Abstract
To plan for an expansion of healthcare services in newly developed neighbourhoods, a planning initiative was conducted to better understand the needs of the population. Ensuring equity of care was identified as a priority for this initiative. To evaluate how closely the planning adhered to the principles of health equity, we applied Ontario Health's Equity, Inclusion, Diversity, and Anti-Racism Framework to determine which areas of action were successfully addressed, and which areas of action require further focus. The framework contains 11 components, each delineating a key area of action. Using this framework helped identify areas where the principles of equity were well addressed, as well as pointing to additional areas where further efforts are required. Healthcare organizations must take a leadership role in advancing health equity by planning, delivering, improving, and advocating for the services and systematic changes that will allow its local community members to realize their highest attainable standard of health. Using such a framework can help develop strategic approaches to advancing equity.
Introduction
‘‘The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition,’’ 1 as stated by the constitution of the World Health Organization (WHO). Health is influenced by varying biological, structural, and social determinants, which all differ depending on the individual and population of focus. Equity is defined by WHO as the ‘‘absence of unfair, avoidable, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality.’’ 2 Leaders and organizations have a responsibility to ensure their programs and services are planned, implemented, and evaluated with the purpose of ensuring equity in meeting their mandate. Numerous personal, social, economic, and environmental factors termed as social determinants of health encompass the conditions in which people live and work, variably affecting the quality of their life. In the Canadian context, 17 social determinants of health are identified as a high priority, significantly impacting residents' health. These include income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety network, health services, geography, Indigenous ancestry, gender, race, immigration, globalization, and disability. 3 These determinants serve as double-edged swords with the potential to maneuver individuals toward either positive or negative health outcomes based on the social networks, institutions, governments, and organizations that surround them. 3 As such, leaders and organizations need to have an intimate understanding of the social determinants of health of the people and communities they serve that can be used to inform the implementation of services and policies within the organization. Organizations can achieve this by routinely applying an equity lens to their services and embedding the lens in their planning activities to ensure equity is prioritized upfront.
Queen Square Family Health Team (QSFHT) aims to provide accessible, equitable, patient-centred team-based primary care to its local community in Brampton, Ontario. QSFHT is committed to providing wrap-around care services that are proven to improve health outcomes. 4 Through its program planning, QSFHT identified insufficient local access to health services in newly developed neighbourhoods. To explore expanding health services in this region, a better understanding of the gaps in care was needed. Knowing this region consisted of individuals new to Canada, and the cultural diversity of the neighbourhoods, it was important to ensure an equity-based lens was foundational to the planning approach. Quantitative and qualitative data was sourced from community stakeholders within the health and social service sectors that were then assessed to make conclusions on specific health trends and needs of the community. In addition, the community was engaged directly to gain a greater understanding of their health needs.
This paper describes and evaluates the planning process undertaken to determine how it adhered to the principles of health equity. To conduct this evaluation, Ontario Health's Equity, Inclusion, Diversity, and Anti-Racism Framework is used to determine which areas of action were successful and which areas require further focus. This evaluation is meant to assess the equity efforts of the health service planning and is not a presentation of the health service planning initiative.
Method
To evaluate the equity efforts of the planning work undertaken, the framework was selected as it is a local, available resource for health planning in Ontario. The framework was developed with the intent to provide independent, expert examination of Ontario Health’s current assets focused on health equity, inclusion, diversity, and anti-racism, and to recommend a framework and approach to improve access, outcomes, and experiences across Ontario’s healthcare system. 5 Its development was guided by multiple actions, including, a series of engagement consultations with internal stakeholder’s at Ontario Health and external stakeholders across Ontario, the completion of a high-level scan of relevant health equity information within the public domain, and engagement with Black team members and leaders at Ontario Health. 5
The framework contains 11 components, each delineating a key area of action (Figure 1).
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Ontario Health determined two key uses of the framework, the first use being within the Ontario Health organization itself and the second use being across the healthcare system in Ontario.
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Ontario Health intended this framework to be used as a foundation for system planning by service provider organizations, to inform policies, practices, processes, and supports to advance equity, inclusion diversity, and address anti-racism.
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Therefore, this framework is being used to evaluate whether the efforts taken in the expansion planning initiative achieves this key use outlined by Ontario Health. Ontario health’s equity, diversity, inclusion, and anti-racism framework.
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Discussion
Each component of the framework is used to assess the program planning efforts undertaken.
Collect equity data
Collecting equity-based data is the first step towards identifying existing inequities. Ontario Health recommends setting up systems to collect, analyze and utilize equity data in decision making. QSFHT researched and leveraged existing public resources to extract population-based data. The national census collects information on various equity indicators including education, income, place of residence, and ethnicity. To identify the region of interest, five Forward Sortation Areas (FSAs) for health profiling were selected for analysis. At a municipal level, the Region of Peel has a central data centre for various topics including demographics, economic activity, environment, and transportation. FSA level data required for profiling was accessed by connecting directly with the Peel Data Centre who provided support and datasets from the 2011 and 2016 census. The data was used to prepare sociodemographic profiles using the following variables: age, income, household size, immigration status, language, education, and ethnicity.
Data regarding the gender identity of Canadians has historically not been collected by public institutions in Canada, most noticeably by the Census of Population. This presented a challenge when planning for service expansion. The lack of publicly available and publicly collected data can create the ecological fallacy that there are no individuals who identify as transgender in the region of study, therefore creating the impression within policy circles that there is no need for transgender healthcare services. Consequently, this contributes to the inequity that transgender individuals experience in healthcare access and health outcomes. For the first time, the 2021 Census of the Population asked one question inquiring about a person’s sex at birth and a second question inquiring about their current gender identity. This will start to shed some insight on this topic.
Overall, the approach to use existing collected data provided benefit in conducting the analysis for the population of interest.
Embed in strategic plan
Ensuring equity work is embedded in the organization’s strategic plan helps ensure all activities are guided by this principle. QSFHT meets this as its values and strategic priorities are rooted in the delivery of community-based, equitable care. With a strategic direction focused on supporting patients to thrive in their community and the value of person-focused care.
Invest in implementation
Financial and human resource investment indicates an organization's commitment and fortifies sustainability of actions to combat inequities. QSFHT formulated a committee to advance equity in the organization. Carving out time for this work, the team advises various programs and services on equitable care through identifying professional development opportunities and participation in program development to ensure equity-based data and processes are used to inform program planning, delivery, and evaluation.
Identify clear accountability
Through this initiative, all findings were reported to and discussed by the leadership team of QSFHT to ensure alignment of equity-based recommendations with other strategic priorities. Presentations were also shared with the interdisciplinary team at QSFHT for input and reflection, emphasizing shared accountability for all through implementation.
Represent and reflect Ontarians
As part of this initiative, a survey was developed to better understand the needs of the community and to gain insights on how services should be tailored. The community of interest is rapidly growing, and COVID-19 has shed light on the impact of health service gaps in the region. This initiative provided an opportunity to gather insights on how to start bridging that gap by understanding the needs right from the people in the community. Surveys were deployed on-line and in-person—which resulted in the highest engagement and most enriching content.
Include and engage key voices
Type of community organizations engaged and nature of engagement.
Address racism
Peel is among the most diverse regions in Canada, with 73.3% of the Brampton population made up of visible minorities.7,8 These are the facts; however, understanding how to address racism requires continuous engagement with communities into how racism impacts the health of those living in Brampton and its surrounding communities, and how it contributes to health inequities. Continuing to partner with community organizations that provide culturally competent care was made evident and will require ongoing partnership. We believe that further investigation is required in this area.
Reduce disparities
This region was identified due to the lack of available primary and community care options. Through the COVID-19 pandemic, when a temporary COVID, cold, and flu clinic was opened in the region, it became visibly apparent to QSFHT the community lacked access to primary care services. Data on providers in the region indicates that Brampton has considerably fewer family physicians in comparison to Ontario (68 versus 102 per 100,000 population),9,10 and using the College of Physicians and Surgeons of Ontario directory, there are even fewer family medicine physicians in the region of interest (45 per 100,000 population). 11 This information supported the known view of residents and community providers that this region is a “health desert” and this disparity needs to be addressed.
Partner to advance Indigenous health equity
Through the planning initiative, this population was identified to not significantly be represented in the community. Use of this framework highlights the need to plan for this population and form such partnerships, and therefore represents a gap in the initial planning work with an opportunity to partner with local groups to plan health services for this population.
Contribute to population health
A review of available public health research indicates there are certain health behaviours and non-communicable diseases that are of concern in this region. Residents have higher rates of obesity and physical inactivity compared to the rest of Peel region and Ontario.12-14 Deaths due to ischaemic heart disease and stroke occur at higher rates than the rest of Peel and residents are impacted by diabetes at increased rates compared to Ontario.12,14 The high prevalence of modifiable risk factors, the ageing population, and the considerable portion of the population who are susceptible to non-communicable disease due to immigrant status and ethnicity necessitates the need for an expansion of health services with an equity lens. Service planning recommended through this initiative will aim to address these population health concerns.
Report and evaluate to drive improvement
The actions that took place in the health service expansion project were presented to the leadership team of the organization and then subsequently incorporated into a business case to funders for expanding services in this region. Specficially, the business case information included a health profile of the region and provided insight into the state of transgender care.
Recommendations and conclusion
Health leaders and organizations have a responsibility to meet community members and patients where they are to ensure equitable care is being delivered and community members can trust their local healthcare system can meet their needs. Community organizations must take a leadership role in advancing health equity by planning, delivering, improving, and advocating for the services and systematic changes that will allow its local community members to realize their highest attainable standard of health.
Using this framework to evaluate program planning efforts identified that regionally derived census data, and the partnership with agencies that serve specific populations helped strengthen the approach to equity, while the need to engage Indigenous populations and develop implementation efforts with racism top of mind identify key areas for further efforts in advancing equity. This provides focus for the organization’s leadership on its next planning steps.
Use of this framework can help leaders assess their efforts in advancing equity and prioritize where further resources or investment are required. While this effort was undertaken for a specific region in Ontario, the process could be replicated across the province. National or international use of such a process would require examining the framework to ensure it identified the populations of focus for the geographic region and any local health system differences. However, the use of an agreed upon regional framework helps to ensure leaders are focusing on the right elements in addressing equity when planning for health resources.
Leaders play a key role in advancing equity. For instance, with forming and fostering partnerships, making equity a strategic priority for the organization and embedding it in the culture. These steps help advance an organization’s approach to equity. Achieving equity is a journey. Leveraging tools such an equity framework can help support leaders to follow this journey and demonstrate successes and gaps along the way.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
Institutional Review Board approval was not required.
