Longwoods Blog

Equity – a blog with 12 entries from The Equity MAgIC  group, a collective of stakeholders actively working on pushing the equity agenda forward.

Ontario’s Ministry of Health and Long-Term Care (MOHLTC) has identified equity as a key component of quality care. The Ministry has developed a Health Equity Impact Assessment (HEIA) to support improved health equity, including the reduction of avoidable health disparities between population groups. HEIA also supports improved targeting of healthcare investments—the right care, at the right place, at the right time. And that is what this blog covers. Join us in the conversation.

The “For All” in Ontario’s Excellent Care for All legislation is a deliberate recognition that we can only improve the health of the population if everyone receives the recommended standard of care.

Though we have made strides in providing more equitable healthcare, the Toronto Central LHIN and its partners continue to improve access.

Today, more than ever, equity needs to be integrated into every single healthcare decision; every single health planning exercise.

Equitable care simply cannot be left as an afterthought or add-on to healthcare planning.

Number 12: A Time for Action

“Systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means” – Michael Marmot on defining health equity

In the current Health Equity Dialogues series we have heard from researchers on the importance and value of translating health equity research and strategy into policy and program action. Yet despite being on the leading edge of health equity research, Dr. Adalsteinn Brown’s analysis demonstrates that Canada lags behind many other developed countries in incorporating health equity into policy and practice, even behind our neighbours to the South. Using a similar tone, Dr. Arjumand Siddiqi suggests that Canada has much work to do in reducing health disparities when compared to outcomes among disadvantaged populations, especially in the Scandinavian countries. Yet despite the United States faring worse than Canada in wider health inequities, they have entrenched health equity at the national level (Patient Protection and Affordable Care Act of 2010), at the state level, including Massachusetts (An Act to eliminate racial and ethnic health disparities in the Commonwealth, creating the Office of Health Equity), California, New Jersey, and Washington, and at the local level (MD Anderson’s Centre for Health Equity and Evaluation Research).

So, why should we care about health equity?  Seminal work by Dr. Arlene Bierman and her colleagues in the POWER study reveal disconcerting rates of disease outcomes associated with inequitable differences in incomes. For example, if all Ontarians had the same health as the population with the highest income   the result would be improved health for over 300,000 people and thousands fewer deaths. The MAgIC project, having developed an equity measurement tool, demonstrated differences in access to healthcare between men and women after accounting for many other clinical and social determinants. The argument for equitable treatment of all citizens using moral suasion is far easier to articulate as compared to the business case, which is far more complex.  According to Dr. Ahmed Bayoumi, addressing equity or more specifically the social determinants contributing to inequity (education, income, housing) is a cross sectorial problem not exclusive to healthcare alone. While there may be clear instances where equitable policy may be cost effective or even cost saving, the accrued benefits may take years to fully appreciate or measure.  Costs alone should not be the sole determinant in any decision to pursue interventions improving equity. Potential reductions in unfair and damaging differences in morbidity and mortality are difficult to put a price tag on.

So if confronting inequitable practices is important, where do we begin? As researchers and policy-makers have pointed out, a key to advancing the equity debate and informing policy is the implementation of rigorous measurement and assessment tools. Today in Canada, equity receives occasional attention in planning and performance management. Despite leadership in some health organizations (LHIN’s, hospitals, CHC’s, CCAC’s), there is no continuity in approaches to equity that spans the single system.  As Dr. Bob Gardner of the Wellesley Institute  has suggested, we need a clear strategy for equity, summarized by the following  points: 1) Building health equity into all healthcare planning and delivery; 2) Aligning equity and system drivers and priorities; 3) Embedding equity in provider organizations’  deliverables , incentives and performance management ; 4) Targeting some resources or programs to address disadvantaged populations or key access barriers, and 5) Thinking upstream to health promotion and addressing the underlying determinants of health, that makes it a provincial priority that spans sectors and drives data collection for improvement. The examples raised in previous posts make it clear that we have workable models that can be applied in other provinces. Now is the time to stabilize and spread the current set of programs and strategies across leading health organizations to provide a firm foundation for the monitoring and improvement of equity in health based on SMART targets. As we cope with a global financial crisis that erodes solidarity, the time for action to promote equity in our health system is here.

How do actions translate into improving health equity? Following a forum hosted by the Equity Magic group and the Wellesley Institute, many of the experts alluded to the importance of quality in data collection embedded into accountability agreements linking outcomes to equity targets. Having data and targets or performance measures may provide a baseline for where we stand on equitable healthcare and where we need to go, but without an evaluative process achieving ones goals may be difficult. As Sanjeev Sridharan has articulated in an earlier blog, an evaluative process or framework involves selecting an optimal intervention based on the best available evidence leading to the greatest likelihood of bringing about a successful impact on reducing inequities. Furthermore, such a framework depends on appropriate choices of performance measures, realistic timelines, a means to monitor progress and scale the intervention to more general populations if successful, or revise otherwise. Without a clear design, any health equity initiatives are less likely to have their desired effect.

Finally, Michael Marmot argues that putting health equity at the heart of  all policy making is  not  so much utopian  as it is a  pragmatic endeavor.(1)

The time for action is upon us – and we have the tools to get started.

About the Author

Carey Levinton, MSc, is a statistical consultant with extensive experience in data modeling using techniques such as decision tree analysis, and cost-effectiveness analysis. He has spent the last several years developing methods for measuring equity using large administrative and clinical data sets.

For more information about the Equity MAgIC tool, please visit www.equitymagic.ca or contact Carey Levinton at clevinton@equitymagic.ca carey.levinton@utoronto.ca

1.  Marmot M. Policy Making with Health Equity at its Heart. JAMA 2012;307:2

This entry was posted on Wednesday, June 20th, 2012 at 9:06 am and is filed under Longwoods Online.