Pursuing Equity

The following has been extracted from the "Pursuing Equity" report of the Ontario Premier’s Equity and Access Committee, February, 1995.

The Equity and Access Committee of the Premier’s Council on Health, Well-being and Social Justice has presented Phase One of its project, "Pursuing Equity." This report represents a first step in the process of advancing equity and access for all Ontarians.

The Premier’s council originally developed a vision of health which places health in a broad context and stresses the importance of creating equitable opportunities for all Ontarians in achieving improved health.

The Equity and Access Committee recommends participation and dismantling discriminatory barriers to enhance equity and access.

THE COMMITTEE MANDATE
The Equity and Access Committee was formed in 1992 with a mandate to advance the position of groups historically lacking equitable access to, and enjoyment of, resources such as health, housing, jobs and education. The committee was given three specific goals:
- develop and test an equity framework which could assess the equitability of existing policies and programs, and guide the development of new measures;
- profile and promote exemplary initiatives of "equity in action" and disseminate the lessons; and
- Recommend ways in which existing programs and services can be made more responsive to historically disadvantaged groups, and can contribute to a more equitable distribution of resources.

The committee’s mandate was to focus on inequities experienced by historically disadvantages groups, including people with disabilities. Government programs and services are often important in eliminating the inequities these groups face. Yet, economic trends in Ontario indicate that as we move into the next century, government will have less money to spend on social programs. There will be pressure to cut social programs and shift resources toward job creation. Under these circumstances, Ontario has to revamp its social programs and services to ensure they deliver more equity per dollar if there is to be any hope of achieving full equity.

In examining existing programs and services, the Equity and Access Committee attempted to identify the different kinds of barriers to Ontarians’ access to, and participation in, the decision-making processes that shape individuals’ choices. The committee believes that a fairer distribution of power is the first step to achieving a fairer society as expressed in their vision statement.

SOCIAL JUSTICE
As its first task, the committee developed the following "Vision of Social Justice":

"We see an Ontario where people value the dignity and self-worth of individuals, where systemic discrimination and barriers are eliminated, and where society celebrates human diversity and strives towards a common purpose.

"We believe that a socially just community supports and expects a balance between individual and collective rights and responsibilities.

"We see an Ontario in which everyone has a fair chance to achieve economic, social and personal well-being. We believe that individuals and groups can realize their potential and achieve social justice through full access to the determinants of health which enhance well-being, and through active participation in community life.

"We believe that resources must be equitably distributed. Policy makers, service providers and institutions must involve the public so that services and programs are accessible and appropriate to the people who are entitled to use them."

The committee also developed seven principles of social justice which, in specific terms, embody that vision.

Ontario has not yet embraced the vision of social justice. It fails to do so in part because of barriers obstructing access to, and enjoyment of, resources such as health, jobs, housing and education. This problem of differential access denies some Ontarians fair participation, because it is usually those with the requisite resources of time and money who participate in decision-making processes, and opportunities and choices are thereby shaped to their own requirements.

HEALTH CARE
Any discussion of equity and access must acknowledge the ongoing importance of universal health insurance as an instrument for providing equity in health care. When introduced in the late 1960s, national health care insurance was based on the principles of universality and accessibility. Specifically, this has been interpreted to mean that health care is available to all citizens without financial barriers preventing access.

Medicare continues to provide the basis for achieving the established Ontario provincial health goal of delivering accessible, affordable and appropriate health services for all. Despite this, however, our single-payer universal health care system has become increasingly threatened on both national and provincial levels. Federal transfer payments have been reduced and some provinces have allowed coverage to erode. A broader range of health care services have now become uninsured.

Because such services are no longer covered, problems of affordability are becoming widespread. This creates the potential development of a two-tiered system which would pose a major threat to equal-access health care services and would violate our nation’s basic principles of equity. The Equity and Access Committee affirms its ongoing support for the principles of medicare.

A NEW APPROACH TO EQUITY
Provincial action is governed by the Canadian Charter of Rights and Freedoms, by some of the international conventions ratified by Canada, and by many federal laws. In 1961, the Province passed the landmark Ontario Human Rights Code, which prohibits discrimination on 15 grounds -- including mental or physical disability.

Most of the measures introduced by the provincial government reflect a specific approach to addressing inequity. Under this approach, it is assumed that the overall system is fair, but that it is misapplied in certain individual cases. To improve social justice, society tries to redress the damage inflicted on those individuals. This approach attempts to deal with inequities by entrenching individual rights to fair treatment, and giving individuals the power and opportunity to redress violations of these rights.

But a more fundamental issue is that processes or practices which appear to be fair may be unfair because of the way in which they were developed. The majority may think that these practices or processes are fair, because their perspectives were reflected in the development and implementation stages. But for those whose interests were not considered in the design of the system, since they were not represented, the overall process may be unjust.

Attempts to redress these inequities on an individual basis could result in a system bogged down with constant complaints. In these situations, a more efficient way to address the inequity is to change the practices themselves.

Since the late 1980s, society has been evolving towards a more comprehensive, inclusionary approach to equity. This approach recognizes that inequity occurs when practices, though they do not single out individuals for special treatment, may nonetheless treat individuals unfairly because they fail to show fair consideration towards every citizen. The new approach recognizes that some individuals face disadvantages under these systems, and refers to these as systemic inequities.

Deciding who will establish the rules impacts on what the rules are. By involving more people in decision making, more perspectives will be included, and much can be done to address systemic barriers. This new approach is reflected in recent legislation such as the Advocacy Act and the Employment Equity Act.

Adopting the new approach to equity requires us to transform our institutions, organizations, policies and practices so that the policies, practices and procedures fairly reflect the needs and desires of all Ontarians, and that the power to make the policies, practices and procedures is fairly distributed. But legislation alone cannot achieve all the changes required. In fact, legislation can sometimes be a poor mechanism for achieving equality. There is a need to make changes in practices, processes and attitudes which are beyond the legislation’s power to change.

ASSESSING EQUITY
If Ontario is to succeed in making its programs and services more equitable, it needs some way to measure improvements in equity. The Equity and Access Committee surveyed the available assessment tools, and decided to explore the effectiveness of an "Equity Assessment Matrix" adapted from the work of the Centre of Health Economics and Policy Analysis at McMaster University. This matrix was attractive because it offered a flexible mechanism for assessing equity within widely divergent contexts, rather than a single, rigidly defined tool that would have to be applied in the same way in all contexts. The matrix has two elements: the resources or factors which are being distributed, and the groups or individuals who receive them. The committee tested the efficacy of the matrix at both macro and micro levels, since equity may exist at one level but not at another.

The committee recommends that the province also explore the use of mechanisms such as this matrix.

STRATEGIES FOR CHANGE
To enhance equity, we must transform the rules that govern our institutions, organizations, policies and practices, and make decision-making processes more inclusive. Ontario can lead the way by transforming its own policies, programs and decision-making processes.

The equity agenda is marginalized through a number of mechanisms. At present, the government has no common framework for analyzing equity issues which could be used to integrate reforms across provincial programs. Instead, these programs address equity concerns as "add-ons" with special programs targeting inequities. A better approach would be to integrate equity considerations into broader policy development at an early stage.
The committee identified barriers that restrict access to decision making and, in particular, restrict access by members of historically disadvantaged and excluded groups.

Transforming the government’s decision-making processes involves expanding the membership of boards, committees and agencies that make decisions. Membership must be as diverse as the communities these bodies serve. Many community groups cannot afford to participate because it costs so much in terms of time and money, but the committee collected suggestions of several ways to overcome the resource barriers. These include direct subsidies to low-income individuals who participate, funding costs of participating (such as mailing and photocopying), and systematic intervenor funding (modelled on approaches such as that of the Long-Term Care Review).

Some feedback the committee collected included complaints that community groups members’ participation was ineffectual most of the time. They felt government too often solicits their advice, but ignores it. Many of them applauded the Sewell Commission on land use planning for keeping community groups in touch with the policy drafting process as it progressed, letting groups know which advice could or could not be used, and why or why not.

Many other suggestions were offered to the committee by community groups for overcoming barriers to participation. These included a community development approach to decision making, where feasible. This approach stresses flexibility and open-endedness in developing and debating issues, greater community initiative in setting the policy-making agenda, and consensual decision making.

Efforts to reform the practices and procedures obstructing participation must also respect the broader constraints on decision making. Government is constrained by the public’s demand for strong leadership, by its accountability to the electorate, by jurisdictional limits, and by the limited time and resources it can reasonably devote to its decision-making processes.

CONCLUSION
Research has shown that a sense of efficacy -- the ability to effect changes in one’s circumstances and determine one’s own fate -- is crucial to well-being and to health. By being able to shape a project’s agenda and influence its decisions, community members come to feel that they can successfully negotiate the forces which shape their lives.

The Equity and Access Committee hopes that Phase One of "Pursuing Equity," through the challenges it poses, will provide the impetus for further discussion and action. For Phase Two, the committee will aim to develop guidelines for the consultation process that will ensure equitable representation of the community in the decision-making process.

PREMIER’S COUNCIL MEMBERS:
The Hon. Monique Begin
Ms. Mary Cornish
Ms. Carol McGregor
Dr. Joseph Wong
Ms. Mila Wong

EXTERNAL MEMBERS:
Mr. William Butler
Dr. James Chacko
Mr. Peter Deane
Mr. John DeMarco
Ms. Maria Herrera
Ms. Julie Jai
Mr. Gerry McIntaggart
Dr. Raymond Pong
Ms. Felicity Somerset
Dr. Tyrone Turner

For more information on the Equity and Access Committee of the Premier’s Council on Health, Well-being and Social Justice, write to: 1 Dundas St. W., 25th Fl., Toronto, ON M7A 1Y7; tel.: (416) 326-6754; fax: (416) 326-6769.