Towards a Health Equity Roadmap

Equity – a blog
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.

Towards a Health Equity Roadmap

Pervasive and damaging health inequities are one of the most important problems facing many people – and the health system as a whole.  Whether measured by self-reported health, the burden of diabetes, mental illness and other chronic conditions, or life expectancy, there is a consistent systemic gradient of health.  People with higher income, more education, better housing and who fare better on other indicators of socio-economic conditions have better health than those lower down the scale.  The impact of these systemic inequities is significant: in Ontario, pain and discomfort prevent the daily activities of fully one-quarter of people in the lowest income group, twice that of the high income group1.  For Canada as a whole, the difference between the health adjusted life expectancy of the top and bottom income decile is 11.4 years for men and 9.7 for women2.

Even though the roots of health disparities lie in far wider social and economic inequality, equity also needs to be addressed within the health care system.  Equitable access to high quality health care and support can help to mediate the harshest impact of wider social determinants on health disadvantaged populations and communities.  Additionally, there are systemic disparities in access and quality of health care that need to be addressed: people lower down the social hierarchy have poorer access to health services, even though they may have more complex needs and require more care.

To ensure equitable access to high quality and responsive health care, we need a multi-pronged strategy:

  1. Building health equity into all health care planning and delivery:
    • This doesn’t mean that all programs are only about equity, but all must take equity into account.  For example, health care planning in Northern Ontario can only work by addressing the huge health inequities and multiple access barriers faced by Aboriginal communities.  Ontario has developed a Health Equity Impact Assessment tool to help with this planning. Some LHINs and providers have made significant progress by developing explicit equity plans.
  2. Aligning equity with system drivers and priorities:
    • A major provincial priority is improving primary care, and this would have positive equity implications: improving access to primary care is one of the most effective levers for improving the health of disadvantaged populations.  Provincial, LHIN and local planning should consider how to coordinate and concentrate primary care in populations, neighbourhoods, and regions with the greatest needs.
    • Preventing and reducing the impact of chronic conditions such as diabetes is a major system priority, and lower income people, some recent immigrant communities, and others have far higher risks and burdens of diabetes.  Prevention and treatment programs need to address these higher risks and burdens and care must be customized to take account of how poorer living conditions affect treatment prognoses.
    • Quality improvement is a priority under the Excellent Care for All Act, and levers such as hospital Quality Improvement Plans will drive organizational change.  To really ensure quality for all, these plans can be required to include equity indicators and targets.
  3. Embedding equity in provider organizations’ deliverables, incentives and performance management:
    • To extend the diabetes example, expectations for LHINs and providers should not just be reducing the overall prevalence of diabetes, but eliminating inequitable differences between neighbourhoods and populations.
    • Similarly, a key LHIN or community-level target needs to be ensuring that access and use of primary care does not vary inequitably by income level, immigration status, neigbourhoods, gender, race, etc.
    • One effective way to build equity into performance measurement is by layering it onto existing initiatives and targets. For example, reducing hospital readmissions is a key goal and is tied to funding and other incentives. Hospitals should monitor if there are differences in readmission rates and duration by income, neighbourhood, or region, and they should be expected to reduce any inequitable differences.
    • Similarly, many hospitals, Community Health Centres and other programs assess their services through client satisfaction surveys, and aim for high, and improving, satisfaction levels.  Equity expectations should be reducing any differences in satisfaction by gender, income, ethno-cultural background, etc.
    • Payment schemes, budget allocations, and other incentives need to be structured so they encourage and reward achieving these types of equity-orientated expectations.
  4. Targeting some resources or programs to address disadvantaged populations or key access barriers:
    • Identifying investments and interventions that will have the highest impact on reducing health disparities or improving health care for the most vulnerable.
    • The benefits of equity interventions can be broad.  For example, improving interpretation services will not only improve quality for those who face language barriers, but can also contribute to reducing misdiagnoses, over-prescription, and avoidable complications due to poor communication.
  5. Thinking upstream to health promotion and addressing the underlying determinants of health:
    • Building on the above examples: diabetes and other chronic conditions are concentrated in poor neighbourhoods and marginalized communities. If we don’t improve access to good housing, adequate food, and safe neighbourhoods we will not be able to reduce the impact of these preventable diseases.

What gets measured, matters.  Each of these directions requires good data, planning and measurement (which is where our MAgIC project for Measuring and Managing Access Gaps in Care comes in). To drive the necessary equity reforms we need to know what the key barriers and needs are, set clear targets for equitable access and high quality, monitor performance against those equity expectations, line up incentives and investments, and rigorously evaluate what works to reduce systemic health inequities.

These essential health system reforms are only part of the equity roadmap.  The really healthy changes3 will come through addressing the underlying social determinants of health.  Affordable housing, access to child care, equal opportunities to get a good education and decent living environments are all pre-conditions for good health.  And precarious work, racism, poverty and income inequality are the underlying foundations of damaging inequities in health and well-being.  Governments need to act in a coherent way across Ministries and programs to create the foundations of good health for all, including those communities consistently marginalized and left behind.

Notes:

1Bierman, AS et al. Social Determinants of Health and Populations At Risk in: Bierman, AS, ed. Project for an Ontario Women’s Health Evidence-Based Report, Volume 2, 2012, 12B.4, p 65.
2Cameron N. McIntosh, Philippe Finès, Russell Wilkins & Michael C. Wolfson. “Income disparities in health-adjusted life expectancy for Canadian adults, 1991 to 2001.”  Health Reports. December 2009. Statistics Canada.
3The title of the Ministry of Health and Long-Term Care’s new action plan.

About the Author:

Bob Gardner is Director of Policy at the Wellesley Institute, a non-profit research and policy think tank focusing on advancing urban health and health equity.  He researches, writes and speaks widely on health equity policy; works with governments, LHINs, service provider networks and community partners to develop effective strategies and action plans to enhance health equity; and is on the board of Health Quality Ontario.  Bob has a PhD in sociology; has been an academic, public sector executive and consultant; and has been a community activist on HIV/AIDS, reproductive health and other issues.

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