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On: Feb. 6, 2012 The Big Action on Health Is Far Beyond Health Care

I blogged earlier on how crucial it is to build equity into the new Action Plan for Health Care released by the Minister of Health and Long-Term Care. This is not just to ensure that high-quality patient-centred care is available equitably to all. But reducing pervasive health inequities is crucial to overall system sustainability: these health inequities lead to avoidable death, disability and service use. A more equitable system is fairer, better quality, more efficient and better value.

But these health system reforms are only part of the picture of achieving the Ministry’s goal of  ”Making Healthy Change Happen.” The really healthy changes will come through addressing the underlying social determinants of health. Affordable housing, access to childcare, equal opportunities to get a good education and decent living environments are all pre-conditions for good health. And precarious work, racism, poverty and income inequality are the underlying foundations of systemic and damaging inequities in health and well-being. Governments need to act in a coherent way across Ministries and program areas to create the foundations of good health for all, including those communities consistently marginalized and left behind within current structures.

The province has a number of opportunities on the immediate horizon to start to address these fundamental determinants of health in a coordinated way. First of all, the Commission to review Ontario’s social assistance system has just released its options paper for discussion and will be continuing its work over the coming months. Wellesley, health practitioners and other health policy leaders set out a vision and series of concrete recommendations to create a health enabling social assistance system.

Similar principles of expanding opportunities and ensuring the living conditions that support good health should drive the provincial poverty reduction strategy. The Minister of Health and Long-Term Care leads this initiative and is in a good position to drive more coordinated cross-government action. Such action could  demonstrate the value of more “joined-up” and integrated government efforts to address complex problems like poverty – and health inequities.

A pre-condition for addressing the social determinants of health within governments is developing new ways of developing and implementing policy. Luckily, a good deal of foundational work has been done within the Ontario government. Several years ago a major cross-Ministry initiative to develop a coordinated policy framework around health equity was undertaken, and was well received at the Deputy Minister’s Social Policy Committee. MOHLTC also developed a Health in All Policies approach: the basic idea, being pursued in leading European agencies and jurisdictions (see an example of a Finance-led HiAP lens from New Zealand), is that the population health implications of legislation, policy and programs from non-health ministries and departments are considered as policy is designed. The Ministry has a Health Equity Impact Assessment tool to facilitate this analysis. Health impact assessment is not just better coordination, but it essential to preventing unintended consequences: this common policy term is a bit of a misnomer – that poor urban planning results in food desserts and inadequate access to safe parks, that fiscal and monetary policy underlies income inequality, or that inadequate safety regulation will have adverse health effects may not be intentional, but it is certainly predictable – and avoidable.

We need policy across all spheres – from social assistance reform, through employment support and training, to fiscal policy – that contributes to reducing structured social inequality and enhancing the fundamental conditions for good health for all.

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On: Jan. 31, 2012 Fixing Social Assistance is all about Collaboration

Over the last couple of months I’ve blogged about reforming Ontario’s social assistance system, setting out the nature of the problem and suggesting some solutions such as creating a vision of a high-performing social assistance system, building a basket of essential supports, supporting people on social assistance into training and employment, and building on health promotion and primary care initiatives.
While our solutions have emphasized that reform needs to come from within the Ministry of Community and Social Services, building a health-enabling system requires a more comprehensive strategy that brings together a range of partners. This blog builds on this theme by highlighting the role of communities and the need for formalized policy alignment across government.

Build Community Capacities

One crucial means of enhancing people’s opportunities for good living conditions is to build community opportunities and capacities, in other words, to build healthy communities. Extensive research shows that individuals who live in strong, vibrant, well-connected, and well-resourced communities fare better on many social indicators of health.

Within Ontario, many community-based groups are working to build strong and vibrant communities, and the social assistance system should tap into – and expand – initiatives and interventions that are already underway and proven to work.

One promising direction to address complex social problems is comprehensive community initiatives. These bring together broad-based partnerships of local residents, service providers, community organizations, businesses and governments to coordinate services, share and leverage resources to build community capacity and infrastructure, and mobilize towards policy change to address the roots of poverty or other social problems in a way that is from – and for – the community.

For example, the Vibrant Communities initiative lead by the Tamarack Institute is a community-driven effort to reduce poverty in Canada by creating partnerships that make use of people, organizations, businesses and governments. This initiative, which involves partners from coast to coast, empowers communities to identify issues that are relevant to them and supports them to identify community assets and to build their own actions and strategies to address these challenges.

To harness these community strengths, the Commission for the Review of Social Assistance in Ontario should recommend that the mandate of social assistance providers include partnering with appropriate local community initiatives from across sectors.

Breaking Down Government Silos

There is growing understanding that complex social and economic problems require integrated and comprehensive policy solutions. This means getting beyond the current disjointed structure of ministries, agencies and programs, and the rigid jurisdictional boundaries between different levels of government.

Reform of social assistance cannot effectively be pursued in isolation, but needs to be considered within the context of other changes in public policy needed to reduce poverty and inequality. Integrated policy development is crucial to addressing complex social problems such as improving social assistance and reducing systemic health inequities. For example, better skills training leads to better job opportunities, and education and child care investments can help to break the cycle of poverty.

Health in All Policies is an approach where all policy development is required to consider possible health impact and implications. A version of this approach has had promising effects in Quebec: any legislation or regulation with possible health implications must be reviewed with the Ministry of Health and signed off by the Minister.

In our submission to the Commission, we argued that they should advocate for the province to implement a Health in All Policies framework across ministries. This includes working with other levels of government to fund and develop affordable housing, increase access to child care, address labour market security and employment conditions, all of which will ultimately improve population health, reduce poverty, and decrease unemployment.

This is the final blog in the series about our submission on social assistance reform, but stay tuned for updates about our work in this area and developments from the Commission. Thank you to everyone who has engaged with these blogs via Twitter and Facebook, and by getting in touch.

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On: Jan. 31, 2012 Building Equity Into Ontario’s New Health Care Action Plan

The Minister of Health and Long-Term Care today launched an ambitious plan to transform Ontario’s health care system. It identifies key drivers of change to improve access, quality and value; all underlain by improved system coordination and coherence, and by service and quality innovation. These are positive directions, but the opportunity must not be lost to ensure that this transformation also contributes to reducing pervasive and damaging inequities in health in the province – we need to build equity into these reforms from the outset.

The Minister emphasizes the high proportion of costs attributed to preventable illness. The Action Plan should also stress that health inequities are a major cause of avoidable illness and system costs. There is an overwhelming body of evidence demonstrating the impact of wider social determinants of health and of structured social and economic inequality on shaping population health. All of the particular challenges noted on the Action Plan – chronic conditions, emergency room use, navigation – are worse for lower income people, immigrants and others facing social exclusion.

Similarly, the solutions proposed – from increasing access to community-based services, through ensuring seniors can stay in their homes longer, through improved health promotion – can only succeed if people’s living conditions and community context and are taken into account. Children cannot be expected to exercise more if there are no safe parks in their neighbourhood or if recreation programs have user fees. What if poor housing is the real problem underlying some senior’s ill health? How can health information and support be provided in the different languages and cultures of our diverse communities?

Equity must also be built into the specific reforms identified. For example, the more comprehensive and integrated care that can be provided by Family Health Teams has great potential, but this potential may not be available equitably – existing data indicates that FHTs have tended to serve the better off and healthier. This also shows how one success condition to this Action Plan is paying attention to incentives: for FHTs and other practice models paid per patient, there is an incentive to take on the healthiest (and easiest) people to serve and to locate in wealthier and healthier neighbourhoods. Ensuring any new patient-based funding does not have such unintended and inequitable consequences, and that funding models take account of the greater burden and risk of ill health in disadvantaged populations will be crucial.

There are many levers within the Action Plan that can be used to improve health equity:
• Hospital Quality Improvement Plans can be required to include equity indicators;
• Initiatives to reduce hospital readmissions should collect data to monitor if there are differences by income, neighbourhood, or region, and should be expected to reduce any inequitable differences they find;
• As LHINs shift resources where need is greatest they must take equity into account – focussing on those neighbourhoods and populations who have the greatest burden of ill health and have traditionally had less equitable access to services;
• Every LHIN should make an explicit strategic commitment to reduce health inequities within its area; and
• The Ministry of Health and Long Term Care should apply its own very useful Health Equity Impact Assessment tool within the elaboration of its seniors’ strategy.
By building equity into the Action Plan, these reforms can help to provide quality care to all Ontarians, including the most vulnerable, and deliver better value for the health care system.

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On: Jan. 30, 2012 Emerging Health Professionals and Driving Health Equity From Within

The Wellesley Institute researches and analyzes the policy changes needed to address the social determinants of health that underlie pervasive and damaging health inequities. These changes will need to be driven by broad community-based innovation, social movements and political pressure. But acting to ensure equitable access to high-quality health care for all and improving resources and services for the most health disadvantaged populations can also make a huge difference. I spoke to a forum of medical and other health students at the University of Toronto on key equity levers and mechanisms within health care. It’s always a great pleasure to work with these leaders of tomorrow who will be driving action on equity within the health care system.

Thinking About Health Equity/ Acting on Health Equity

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On: Jan. 24, 2012 Drawing Out Links: Health Equity, Social Determinants of Health, and Social Policy

The Wellesley Institute engages in policy development and advocacy to advance population health. Our work also sees us working with researchers and community groups to help develop policy capacity, and we often speak on how to maximize the policy influence of research and knowledge exchange.

Earlier this week, we spoke to a graduate-level social work class at the University of Toronto about why policy matters to the social problems they address. We highlighted parallels between the kinds of policy changes needed to address social determinants of health and health equity and those needed to address the structural foundations of social inequality and exclusion. We set out some key ways to develop effective policy recommendations. The slides from Bob’s presentation are below.

We also often speak on knowledge exchange with policy impact: including recently to a major national KE conference and a CIHR research conference (here is the audio of that speech).

Social policy grad class jan 2012

 

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On: Jan. 24, 2012 Should social assistance ensure access to health care services, or keep people from getting sick? Both, actually.

The social assistance system causes poor health. The low levels of income supports combined with inadequate supplementary supports like affordable child care and transportation mean that people on social assistance do not have a fair chance at good health. I’ve blogged about this, and have set out some solutions such as building a basket of essential supports and supporting people on social assistance into training and employment.

This blog talks about how the social assistance system can build upon existing infrastructure to reduce health inequities by facilitating access to primary care and health promotion initiatives.

Primary Care

Extensive health research has found that one of the most effective ways to reduce health inequities is to enhance access to primary care for disadvantaged populations. Effective primary care can stop people from getting sick and can catch and treat illnesses before they become critical. This means greater system efficiency and improved quality of life for patients.

There is, however, more than one way to deliver primary care. In recent years Ontario has focused on family health teams: interdisciplinary teams that work out of a shared location. Depending on your needs, this can be an effective health care option. But the funding incentives have not been well aligned, and family health teams have tended to serve more advantaged and healthier populations.

For disadvantaged populations in particular, community health centres (CHCs) are a proven model. CHCs provide multidisciplinary and person-centred care to disadvantaged populations, connect clients into further services and emphasize health promotion activities to keep people well. This comprehensive model of care means that CHCs deal with issues that reach far beyond health care into individual and family social supports, and community capacity-building and development.

Although direct health care is outside of the scope of the social assistance system, the Commission for the Review of Social Assistance in Ontario should advocate for improved access to primary care and CHCs should be empowered to provide a greater role through their unique grass-roots level infrastructure and specialized knowledge of the community that social services could link into.

Health Promotion

Leading health policy experts and researchers consistently emphasize the importance of health promotion strategies to delay or prevent illness. This is especially important for lower income and more vulnerable populations. Conditions such as asthma, hypertension, diabetes, depression and other chronic conditions are particularly sensitive to social circumstances (for example, one key to preventing and managing diabetes is good diet). Poorer people are at greater risk, yet also tend to have less access to health promotion services.

Social assistance should positively facilitate access to health promoting activities and support. This may include subsidizing user fees and removing other barriers that may prevent people on social assistance from being able to participate in health-promoting activities.

For this to happen, social assistance reform needs to be linked to other spheres; for example, ensuring there are adequate parks and activity opportunities in poorer neighbourhoods, and working with healthy community partnerships to ensure the needs of the poorest and most marginalized are met – more on this in my next blog.

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On: Dec. 15, 2011 Building Health Equity: Saskatoon’s Dr. Cory Neudorf Shares Lessons Learned

Diane Dyson is Director of Research & Public Policy, Strategic Initiatives Unit at WoodGreen Community Services, and is guest blogging for us today.  You can read her blog at http://belongingcommunity.wordpress.com.

A few days ago, the Saskatoon Poverty Reduction Partnership, an intersectoral approach to poverty spearheaded by the Saskatoon Health Region, released an update of its progress over the past three years on health equity among its residents, and its plan for the next five years. The approach taken by the Saskatoon Health Region serves as an example of how collaborative efforts can work to solve some of the harder social problems we face.At a recent Health Equity Forum hosted by Wellesley Institute, Dr. Cory Neudorf, Chief Medical Health Officer for Saskatoon Health Region, described the lessons learned over the past five years in his city.

1. Build a strong evidence base.

Robust data made the case for the need to change local health interventions.  A 2006 Health Disparity by Neighbourhood Income study compared a set of low- and high-income neighbourhoods with each other and with the City average and found wide health disparities. Research found that low-income neighbourhoods, lying in the shadows of a leading acute-care children’s hospital, reported half the immunization rates of higher income neighbourhoods and four times the infant mortality rates. In these poor neighbourhoods, life expectancy was dropping.

Saskatoonians were appalled to find some of the highest levels of urban inequality in Canada were within their own neighbourhoods.Under Dr. Neudorf, the Health Region set about building a stronger evidence base. The result was the 2008 report, Health Disparity in Saskatoon: Analysis to Intervention, co-authored with Dr. Mark Lemstra. The report scanned over 10,000 articles for evidence-based policy solutions to the inequities identified. With further consultation, they were able to identify some concrete options for Saskatoon.Dr. Neudorf also worked with the Canadian Population Health Initiative and colleagues like Dr. David McKeown, Toronto’s Medical Officer of Health, and epidemiologist Dianne Patychuck to produce a cross-Canadian examination in the Reducing Gaps in Health: A focus on Socio-Economic Status in Urban Canada report. It was the first time the issue had been looked at nationally at such a small geographic level. (Around the same time, the Public Health Department in the City of Toronto produced a parallel report, The Unequal City, showing similar levels of disparity.)Three strategic directions emerged: a housing strategy, an employment strategy for Aboriginals, and a poverty-reduction strategy.

2. Build political will.

Data like these got people to the table, ready to talk and ready to look for solutions.  Dr. Neudorf intentionally began to test public awareness and receptivity. Out of that came 200 community consultations and randomized surveys of 5,000 residents (including those without phones) exploring possible solutions and their levels of commitment to them. Forty-six policy options with a strong popular base were identified in areas such as income, housing, education and aboriginal self-governance.
Dr. Neudorf purposefully looked to include people beyond the “usual suspects” in exploring solutions to these problems. Business leaders, people in poverty with “first voice,” Aboriginal groups, faith groups, community associations, and others who weren’t usually at policy tables were asked to weigh in. The wider community found consensus on about twenty of the policy options.After convening another community roundtable, Dr. Neudorf asked community leaders and organizations to commit to a newly-minted and broad-based Leadership Group, out of which a smaller Coordinating Group and more specifically focused Action Groups emerged.

3. Work across sectors.

Because health disparities have roots in many other fields, they are “wicked problems,” as Wellesley’s Director of Policy Bob Gardner calls them, with no agreed solution and requiring multiple players. Dr. Neudorf explained this work has to be done in coalitions and partnerships – as evidenced by the 63 letters of support which lead off the 2008 report.Dr. Neudorf worked with the already-established Saskatoon Regional Intersectoral Committee to develop a community action plan on the range of social determinants of health. More focused community action groups emerged out of this plan.The City of Saskatoon, local school boards, and other regional agencies also launched a common data portal, CommunityView, to make data sharing among human service organizations easier and to improve community planning.As Saskatoon’s Medical Officer of Health, Dr. Neudorf also began to re-shape the delivery of public health services, building health equity audit tools. Low-income schools also became one of the new areas of intervention, despite some pushback from parents. Immunizations were also enhanced. Health programs underwent equity audits, identifying barriers to quality health care at both the patient and the service level.

Finally, the Region of Saskatoon formed the Poverty Reduction Partnership to develop a common plan, which has just been launched. Stakeholders are also exploring innovative ideas such as an idea incubator, with seed money from local philanthropists, to respond to some of the proposals coming forward. The work of the Saskatoon Poverty Reduction Partnership can be found at www.saskatoonpoverty2possibility.ca.

The Region of Saskatoon has committed to advocating for real change in the region, recognizing that poverty levels are determined by the public’s tolerance of them. Public health units, Dr. Neudorf explained, can lead the way by doing the research, implementing evidence-based interventions, reporting regularly on progress made, and facilitating intersectoral solutions to reduce health disparities.The idea that poverty and inequality lead to poorer health outcomes is not new. Dr. Neudorf began by referring to the now commonplace civic themes of health disparities, health equity, and closing the gaps. What has shifted, is the field of public health’s return to an examination of the significance of the wider social determinants of health and how “non-health” interventions can be one of the best forms of prevention.

To watch Dr. Neudorf”s presentation at the Wellesley Institute’s Health Equity Forum, click here.

 

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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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