond survival (e.g., morbidity, disability, mental health and other burdens of ill health, as well as the benefits of well-being); and that cluster stratifiers so that relationships among specific determinants are tested. To get these data we need population-based surveys, health equity audits and dissemination portals that combine information with advocacy – Hoda Rashad, Social Research Centre, The American University in Cairo.

3.     Decentralizing policymaking and program delivery to municipalities results in the creation of nuanced local data critical to planning and measuring but often difficult to capture in larger data sets – Maria Guzenina-Richardson, Minister of Health and Social Services, Finland.

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Margot Lettner is Principal, Wasabi Consulting and an Associate of The Wellesley Institute. She has just returned from Rio de Janeiro as a delegate to the WHO World Conference on Social Determinants of Health. In 2010, she facilitated WHO’s pre-conference Advisory Group consultation on social determinants of health. The title quote is taken from “Strategies and Methods for Promoting Social Participation in the Development and Implementation of Public Policies to Fight Health Inequities,” Bernardo Kliksberg, World Health Organization (WHO), 2011, p.24. She is also a board member and editor of Influency Salon, a magazine of contemporary Canadian poetry. She can be reached at ml.wasabi@rogers.com.

 

 

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On: Nov. 1, 2011 Welfare Reform in New Zealand: Lessons for Ontario?

Welfare reform has been on the agenda in New Zealand for some time, with both the previous Labour-led and current, more conservative National-led government musing about how to fix a system that many believe is broken. With a general election coming up in just under a month, the National Party has released its welfare platform and is promising a significant shake-up of the welfare system, particularly in its expectations of workforce participation. National is widely expected to win the election, so it can be assumed that at least the structure of this platform announcement will be implemented.

The plan has two key elements:

  • combining the Unemployment and Sickness Benefits into a Jobseeker Support Benefit and requiring recipients to undergo work-testing and look for full-time work; and
  • replacing the Domestic Purposes Benefit (a benefit to support sole parents) with Sole Parents Support and requiring recipients to undergo work-testing once their youngest child turns one and to work at least part-time once their youngest child turns five.

The proposed changes are expected to result in 46,000 fewer people receiving social assistance. People who receive social assistance are amongst the most vulnerable in society, so reducing access to social assistance will disproportionately affect those who are already disadvantaged. The cost of implementing the changes would be $130,000 per year and would result in cost savings in the welfare budget of $1 billion over four years.

There are several elements of the proposed changes that would have equity impacts, and analyzing the details show that adverse effects would be felt by the most vulnerable:

1.   Work-testing is a blunt instrument that doesn’t recognize the episodic nature of disability

Many types of health issues and disabilities are episodic in nature, meaning that periods of acuity are followed by periods of remission. This is particularly true of mental illness. Using a point-in-time work-testing tool cannot accurately determine whether a person with a disability is truly able to make a successful transition into the workforce.

 

2.     Combining the Unemployment and Sickness Benefits doesn’t recognize the different needs of people who are unemployed and people who have disabilities

These two groups have very different needs. People who are disabled often find it difficult to find paid employment that can accommodate their particular needs, even if they are ready and able to participate in the workforce. Thus people with disabilities need supports that allow them to move between paid employment and social assistance as their condition allows.  This includes the provision of health supports that continue even when the person is in the workforce.

People who are unemployed, on the other hand, may require different types of support, such as vocational training or re-training and job-seeking support and advice. Health supports are also essential given the low level of income supports this group often receives.

 

3.     Deeming people on social assistance as work-ready may force people into low wage jobs with no benefits

The best way to permanently transition from social assistance to paid employment is to provide supports that allow people to find – and keep – good jobs: jobs that are well-paid, secure, and provide health benefits. Simply deeming a person to be work-ready may force people on social assistance to take the first job that becomes available, regardless of whether this is the best job for them.  This creates a situation where people come and go from the welfare system.

 

4.     Requiring sole parents to work must include complementary supports such as subsidized/free child care and transportation

The New Zealand government has suggested that changes to the welfare system will include supports to help people get ready for work, such as child care and transportation supports. This is positive, but they must be flexible enough to ensure that parents are able to rely on these supports while they establish themselves in the workforce. These kinds of supports are more effective when linked to income level rather than welfare status.

 

If the New Zealand government does not address these policy challenges and chooses to move towards a one-size-fits-all social assistance system that does not reflect individual need or enhance opportunities, the most vulnerable people will be the most severely affected. And if this occurs, savings in the welfare budget may lead to increased costs in the health budget, which has major system implications.

These are lessons that should be learned closer to home as the Commission for the Review of Social Assistance in Ontario completes its deliberations. Wellesley Institute was part of a broad partnership of health sector leaders that came together to ensure that health and health equity are emphasized in the review. Our submission sets out a range of recommendations that would create a health-enabling social assistance system, including the development of a basket of essential supports, providing enhanced opportunities for workforce participation and training that reflect individual need and capacity, and enhanced policy coordination and alignment across government.

I’ll be blogging over the coming weeks about how to make this happen, so stay tuned. Next week’s Wellesley Institute newsletter will also include our submission to the Commission (be sure to sign up for our newsletter to receive a copy as soon as it’s available).

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On: Oct. 31, 2011 Health Equity and the Occupy Movements

With Occupy movements, born out of Occupy Wall Street, happening in Canada and around the world, social and economic inequality are on the agenda. More and better jobs, more equitable distribution of wealth, and greater corporate responsibility and accountability are important goals, and the Occupy movements have made great progress in making these issues mainstream.

One important element that needs to be built into public debate is health. We know that poorer people have worse health outcomes than richer people. In Toronto, men from the poorest income bracket have a life expectancy that is 4.5 years less than men from the richest income bracket. For women, the gap is two years. But health inequities don’t just affect mortality; they also affect quality of life. Over three times as many people in the lowest income group report their health to be only fair or poor compared to those in the highest income group. The routine activities of a quarter of low income people are limited by pain, twice that of high income people. The Wellesley Institute has funded a range of research on health inequities, including Sick and Tired and the Street Health Report.

These differences do not have to exist. Health inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage. This means that with the right policies and priorities, built into a comprehensive strategy, health inequities can be eliminated.

The Wellesley Institute has a range of resources to help organizations to build equity into their planning and service delivery:

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On: Aug. 24, 2011 Addressing health inequity is crucial for creating an effective health-care system

Dr. Jeff Turnbull, outgoing president of the Canadian Medical Association, emphasized that addressing “devastating and epidemic” health inequities is crucial for creating a responsive and effective health system for the future, in an article in today’s Globe and Mail. Read the rest of this entry »

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On: Aug. 17, 2011 Vibrant, effective, innovative community sector and population health: Exploring the links

An effective and innovative community sector can help to shape opportunities for good health and, in particular, play a role in addressing health disparities experienced by vulnerable populations. A new research paper from the Wellesley Institute, “Reducing Disparities and Improving Population Health: The role of a vibrant community sector,“explores the role of a vibrant community sector in reducing health disparities and improving population health. Read the rest of this entry »

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On: Aug. 9, 2011 Health Equity Into Action in Central LHIN

Central LHIN has taken a promising two-pronged approach to equity: equity is one of the key priorities within their Integrated Health Service Plan or strategic plan; and they have focussed on several particularly health disadvantaged areas within their region. They called a provider and community consultation on how to move forward on these focused initiatives. Read the rest of this entry »

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On: Jul. 28, 2011 Rushed Policy Process Leaves No Opportunity For Due Diligence

While we understand the City’s fiscal pressures, the Wellesley Institute has concerns about the compressed nature of this year’s budget cycle. Typically, the City budget process continues at least through the fall, allowing the City to more effectively dovetail its budget deliberations with those of the federal and provincial levels of government.  This new timeframe has left no time to ensure decisions are grounded in a broader vision of a prosperous, healthy and equitable city. Read our full submission to the Executive Committee here.

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