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.