driving health equity for kids: from the earliest years to transforming the system

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Achieving Health Equity for Kids: Whatever it Takes

Hospital for Sick Children Conference

Bob Gardner, PhD

March 30, 2010


• Start with big picture – fundamental roots of inequality in children's health lie in wider structures of social and economic inequality → action needed at macro policy level

• But what happens in healthcare system is still vital• Analyze how to embed equity in planning and service delivery

• strong strategic commitment from the top• equity-focused planning and performance management

• And how to address particular health disadvantaged populations or access barriers

• Circle back to social inequality – one way hospitals and providers can address SDoH is through • cross-sectoral collaborations and planning• building understanding of SDoH and inequality into service delivery• partnering with community providers and others to address roots of inequality

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• 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

• concentrated disadvantage and poor health in particular communities – poor, immigrant, socially excluded and isolated

• major differences between women and men• the gap between the health status of the best off and

most disadvantaged can be huge – and damaging• in addition, there are systemic disparities in access to

and quality of care within the healthcare system

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• from the start: while infant mortality rates have been declining overall, rates in Canada’s poorest neighbourhoods remain two-thirds higher than those of the richest neighbourhoods

• to the end: inequality in how long people live• difference btwn life expectancy of top and bottom income

decile = 7.4 years for men and 4.5 for women

+ inequality in how well people live:• more sophisticated analyses add the pronounced gradient in

morbidity to mortality → taking account of quality of life and developing data on health adjusted life expectancy

• even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women

(Statistics Canada Health Reports Dec 09)

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

• impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes 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


Determinants interact and intersect with each other in a constantly changing and dynamic system

In fact, through multiple interacting and inter-dependent economic, social and health systems

Determinants have a reinforcing and cumulative effect on individuals throughout their lives and on overall population health

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• important elaboration in SDoH analysis – recognizing that:• the effect of determinants varies across people’s lives – so need

to analyze impact on children and youth specifically• and that impact of inequalities is cumulative

• for children:• research showing that pre-natal and early years are especially

sensitive to social conditions and can have a major impact on future health

• that intervening in early years to counteract adverse effects of wider social and economic inequalities has great potential

• growing up in inadequate and inequitable social and family circumstances can store up a life-time of health problems

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• the point of all this analysis is to be able to identify policy and program changes needed to reduce health disparities

• but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing

• think big and think strategically, but get going• make best judgment from evidence and experience• identify actionable and manageable initiatives that can make a

difference• experiment and innovate • learn lessons and adjust – why evaluation is so crucial • gradually build up coherent sets of policy and program actions –

and keep evaluating

• need to start somewhere – and focus here is on children’s health and health system


1. it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care

• equitable healthcare and proactive health promotion can help to mediate the harshest impact of the wider social determinants of health

2. in addition, there are systemic disparities in access and quality of healthcare that need to be addressed

• people lower down the social hierarchy tend to have poorer access to health services, even though they may have more complex needs and require more care

• unless we address inequitable access and quality, health system could make overall disparities even worse

• at the least, the goal is to ensure equitable access to care/support for all who need it, regardless of their social position

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while health disparities are pervasive and deep-rooted, they can be changed through policy and program action

comprehensive strategy developed in 2008 for Toronto Central LHIN –50> recommendations

many recommendations have been acted on

other LHINs are also prioritizing and moving to address health disparities

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• goal is to ensure equitable access to high quality healthcare regardless of social position

• can do this through a two pronged strategy:1. building health equity into all health planning and delivery

• doesn’t mean all programs are all about equity

• but all take equity into account in planning their services and outreach

2. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers

• looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable

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• need to start from clear vision of what high quality children's healthcare looks like – and how crucial equity is to achieving that vision

• then make equity one of driving priorities for health system and reform• define equity as an essential part of high-performing

health system – as Ontario Health Quality Council• in fact, stronger argument that equity is pre-condition to

success on quality, efficiency and patient-centred priorities• need clear provincial strategic commitment to health equity• cascading down through LHINs’ strategic plans and policies• and to expectations to all providers that equity is among

their central priorities

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• a promising direction several LHINs have taken up is to have providers undertake specific equity planning exercises designed to:• identify access barriers, disadvantaged populations, service gaps and

opportunities in their catchement areas and spheres• develop programs and services to address those gaps and better meet

healthcare needs of disadvantaged communities

• these provider plans can:• raise awareness of equity within the organizations• build equity into planning, resource allocation and routine delivery• pull existing initiatives together into a coherent overall equity strategy• build connections among providers for addressing common equity

issues

• imagine the great potential if all specialized children's hospitals and providers developed equity plans in integrated manner

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• greater chance of success for equity strategy if aligned with provincial priorities: diabetes, wait times, mental health

• all these priorities are particularly sensitive to social conditions

• e.g. chronic disease prevention and management programs cannot be successful unless they take account of social conditions and constraints

• risks people face and resources available to them vary over life course --- need to analyze specifically for kids

• e.g. diabetes is also crucial for children’s health

• recognized to be an increasing threat to future generations

• illustrates the case for early investment -- preventing childhood diabetes is crucial to avoiding a lifetime of health problems

• supporting resources and opportunities for healthy behaviours for kids can help to prevent chronic conditions later on

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• addressing health disparities in service delivery and planning requires a solid understanding of:• key barriers to equitable access to high quality care• the specific needs of health-disadvantaged populations• gaps in available services for these populations and kids

• need to understand roots 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• involvement of local communities and stakeholders in planning and

priority setting is critical to understanding the real local problems

• requires an array of effective and practical equity-focused planning tools

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• has been piloted and refined in Toronto and is being implemented in LHINs across the province

• planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations

• can help to plan new services, policy development or other initiatives

• can also be used to assess/realign existing programs

• essentially a checklist to anticipate possible equity implications

• could adapt for specific dynamics of children and youth health and service provision

• think of potential:

• if all children's hospital and other specialized children’s health services began using HEIA

→ build up great deal of comparable evidence, insight and experience quickly

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• all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds

• can build in specific expectations – will vary by community and provider -- but could include:• undertaking appropriate equity-focused planning• ensuring service utilization matches appropriately with demography

and needs of their catchment profile• providing sufficient services in languages of community and

appropriate interpretation• identifying areas where access to services is inequitable and

developing plans to address barriers and gaps• developing specific services or outreach to particular disadvantaged

populations – homeless young moms, immigrant kids, racialized youth, etc.

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• second theme of overall strategic framework is to target services to:

• those kids facing the harshest disparities – to improve the health of the worst off fastest

• or those most in need of specific services

• or to 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.

• highlights need to collect equity-focused data and do HEIA-type planning

• also requires good local research and detailed information – speaks to great potential of community-based research to provide rich needs assessments and evaluation data

+ incentives and funds to develop equity initiatives


• having identified key barriers to equitable access and outcomes for kids

• if critical barrier is language → expand translation and interpretation services

• if issues is differential treatment for racialized or new immigrants → cultural competence training and requirements

• if issue is poor conditions in which kids live – and to which they will be discharged →• financial and other support to parents• support with costs not covered under OHIP – drugs, transportation,

childcare• enhanced community support – likely working in partnership with

providers

• if issue is parents/kids don’t have health card →• provide services to uninsured resident kids for free

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• taking social inequalities into account when designing children’s health services• My Baby and Me Passport• peer ambassador type support for well babies and mothers

• align health equity with other key priorities• investing in children – and in health of most disadvantaged kids -

- has to be central to poverty reduction strategy

• cross-sectoral coordination and planning are vital ways to act on wider SDoH• every LHIN should support or establish cross-sectoral planning

tables• with expectations that hospital and other providers undertake

cross-sectoral collaborations

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• idea of comprehensive community initiatives – Vibrant Communities, healthy city movements

• British Health Action Zones, German ‘social cities’ and other models were designed to combine community economic development with targeted healthcare and social service improvements

• in Canada, some Regional Health Authorities have developed operational and planning links with local social services or emphasized community capacity building:• Saskatoon began from local research documenting shocking disparities

among neighbourhoods• focusing 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


• has been increasing interest in 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 ‘one stop' locations• some new satellite CHCs being developed in designated high-need areas

in Toronto will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location

• also considerable experience/evidence for potential of:• early years centres• investing in comprehensive and integrated services for children at

highest risk and with most complex problems• earlier eras of public health nurses in schools• idea of childcare centres also providing broader child development

and social support – both on-site and linking into community services

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

• proven success of ‘head start’ type programs• 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, especially Nordic

• also increasing international and high-level attention:• WHO Commission on Social Determinants of Health -- and its

knowledge network on early child development• European Union, with its Closing the Gap and Determine projects to

tackle health disparities• reducing poverty and investing in comprehensive programs to address

health inequalities for children are central to all these strategies

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• to drive equity-focused innovation and effective interventions, we need to be able to:• collate and analyze all the useful intelligence gained from equity-focused

planning• capture and share information on local initiatives, and build on local front-line

insights• share the resulting knowledge across regions – and beyond • assess the most promising initiatives or directions• scale up promising initiatives across the province where appropriate

• creating a forum and infrastructure for this innovation knowledge management is crucial

• but who takes it up?• innovation doesn’t fit nicely into Ministry and other institutional boundaries• whatever the form, needs to be collaboration with Ministries, Prov associations, other

stakeholders?

• idea of collaborative of children's hospitals and other providers creating forums to share and build innovation on children’s health equity

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• health professionals, hospitals and other providers have considerable prestige and influence with pubic and policy makers

• plus there is general public support for improving the lives and opportunities of children

• can use that standing to advocate for health equity for children:• think if Sick Kids and its counterparts were to make public

commitments that it is intolerable that some of its kids do worse than others because of poverty and inequality, and they are going to make sure their programs do something about it

• or that they will provide the best care to every kid regardless of where they were born or whether they have an OHIP card

• think of the impact of leading providers and experts developing a Charter or Manifesto for Children’s Health Equity

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• 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

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mailto:[email protected]


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 program action;

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6 rigorously evaluate the outcomes and potential of program 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;

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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 program and policy instruments, and into a coherent and coordinated overall strategy for health equity.

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driving health equity for kids: from the earliest years to transforming the system

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