• Evidence on SDoH: During the Commission’s work, the WHO and its partners have established nine broad themes – including social exclusion, early child development, and employment conditions – that contain the major determinants of health. Further, this section offers national case studies of successful examples on policy action aimed at reducing health inequities.
• This section builds on the very useful Knowledge Networks first established to provide more detailed and focused analysis to support the main report. These theme areas remain a very valuable source on overarching issues such as women and gender equity and globalization, and on specific tools and mechanisms for change such as measurement and evidence, acting on SDoH within health systems and addressing the needs of economically and social disadvantaged populations.
• Action to Improve Health Equity: WHO, in collaboration with Member States and other organization and sectors, have taken action in the five priority areas specified by the Rio Political Declaration. This section describes the action being taken to address SDoH through the priority areas.
• Global Commitments: This section features declarations and mandates expressing the political commitment of WHO governing bodies in working on the SDoH.
• Publications: This section contains a variety of publications and resources related to SDoH, including governance tools and capacity building, reports on Health in All Policies (HiAP) approach, and work completed by the civil society and public health departments.
• Learning and Tools: This section has manuals and self-instructional courses on better understanding SDoH and how to encourage change on political agendas.

The revitalization of the WHO website collects useful evidence and resources for addressing the social determinants of health on a global scale. At the Wellesley Institute, we aim to contribute to this ongoing dialogue through projects such as Making the Connections, which seeks to make the complex and dynamic nature of SDoH understandable and actionable, and through policy analysis on how to embed social determinants and approaches such as Health in All Policies into the incentives and pressures that actually drive state policy.

Uninsured populations currently face serious and damaging barriers to good health and access to health care. But these barriers and their inequitable health impact can be addressed through better policy. Although Toronto City Council, like many local governments, do not have direct control of policy levers that drive change on health inequalities and determinants of health, it does provide numerous programs and services that directly influence the health of individuals. Also, the City and Toronto Public Health have credibility and influence to collaborate and advocate change with provincial and federal governments.

The decision to pass the recommendations and report means that the City of Toronto is the first municipality in Canada to support health care access to all people in its jurisdiction. Further, City Council will:

• Request that the Ministry of Health and Long-Term Care (MOHLTC) in collaboration with the Local Health Integration Networks (LHINs) provide increased funding for community health centres (CHCs) and other primary care clinics that currently provide health care for uninsured residents
• Request that the MOHLTC and LHINs establish a centralized information source to promote programs and services available to uninsured residents for both users and practitioners, as well as Toronto Public Health working with service providers to ensure  Access Without Fear policies at health care facilities
• Reaffirm to the Federal Minister of Citizenship and Immigration Canada (CIC) its support to rescind the cuts to the Interim Federal Health Program (IFHP)
• Request that CIC, MOHLTC, and LHINs undertake initiatives to educate refugees, refugee claimants, community and settlement organizations and health care providers on the health care services covered by the IFHP
• Reaffirm to the MOHLTC its support for the elimination of the three month wait period for OHIP coverage for new immigrants.

The passing of this report builds upon Toronto’s recent adoption of Access Without Fear policies for undocumented immigrants, and on a grander scheme, demonstrates Toronto’s leadership in addressing health care inequities in our city. However, the development and adoption of such policies are rendered ineffective unless the government implements and ensures that they are consistently in place. With this in mind, we must continue to gather evidence and collaborate together to provide advice and recommendations for decision-makers, with aims to create a more equitable Toronto.

Over the past few years, budget cuts and restrictions have altered the size and scope of many government programs and services. The Young Foundation, a British think tank aimed at making positive changes through social innovation, is undertaking a three- year study to document the impact of national and local changes to benefits and services on some of the most vulnerable residents in Camden, a district of Inner London. The report offers insights into the everyday experiences of some of Camden’s most adversely affected – young people, families on low incomes, and people with disabilities or those with low to moderate needs – and point to the seriousness impact on their quality of life.

Some highlights from the report include:

• The pressure on families was palpable; Parents feared the impact of cuts on their children, leading to increased stress levels and manifesting in fewer work opportunities and reports  of domestic violence
• Panic and helplessness; living conditions were poor and people face the possibility of eviction due to financial strain
• Fears of isolation and loneliness; as sources of support shrank, carers and those with special needs became more isolated and vulnerable

Although Britain and Ontario are not under identical circumstances, the report’s findings provide some insights into the real and negative impacts that many Ontarians may be facing due to the cuts to the CSUMB in January 2013. The CSUMB helped people receiving social assistance to pay for large or unexpected housing-related costs, supporting them to become and remain housed.

In our Health Equity Impact Assessment of the real cost of cutting CSUMB, we outlined how the elimination of the CSUMB will have inequitable  effects on those who are homeless, have disabilities, receiving social assistance, women, and children. The Wellesley Institute and the Income Security Advocacy Centre have partnered together and are currently tracking the impacts of the loss of the CSUMB across Ontario by asking municipal, community, and other staff working with clients who would have been eligible for the CSUMB to describe their situations.

The Young Foundation’s study on Camden and the Wellesley Institute/Income Security Advocacy Centre’s current tracking of the loss of the CSUMB are valuable attempts to make concrete the impact of budget cuts within our communities.  This work offers insights into the lives of some of our most vulnerable residents, illustrates the real impacts of cutting essential public services, and identifies a lever to pull when advocating for policy change. Help us in spreading the word.

Uninsured populations currently face serious and damaging barriers to good health and access to health care.  

• The Board of Health heard about ground-breaking research regarding:
  • the mental health crises, injuries and other serious problems that bring uninsured people to hospital emergency departments;
  • how the uninsured are more likely to be seriously ill when they come to a hospital;
  • and the inequitable care they receive – the uninsured are more than twice as likely to leave without receiving care.

• The Toronto Public Health Report reviews available evidence, outlines the underlying causes and drivers of the inequitable health faced by uninsured residents, and identifies particularly vulnerable groups such as women giving birth without adequate pre-natal care, children, people facing mental health challenges, those requiring emergency or urgent care, those with chronic conditions that will worsen without adequate care, and people with communicable diseases.

•  Toronto has also seen how committed front-line service providers can make a huge difference through the many innovative services that have been developed locally by the Scarborough Volunteer Clinic, Community Health Centres, midwives, physicians, and other providers. This base of innovation and experience should be built upon.

These barriers and their inequitable health impact can be addressed through better policy.  Here’s how:

1. Council should approve the Board of Health’s recommendations.
2. The City should build on its Access Without Fear policies for undocumented immigrants; Toronto Public Health should proactively implement its report’s recommendation to work with health sector colleagues and authorities to ensure Access Without Fear policies are consistently in place in facilities across the city.
3. The Report’s recommendations include working with local, provincial and federal governments to address the access barriers identified and advocate for the changes proposed.  Toronto Public Health can undertake this collaboration from a position of considerable strength; being widely recognized as a research-based, credible and influential champion for population health. TPH should monitor relevant policy changes and debate and proactively ensure that its strong population health approach is influential in ongoing policy development regarding immigrant health.
4. Toronto Public Health has a long and effective history of local health leadership and collaboration. It should build on this tradition by continuing to work in ground-level front-line service innovations and local coordinating networks to improve care for uninsured residents. It should also collaborate with LHINs, service providers, researchers and appropriate networks to monitor the health of uninsured populations, assess the impact of policy and program changes made to improve access to health care, and identify service gaps and access barriers.
5. Senior staff should also work with public health leaders across the province and country, both to help develop creative local solutions to challenges uninsured face in different communities and to forge a strong public health voice on the systemic policy changes needed to ensure health equity for all, including the uninsured.

And, of course, action needs to be taken by other levels of government. Starting points that would make a huge difference would be for Ontario to remove the three-month wait period for OHIP for new immigrants and for the federal government to rescind its very damaging cuts to refugee health care.

The budget delivered best on social assistance reforms. In contrast to the cutbacks to Community Start-Up and Maintenance Benefits in last year’s budget, this year’s budget showed concrete progress in three areas. First, it moved forward in eliminating a number of “stupid rules” that were punitive and made life for people living on social assistance difficult and unaffordable. Second, it increased social assistance rates and acknowledged the desperate situation for single people living on Ontario Works by providing them with a larger increase (however, rates still remain so low that they continue to endanger health; people will still have to choose between rent and food). Last, it outlined next steps in the development of the poverty reduction strategy, including consultation with affected communities.

As we all know, people who are living in poverty are working for low pay as well as receiving social assistance. Therefore, the Budget’s action on the minimum wage is very disappointing. The only commitment is to an advisory panel to report back to government within 6 months. The role of the labour market in increased income inequality calls for more concrete action. An immediate increase to the minimum wage would make life more affordable for low-income individuals and families. While the budget made progress on addressing labour market inequality by increased funding for enforcement of employment standards by $3 million per year, it still falls short of meeting the government’s commitment.

A truly missed opportunity to reduce inequality is the Budget’s commitment to continued reductions in real, per-capita program expenditures. The government’s deficit reduction targets could be met through tax increases that would support its economic and social policy goals. Balancing the budget by increasing taxes is much less harmful to growth than by restraining spending. Recent work by the CCPA showed a number of alternatives for Ontario to rebuild its fiscal capacity to reduce the deficit and enhance public services. A gradual increase in taxes would be sounder economic policy than the announced reduction in real, per capita spending. And, rather than increasing inequality, it would reduce it.

In this minority legislature, Andrea Horwath has the chance to improve this budget in a way that will make life more fair and affordable for Ontario families.

It is estimated that there are 75 000 – 300 000 uninsured residents in the Greater Toronto Area alone. Uninsured residents include individuals who have lost their identification, people in the three month OHIP wait period, temporary visa holders (ex. students, visitors), some refugees and undocumented residents.

Presently, essential health care services are extremely limited and inadequate for uninsured residents. Research indicates that priority health needs include obstetrical, newborn, and mental health care; without action, the most vulnerable of this already disadvantaged group, such as children – who do not have a say in where they are living – continue to face dire and inequitable health outcomes.

Dr. Michaela Hynie, a Wellesley Institute Board member, presented her research demonstrating that there are significant costs of a large uninsured population:

• uninsured clients – very limited access to primary and preventative care, sicker before they seek treatment and less likely to receive care
• health care system – staff time lost in scrambling to find care, increased and preventable costs because of delayed care, and costly visits to the emergency room due to lack of access to primary care
• health care workers – forced into difficult ethical situations and increased stress and workload

Frontline doctors and midwives shared their firsthand experiences while working with uninsured individuals. Midwife Jay MacGillivray spoke of an expectant mother of eight months who declined her offer of a piece of gum because it reminded her of how hungry she was. She was saving her money to feed her other child, and since she was unable to pay for the costs associated with ultrasounds and other earlier checkups, the visit was her first prenatal care during this pregnancy. However, it was stressed that the sharing of firsthand experiences was not merely to evoke emotions and be “sob stories,” but to demonstrate the reality of many individuals’ situation, and importantly, that policy action is needed and can make a difference.

Bob Gardner presented the Wellesley Institute brief, outlining our recommended policy solutions. One of the greatest challenges for local government and public health is that they don’t control most of the policy levers that can drive change on health inequities and determinants of health. But they do provide significant programs directly and can ensure that these are geared to enhancing equity, and Toronto Public Health does have considerable credibility and influence to collaborate and advocate for change with provincial and federal governments. We highlighted policy changes needed:

• Create equitable and effective policies –  the Wellesley Institute supports the report’s recommendation to work with the health sector to ensure Access Without Fear policies are consistently in place
• Address inequitable policies – cuts to the Interim Federal Health Program are having adverse and inequitable consequences for refugees and should be rescinded; also, the three month wait for OHIP eligibility is one of the most significant barriers for immigrants to accessing health care, and should be rescinded as well
• Build on what is working – the innovative services and “work-arounds” developed by community-based practitioners is remarkable and more funding is needed for CHCs, specialized clinics and midwifery practices to provide greater quantity and quality of care to the uninsured
• Monitor impact – collect comprehensive and accurate information on the health of uninsured people to better assess gaps and service needs.

All members of the Toronto Board of Health voted to move this issue forward to the Toronto City Council.

We are living in an increasingly globalized world; human migration will not be ending or declining anytime soon. Uninsured residents are real and in Toronto, they are our family, friends, neighbours, community members, and colleagues. It is time to come together and offer our “ferocious” support.

As outlined in an earlier blog, to get any real traction, a successful HiAP approach must be grounded in the fiscal and political pressures, accountability regimes, incentives for decision makers, and accountability systems that actually drive the ways governments work. Finland’s HiAP approach has been increasingly successful over the past four decades because it has been effectively aligned with the workings of government.

The article illustrates how the key success conditions work in practice when using the HiAP approach:

• legislative, regulatory or policy directives are essential in making participation mandatory across  government departments – the reformation of the Finnish Constitution in 1999 and the Public Health Act in 2006 and 2010 imposed specific obligations on local authorities in large-scale health promotion, and a law on public health reports required all administrative sectors to provide the Ministry of Social Affairs and Health (MSAH) with information of their work in the area of health
• requirements from departments and agencies must be matched with explicit deliverables and targets – as seen in the 1985 health policy report, the first document to acquire high-level approval on 24 separate targets with respect to health and sectors outside health care, and the Health 2015 Programme, that set eight broad quantitative targets and indicators to measure them, as well as 36 plans for action
• targets must include transparent reporting on progress – such as the evaluation of the 1985 health policy report and Health 2015 Programme by a group of experts set up by the WHO’s Regional Office in Europe
• support and leadership from central agencies are important – the adoption of a cross-sectoral health promotion policy program during the 2007-2011 government term was under the coordination of the Prime Minister’s Office
• active participation and knowledge sharing enhances the ability to solve health issues – Finland and the World Health Organization (WHO) worked together to develop cross-sectoral health policies, and, the MSAH, the National Institute for Health and Welfare, and the Institute of Occupational Health have developed greater expertise in different areas of health by connecting with international networks
• Health Impact Assessment (HIA) or Health Equity Impact Assessment (HEIA) is a key tool – although studies show that HIA plays a small role in Finland’s legislative proposals, HIA is an essential part of some ministry’s work even if there is no legal basis for it, such as in the Ministry of Transport and Communication

The social determinants of health are complex and require changes and action in many departments outside of health. The work in Finland has shown that HiAP is an appropriate approach to take, and ultimately, that HiAP can actually work in practice.

Along the lines of exploring strategies in Europe to better health outcomes, look for our paper Learning from Others: Comprehensive Health Equity Strategies in Europe. 

Wellesley Institute CEO Rick Blickstead addresses
the business-community roundtable in London, Ontario.

A full house of 50 business and community leaders packed the boardroom of the London (ON) Chamber of Commerce for that community’s first-ever business-community roundtable on mental health and employment on April 26. The event was co-hosted by Pillar Non-Profit, the London Chamber of Commerce, the United Way of London and Middlesex, Prince’s Charities Canada and the Wellesley Institute.

Mental health and mental illness loom as big issues for business and for workers. For people directly experiencing mental health issues, there are challenges accessing and maintaining employment. For employers, there are not only challenges in supporting workers who are directly experiencing mental health issues, but also supporting workers who have family members (children or others) who are facing mental health issues.

The roundtable helped business and community leaders to better understand the range of issues and concerns, and to start to identify good practices in terms of mental health in the workplace. In the Wellesley Institute’s research and policy work, we know that there are strong links between precarious employment, mental health and personal health – and that all of this impacts on the population health of the entire community.

As an applied research and policy institute, we know that multi-sectoral partnerships are key to making real progress. In our work, we seek to identify good practices that can make a positive difference, and then work with key partners to build the conditions for those good practices to be scaled and replicated.

The London session had several key objectives: To engage London business and community leaders in a meaningful dialogue about mental health and employment; to identify good practices in mental health and employment; and to engage business leaders in a major event being planned for the early summer that will include visits to three successful social enterprises in London that work in the area of mental health and employment.

More on the Wellesley Institute’s innovation and enterprise work here.

The federal government’s decision to stop funding the Health Council of Canada as of March 2014 had prompted an outcry from the Canadian Medical Association (CMA) and other health care organizations, which fear the loss of an independent voice to monitor health system performance and reform.  CMA president, Dr. Anna Reid asked: “How are we to transform the health care system to improve patient care if we can’t measure what we’re doing well and what we need to improve?”  and argued that “Canada’s health care system needs all the information it can get, but instead we are about to lose one of the few bodies responsible for monitoring and measuring progress toward ensuring the health care system is able to meet the needs of Canadians.”  Other health care advocates such as the Council of Canadians and the Canadian Health Coalition worried that dismantling the council will create a gap in knowledge about how well different parts of the country perform on health care.  Several provinces expressed concern that the Council contributed to sharing information across jurisdictions.

It may be useful to step back from the immediate controversy to assess its implications for health care reform.  Let’s begin from a powerful framework commonly used to analyze and compare the structure and performance of health care systems: identifying the essential features of a high performing health care system, assessing where your system is in relation to these defining elements and analyzing how to improve along the identified lines?  Essentially, we are asking what are the success conditions for significant system transformation? Where and how do the functions fulfilled or potentially fulfilled by the HCC contribute?

Three vital success conditions are especially relevant here. The first is about enabling and driving innovation:

• Identifying promising practices;
• Evaluating what is working, for which purposes and populations, in what organizational and social contexts?
• Sharing lessons learned;
• Providing evidence-based and easy to use guidance and support for practitioners and decision makers.

Clearly, forums and institutions are needed to organize and coordinate this knowledge sharing and management. HCC has played an important role in highlighting areas of innovation.  But it has been limited in its ability to monitor, enable or drive implementation of promising practices.

The challenge becomes clearer when considering a second success condition for system change and improvement: creating a comprehensive and integrated performance measurement and monitoring system.  The Council played a role in identifying measurement structures to some degree and monitoring some key dimensions.  Arguably, a more comprehensive and coordinated system is needed.  Many provinces have quality councils or other structures performing elements of system monitoring and reporting. There would be great value in these functions being coordinated and consistent. For example, each province using a similar suite of equity indicators would help to identity the trends and contours of health inequities much better.  The federal, provincial and territorial governments could recognize the importance of this coordination and given the HCC a role here.

However, the reason for this limited performance monitoring and improvement lies in a third key success condition: tying performance measuring and management to resource allocation, funding incentives, accountability mechanisms and other system drivers. In other words, giving performance measurement teeth and traction.  HCC did not have this kind of power; nor does any other current institution.  The problem is structural: the provinces and territories are responsible for health care policy and delivery; the federal government provides some significant funding but has steadily pulled back from attaching those funds to performance or outcome requirements; and the result is a fragmented system of 13 health care systems. In effect, there is no national health care system in Canada.

Key policy and system questions then arise. Is there value in national forums and mechanisms to share lessons learned and drive innovation across the country? The answer is absolutely yes.  Given that the HCC exists and has a track record in this area, this implies that the Council should be retained and strengthened.

Could comparative performance measurement and monitoring contribute to more consistent and equitable delivery of care across the country?  Yes again.  A starting point could be for each jurisdiction to commit to comprehensive system measurement and monitoring – some provinces are very advanced.  Even better would be Federal-Provincial-Territorial commitment to sharing results and moving towards consistent standards, indicators, data collection and performance measurement systems.  A strengthened  HCC could be part of that, but the real challenge is political will.

Similarly, would embedding performance measurement and monitoring into broader management, resource allocation, accountability and system drivers be useful?  Yes again.  And again, at best in a coordinated and collaborative way that enables cross-jurisdictional innovation and sharing.   This would need to be a considerably strengthened institution than the current HCC.  And it can only come out of more serious strategic commitment from all governments to health care reform that moves well beyond the current fragmented system.