Driving Health Equity in Tough Times

Presentation to the Hospital Collaborative on Marginalized Populations

April 2012

Bob Gardner

Social Determinants of Health + Complex SystemsNeed to look at how these other systems shape the impact of SDoH:

•access to health services can mediate harshest impact of SDoH to some degree•community resources and resilience are important

POWER Study: Gender andEquity Health Indicator Framework

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Three Cumulative and Inter-Dependent Levels Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health →

1. gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. also because of broader social and economic inequality and exclusion →

2. some communities and populations have fewer capacities, resources and resilience to cope with the impact of poor health

3. because of all this, disadvantaged and vulnerable populations have greater/more complex needs, but face systemic barriers within the health and other systems →

3. these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

Towards Solutions:Building Equity Into the Health System

1. building health equity into all health care 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. aligning equity with system drivers and priorities:• such as chronic disease prevention and management, quality – won’t

succeed without building equity into planning/delivery• also to enhance chance for success of equity agenda

3. identifying those levers that will have the greatest impact on reducing health inequities and driving system change:

• enhanced primary care

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Towards Solutions:Building Equity Into the Health System II

4. embedding equity in provider organizations’ deliverables, incentives and performance management

5. 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 looking to improve the health of most vulnerable, fastest

6. while investing up-stream: • in health promotion and prevention – crucial to long-term

sustainability and pop’n health• addressing the underlying determinants of health – crucial to

reducing health inequities

Drummond on Health

• The Drummond Report’s emphasis on reform and innovation in the way health care is organized and delivered is vital:• focus on quality and patient-centred care• emphasis on value, efficiency and innovation• integration of health services• long-term planning – call for 20 year plan with coherent

principles (ironically – has been draft within MOHLTC for years)

• a shift to home and community care• prevention

• argues that there are many opportunities for reform – and that many are underway across the system

• But….

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Huge element is missing: equity

• equity is not included in his key principles of an ideal system• which contradicts ECFFA

• equitable access to services, equitable outcomes and improved population health must also be fundamental goals of reform.

• without taking equity into account:• reforms being contemplated could make access to health

care less equitable• good idea of more home and community-based care – but what of

poor home and living conditions of so many?

• or worsen the health of marginalized populations• good idea of self-care and better information to promote one’s own

health – won’t work for poor, marginalized or those facing language/literacy barriers

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Drummond on Health: Misdiagnosis

• Drummond highlights that a small proportion of patients with complex needs account for a high proportion of overall health system costs• but this isn’t just elderly or end-of-life, or complex mental health• consistent inequitable gradient of health = higher

needs/utilization of disadvantaged• that can be avoided with more equitable strategy and outcomes

• emphasizes that preventing ill health and controlling chronic diseases is crucial moving forward• again, can only work if we take inequitable risk and burden of

chronic diseases into account• and if we address social and economic inequality that underlie

these health inequities

Canadians With Chronic Conditions Who Also Report Food Insecurity

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Drummond on Health: Primary Care

• The report also highlights the importance of primary care. • emphasizes Family Health Teams, with their more integrated model of care

than sole practices• but without addressing their inequitable distribution, incentives and outcomes• and ignoring Community Health Centres, who have explicit mandate and solid

record in addressing needs of health disadvantaged populations and community building

• An equity approach would ensure that expanded family health teams, community health centres and other key reforms are concentrated in under-served and higher need areas• highlighting that his good idea of integration needs to be clarified – integrated

for what?• not just efficiency but to reduce inequitable access and improve health of most

disadvantaged

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Drummond on Health: System Drivers

• pays remarkably little attention to how fundamental transformation could actually be driven

• pay attention to incentives:• e.g. of Family Health Teams – when OMA negotiations drive policy• dangers of performance or activity-based funding to come – avoid the

complex and challenging• and performance measurement:

• success conditions – equity-relevant data• embed equity in provider and LHIN level indicators and targets:

• not just reduce overall hospital readmission rates or incidence of diabetes

• reduce differentials by gender, income, language, neighbourhood• provider equity plans• building equity deliverables into Quality Improvement Plans

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Drummond on Health: Integration

• the report rightly points to the need for coordination and integration of services• essential to major provincial priorities such as reducing hospital

readmissions• discharging a patient into overcrowded or unsafe housing means that

they are likely to end up back in the hospital → undermining the savings and efficiencies the Commission is looking for

• it highlights that the LHINs are most appropriate vehicle for this integration, but limited by MOHLTC policy/admin• importance of building solid equity strategy and action at LHIN level• also speaks to the importance of coordination beyond health care to

social services, housing and other determinants-related spheres• could be positive role for LHINs moving forward

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Drummond on Health: Neglected Social Determinants

• Drummond did recognize – although unevenly – that not investing in the social/community foundations of a healthy society will lead to higher costs down the road

• but didn’t recognize in its health analysis how inequitable social determinants of health will undermine efforts at reform and continue to create poorer health

• health providers and institutions have considerable credibility and influence → use as platform to highlight these wider connections• e.g. power of hospital CEOs saying that welfare cuts will

increase pressure on ER and strain health care delivery

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Look for Areas to Intervene

•Commission on the Reform of Social Assistance in Ontario•A broad collaborative of leading Toronto health sector institutions and experts came together to:

• Define a vision of health-enabling social assistance system; and

• Practical actions to implement such a system

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Public Policy Post-Drummond• an enormous range of specific recommendations and welcome

recognition of need for govt and public services to be more innovative and responsive

• but most important influence may be in shaping the tenor/parameters of public policy• it justifies and ushers in an era of austerity, restraint and limited public

investment• this poses a real danger to health

• reducing vital support for affordable housing, safe communities, transportation, and other community infrastructure will undermine the foundations of strong and healthy communities

• will have an adverse impact on overall health and will increase health inequities — in turn, putting more pressure on the health care system