Ontario continues to undertake a massive transformation of its health system: the 2010 Excellent Care for All act enshrines quality and performance management; provincial priorities such as reducing wait times for key procedures, chronic disease prevention and management, mental health and other system-wide issues are driving change across the system; the expansion of Community Health Centres, Family Health Teams and other new models have enhanced primary care; and reforms in funding models, e health and other foundations of the system are proceeding. LHINs are at the leading edge of these broad transformations and are dealing with a range of complex issues and priorities.
One of these issues is equity – the fundamental principle that all should have equitable access to the highest quality care when they need it regardless of their income or social position, race, gender or where they came from; and that health care should contribute to reducing overall inequalities in health among the population. Equity and population health are among the key attributes of an effective health system included in the new Act.
This workbook provides tools and resources for LHINs to be able to effectively implement health equity strategies and initiatives.
Why Health Equity?
Health inequalities are pervasive and damaging in Ontario. There is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health.[1]
Self-reported health is seen as a reliable measure of overall health status:
- the % who report their health as poor or only fair increases as income decreases
- about 1/4 of low income = 3 X as many as high report health to be only fair or poor
The same pattern exists for mental health, chronic conditions, etc.:
- 3 X as many low-income as high report mental health to be only fair or poor
- the incidence of diabetes in in low income neighbourhoods in Toronto Central LHIN is over 2 X that in high income
This can have a devastating impact on people’s lives:
- in daily lives — the activities of ¼ of low income people are limited by pain = 2X high income
- premature mortality – deaths before 75 – increases with lower income = about 50% worse in low income neighbourhoods
The life expectancy of the top income decile in Canada is 7.4 years for men and 4.5 for women greater than for the bottom quintile. Taking account of the pronounced gradient in morbidity and quality of life, health adjusted life expectancy reveals even higher disparities between the top and bottom of 11.4 years for men and 9.7 for women.[2]
Another way to look at this – if all Ontarians had the same health as high income people:
- an estimated 318,000 fewer people would report their health as only fair or poor
- there would be 231,000 fewer people who are disabled
- an estimated 3,373 fewer deaths each year.
These systemic and damaging disparities are the problem that health equity strategies are designed to solve.
Context
Recognizing this, the province has prioritized equity in its expectations to LHINs for some time. Some LHINs have developed comprehensive health equity strategies; many have developed a range of programs and initiatives addressing barriers to equitable access or the needs of health disadvantaged populations. Some LHINs have made equity an explicit priority within their Integrated Health Service Plans; other see equity as a theme that underlies all of their priority directions. All have identified equity issues to some degree within their IHSPs and other programs.
More generally, it is clear that the Ministry of Health and Long-Term Care will be driving its priorities through performance management means – through adjusting allocations to programs and providers, tying some funding to meeting deliverables, including meeting deliverables in CEO/senior management performance management and compensation processes, etc. The Excellent Care for All Act includes equity and population health among its key principles. While clear directions from the Ministry on how to interpret the new Act and related expectations may not be available for some time, LHINs could be vulnerable if their fiscal and priority decisions do not take all the principles enshrined in the new legislation into account.
Put more proactively, LHINs should realize that equity is part of the overall context of delivering quality enshrined in the Excellent Care for All Act and get out ahead of these coming pressures by prioritizing equity within their overall strategies and initiatives.
What This Resource Provides
This resource is about moving from strategy to practice – operationalizing equity. It provides a range of tools, techniques, briefing notes, research findings and other resources LHINs, and the providers and stakeholders they partner with, can use to implement health equity strategies and initiatives in the most effective ways for their regions and needs.
The basic format is essentially:
| To operationalize equity, LHINs may need to be able to …. | This resource provides tools, techniques and experience on … |
| build equity into planning | a series of planning tools are outlined which can be matched to the planning purposes and needs;Health Equity Impact Assessment is proving practical and popular – the resource provides training and implementation tips and links to workshops |
| require or enable hospitals, Community Health Centres and other providers to develop equity plans for their organizations | several LHINs have done so –and their experience can be drawn upon;templates are available;analyses have been done of the impact and implication of provider equity plans |
| build equity into ongoing performance management | advice on how to develop equity targets;links to promising work underway on equity data and indicators |
| etc…. | etc…. |
These tools and directions are all evidence-based; well-supported in international research, professional practice and health policy and management literature. Just as importantly, they are all experience-based: all have been deployed for many years and in many settings in jurisdictions across the country and around the world, and many of these tools and initiatives have been adapted and implemented within Ontario LHINs.
One great potential of the LHINs is that they all face a similar broad range of challenges, within significantly varied local circumstances; have developed a wide range of initiatives and programs; and could build on each other’s experience and insight by effectively sharing lessons learned. The fact that many of these tools and resources have been adapted or tried in various LHINs means that others can learn from that – at the simplest, there is enough experience with tools ranging from Health Equity Impact Assessment through providers developing health equity plans to not ‘re-invent the wheel’.
This is not so much a blueprint – as conditions and requirements in individual LHINs will vary – but a repertoire or menu of proven tools and resources from which LHINs can draw and adapt to put equity into practice.
This series of tools and techniques can be implemented individually or – better still – as part of integrated and comprehensive equity strategies.
[1] The following data is from the POWER reports: Project for an Ontario Women’s Health Evidence-Based Report at http://www.powerstudy.ca.
[2] Cameron N. McIntosh, Philippe Finès, Russell Wilkins & Michael C. Wolfson. “Income disparities in health-adjusted life expectancy for Canadian adults, 1991 to 2001.” Health Reports. December 2009. Statistics Canada.