driving health equity into action: hospital planning and delivery

© The Wellesley Institutewww.wellesleyinstitute.com

Bob Gardner

UHN Psychiatry Rounds

January 28, 2011


1. health disparities in Ontario and Canada are pervasive and damaging2. but these disparities can be addressed through comprehensive health

equity strategy3. equity strategy can be driven into action within the health system

through• equity-focused planning• aligning equity with key system drivers such as sustainability and quality,

and priorities such as ER, ALC, diabetes, etc.• building equity into ongoing performance management and service delivery• investing in promising interventions, and pulling them together within a

coherent and coordinated overall strategy• enabling innovation through sharing and building on front-line and local

initiatives, evaluation, and organizational learning

4. focus today is on a key setting for implementing this overall strategy --equity-focused planning and delivery in major hospital – in context of psychiatric care in particular

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• there is a clear gradient in health in which people with lower income or socio-economic status, or facing discrimination, racism or other lines of social exclusion, tend to have poorer health

• plus major differences between women and men• in addition, there are systemic disparities in access to and

quality of care within the healthcare system• not just unfair and unjust, but health disparities make it more

difficult to achieve provincial priorities such as ALCs, ER, diabetes, etc, and contribute to avoidable costs

• enhancing health equity has become a clear priority – from the Province to LHINs to many providers

• that’s why we need strategies, tools and best practices to build equity into effective system and service planning

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• Lowest-income neighbourhoods had a significantly higher prevalence of probable depression than highest-income neighbourhoods (risk ratio - 1.36).

• Women and men living in the lowest-income neighbourhoods were also somewhat more likely to use OHIP core mental health services and to receive ECT and much more likely to be hospitalized for depression.

• However, individuals living in the lowest-income neighbourhoods accounted for lower OHIP core mental health care costs, which suggests they either made fewer visits or received less expensive services than those living in the highest-income neighbourhoods.

Source: POWER Study Vol 1 Exhibit 5a.9

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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


• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage

• This concept:• is clear, understandable and actionable• identifies the problem that policies will try to solve• is also tied to widely accepted notions of fairness and social justice

• The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes

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

• Equity is a broad goal, including diversity in background, culture, race and identity

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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 building equity into best hospital and psychiatric care


• even though roots of health disparities lie in far wider social and economic inequality

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

• consistent theme in WHO, EU and all the major international reports and in the many countries that have developed comprehensive multi-sectoral strategies to reduce health disparities

• in all of them, transforming the health system is an indispensable element, including:• reducing barriers to equitable access to high quality care• targeted interventions to improve the health of the poorest, fastest• up-stream investments in primary and preventative care directed to

most vulnerable• delivering a full continuum of services in coordinated way at

community/local level

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

• equitable healthcare and support can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities

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, healthcare and community support services could make overall disparities even worse

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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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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

many recommendations have been acted on

other LHINs are also prioritizing and moving to address health disparities

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• align equity with system drivers:• equity is pre-condition to quality and efficiency agendas• essential part of high-performing health system, now enshrined in new

Excellent Care for All act

• align with system priorities:• can’t solve wait times or chronic conditions without addressing equity

• build equity into priority setting and service planning• for example, by identifying and addressing critical access barriers and

populations with unmet needs

• build into performance management:• explicit equity targets and incentives• cascading through the system -- Prov → LHINs, agencies, etc.→

providers• within providers → into specific programs and depts.

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• need to make equity one of driving priorities for health system and reform

• equity and a population health focus are among key principles enshrined in new Excellent Care for All Act = opening and context

• need clear provincial strategy for equity:

• implicit from MOHLTC, but promised ten year strategy has not been released

• need strategic coherence across health system in approach to equity

• LHINs, CCACs, and other coordinating agencies need to prioritize equity –and many have

• cascading down to all providers prioritizing equity in their service delivery and resource allocation

• UHN: equity incorporated in Strategic Plan and cross-hospital Health Equity Council has been established

• the Council has set out ambitious and progressive goals for the coming year

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• hospitals are developing Quality Improvement Plans• will be reporting every year

• equity can be developed as one of dimensions to report on

• similarly, build equity into your accreditation processes

• and into internal processes -- balanced scorecards, dashboards and other planning tools

• at UHN: 2011-12 goals of Health Equity Council and included in refresh of equity plan include:

• each program will include at least one health equity indicator in its Quality Report to Board

• developing a gender equity indicator for each program

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• cost-effectiveness and safety:

• reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over-prescriptions → enhanced quality and cost effectiveness

• ER:

• one key pressure on ER wait times and ALC is inappropriate use by disadvantaged populations

• part of the solution = better access to primary care, better referrals and linkages with community care

• highlights the importance of partnerships with community agencies

• quality and patient-centred care:

• taking lived conditions/experience into account – meaning equity and diversity → essential to high quality patient-centred care

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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

• 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 for particular populations, etc.• which requires good local research and detailed information – speaks to

great potential of specific analyses within provider organizations and community-based research

• involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems

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

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1. quick check to ensure equity is considered in all service delivery/planning

2. take account of disadvantaged populations, access barriers and related equity issues in program planning and service delivery

3. assess current state of provider organization

4. determine needs of communities facing health disparities

5. assess impact of programs/interventions on health disparities and disadvantaged populations

1. simple equity lens

2. Health Equity Impact Assessment

3. equity audits and/or HEIA

4. equity-focused needs assessment

5. equity-focused evaluation

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• analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations• generally designed for planning forward – as easy-to-use tool to

ensure equity factors are taken into account in planning new services, policy development or other initiatives

• but experience here and in other jurisdictions identified other uses:

• for strategic and operational planning

• for assessing whether programs should be re-aligned or continued

• more generally, discussions around HEIA provide a way to ensure equity is incorporated into routine planning throughout an organization

• increasing attention to potential – from WHO, through most European strategies, PHAC, to Ontario

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• piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and Wellesley Institute• refined the one-page template

• and developed a new workbook

• HEIA is being used in Toronto Central and other LHINs

• Toronto Central has required HEIA within recent funding application processes for Aging at Home, and refreshing hospital equity plans

• been used in many settings relevant for you:• all programs within a sister hospital are undertaking HEIA

• has been used in various setting over last few years – e.g. community-based psychiatric program in suburban area

• one goal of UHN Health Equity Council = pilot HEIA in 2 programs

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• a promising direction several LHINs have taken up is to require providers to develop equity plans• hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TC• and other providers in Central• CHCs are developing sector-wide plan in GTA

• these plans are 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 have the potential to:• raise awareness of equity within the organizations• build equity into planning, resource allocation and routine delivery• pull their many existing initiatives together into a coherent overall equity strategy• build connections among providers for addressing common equity issues

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http://www.torontoevaluation.ca/tclhin/index.html

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http://www.torontoevaluation.ca/tclhin/index.html


• clear consensus from research and policy literature and consistent feature in comprehensive policies on health equity from other countries =• setting targets for reducing access barriers, improving

health outcomes of particular populations, etc• developing realistic and actionable indicators for service

delivery• closely monitoring progress against the indicators or

targets• recognizing that what gets measured, matters• disseminating the results widely for public scrutiny

• interesting international and local work on developing evidence-based equity indicators hospitals can use

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http://www2.massgeneral.org/disparitiessolutions has valuable resources, including Improving Quality and Achieving Equity:A Guide for Hospital Leaders

CRICH has reviewed research and UHN is developing its own indicators

http://www2.massgeneral.org/disparitiessolutions


• where targets and indicators get tied to deliverables and incentives

• all hospitals sign Service Accountability Agreements with LHINs that govern flow of funds

• can build specific expectations and deliverables into these agreements

• will vary by community and provider -- but could include:• undertaking appropriate equity-focused planning to identify areas

where access to services is inequitable and developing plans to address barriers and gaps

• stratifying quality indicators by equity – e.g. readmission rates is common objective

• equity angle is to reduce any inequitable differences in readmission rates by language ability or neighbourhood

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• precondition for all this planning, monitoring indicators, and assessing progress against objectives and targets is reliable data on:• ethno-cultural background, language, income, sexual orientation• service use and health outcomes, differentiated by these equity and

determinants of health variables• hospitals have been using postal code data as proxy

• when hospitals in Toronto Central began working on their equity plans it became very clear that they simply did not have the necessary data to do equity-driven planning• a workshop was held on what kinds of data on equity and diversity are

available, how the existing data sets can be effectively used, and what further types of data are needed

• three hospitals are collaborating on developing plans on how to collect and incorporate equity data -- UHN stays connected to project

• UHN will be analyzing how to enhance data collection – e.g. language preference at ER

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http://www.healthequitycouncil.ca/dev



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• 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.

• again, need solid data within the institution

• also need 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


• huge number of innovative programs underway across the province and City• e.g. psychiatric and other services in homeless shelters• community mental health services geared to specific ethno-

cultural and immigrant communities

• LHINs identify priority populations and providers can identify those most relevant to them

• initiatives underway at UHN include:• Toronto Western Family Health Team is focusing on homebound

– typically frail and isolated seniors – and young and new immigrant families

• programs have been enhanced to support people with Thalassemia and Sickle Cell Disorder


• one of identified equity challenges across Toronto Central LHIN hospitals – and within UHN -- is language:• identified as critical issue in first hospital equity plans and other Toronto

Central planning → major project to develop more systematic coordinated approach to interpretation in downtown hospitals

• at UHN:• identified in first equity plan → improved access to language line –

including portable phone lines → increased use and satisfaction significantly

• expanding in-house interpretation call centre in key languages of your patient community

• not just better quality, but research shows access to interpretation can contribute to safety, appropriate drug and service utilization, etc.

• UHN sees cultural competence training as essential underpinning of interpretation and other quality services

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• same principles drive partnering with community agencies to meet needs of specific communities

• e.g. Concurrent Disorders Services partnering with Native Child and Family Services:• recognizing systemic disparities facing Aboriginal peoples• goal is to ensure traditional health techniques are integrated with

clinical best practices• and that people can move seamlessly between community and

hospital care within a flexible client-centred model

• well-established network of community mental health providers and organizations is key resource to be linked to

• working in community-based cross-sectoral collaborations is widely seen to be a key way to address the impact of social determinants of health

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• all of this equity planning loops back to quality• patient-centred care means taking the full range

of people’s specific needs into account• social context and living conditions people face are

part of this• when people face adverse social determinants of health →

can increase risk of mental health challenges and illness • → fewer resources to cope (from supportive social networks,

to good food and being able to afford medication)

• providers and programs need to know this to customize and adapt care to needs and contexts• more intensive case management, referral planning and

post-discharge follow-up

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• quality standards are especially important to most disadvantaged populations

• how to forge quality standards that reflect individuals’ and communities’ diverse perspectives and needs

• e.g. what does quality psychiatric care look like from point of view of poor older recent immigrant?

• highlights the need for more community-based forms of research and needs assessment, and critical importance of community engagement and connections

• one danger of overall quality agenda and performance management is:

• guidelines could be too clinical or academic, or monitoring too quantitative

• not so easy to apply to complex interventions such as ongoing support for health disadvantaged populations with complex mental health needs

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• Ministry, LHINs and research bodies need to fund and enable evaluation – not just as a tacked-on expectation in accountability regimes

• need to figure our what interventions and approaches work, in what contexts and why

• at a program as well as system level:

• can’t just measure activity – number or % of pop’n that participated in a program or received particular services

• need to measure health outcomes – even when impact only shows up in long-term

• need to assess reach -- who isn’t signing up or getting the services they need?

• need to differentiate those with greatest need = who programs most need to reach and keep to have an impact

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• huge number of front-line initiatives already addressing equity across city and province• many hospital programs, CHCs, mental health, community

care and support, community organizations based out of specific ethno-cultural and other communities

• promising practices such as ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities

• but

• experience and lessons learned are not being shared systematically

• potential of promising interventions is not being realized

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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 rigorously• scale up promising initiatives across the province where

appropriate• need to create forums and infrastructure for this innovation

knowledge management• LHIN and provincial responsibility, but forums such as this are

also key

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• health disparities are pervasive and deep-seated – but can’t let that paralyze us

• do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy

• think big and think strategically – but get going• build equity into strategic priorities, align with quality

agenda and system priorities, embed in routine planning and performance management

• and build equity into front-line planning and delivery where you practice

• no magic blueprint -- experiment and innovate -- and build on learnings and success

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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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http://wellesleyinstitute.com/

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 into action: hospital planning and delivery

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