There are currently large and significant disparities in mental health. The vision of Every Door Is the Right Door is to create a more integrated system that will promote all Ontarians’ mental health and well-being, and support people with mental illnesses and addictions. Not paying attention to equity while reforming the system may in fact widen disparities. (August, 2009)
There are currently large and significant disparities in mental health. The vision of Every Door Is the Right Door is to create a more integrated system that will promote all Ontarians’ mental health and well-being, and support people with mental illnesses and addictions. In order to do so, we need to ensure that the benefits of a transformed system are shared by all. If the 10 year strategy for mental illness and addictions does not explicitly identify equity as a core principle and build equity into its goals and targets, this potential will be only be realized by some. Not paying attention to equity while reforming the system may in fact widen disparities.
There are many examples where equity is mentioned in the report. What is needed is a roadmap for a coherent equity strategy and action plan.
The way to address equity within the mental health services system is two-fold:
- take equity and disparities into account in all service delivery and planning
- reduce barriers to equitable access for services, and invest in programs that are targeted to populations at-risk and those experiencing health disparities.
As the strategic directions so clearly emphasize, Ontario also needs to look beyond health care by focusing upstream, and developing effective and equitable strategies to promote mental health and well-being and prevent illness. This includes addressing the foundations of health inequalities: social and economic inequality, social exclusion and other determinants of health.
Addressing equity beyond health care involves:
- macro economic and social policy to reduce poverty, addressing the roots of inequality, and enhancing opportunities for social mobility
- increasing horizontal and cross-cutting approaches to developing and implementing public policy – often called ‘whole of government’ approaches or ‘joined-up’ government — that coordinate and link inter-sectoral activities, and foster healthy public policy
- building community resilience and healthy communities
- supporting front-line community-based cross-sectoral collaborations.
The Wellesley Institute and CMHA, Ontario endorse the strategic directions outlined in Every Door is the Right Door: Towards a 10-Year Mental Health and Addictions Strategy: A Discussion Paper. Ontario needs to ensure that the benefits of a transformed system are shared by all. This paper identifies how equity can most effectively be built into the strategy and put into action.
Mental Health Disparities in Ontario
Mental health outcomes are distributed unequally in different populations in Ontario:
- low-income women were three times as likely as higher income women to report their mental health as poor or fair
- low-income men were five times as likely as higher income men to report their mental health as poor or fair
- there is a clear mental health gradient – the percentage who report their mental health as only fair or poor rises as income decreases
- over twice as many low-income as higher income women had probable depression
- there are clear gender differences – men reported lower rates of depression than women.1
Health disparities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage. Disparities are related to the concept of equity. Although the two terms are often confused, equity is not the same as equality. The key differences between equity and equality are that equity focuses on the distribution of resources among specific populations, whereas equality looks at whether differences exist or not. Recent research has shown that social and economic inequities have far-reaching consequences on health. Not only do inequities undermine the social glue which underpin cohesive societies (i.e., trust, social capital), but they are also associated with higher levels of mental illness.
Taking equity into account involves acknowledging and addressing diversity. This means ensuring that the different needs and preferences of diverse communities are always analyzed, and that inequitable access, treatment and outcomes by race, country of origin, sexual orientation or any other line of discrimination and oppression are identified, challenged and eliminated.
The overall goal of a health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes to ensure opportunities for good health are able to be realized by all Ontarians. The impact of achieving this goal would extend far beyond enhancing individual and collective well being. It would also contribute to social cohesion, shared values of fairness and equality, economic productivity, and community resilience.
The clear mental health gradient identified in the POWER study highlights the importance of tailoring services to meet the diverse needs of Ontarians, particularly for those on a low income, whose mental health is worse than those on higher incomes. People with low-income and other disadvantaged circumstances bear a disproportionate burden of poor mental health. This highlights the importance of improving access and customizing services to the specific needs and circumstance of vulnerable populations. The strategic directions acknowledge the importance of tailored and targeted services.
To complement these services and to ensure that a planned mental health strategy benefits all Ontarians, whatever their social and economic circumstance, gender or ethnicity, it is vital that equity be both a core principle of the strategy, as well as a fundamental goal with clear and measurable targets and indicators.
There are several instances where equity considerations could be made more explicit. We propose a ‘roadmap’ to integrate equity into the strategy in a coordinated and cohesive way.
An Equity Roadmap for Mental Health and Addictions
1. Build Equity into All Planning and Service Delivery
All planning, programs and services should take into account health disparities and the principle of equity, in order to achieve Ontario’s vision for promote mental health and well-being, and support people with mental illnesses and addictions.
This can be done by developing equity-focussed
- Tools – such as mental health impact assessments, health equity impact assessments and an equity lens
- Drivers – equity targets could be built into the provincial mental health strategy, cascading expectations and objectives to LHINs, and in turn, objectives built into provider and system performance management
- Enablers – adopting a culturally competent approach to all aspects of mental health, and collecting data on gender and equity in health indicator monitoring to assess attainment of targets
Effective tools have been developed to help operationalize equity. These include equity lenses – simple questions to consider potential differential effect of programs on disadvantaged populations and overall health disparities – which can be quickly applied to potential programs and issues to assess their equity implications. The Victoria Health Promotion Foundation in Australia is piloting a framework to provide a “lens” by which to incorporate equity into planning. It includes three dimensions of inequality of access, opportunity and outcomes:
- inequality of access – such as language, accessibility, cost and other barriers to mental health services, and mental health services that are not culturally appropriate for the target population
- inequality of opportunity – barriers to the social, geographic and economic resources necessary to achieve and maintain good mental health, such as levels of education and literacy; income; personal safety and security; and social inclusion
- inequality of impacts and outcomes – assessing differences in mental health status between groups in order to allocate resources to more vulnerable and disadvantaged populations.2
The Ministry of Health and Long-Term Care, Toronto Central LHIN and the Wellesley Institute recently piloted a health equity impact assessment tool, which analyzes the potential impact of programs or initiatives on disadvantaged populations and how program utilization and impact is affected by wider social determinant factors.3 Local health integration networks (LHINs) could require transfer payment agencies receiving funds to use health equity impact assessments to guide their planning.
Mental health impact assessments have been recently identified in Europe as part of mental health action plans. These are structured assessments of how policies, proposals, programmes and projects may influence mental health and well-being and take into account the pathways through which inequalities influence mental health. They have been used in jurisdictions such as the UK to support policy-makers, planners and people delivering programs and services that have the potential to improve the mental well-being of communities.4
One critical component of equity action plans is setting clear targets. All jurisdictions with comprehensive equity strategies include targets. England is the leading jurisdiction in setting clear targets, monitoring and reporting progress against the identified targets, and adjusting policy and programs in response.5
Equity outcome targets in mental health and well-being could include reducing disparities in self-reported mental health and major depression by gender, income, ethno-cultural background, immigration status or other social-economic variable by a certain percentage by a certain date. Data now exists through data sources such as the POWER project and the Canadian Community Health Survey to monitor progress on these indicators.
In addition, new composite indicators are becoming available, such as the Canadian Index of Well-being, which will identify, develop and regularly report on progress toward well-being in Canada. When fully developed, the index will include categories such as healthy populations, community vitality, education, environment, civic engagement, etc.6
ii. System and Performance Management
Objectives, targets and indicators can be incorporated into routine performance measurement and into the dense web of financial incentives that drive day-to-day work. For example, LHINs can require all transfer payment agencies to develop health equity plans, and be accountable for achieving equity-focused objectives.
2. Targeted Equity Initiatives
The second element of the roadmap involves directing a significant proportion of investments into reducing barriers to equitable access for services; and investing in programs and services that are targeted to populations at-risk and those experiencing health inequalities. Leading jurisdictions with comprehensive health equity strategies combine overall broad policy directions with specific programs and services targeted to the most health disadvantaged communities.7
One key element of effectively targeting investments and initiatives is to analyze where equity impact will be greatest, using the equity planning tools we have identified above.
Targeting resources and services where they will have the greatest impact on reducing critical access barriers and improving the services and health of those facing the harshest disparities requires good local research and information to be able to analyze which populations are most in need and will benefit most from targeted interventions, and what barriers and problems are creating the disparities. Community-based research has been particularly effective at providing rich and nuanced understandings of the mental health needs of disadvantaged populations, many of which go beyond health care.8
Beyond Health Care
The foundations of mental health lie outside the health system – rooted in systemic social and economic inequality, social exclusion, discrimination and violence. The relationship between social determinants and health is not direct and one-way, but complex, cumulative and dynamic. Overall social and economic inequality, and specific conditions such as poor housing, education, income and living conditions, have a negative impact on health, and there is a clear gradient in which health opportunities and outcomes become worse the lower down the social hierarchy. At the same time, however, poor health can contribute to lower paying and less secure positions within the labour market, lower educational achievements and more limited overall opportunities for social mobility. In these ways, poorer health can reinforce the social and economic inequality associated with poorer health in the first place. This relationship is interactive and cumulative over people’s lives.9,10
The strategic directions for the 10 year strategy recognize these broad determinants of health and identify a number of objectives to create healthy communities and build community resilience. Implicit in these directions is the desire to effectively address the root causes of health inequalities. The strategy can address equity beyond health care and the root causes of inequality through these inter-related approaches:
Focus on Economic and Social Policy
A broad focus on macro economic and social policy to reduce poverty, address the root cause of inequality and enhance opportunities for social mobility.
Whole of Government Approaches
More horizontal and cross-cutting ways of developing and implementing policy – often called ‘whole of government’ approaches or ‘joined-up’ government — that coordinate and drive cross-government accountabilities and build health into all policies.
A recent review of whole-of-government initiatives in North America, New Zealand, Australia and the United Kingdom, has identified a number of lessons learned. Firstly, whole-of-government strategies need to be thought of as long-term, as it takes time to broaden one’s understanding of issues in order to set common goals, jointly act, create common standards and shared systems. More so, whole-of-government initiatives should receive the same status as distinct policy, departmental or sector initiatives, in order to create the necessary recognition and incentives to avoid re-focusing on intra-organizational vertical accountability. In addition, changes in organizational culture need to occur, in order to build a common ethic and cohesive culture in which to collectively work. Lastly, these approaches will have the greatest likelihood of success when they engage other actors and institutions; that is, in municipalities, non-governmental organizations and grass root community actors, as whole-of-government approaches need cooperative effort and cannot easily be imposed from the top down.11
The Adelaide Recommendations on Healthy Public Policy (WHO, 1988), call for a political commitment to health by all sectors. Policy-makers working at all levels (international, national, regional and local) were urged to consider the impact of their decisions on health. The heath in all policies approach “aims to address complex health challenges through an integrated policy response across portfolio boundaries”.12
Place-based approaches seek to improve the social, cultural, economic and physical environment within a defined boundary, in order to improve health and reduce the differences in health among the people living within that area. The four principles underlying a “place-based approach” include: tapping local knowledge (e.g., lived experience of residents, action research of community organizations), finding the right policy mix (combining universal policies and targeted programs), governing through collaboration (developing horizontal and vertical government partnerships) and recognizing local government and providing them capacity to inform public policy and serve as an optimal access point for citizen input.13
This model is asset-based since it emphasizes finding and supporting local strengths. Its solutions are tailored to the specific needs of each community, and it encourages community-building amongst local residents.
For example, The Review of the Roots Of Youth Violence recommends identifying disadvantaged neighbourhoods in Toronto and creating community hubs to provide a forum for integrated community capacity-building and service delivery. 14
Fostering community-based cross-sectoral collaborations. Supportive housing is one of the best examples of local partnerships between housing, health care providers and wider social services that can make an enormous difference to people’s well being.
- A.S. Bierman (editor), Project for an Ontario Women’s Health Evidence-Based Report: Volume 1, Toronto, 2009, available atwww.powerstudy.ca
- Victoria Health Promotion Foundation, “People, Places, Processes: Reducing Health Inequalities through Balanced Health Promotion Approaches,” Victoria, Australia, April 2008, available atwww.vichealth.vic.gov.au
- B. Gardner, “Health equity discussion paper,” Toronto Central LHIN, July 2008, available at www.torontocentrallhin.on.ca
- T. Coggins, A. Cooke, L. Friedli et al., “Mental Well-Being Impact Assessment: A Toolkit,” Care Services Improvement Partnership, North West Development Centre, U.K., 2007, available atwww.northwest.csip.org.uk
- Department of Health, “Tackling Health Inequalities: 10 Years On & A Review of Developments in Tackling Health Inequalities in England over the Last 10 Years,” United Kingdom, May 2009, available atwww.hpclearinghouse.ca
- Institute of Wellbeing, “The Canadian Index of Wellbeing,” available atwww.ciw.ca
- B. Gardner, “Building Action on the Social Determinants of Health: Senate Subcommittee on Population Health, Committee on Social Affairs, Science and Technology,” Wellesley Institute, March 12, 2009, available at www.wellesleyinstitute.com
- A. de Wolff, “We Are Neighbours: The Impact of Supportive Housing on Community, Social, Economic, and Attitude Changes,” Wellesley Institute, May 2008, available at www.wellesleyinstitute.com
- H. Graham, “Unequal Lives: Health and Socioeconomic Inequalities”. Maidenhead, 2007.
- R. Wilkinson and K. Pickett (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin.
- T. Christensen and P. Laegreid, “The Whole-of-Government Appproach to Public Sector Reform, Public Administration Review, November/December 2007: 1059-1066.
- I. Kickbusch and W. McCann, “Adelaide Revisited: From Healthy Public Policy to Health in All Policies” Health Promotion International, 23 (1); 2008: 1-4.
- Canadian Policy Research Network (CPRN), “Place-Based Public Policy: Towards a New Urban and Community Agenda for Canada,” March 2005, available at www.cprn.com
- R. McMurtry and A. Curling, The Review of the Roots of Youth Violence,Toronto: Queen’s Printer for Ontario, 2008, available atwww.rootsofyouthviolence.on.ca