All LHINs have prioritized community engagement.  In equity terms, it is especially important to ensure the voices of the most health disadvantaged communities are heard and that their needs and perspectives are built into equity planning and interventions.  Similarly, it is vital that these populations are involved in defining the terms for equity-focused evaluation. Wellesley did some earlier work on these issues as LHINs were developing their community engagement strategies.

Given that the roots of health inequalities lie far outside the health system, LHINs and their partners need to be able to incorporate the wider social determinants of  health into their planning and actions.  Cross-sectoral partnerships and collaboration are seen to be critical ways in which the underlying social determinants of health inequalities can be addressed on the ground.

Among Wellesley papers, a brief to the  Senate Sub-Committee on Population Health, a policy paper, an article on the potential of local mobilization, a seminar for the Ontario Agency for Health Protection and Promotion, and a series of speeches have addressed how this can be done.

These notes set out some starting points on both community engagement and building collaborations and partnerships to address the social determinants of health.

When successful polices and interventions are indentified and assessed, we need forums and infrastructure to share information and experience on what is working and the means to scale up the most promising interventions.

These notes highlight this potential.

In an era of limited resources and quality-driven reform, it is crucial to know how policies and service interventions are working.  This is just as important to equity, and an important part of equity strategy must be evaluating what initiatives are most effective in reducing barriers and enhancing services for the most vulnerable. I presented to a workshop on this challenge.

Wellesley partnered with the Paloma Foundation to develop resources for participatory evaluation.

These notes set out a framework to ground equity-focused evaluation.

While equity needs to be built into all planning and service delivery, it is also critical to direct some investment and initiatives to specific equity challenges.  Services may be targeted at particular access barriers or disadvantaged and vulnerable population.

These notes set out starting points.

A number of key priorities – such as those for wait times, diabetes and chronic disease prevention and management, and mental health — have been identified by MOHLTC that all LHINs must deliver on, and vital reform initiatives are underway across the province.

Wellesley participated in a workshop on how to apply a specific equity planning tool – the urban health framework developed by GTA Community Health Centres – to diabetes planning.

This provides resources on how equity can be built into plans and initiatives to achieve these priorities.

Diabetes and Chronic Disease Prevention and Management

Put more proactively, diabetes and other chronic conditions, mental health and other key issues are greatly influenced by the wider social determinants of health and these priorities cannot be achieved without taking equity into account.

This links to how.

A common lesson from jurisdictions around the world and Regional Health Authorities across the country is the need to identify clear equity targets, develop data and indicators to assess progress against the targets, create incentives and requirements to build meeting equity targets into ongoing accountability structures and ensure equity is build into overall performance management systems.

As Toronto hospitals developed health equity plans in 2009, one challenge they faced was a lack of clear indicators for operationalizing equity.  The Centre for Research on Inner City Health at St Michael’s Hospital undertook comprehensive research and prepared a report on equity indicators in hospital settings.  A related challenge was the lack of equity, diversity and social determinants of health relvant data; a workshop was held on existing sources and equity data requirements moving forward.

Moving forward, a key objective can be building equity into balanced scorecards and other planning mechanisms used by LHINs and their provider partners.

This links to notes on how to begin to build equity into performance management.

LHINs do have considerable powers and they have the potential to develop effective partnerships with providers to operationalize equity.  One lever that has proven effective in several LHINs is having hospitals and/or community service providers develop health equity plans to guide their organizations. 

The 18 hospitals in Toronto Central developed comprehensive health equity plans in 2008.  See the extremely useful analysis led by Sanjeev Sridharan of the Centre for Research in Inner-City health.  These plans were refreshed in 2010.  In both cases, templates were developed that other LHINs could adapt.

Central LHIN also had their hospitals do equity plans; priorities identified in the plans were then reported on quarterly.  Central went on in 2009-10 to have all other providers undertake plans.  Bob Gardner conducted a workshop on health equity for community providers in Central LHIN who were developing their equity plans.

An interesting variant came up in recent conversations with another LHIN: enabling provider coordinating or planning networks or committees to do equity plans for the cluster of services or sector as a whole.

This links to notes on the potential of requiring provider equity plans and other levers LHINs can use to build equity into the system.

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.  The slides below set out some starting points.

And here are some notes on how hospitals can put equity into practice.

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.