Social Determinants of Health Inequalities: Roadmap for Health Equity

Social Determinants of Health Inequalities:

Roadmap for Health Equity

Social Housing and Homelessness

Conference

Bob Gardner

September 23, 2009

Outline

1. provide data and analysis of the social and economic

determinants of health and health inequalities

2. show that none of this is inevitable – that the adverse

impact of social determinants of health can be changed

through policy

3. will set out a roadmap for building health equity through

policy change and community mobilization

4. talk about how these lines of action intersect with social

housing, municipal services and local planning

© The Wellesley Institute

www.wellesleyinstitute.com2

Systemic Health Disparities

• in Ontario and Toronto :

– people with lower income, education or other indicators of social

conditions and position tend to have poorer health

– major differences between women and men

– the gap between the health status of the best off and most

disadvantaged can be huge – and damaging

• the foundations of these inequalities lie far beyond the

health system in wider social and economic inequalities



Why Health Disparities?

• health inequalities are of wide interest for two reasons:

1. overall health of population and inequalities in health are telling

indicators of the state of a society

2. opportunities for good health – in the broadest sense of overall

well-being – affects us all

• the scale of differences between the best and worst off =

indictment of the health of Cdn society and current social

policy

• more specifically: close link between homelessness,

poor housing and poor health



Lower Income: Poorer Self-rated

Health

% Reporting Poor or Fair Health,

Toronto Central LHIN, 2001 CCHS

11

34

0

5

10

15

20

25

30

35

40

Low Income High Income

Three fold difference in self-rated health among lowest and

highest income neighbourhoods.Canadian Community Health Survey 2001

Glazier et al. Primary Care among Disadvantaged Populations. Primary Care.

ICES Atlas, 2006. www.ices.on.ca/intool© The Wellesley Institute


Inequality by Race and

Ethno-Cultural Background

• solid data on racialization of poverty and inequality, and

racism and social exclusion are critical overall

determinants of health

• research on ‘healthy immigrant’ effect – people coming

in with better health than average and then deteriorating

• but Cdn jurisdictions don’t keep statistics by race, so

have limited comprehensive data

• stark differences for Aboriginal people:

– life expectancy at birth, on average, is 5 to 10 years less for First

Nations and Inuit peoples than for all Canadians

– self-reported health in Ontario is over twice as bad as for white

– seeing greater vulnerability of First Nations communities around

H1N1 © The Wellesley Institute



www.wellesleyinstitute.com

Lower Income: Higher Diabetes Rate

Diabetes Incidence, TC LHIN 2004/05

5.8

13.3

0

2

4

6

8

10

12

14

16

Low Income High Income

New

Cases/1

,000

Two fold difference in diabetes incidence between lowest and

highest neighbourhoods.

Age Standardized Rates. Data Source: Ontario Diabetes Database, 2004/05

www.ices.on.ca/intool © The Wellesley Institute


Homeless Health

• 2007 Street Health Report – comprehensive survey of

homeless people in downtown Toronto

• self-reported health: 4X as many rated only fair or poor

vs. general pop’n in Toronto

• oral health: 62% rated fair or poor – 4X general pop’n

• 14% are usually in severe pain

• 74% had at least one serious condition

• 59% do not have a family doctor – vs. 9% for general

pop’n





Foundations of Health Disparities

Lie in Social Determinants of

Health

• clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion

• impact on health outcomes of inadequate childcare, poverty, precarious employment, unequal income distribution, social exclusion, and inadequate housing is well established here and internationally

• real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities



17© The Wellesley Institute


Health Equity = Reducing

Unfair Differences

• health equity is the absence of socially structured inequalities and differential outcomes

• the goal is to reduce those differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage

• this concept is:

– clear, understandable & actionable

– it identifies the problem that policies will try to solve

– it’s also tied to widely accepted notions of fairness and social justice

• a positive and forward-looking definition = equal opportunities for good health



Think Big, But Get Going

• one problem is that health disparities can seem so overwhelming and their underlying social determinants so intractable

→ can be paralyzing

• think big and think strategically, but start somewhere

– make best judgment from evidence and experience

– experiment and innovate

– learn lessons and adjust

– gradually build coherent sets of policy and program actions

• set out 12 point roadmap for health equity

Wellesley Institute Roadmap for

Health Equity 1:

Learn from Leading Countries

• there is always much to be learned from policies, programs and initiatives in other jurisdictions

• a number of countries have made lessening health disparities a top national priority and have developed cross-sectoral policy frameworks and/or action plans:

– England, Scotland, Australia, New Zealand

– many European countries

• also increasing international and high-level attention:

– WHO Commission on Social Determinants of Health

– European Union, with its Closing the Gap project to tackle health disparities

• look broadly for policy solutions, and adapt flexibly to local/provincial circumstances





Commitment to Equity:

Sweden

• coordinated national policy to reduce health disparities by reducing the number of people at risk of social and economic vulnerability

• national public health strategy has 12 key objectives –five of which, defined as fundamental to all the others, are about improving social and economic determinants – also focus on inclusive labour market, anti-discrimination,

childcare, affordable housing and other policies

– equitable access to improved health care was seen to be just one part of this broader package

• emphasized partnerships with community service providers and organizations – in both policy development and service delivery

Local Ideas and Innovation

• not just from other jurisdictions – but good ideas from

here as well

• increasing emphasis in research literature and in service

planning on place-based analysis

• recognition of healthy communities as a foundation of

overall good health

– Toronto and Canada were early leaders in healthy cities

movement

• the importance of social resilience and social capital as

enablers of good health

• and of community mobilization and involvement as a

driver of community-based health and social action© The Wellesley Institute


Roadmap for Health Equity 2

It’s All About Policy

• reducing overall social and economic inequality may be the most significant single way to reduce health disparities → requires a significant commitment and re-orientation of social and economic policy

• need to build health equity into all macro social and economic policy:– not just as one factor among many to be balanced, but as core

priority

– some jurisdictions have built equity consideration into their policy processes – e.g. a change in tax policy or new environmental policy would be assessed for its health equity impacts

– Canadian Index of Wellbeing = idea that how well a country is doing cannot be captured by GDP or stock market indexes, but should include social, cultural and other facets of wellbeing




Split Action Into Achievable

Chunks

• everything can’t be tackled at once:– need to split strategy into actionable components and phase them in

• but coordinate through a cohesive overall framework

• fundamental policy action on equity takes time – need patience

• pick issues and levers that will show progress and build momentum for action on equity– look for collaborations on issues with broad consensus – e.g. child

poverty

– and initiatives that will show results and build momentum – linking schools, local health and social services to enhance early years services for high-need children, families and communities

– re-frame issues from spending – esp. in this tight climate – to investments that build social cohesion and enhance human capital




Work Across Silos

• significant improvements in health disparities require broad cross-sectoral coordination of public policy

• your member depts often deliver services for various levels of govt:– prov: child care, social assistance

– feds: settlement, training

• great potential for integrating all this for both efficient provision and seamless service to clients– idea of ‘wrap-around’ services

– supportive housing is one of best examples -- proven impact and cost-effectiveness

• but policies of various governments often have

contradictory objectives and structures© The Wellesley Institute




‘Joined Up’ Government

• more coordinated horizontal and cross-cutting way of developing

and implementing policy are often called ‘whole of government’

approaches or ‘joined-up’ government

• Saskatchewan:

– coordinating table of ADMs -- Human Services Integration Forum

– to promote inter-agency collaboration and integrated planning

and service delivery

– current priorities include strengthening families’ capacities, early

childhood support, increased opportunities for youth, increase

well-being and employment situations, improve coordination and

integration of services, etc.

– also regional coordination bodies across agencies

– which in turn provides space/encouragement for interesting local

integration in areas such as Saskatoon25



Better Policy Coordination II

• over the last decade in Quebec:– provincial strategy coordinates health and related social spheres – in

one Ministry

– Health and Wellbeing Council encourages inter-sectoral action

– widespread consultation and involvement of community sector in policy development

– comprehensive 10 year plan to address social determinants and wellbeing

– all Ministries are required to consult the Ministry of Health on new legislation or regulations that could impact health

– regional health plans are required to develop integrated pans with social services

– local health authorities must coordinate with non-health services

• Ontario:– Premier’s Councils of early 1990s emphasized coordinated policy

across ministries and spheres

– current project to develop cross-Ministry policy coordination on health equity

26

Acting Across Silos for

Housing

• need to act across silos is very clear in housing

– all levels of govt have part of housing pie

– need for federal-prov cooperation and coordination for effective

and progressive housing policy

– vital role of municipalities and their local/community partners in

determining what is needed and delivering vital services

• so how could this work?

– commitment of sufficient funds from senior levels – with less

squabbling

– local and community-driven needs assessment and planning

– range of flexible services geared to local needs, but within

consistent overall objectives

– means to learn from all these local innovations© The Wellesley Institute


Promising Local Initiatives

• Seaton House in Toronto

– has a primary clinic on site

– interesting innovation grew out of providers and service users

there – CAISI integrated client record database

• Ottawa – palliative care in shelter

• Sherbourne Health Centre, Immigrant Women's Health Centre and

many others’ health buses

– break down barriers by going to where people are

– Sherbourne bus has integrated electronic health records

• psychiatrists and others out of downtown Toronto hospital provide

mental health services to homeless people wherever they are

• Street Health, harm reduction and other community workers in

shelters and streets




Targets and Incentives

• a vital part of comprehensive policy on health equity = – setting targets or defining indicators – that build on available

reliable data and make the most sense in the particular policy context

– closely monitoring progress against the indicators or targets

– disseminating the results widely for public scrutiny

• build these targets and objectives into routine performance management– in health, all hospitals and CHCs sign Service Accountability

Agreements with LHINs that govern flow of funds

– build in specific expectations:• provide sufficient services in languages of community

• provide services that match their catchment profile

• provide outreach to specific disadvantaged populations – homeless, isolated seniors, etc.



England

• UK Tackling Health Inequalities; A Programme for Action

– first published in 2003 and updated every two years

– committed to reducing inequalities in specific health outcomes by 10% by 2010

– argued that links across government are essential to sustaining long-term change

– spelled out specific targets for reduced child poverty, more affordable housing, early childhood development, employment, building healthy communities, and broad national redistributive and social policies

– Departments were responsible for meeting those targets




Build On What Is Working

• huge number of promising and innovative service

initiatives underway in every community

• rigorously evaluate the outcomes and potential of

program initiatives and investments – to build on

successes and scale up what is working

• needs a different form of evaluation:

– not just activity reports or even value for money

– not being swamped by reporting requirements to funders – who

never use the data

– but how does program or initiative affect health and related

inequalities?

– involve consumers and disadvantaged people directly in

determining what matters to them – what success looks like © The Wellesley Institute



Build Equity Within Health

System

• roots of health disparities lie in broader social and economic factors

• but how the health system is organized and how services and care are delivered are still crucial to tackling health disparities

• transforming the health system is an indispensable element of comprehensive health equity strategy, including:– reducing barriers to equitable access

– targeted interventions to improve the health of the poorest fastest –generally as part of community/local initiatives

– primary care as a key enabler of health equity

– enhanced community participation and engagement in health care planning

– more emphasis on health promotion, chronic care and preventive programmes, especially for most disadvantaged



Action to Reduce Health

Disparities

• comprehensive strategy

developed in 2008 for Toronto

Central LHIN

• many of recommendations

have been acted on

• other LHINs also prioritizing

and moving to address health

disparities

• emphasized cross-sectoral

collaboration beyond the

LHINs on wider determinants





Reduce Access Barriers to

Good Healthcare

• identify and reduce barriers to access:– within system architecture: considerable evidence that private

provision and payments -- such as user fees, prescription costs -- create greater barriers for poorer people

– language and culture → ensure culturally competent care and build anti-racism/oppression approach into service provision

• assess what models have best served the most vulnerable communities and invest in them– e.g. Community Health Centres, public health and other

community-based service providers have explicit mandates to support the most under-served communities

→ expand their coverage and impact




Invest for Equity Impact

• target services to specific areas or populations:

– those facing the harshest disparities – to raise the worst off fastest

– or most in need of specific services

– or the worst barriers to equitable access to high-quality services

• this requires sophisticated analyses of the bases of disparities:

– i.e. is the main problem language barriers, lack of coordination among

providers, sheer lack of services in particular neighbourhoods, etc.

– which requires good local research and detailed information – speaks to

great potential of community-based research to provide rich local needs

assessments and evaluation data

– involvement of local communities and stakeholders in planning and

priority setting is critical to understanding the real local problems

• and invest in those levers and spheres that have the most impact on

health disparities



Enhance Equity Focused

Primary Care

• considerable international evidence that expanding primary care can reduce health disparities

• major reforms are underway across Canada to restructure primary care– these system-level reform initiatives are an opportunity to build

equity in by concentrating increased primary care in areas with poorest access or health status

– think of practice innovations as well -- e.g. nurse practitioner and nurse-based clinics have been very effective in delivering primary care and managing chronic conditions

– silos: CHCs in LHINs, Family Health Teams established by MOHLTC, private practice docs essentially independent

– in terms of policy levers, it has been easier to establish CHCs and other clinics, than to reform private medical practice

Collaboration Again

• can also see primary care reform as a catalyst for wider changes:– many countries have clinics that provide both health and wider

social services in one place

– new satellite CHCs are being developed in designated high-need areas in Toronto — and some will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location

• think back to earlier eras with public health nurses in

schools

– key role in identifying problems early, providing routine care and

health promotion

– begin by putting public health nurses or associated workers in

schools in most disadvantaged areas

– link them into a network of services they can refer kids onto

when needed © The Wellesley Institute



Act Locally

• action on equity cannot just come from senior governments

• many of the most innovative and insightful programmes addressing health disparities have come from local authorities or community providers– emerging evidence that neighbourhood has an independent or

reinforcing impact on health disparities

– lived experience of health problems and opportunity structures always takes place in a local context

– this requires that equity-driven interventions be locally focussed

• regional health authorities (LHINs in Ont) have been an important enabler and forum for planning and promoting local initiatives





Act Locally And Systematically

• to implement equity locally LHINs can:– use planning tools such as diversity lenses and health equity

impact assessments

– concentrate key programs in disadvantaged neighbourhoods

• build the voices and interests of the whole community –including marginalized and traditionally excluded – into their governance and planning

• enable innovation:– fund or pilot new ways of addressing barriers or supporting hard-

to-serve communities

– encourage on-the-ground collaborations and partnerships among health care providers and beyond

– establish and support cross-sectoral planning tables



Cross-sectoral Collaboration

at Local and Regional Levels

• back to British example – Health Action Zones and other models were designed to combine community development with targeted healthcare and social service improvements

• and in Canada, some Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building:– Saskatoon is developing cross-sectoral action on health equity:

• began from local research documenting shocking disparities among neighbourhoods

• focussing interventions in the poorest neighbourhoods – locating services in schools, relying on First Nations elders to guide programming, etc.

• wide collaboration among public health, municipality, business, community, Aboriginal and other leaders

Looking for Innovation: Hub

Models of Integrated Care

• hub-style multi-service centres in which a range of health and

employment, child care, language, literacy, training and social

services are provided out of single locations.

• Winnipeg Regional Health Authority and Manitoba Family Services

and Housing have been partnering on a new model to integrate

health and social service delivery – one-stop access models in

various communities to deliver a broad range of health and social

services directly and to refer on to other agencies when services

aren’t available

• Ontario provincial associations representing CHCs, mental health

and community service agencies have been promoting idea

• federal and provincial governments could fund demonstration

projects and investments in hub-type integrated social and health

service centres






10: Up Stream Through an

Equity Lens

• investing in better chronic care management, preventive care and health promotion are seen to be vital elements of health reform– a very interesting primer has been developed by the Ontario Prevention

Clearinghouse (Health Nexus), Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20Final.pdf

• up-stream initiatives need to be planned and implemented through an equity lens

– anti-smoking, exercise and other health promotion programmes need to explicitly foreground the particular social, cultural and economic factors that shape risky behaviour in poorer communities– not just the usual focus on individual behaviour and lifestyle

– move to see ‘healthy communities’ as vital to overall health promotion

– implies wider community development and capacity building approaches

http://www.ocdpa.on.ca/docs/Primer to Action SDOH Final.pdf

http://www.ocdpa.on.ca/docs/Primer to Action SDOH Final.pdf




11: Support Community-

Based Innovation

• themes so far:– ‘chunking out’ actionable projects

– experimenting , but strategically

– relying on local community-based and other front-line innovations

• to realize this potential, senior governments need to develop a framework to support experimentation and innovation:– common data and information platforms

– funding for pilot projects – available to CHCs, different practice models and community-based providers

– dedicated funding lines to LHINs for pilots, and expectations that each LHIN will undertake innovations

– looking for results and value, but also need funding regimes that are flexible and not too bureaucratic


12: Build On This Innovation

• pull all this innovation, experience and learning together

into a continually evolving repertoire of effective program

and policy instruments

• and into a coherent and coordinated overall strategy for

health equity.

• then need a provincial or national infrastructure to:– systematically trawl for and identify interesting local innovations

and experiments

– evaluate and assess potential beyond the local circumstances

– share info widely on lessons learned

– scale up or implement widely where appropriate

• all to create a permanent cycle and culture of front-line driven innovation on equity



Key Messages

1. health inequalities are pervasive and damaging – and

that’s not just a health system issue

2. the roots of health disparities lie in wider social and

economic inequality and exclusion

3. but none of this is inevitable – the adverse impact of

social determinants of health can be changed through

policy

4. have set out a roadmap for building health equity

through policy change and community mobilization

5. these lines of action intersect with your spheres of

social housing, municipal services and local planning





Moving Forward

• there isn’t a magic plan that can be applied in every country or

region to reduce disparities, but we broadly know what is needed

• but knowing policy directions that will work doesn’t mean

governments will adopt them:

– its unfortunately not just solid research or clear evidence from other

countries that drives government action

– its politics

• challenge is to mobilize community support/action and shift public

opinion:

• we need to find ways that governments, providers, community

groups, unions, and others can support each others’ campaigns

and coalesce around a few ‘big ideas’

Health Equity

• could be one of those ‘big’ unifying ideas..

– if we see opportunities for good health and wellbeing as a basic

right of all

– if we see these pervasive health disparities as not only incredibly

damaging to so many, but also as an indictment of an unequal

society

– if we recognize that coming together to address the social

determinants that underlie health inequalities will benefit many

other spheres – from better early child development to

community supports to live independently when we need it

– if we see that addressing the roots of so many of our social

problems requires broad collaboration and mobilization



Wellesley Roadmap for

Action on the Social

Determinants of Health

1. look widely for ideas and inspiration from jurisdictions with comprehensive

health equity policies, and adapt flexibly to Canadian, provincial and local

needs and opportunities;

2. address the fundamental social determinants of health inequality – macro

policy is crucial, reducing overall social and economic inequality and

enhancing social mobility are the pre-conditions for reducing health

disparities over the long-term;

3. develop a coherent overall strategy, but split it into actionable and

manageable components that can be moved on;

4. act across silos – inter-sectoral and cross-government collaboration and

coordination are vital;

5. set and monitor targets and incentives – cascading through all levels of

government and programme action;



Wellesley Roadmap II

6 rigorously evaluate the outcomes and potential of programme initiatives

and investments – to build on successes and scale up what is working;

7 act on equity within the health system:

– making equity a core objective and driver of health system reform –

every bit as important as quality and sustainability;

– eliminating unfair and inefficient barriers to access to the care people

need;

– targeting interventions and enhanced services to the most health

disadvantaged populations;

8 invest in those levers and spheres that have the most impact on health

disparities such as:

– enhanced primary care for the most under-served or disadvantaged

populations;

– integrated health, child development, language, settlement,

employment, and other community-based social services;



Wellesley Roadmap III

9 act locally – through well-focussed regional, local or neighbourhood cross-

sectoral collaborations and integrated initiatives;

10 invest up-stream through an equity lens – in health promotion, chronic care

prevention and management, and tackling the roots of health disparities;

11 build on the enormous amount of local imagination and innovation going on

among service providers and communities across the country;

12 pull all this innovation, experience and learning together into a continually

evolving repertoire of effective programme and policy instruments, and into

a coherent and coordinated overall strategy for health equity.





Contact Us

• these speaking notes and further resources on policy

directions to enhance health equity, health reform and

the social determinants of health are available on our

site at http://wellesleyinstitute.com

• my email is [email protected]

• I would be interested in any comments on the ideas in

this presentation and any information or analysis on

initiatives or experience that address health equity

http://wellesleyinstitute.com/

mailto:[email protected]

Social Determinants of Health Inequalities: Roadmap for Health Equity

Health & Medicine

Transcript of Social Determinants of Health Inequalities: Roadmap for Health Equity