We can’t just build a more equitable system.

Healthcare in Canada has a healthy history of mobilizing funds for pilot projects with an aim to find new and implementable improvements to service. The aim is collectively shared and has best intentions from policy makers to service providers to researchers and leaders alike.

My leadership experiences have made it clear that while everyone is working towards the best outcomes for clients something in the way Canada is approaching system transformation isn't working for the most systemically marginalized clients and their families.

So I’ve been thinking: Why is the system not having the collective impact we've hoped for?

There are two factors that I think are critical to highlight here that impede our best implementation intentions.

1. We design solutions and/or service improvements based on dated research (we know that 17 year knowledge to practice gap still exists) that highlights the needs of the traditional research participants. This demographic is rarely representative of those made most marginalized by systemic injustices. Therefore we implement models and programs that serve the same groups (those that are already the most supported) and try to adapt these for equity seeking groups. There is no equity in adaptation. We must develop equity-first approaches to research, model conceptualisation, implementation and evaluation. What does this mean to folks and do we have any collective wisdom to share about this?

2. We struggle with de-implementing. We will never have the space for equitable service improvements to flourish when we are only adding on new programs and services without removing, decommissioning and (in some cases) demolishing those that do not work. Now arguably, this is a significant change management process with the challenge of not having something shiny and new to highlight upon completion; which is part of the rationale for not investing funding dollars into de-implementation. However, our less effective and sometimes harmful models and services are a major barrier to enhancing equity in our system.

With these two points at the forefront of my mind as a system leader who works in the area of evidence and implementation I’m curious as to what others think about this topic. How can we shift the collective approach in our country to value de-implementation as a driving force for equity? And when we implement, how do we ensure we have an equity-first approach from the outset?