Social Determinants of Health and Healthy Public Policy

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Social Determinants of Health and Healthy Public Policy

Bob GardnerDirector, Public Policy

Conference Board Roundtable on Social Determinants of Health

October 27, 2006


Wellesley Institute

• funds community-based research on the relationships between health and housing, poverty and income distribution, social exclusion and other social and economic inequalities

• provides workshops, training and other capacity building support to non-profit community groups

• works to identify and advance policy alternatives and solutions to pressing issues of urban health

• works in diverse collaborations and partnerships for progressive social change

• all of this is geared to addressing the pervasive impact of the social determinants of health


Unique Hybrid

• lots of policy institutes and think tanks – but few focus on SDoH and urban health

• many provide training and capacity building – but not all have an explicit goal of rebuilding community capacity lost in funding cuts and constraints

• few focus on funding CBR or have an extensive community training programme in methods

• no other institute brings all three strands together – all focused on SDoH


Focus Today

1. flesh out concretely these various programmes and activities at Wellesley – and how we are working to support action on SDoH

2. at the same time, highlight some key challenges and barriers – and some opportunities and potential directions we could consider -- in getting policy action on the SDoH


Key Messages

1. the problem isn’t lack of research and evidence on the impact of the social determinants of health – it’s politics

2. some European and other governments have developed comprehensive social policy that addresses determinants of health – so policy action is possible

3. similarly, better inter-government coordination and integrated policy is possible – and we can learn from examples in Canada and aboard

4. community-based research can be an important tool in identifying gaps, barriers and potential lines of action

5. front-line health and social service delivery have been building the social determinants of health into their programming – that has great potential


Evidence-based policy making

• public administration is increasingly and incredibly complex – policy in different spheres needs to be ‘joined up’

• reliable research is crucial to guide the development of effective public policy

• research on the outcomes and impact of policies and programmes is equally crucial to effective implementation and monitoring

• public policy and investment should be driven by what works – and this needs to be demonstrated

• public policy needs to be flexible and responsive to new evidence and research

• govts as learning organizations


The evidence on social determinants is consistent and

solid

• wide and rich research literature in Canada and aboard

• impact of key determinants such as early childhood development, education, employment, working conditions, income distribution, social exclusion, housing and social safety nets on health outcomes and disparities

• the Health Council of Canada’s February 2006 report:

– “The biggest health problem in Canada is inequality. The overall improvement in our health status masks the grim reality that health inequalities among social classes are growing…”


But

• Canadian govts recognize the importance of SDoH – internationally regarded as policy leader since Ottawa Charter

for Health Promotion in 1986• yet this has not translated into consistent policy change,

investment and change:– homelessness remains a key indicator of a society in disarray– far too many do not have affordable housing– poverty remains high, and concentrated in particular populations– access to childcare is limited and inequitable, etc., etc.

• why has there been so little action• in many ways, that is the driving force for this

Roundtable


Powerful Institutional Constraints

• we could analyze solidly established institutions and structures that are crucial to fabric of contemporary society:– operation of labour, capital and other markets– trends and impacts of globalization– the interests of powerful individuals and associations who benefit

from existing social and economic arrangements• these are the institutions and interests that underlie the

inequality of condition and opportunities that constitute the SDoH

• arguably, the adverse impact of the SDoH will not be fundamentally improved until these structures and constraints are fundamentally changed


Political Barriers

• within govts and public admin:– silo structures– competition among Ministries and divisions for funds and power– disconnect between cost and benefits – where expenditure in one

sphere may reduce spending and problems in another Ministry – risk averse working cultures– short-term framework of decision and policy making

• beyond– electoral politics – that’s about what sells, not evidence– and bigger debates about the role of govts in contemporary Cdn society

-- Conservative view of more limited role for state and wider spheres of individual responsibility

– limited public awareness of importance of SDoH → so limited public pressure on govts

– in context of pervasive health promotion around individual lifestyles


Policy Directions and Issues with Potential

• but these long-term issues are beyond the focus of this Roundtable

• this Roundtable assumes that more immediate changes in social policy can make a big difference in ameliorating the impact of the SDoH

• I set out possible directions where important progress could be made in the short and mid-term to shift public policy


Have to Understand Policy Environment

• all of this doesn't mean that we can’t make the case for comprehensive social policy that acts on the determinants of health

• but to make that case, we need to understand the barriers and challenges within the overall political and policy environment

• we need to also understand the dynamics of govt policy making

• we need to make the case in ways that govts can understand and act on


Making the Investment Case for SDoH

• govts are increasingly interested in outcomes and impacts• key officials in Ontario’s MOHLTC think of investment portfolios

where their policies or funding can make a measurable difference to an impt problem

• so what is the economic case for investment in childcare or affordable housing or public policy that reduces inequality?– Cdn manufacturing companies explicitly factor in the competitive

advantages of public health care – are there similar advantages from other public investment?

– cost of doing nothing is far higher – shelters vs. new public housing– will save expenditures on consequences (poorer health, less

employment, deteriorating social relations) in the mid to long-term– will support a more productive and cohesive society – but can that be

demonstrated or quantified?


Support for SDoH Investment

• many prominent business organizations – Toronto-Dominion Bank, the Toronto Board of Trade, Toronto City Summit Alliance – have highlighted housing, income security and other preconditions of a healthy society and a strong economy

• Wellesley released yesterday a Blueprint to End Homelessness in Toronto

• it makes just such a case that investing in affordable hosing will pay off

• and that the alternative – the cost of continuing to do little about the homelessness crisis – cannot be sustained


The Blueprint: A two-part action plan

Step one:Move the

“sheltered”homeless

into homesMonthly cost of a shelter bed: $1,932

Monthly cost of a rent supplement: $701


The Blueprint: A two-part action plan

Step two:Build new homes

� 7,800 new homes� 2,000 supportive homes� 8,600 renovated homes� 9,750 rent supplements� emergency relief� eviction prevention� inclusive planning

25% set-aside for Aboriginal housing


Prospects?

• SDoH into policy action – proponents may not have been making as good a policy case

as we could have– building an economic or longer-term investment case for SDoH

may be useful part of that– but the environment for Cdn govts being open to even the best

case doesn't seem very favourable• want to emphasize two directions that can give some

hope1. European counties show that comprehensive policy and action

on SDoH is possible2. Cdn and international experience shows that better cross-govt

coordination around determinants is possible – and can be effective


European Initiatives

• The European Union has launched Closing the Gap– focusing on health inequalities– with the goal of promoting action in individual member countries– and coordinating and sharing information on national policies,

best practices and new initiatives across Europe– http://www.health-inequalities.eu/

• the World Health Organization’s European office has established a special commission http://www.euro.who.int/socialdeterminants– useful source of data, new and emerging initiatives and shared

best practices

http://www.health-inequalities.eu/

http://www.euro.who.int/socialdeterminants


Two Examples

• Sweden:– coordinated national policy to reduce the number of people at risk of

social and economic vulnerability– focus on inclusive labour market, anti-discrimination, childcare,

affordable housing and other policies– they emphasized partnerships with community service providers and

organizations• United Kingdom:

– Reducing Health Inequalities: an Agenda for Action 1999– goals focused on raising living standards, early childhood development,

employment and building health communities– simultaneous focus on broad national redistributive and social polices– plus supporting local initiatives in disadvantaged communities to

improve living conditions and address social exclusion – Health Action Zones

– mandated community participation in health care planning– high level attention – e.g. social exclusion unit in Cabinet Office


Moving Forward

• but Canada isn’t Sweden • so comprehensive policy along these lines can be an

important mid-term goal, but immediate prospects of those kinds of polices are not good

• what can governments do in the here and now?


Better Policy Coordination

• Saskatchewan:– coordinating table of ADMs -- Human Services Integration Forum– to promote inter-agency collaboration and integrated planning

and service delivery– current priorities include strengthening families’ capacities, early

childhood support, increased opportunities for youth, increase well-being and employment situations, improve coordination and integration of services, etc.

– also regional coordination bodies across agencies– which in turn provides space/encouragement for interesting local

integration in areas such as Saskatoon


Better Policy Coordination II

• Quebec:– provincial strategy coordinates health and related social spheres – in

one Ministry– Health and Wellbeing Council encourages inter-sectoral action – widespread consultation and involvement of community sector in policy

development– comprehensive 10 year plan to address social determinants and

wellbeing– all Ministries are required to consult the Ministry of Health on new

legislation or regulations that could impact health– regional health plans are required to develop integrated pans with social

services– local health authorities must coordinate with non-health services

• Ontario:– Premier’s Councils of early 1990s emphasized coordinated policy

across ministries and spheres


Regional Health Planning

• regional health authorities in many provinces highlight SDoH:– many see determinants and population health as crucial to

guiding appropriate programmes and initiatives– some Alberta RHAs have developed operational and planning

links with local social services– others have emphasized community capacity building as one

strategy in addressing health – Alta, BC and other RHAs have developed comprehensive

community engagement processes and forums


LHINs in Ontario

• advocates have argued that SDoH and related issues of diversity and disparities should be built into LHINs planning– Toronto Central LHIN has explicitly emphasized social determinants and

equity as underlying principles• similarly community engagement has been a major theme:

– all LHINs have undertaken extensive – if quite different and uncoordinated – consultations with their communities when they were developing their initial plans

– all are required to develop ongoing community engagement – again, variable but forums and processes created across the province

– connection here is that issues important to local communities – access, gaps, barriers, many related to SDoH – will be prioritized to the LHINs


Ontario: SDoH Driving a Public Agency

• Ontario HIV/AIDS Treatment Network• funded by Ont govt and well connected to its AIDS

Bureau• its community-based, sociological and clinical research

is designed to yield practical knowledge• its knowledge mobilization and outreach is designed to

support better programmes and public policy → better health and lives for PHAs

• OHTN’s research program and overall strategy is premised upon SDoH


Expected Outcomes

• Three year prospective research on impact of housing and homelessness on PHS’s health:– baseline, factors that affect housing status and available options– peer and community-based research– identify most effective housing options at different stages

• Specific outcomes for this initiative include:– housing options that improve access to health care, treatment

and social services– safe and stable housing situations for PHAs in communities

across Ontario– the development of effective and appropriate housing policies

and supportive care models that support PHAs throughout their life course.


Funders

Ontario Ministry of Health and Long-term Care, AIDS Bureau - $35,000

Ontario HIV Treatment Network (OHTN) -$170,000 + in-kind (office space, teleconference calls etc)

Ontario AIDS Network (OAN) - $6,600

Total = $530,350 over 3 years

Canadian Institutes of Health Research (CIHR) - $300,000

Wellesley Institute - $18,750

http://www.euro.who.int/socialdeterminants


Potential of Community-Based Research

• CBR – at best driven by direct community involvement in defining issues and problems – can yield concrete, deep and rich understanding of the SDoH

• this kind of evidence can be a powerful supplement to the type of macro and statistical data that we have seen

• CBR can uncover the ways in which inequality or limited access to services translates concretely into lived experience and impact on people’s lives and opportunities

• it can help to identify the most important barriers and service gaps communities face

• and it can also build on community networks, cultures and understanding to identify promising directions for change


Examples of CBR into Action

• we want to support CBR that will have programme or policy impact – that can support social change

• two recent examples that Wellesley has worked with concretely illustrate this potential

• can get links to their reports, press coverage and other material on our site at http://wellesleyinstitute.com/research

http://wellesleyinstitute.com/research


Street Health: CBR on ODCSP

• Street Health has provided health and other support to homeless people in Toronto for twenty years

• they were finding that large numbers of the homeless people they worked with were disabled

• but they were not receiving ODSP – the prov assistance programme for people with disabilities -- why not?

• this is vitally impt = being on ODSP would mean that people could afford housing → health implications


Findings and Implications

• the research uncovered administrative, programme and other systemic barriers to homeless people getting benefits to which they are entitled

• and their analysis showed practical and cost-effective ways that these barriers could be fixed

• including pioneering a model of support workers who helped homeless people through the maze of applying for ODSP – highly successful in securing access


Research Into Policy Action

• they worked with ODSP and other govt people from the start

• they identified target govt and media audiences for their findings

• they developed concrete and actionable policy options and programme recommendations that could address the barriers and gaps found– including which govt bodies would need to act on what and how– including cost benefit analyses

• they are undertaking sustained outreach to get their recommendations taken up


Count Us In

• Ontario Women’s Health Network, Ontario Prevention Clearinghouse, Toronto Public Health and other partners

• project was on barriers homeless and marginalized women face in access to crucial health and social services

• also developed a new way of doing research • inclusion research trains, supports and involves

homeless and other marginalized women in doing the research themselves

• a form of peer-driven research that yields richer, more nuanced and deeper understanding


Research Into Policy Action

• this project also identified policy barriers and issues and the govt agencies that needed to act on their findings, and developed and promoted specific policy recommendations

• but this research came at a particularly interesting time in health reform in Ontario and illustrates two further vital points for realizing the potential of CBR:– need to be aware of the strategic environment surrounding the

particular issue and look for opportunities to promote the research and overall perspective

– need to be ready to seize these opportunities when the arise


Look for Opportunities

• LHINs have all been emphasizing community engagement in their initial planning and priority setting

• the province is also developing a new strategic plan for health and extensive community engagement is crucial to it

• both see including marginalized, poor and those diverse voices who are seldom heard in policy deliberations as a critical challenge

• inclusion research – and its underlying principles of involving marginalized communities directly in defining their own experience – can be an important tool in meeting this challenge


Seize the Opportunities

• sustained and targeted outreach:– the Inclusion Research Team met with Toronto Central LHIN and

prepared a backgrounder for them– pushed backgrounder to other LHIN and MOHLTC officials

• increasing emphasis on community engagement has opened space for pushing innovative community-driven methods and perspectives


Wellesley Institute Role in Ensuring CBR Has Policy Impact

• we work with these and other research partners to help them ensure their research has policy impact:– provide advice on policy implications and environment from design

stage onwards– help in translating findings into policy ready analyses and

options/recommendations– help to broker contact with appropriate officials and stakeholders– promote the CBR in the wider policy circles in which we work

• our capacity building programme also organizes seminars and forums, and a workshop series with a stream focusing on exactly this problem of translating results into policy alternatives, knowledge exchange, policy advocacy and effective presentation to policy makers


Community-Based Research and Capacity Building

• another defining feature of community-based research = it works to leave something behind in the community

• community capacity building is part of goal:– connections and networks are built as part of research – active

problem solving is normally part of projects– bringing community perspectives and knowledge into view – and

hopefully into public policy debate – can enhance confidence and build understanding

– peer researchers learn new and useful skills = small step to enhancing their opportunities

– can be part of building up social capital of neighbourhoods and communities


Social Capital

• some disadvantaged neighbourhoods have dense community networks – residents groups, ethno-cultural associations, voluntary service

providers– informal networks for child care, recreation and other support

• does this kind of social capital make a difference to ameliorating the worst impacts of poverty and unequal access to services?

• how important are these and other aspects of specific neighbourhood capacity and cohesion to health?– United Way, govts and other partners investment in capacity building in

disadvantaged neighbourhoods– focus of coordinated research efforts – CRICH, academic/St

Christopher House and other projects


St Jamestown

• long-term Wellesley project to investigate social determinants of immigrant health:– densest immigrant receiving area in country– immigrants come in with better than average health, but it

deteriorates relatively– why – what social and other factors are important?– and what different policies and service interventions could

prevent this disparity?

• will work with community groups to define and implement research

• community capacity building will be crucial part of project


Front-line Service Delivery

• Community Health Centres:– identify barriers → policy advocacy e.g. health care for non-

insured– action research e.g. Access Alliance consultations on specific

needs & perspectives of refugee & immigrant communities to feed into LHINs

– build linking to literacy, employment and other non-health services into programming

• Wellesley project with Association of Ontario Health Centres to collect and database CBR that individual CHCs undertake→ try to expand to collect and organize examples of innovations in

front-line service delivery that take SDoH into account


Front-line Service Delivery II

• public health:– Sudbury discussion paper– linking public health work into non-health services, taking social

inequality and community conditions into account in planning and delivery

– identifying policy issues arising from their work and advocatingfor programme and policy changes to address inequities

• Ontario Prevention Clearinghouse– leader in community-based health promotion and prevention

programme– grounded in SDoH analysis


What Next?

1. the problem isn’t lack of research and evidence on the impact of the social determinants of health – its politics

– need to understand policy and political environment– ‘insider’ research with top officials and political leaders: what

are barriers to avoid, what is best way to make the case, where are quick wins or tipping points?

– need to develop actionable policy alternatives that are winnablewithin existing environment

– build investment case for SDoH


What Next?

2. some European and other governments have developed comprehensive social policy that addresses determinants of health

– comparative research: most promising policy directions, lessons learned on how to build policy and political momentum, on-the ground innovations, etc.

– plus Cdn ‘insider’ research: could European and other initiatives be adapted here, if not, why not?


What Next?

3. similarly, better inter-government coordination and integrated policy is possible – and we can learn from examples in Canada and aboard

– comparative analysis: coordinating processes and forums from across the country, what works and what doesn't, impact?

– ‘insider’ research with senior officials involved and connected– historical research: lessons from past Cdn experiments


What Next?

4. community-based research can be an important tool in identifying gaps, barriers and potential lines of action

– a crucial barrier is that results are not well known or widely distributed → clearinghouse function is needed

– inventory and assessment of CBR on SDoH related issues as starting point


What Next?

5. front-line health and social service delivery have been building the social determinants of health into their programming – that has great potential

– similarly, need for databases, clearinghouses and forums to share, assess and scale up promising innovations

– not just relevant for SDoH, but for health care reform and innovations in general

– given attention to health reform and search for workable solutions → good environment for community-based innovations

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Social Determinants of Health and Healthy Public Policy

Health & Medicine