Transcript The Way Ahead in Ontario - Part 2

Equity from the Start:
The way ahead in Ontario
alPHa Toronto October 22, 2009
Michael M. Rachlis MD MSc FRCPC
www.michaelrachlis.com
Outline
• Why is reducing health inequities particularly
hard work in Ontario?
• Why is it hard work everywhere?
• How do we go forward?
“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
3
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
4
Why is reducing health inequities
particularly hard work in Ontario?
• The weak Canadian confederation
• North American values
• North American style government
– Lavis 2004
Canadian Health Exp as % of GDP (NHEX 2008)
12
8
6
4
Total HC as % of GDP
2
Prov/Terr HC as % of GDP
0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
% of GDP
10
Provincial Territorial HC as % of GDP
9
8
7
5
4
Canada
ON
QC
AB
BC
3
2
1
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
0
1981
% GDP
6
General Gov't Outlays
(From http://www.fin.gc.ca/frt/2008/frt08_e.pdf)
Percent of GDP
60
50
40
30
20
10
0
Canada
US
Why is it hard work everywhere?
• Unsupportive values for primary prevention
and health promotion
“Medicine (Health) is a
social science and
politics is nothing but
medicine writ large!”
Dr. Rudolf Virchow 1848
If politics is health writ large...
• Fundamental change in a society’s pattern of
health requires structural change in society’s
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
How do we move forward?
CIHR Conceptual Framework of Population Health
1. Upstream Forces
political
social
cultural
economic
spiritual
ecological
technological
7. Healthcare Outcomes
6. Health Services/
System Interventions
5. Disparities in
sub populations
Race, Ethnicity,
Gender, SES, &
Geography
2. Proximal Determinants of Health: Physical & social environments
Biological factors
We’re talking about public policy, so
what is your analytic framework?
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•
•
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Institutional Rational choice?
Multiple Streams?
Punctuated Equilibrium?
Advocacy Coalition Framework?
The Root Method, aka RationalComprehensive
(See: http://www.d.umn.edu/~schilton/3221/LectureNotes/3221.RationalityVsMuddlingThrough.2003.Spring.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.
The Branch Method, aka Incremental
(See: http://www.d.umn.edu/~schilton/3221/LectureNotes/3221.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.
Key elements of the Advocacy
Coalition Framework
•
•
•
•
•
•
•
Factors external to the subsystem
– Stable factors which typically don’t 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
From: P. Sabatier and J. Lomas
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”
What is the role for information?
• It’s always incomplete
– It’s impossible to have a synopsis of all there
is to know on something
• Often used after the fact to bolster one’s
own points or to knock down those of the
other coalition
• Rarely used primarily
How can we inject knowledge into Policy?
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)
Conditions for policy oriented learning
–
–
–
–
–
There are > 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.
Moving the Yardsticks
Advocacy Coalition Framework from P. Sabatier and J. Lomas
How do we move forward?
Let’s take off
the blindfolds!
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
Public health is seen
around the cabinet table
as part of the health
empire
When the Minister of
Health is talking about
public health issues he is
still seen as the Minister of
Health, devourer of other
people’s lunches
Do one-fifth of older Canadian women
need to take benzodiazepines?
Do we care what we’re paying for?
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.
Ratio = 1.4
Age-standardized mortality rates, urban Canada, 1971 to 1996.
Source: Statistics Canada, Catalogue 82-003. Health Reports, 2002;13(suppl):57.
What about partnering with our
health care system colleagues?
• The LHINs are starting to have equity plans
• The health system could really use public
health’s perspective and expertise
• God will provide the extra resources!
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.
Saskatoon neighbourhood analysis boundaries,
excluding industrial and development areas, 2005
Legend
Affluent neighbourhoods
Rest of Saskatoon
Low income neighbourhoods
Source: Saskatoon Health Region, Public Health Sevices
Saskatoon Health
Region
Rate Ratio (% higher)
Core neighbourhoods: Affluent
Hospitalizations
Suicide Attempts
15.58 (1458%)
Diabetes
12.86 (1186%)
Physician Visits
Mental Disorders
2.28 (128%)
Diabetes
2.11 (111%)
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.
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
How could public health
work more effectively in
coalitions?
Inequity
Equity
“…empowerment of local
communities is a necessary
step in the rejuvenation of
public health.”
Dr. Robert Beaglehole
Sounds a lot like democracy!
Look for those policy windows!
• The anti-poverty agenda
• The economic downturn
• Re-organization of health
system > election
• Early childhood learning
• Health impact assessments?
• Watch your back!
– The other side is better organized
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
“Courage my
Friends, ‘Tis
Not Too Late to
Make a Better
World!”
TC Douglas
(per Tennyson)