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As Bob Gardner explains in his recent article, Thinking Globally, Acting Locally about Health Reform (in a special edition of Making Waves), it is by understanding and focussing on health disparities on a regional basis, in particular within the structures of Regional Health Authorities, that on-the-ground strategies to reduce health disparities can be developed and implemented. Ontario is in a position to do this now, with the recent establishment of the Local Health Integration Networks. As Bob notes, there have been some interesting and effective examples of initiatives undertaken in other jurisdictions in Canada and internationally where there is a demonstrated commitment to health equity. Bob also points out that a great deal can be learned by sharing promising practices .

If "what is to be done" about health disparities is a question that plagues you, read Bob Gardner's article. We can make a difference by thinking globally and acting locally about health reform.

Ongoing massive changes to health care delivery and organization continue and ambitious plans to restructure the system are much debated within government, practitioner and community circles. The HIV community and service providers are vitally interested in the implications of Local Health Integration Networks, primary care reform, alternative practice structures and other key changes. I recently made a speech to AIDS community groups outlining the possible implications of major reform directions, and arguing that community groups need to be proactive in working to shape the terms of health reform debate. I also stressed that the long history of community involvement, consumer-driven care, multi-disciplinary and integrated delivery, and overall innovation from providers and AIDS service organizations puts them in a strong position to make an important contribution to progressive reform. I had earlier made a speech to the Ontario Society of Physicians in HIV Care along similar lines.

Wellesley and many other community groups have been emphasizing that effective and meaningful community participation will be crucial to the success of the new LHINs and to the development of an innovative new provincial health strategy. One of the critical challenges will be ensuring that the full range of community voices and interests can be heard in strategic deliberations and involved in ongoing planning processes. Part of meeting this challenge will be developing new processes and forums so that marginalized groups traditionally excluded from public policy debate can be included. But part also will be ensuring that recognized stakeholder groups are not the only groups consulted or involved, and that established community organizations do not exclude members of the community they represent. Recent research from the British Joseph Rowntree Foundation illustrates the latter complexity: UK Minorities within minorities: beneath the surface of community participation. This study of participation in Bradford (UK) shows that minority voices within broader minority groups, such as the South Asian community, are not properly heard by planning authorities. See the summary here or the full report here. This research was passed on by my colleague Subha Sankaran at the Ontario Prevention Clearinghouse.

In November I spoke at a meeting of the Ontario Society of Physicians in HIV Care and discussed the implications of the LHINs for their work (download the speaking notes here). While HIV will remain a provincial strategy and community-based programmes will be funded centrally, and while primary care is beyond the formal mandate of the LHINs, the specialized HIV clinics in hospitals and many other settings in which treatment takes place will be within the LHINs' sphere. More generally, the LHINs are a key part of the overall transformation of the Ontario health system that all stakeholders need to be part of. My main point was that the HIV doctors have unique experience in multi-disciplinary teams, alternative forms of practice, patient-centred care, and working with patients with very complex conditions and multiple challenges beyond the purely medical. This meant that HIV physicians were in a very good position to offer insights to policy makers and LHIN planners as they were grappling with such problems.

There has been a great deal of discussion of community engagement in health planning in Ontario. Both the LHINs as they are beginning to plan out regional priorities and the Province as it is developing its new overall health strategy want to involve as many communities and individuals as possible. It is always useful to see how other jurisdictions have met the challenges of involving residents and communities in health care planning in responsive, systematic and influential ways.

New South Wales in Australia has been doing some quite interesting things in community and public involvement in health planning. The Ministry here seems keen on their experience.

• this is a 2001 report on strategies and methods from a broad-based advisory group

• the government responded the same year, committing to implement the recommendations and announcing a state-level Health Participation Council where community members will advise on strategy, state-level support to public participation and information sharing, each Area Health Service was to develop its own structures, each Area was to have staff dedicated to community participation, etc.

• the Department of Health's home page for health participation can be found here.

One of the major challenges of community engagement processes such as the recent consultation undertaken by the Toronto Central LHIN is ensuring that the full diversity of voices and perspectives are heard. Access Alliance, a Toronto Community Health Centre focussing on the health needs of immigrant and refugee communities, was concerned that these communites had not been involved enough in the LHIN consultations. They interviewed 188 people at 8 community consultations using an appreciative enquiry approach. These consultations with Toronto's diverse communities were designed to supplement and support the LHIN processes.

The report of these consultations can be found here.

LHINs across the province have been consulting with their communities and will be submitting their first integration priority reports in the fall. A critical challenge will be building upon these initial consultations and embedding community involvement in all facets of LHIN planning from now on.

I spoke at a conference of the Ontario Hospital Association on how this challenge can be met. You can see the presentation I gave here.