How a social determinants of health lens can improve outcomes and system efficiency

As health systems struggle with capacity constraints, budgetary pressures and the need to navigate complex transformation, they face a critical need to change the way they operate. To do that, organizations will need to embrace a much more coordinated approach that better recognizes the needs of the patient. This means doing more to take the social determinants of health into account.

The social determinants of health cover a range of factors that influence the health status of individuals or populations. They’re important at every stage of a person’s life and reflect the fact that an individual’s health is primarily determined not by health care but through the many complex interactions between social and economic factors, the physical environment and a person’s behaviour.

The social determinants of health typically focus on a person’s income and social status, access to social support networks, level of education and literacy, employment and working conditions and social and physical environments. They’re also embodied in the personal health behaviours and coping skills, such as resilience, that have become so critical to well-being. Although biology and genetic endowment have an important role to play, they’re not the primary drivers of health outcomes and certainly don’t exist in isolation from all of the other factors.

What does this mean for health-care systems and organizations?

We believe addressing the issues must begin with a better understanding of individuals, their context, their health needs and the best way to engage them. Our recent work in Toronto found that geographic areas with the highest health costs tended to have populations that are older and include a larger proportion of new immigrants. They also have have higher rates of unemployment and lower education and income levels.

Hot spots and socioeconomic risk factors for higher health costs in the Toronto Area

A deeper look at the data showed that this was particularly true for some of the most damaging health issues. When we took a closer look at areas with high rates of chronic opioid use, the analysis showed they tended to have higher proportions of new immigrants, large family sizes and lower education, employment and income levels.

Note: Darker shading represents high health costs.


Effect of socioeconomic risk factors for chronic opioid users in Canada

These insights raise the question: What are we doing to cater for these individuals’ specific needs? Actions to take include:

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1. Personalize the social determinants

Personalization is changing all industries, as the relationship between organizations and their customers shifts to become much more segmented, transparent and omni-channel in nature. Health care is no exception. Although we often hear about personalized medicine, there’s less discussion about personalizing the social determinants of health and applying those specific issues to how patients and their families access and receive care.

Achieving a sustainable impact requires organizations to ask how well they’re serving people with low to middle incomes, new immigrants and those who live with aging parents, have low digital literacy or reside in areas with poor transportation options. Some home-care providers, for example, are broadening their approach to include more culturally sensitive services, transportation, home repairs, cleaning, home safety inspections and the use of virtual tools. Other forward-thinking organizations are offering multilingual access to digital tools and making them available on multiple channels.

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2. Reduce barriers by nudging patients to manage their own health

We often hear about the need to focus on patients. But patient centricity is impossible without a comprehensive approach that is guided by the social determinants of health. For example, education and access to information, often digitally, can help activate or nudge patients and support the greatest resource available in health care: patients taking a direct and active role in their own health management.

As noted, there’s a clear link between the various social determinants and health outcomes. While literacy more broadly often comes up in these discussions, there’s less focus on technology literacy in particular. We believe, given the opportunity digital health interventions could create in unlocking better access to health care, digital literacy could also play a major role.

What does addressing digital literacy look like? In some cases, health technology companies are developing more accessible software and mobile applications that patients are able to use regardless of age, language, culture, gender, or literacy level. In other cases, social media companies are emphasizing inclusive, multilingual access and giving cultural organizations opportunities to shape their own experiences online via chat groups, forums and other online communities.

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3. Make use of technology and data to identify health risks earlier

Understanding patients' social determinants can provide insight into everything from how to better nudge people and improve prevention to determining which products and services they need most and designing them with people’s personal situations and what they’re most likely to respond to in mind.

While many organizations aren’t gathering contextual and behavioural information to the extent that they could, they can start to gather more data through low-cost digital platforms. One type of data that’s heralded as a transformative opportunity for health care is patient-reported outcomes, where patients self-report through frequent, low-effort surveys they can be encouraged to participate in through loyalty points or access to personalized insights.

User-driven digital tools like wearable devices, smartphones and apps are also creating an opportunity to better engage with consumers and understand what they want and need. 

If you know your customer, you can understand what they’re at most at risk of. Data lets us see a problem in advance and act upon it in the best way possible. Using big data and analytics, we can also understand disease and its progression, spot those most at risk and direct our investments accordingly.

Our recent analysis looked at areas under the most stress (i.e. those where there’s a projected imbalance between supply and demand for health services). We also looked at which regions people would find the most or least attractive by incorporating walkability scores, amenities and broader access to transportation, health and wellness services. We found that the most stressed areas were less attractive to consumers and more likely to be neglected even though they would need more attention as a result of a more challenging socioeconomic environment.

These types of insights could better inform service planning and other improvements. For example, organizations can conduct audits of building accessibility to pinpoint areas with patients at highest risk of poor mobility or work to improve access, transportation or language supports.

Health stress versus consumer attractiveness: A comparison of Milton and Georgetown, Ontario

Source: PwC health-care-focused, location-based analytics.

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4. Improve cross-sector coordination

There has been a lot of discussion about the need for more integration of services. We would go further and suggest nothing less than a whole-of-government approach is sufficient.

To address the social determinants of health, governments need to take a holistic view of services such as housing, transportation, community safety, education and health and put in place mechanisms for smoother transitions, integrated demand planning and standardized performance measurement. Governments must also actively partner with private sector organizations that are focused on serving these needs.

In parts of Canada and the United States, these efforts are already underway. For example, the US Medicaid program has begun to build solutions that go beyond the physical hospital to invest in helping with food, housing and specific amenities like air conditioning if a patient’s situation requires it.

Cross-industry collaboration and information sharing can help to better coordinate initiatives across government agencies and beyond. The various departments, which are aware that they’re seeing the same high users of services, would agree that only an integrated approach among them will help to reduce costs.

Our recent Global top health industry issues report showed that investing in patients and their communities through non-health technologies and supports can help keep health costs low. Given that clinical care determines just 20% of an average person’s health, lower-cost technologies could help address the remaining 80%, which includes health behaviours, the physical environment and social and economic factors.

A good example of an area that requires supports that go beyond traditional health services is mental health. According to our research, there’s a significant disparity in spending by Canadian provinces on mental-health and addiction services. One way to improve the outcomes from government spending on mental health is to increase the number of navigators working with the various service providers. This will mean improved local coordination across health, justice, education, social and other community-based services.

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5. Focus on small changes to encourage meaningful health improvements

New methods of payment that focus on outcomes can support an integrated approach that brings multiple parties together with a shared incentive to deliver quality services. While multi-party governance, data systems, new models of care and value-based reimbursement arrangements can significantly improve system efficiency, they’re challenging to implement.

But some of the changes that would be possible in an outcome-based model can be implemented now. They include aligned incentives through which providers would take small actions, such as calling patients with medication adherence reminders and offering transportation to and following up after medical appointments. Some may offer enhanced home-based nursing services that can speed up discharge and reduce costly readmissions. Understanding that each patient has his or her own particular context and social determinants to deal with is a great place to start on implementing these types of changes.

The health-care industry has a significant opportunity to improve care and increase sustainability by pinpointing areas to invest in or redirecting resources to address the social determinants of health. These determinants hold the secrets behind some of the best product and service ideas. They’re what will ultimately change behaviours, improve care, reduce costs and enhance people’s lives.

Health systems will eventually need to move to outcome-based models of care, but until that happens, we can look to them to guide our understanding of the consumer, better plan our response to health issues and improve how governments and product and service organizations work together to deliver care.

Contact us

Tara McCarville

Partner, National Health Industries Leader, PwC Canada

Tel: +1 416 869 2493

Kai Lakhdar

Partner, Strategy&, PwC Canada

Tel: +1 416 687 8705

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