Equity from the Start: The way ahead in Ontario

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Equity from the Start The way ahead in Ontario

• alPHa Toronto October 22, 2009
• Michael M. Rachlis MD MSc FRCPC
• www.michaelrachlis.com

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Outline

• Why is reducing health inequities particularly
  hard work in Ontario?
• Why is it hard work everywhere?
• How do we go forward?

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There is a remarkable consistency and repetition
in the findings and recommendations for
improvements in all the information we reviewed.
Current submissions and earlier reports highlight
the need to place greater emphasis on primary
care, to integrate and coordinate services, to
achieve a community focus for health and to
increase the emphasis on health promotion and
disease prevention. The panel notes with concern
that well-founded recommendations made by
credible groups over a period of fifteen years
have rarely been translated into
action.Ontario Health Review panel 1987
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Ontario health policy

• No health goals
• No provincial health plan
• No official MOHLTC strategic plan
• Many provincial policy directions are in draft
  form and are not publicly available,
• e.g. MOHLTC Chronic Disease Management and
  Prevention plan.
• Few service frameworks
• Stroke, cancer, heart disease
• MOHLTC priorities given to the LHINs are phrased
  about treating illness
• Little coordination of overall social policy

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Why is reducing health inequities particularly
hard work in Ontario?

• The weak Canadian confederation
• North American values
• North American style government
• Lavis 2004

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GDP
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Why is it hard work everywhere?

• Unsupportive values for primary prevention and
  health promotion

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Medicine (Health) is a social science and
politics is nothing but medicine writ large!

• Dr. Rudolf Virchow 1848

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If politics is health writ large...

• Fundamental change in a societys pattern of
  health requires structural change in societys
  values, interests, and institutions
• Some powerful interests will be threatened and
  will use their power to oppose change
• Those favouring the status quo will emphasize the
  treatment of sick individuals and downplay
  opportunities to promote population health

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How do we move forward?
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CIHR Conceptual Framework of Population Health
7. Healthcare Outcomes
1. Upstream Forces
political
To
social
Societies
cultural
economic
spiritual
ecological
Race, Ethnicity,
technological
4. From Individuals
Gender, SES,
3. Life-Course
Geography
2. Proximal Determinants of Health
Physical social environments Biological factors
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Were talking about public policy, so what is
your analytic framework?

• Institutional Rational choice?
• Multiple Streams?
• Punctuated Equilibrium?
• Advocacy Coalition Framework?

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The Root Method, aka Rational-Comprehensive
(See http//www.d.umn.edu/schilton/3221/Lectur
eNotes/3221.RationalityVsMuddlingThrough.2003.Spri
ng.html)

• Specify all ends
• Specify weights for all the ends.
• Examine all possible sets of means.
• Evaluate each set of means against ends,
  assigning a score to how well the means achieve
  each end.
• For each set of means, calculate its overall
  measure based on the weighted average of its
  scores on achieving the different ends.
• Choose the set of means with the highest score.

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The Branch Method, aka Incremental (See
http//www.d.umn.edu/schilton/3221/LectureNotes/3
221.RationalityVsMuddlingThrough.2003.Spring.html)

• Ends and means are intimately intertwined,.
• Only a few means are considered and only those
  which don't represent too much of a departure
  from the status quo.
• Evaluation of means is crude.
• Choice among the means is determined by agreement
  among interested parties rather than by summary
  indicators arising from the analysis.
• Agreement is the only empirical indicator of
  virtue, because values are not usually clear-cut
  or even shared.

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Key elements of the Advocacy Coalition Framework

• Factors external to the subsystem
• Stable factors which typically dont change for a
  generation or more, E.g. the constitution,
  climate, economic system
• Dynamic factors which tend to change every 5-10
  years, E.g. governing coalition, weather,
  business cycle
• The formal decision-making process
• The informal decision-making process
• Values how the world should work
• Causal beliefs how the world really works
• Interests how the world works for me
• Information

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From P. Sabatier and J. Lomas
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Key principles of the Advocacy Coalition Framework

• While the type of policy developed mainly depends
  upon activity within the policy subsystem, most
  but not all significant policy change is
  initiated by perturbations in the environment
  external to the subsystem
• Policy is developed in subsystems
• This reinforces Branch-style policy making and
  frustrates Inter-sectoral action for health
• Observations of at least a decade are usually
  required to understand policy change.
• Broad coalitions develop over time
• Information is usually the weakest policy
  determinant
• Under certain conditions, policy systems learn

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What is the role for information?

• Its always incomplete
• Its impossible to have a synopsis of all there
  is to know on something
• Often used after the fact to bolster ones own
  points or to knock down those of the other
  coalition
• Rarely used primarily

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How can we inject knowledge into Policy?
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Under certain conditions, policy systems and
actors learn-- Policy oriented learning
relatively enduring alterations in thought or
behavior intentions that result from
experience/and/or new information and are
concerned with the attainment or revision of
policy objectives (P Sabatier)
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Conditions for policy oriented learning

• There are gt 2 coalitions with conflicting
  positions
• The issue is of moderate importance to both
  coalitions.
• There is a forum available for debate.
• There is an audience
• There are consequences to losing the debate
• Moving the yardsticks
• Learning is amplified if the forum is run
  according to professional norms and when the
  problem is amenable to quantification.

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Moving the Yardsticks
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Advocacy Coalition Framework from P. Sabatier
and J. Lomas
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How do we move forward?
Lets take off the blindfolds!
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Special issues for Public health in reducing
inequalities

• Most of us are employed directly by the state
• The double edged sword one to use on others,
  one to fall on ourselves
• Public health is seen around the cabinet table as
  part of the health empire
• Public health is funded and sometimes
  administered directly by the state
• The importance of coalitions and citizen
  engagement

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Public health is seen around the cabinet table as
part of the health empireWhen the Minister of
Health is talking about public health issues he
is still seen as the Minister of Health, devourer
of other peoples lunches
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Do one-fifth of older Canadian women need to
take benzodiazepines?

• Do we care what were paying for?

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The Inverse Care Law

• "the availability of good medical care tends to
  vary inversely with the need for it in the
  population served."
• Tudor Hart J. The inverse care law. Lancet 1971
  i 405-412.

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Ratio 1.4
Age-standardized mortality rates, urban Canada,
1971 to 1996. Source Statistics Canada,
Catalogue 82-003. Health Reports,
200213(suppl)57.
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What about partnering with our health care system
colleagues?

• The LHINs are starting to have equity plans
• The health system could really use public
  healths perspective and expertise
• God will provide the extra resources!

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The health care system can play an important role
in reducing health disparities. (OHQC 2007)

• Improve the accessibility of the health system
  through outreach, location, physical design,
  opening hours, and other policies.
• Improve the patient-centredness of the system by
  providing culturally competent care,
  interpretation services, and assisting patients
  and families surmount social and economic
  barriers to care.
• Cooperate with other sectors to improve
  population health.

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This does not by any means suggest that complete
public health integration with the LHINs would be
a good thing. Certainly, in the current context
that would be a bad thing.
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Population Health Focus

• Support from the top
• Cabinet level social policy coordination based
  upon a strong value placed on equity
• Common boundaries for governance and services
• E.g. SK Human Services Integration Forum, PQ
  Public Health Laws
• Push from the bottom
• Citizen engagement where the state meets citizens
• E.g. OK Kids Halton, Champlain Cardiovascular
  Prevention Network, Regent Park Pathways to
  Education,
• South Riverdale gets the lead out

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How could public health work more effectively in
coalitions?
Inequity
Equity
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empowerment of local communities is a necessary
step in the rejuvenation of public health.Dr.
Robert Beaglehole
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Sounds a lot like democracy!
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Look for those policy windows!

• The anti-poverty agenda
• The economic downturn
• Re-organization of health system gt election
• Early childhood learning
• Health impact assessments?
• Watch your back!
• The other side is better organized

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Summary

• There are serious disparities in health status
  which are related to disparities in the
  determinants of health
• Public health needs to more analytic to be more
  effective. Unshackled rage is only effective if
  there are thousands of people who get angry with
  you.
• We need different provincial government
  institutions to facilitate whole government
  action on inequities
• We need to engage communities to light the spark
  for action

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Courage my Friends, Tis Not Too Late to Make a
Better World! TC Douglas (per Tennyson)