The Medical Officer of Health and the First Nations and Inuit Health Branch Transfer Initiative
This document was prepared by C. Mustard, 1996, and revised by
D. Shedden with advice from Regional Communicable Disease Officers
and other First Nations and Inuit Health Branch (FNIHB) medical officers.
January, 1997 / Ref.: cmmoh.3
Under the First Nations and Inuit Health Branch (FNIHB) Transfer
initiative and other activities undertaken to facilitate the transfer
of control of First Nations health services to First Nations, communities
are able to assume control of "community-based" health
services. In order to ensure that programs are in place for health
protection, the following programs have been designated "mandatory":
- Communicable Disease Control;
- Environmental Health; and
- Emergency Response.
Special arrangements are also required in many communities to
ensure that there is access to treatment services. This is particularly
so in communities where nurses practise in an expanded role (i.e.
providing limited treatment).
For the purposes of the environmental health, communicable disease
control and emergency response programs, each community must ensure
that services are available from an environmental health officer
(EHO) and a medical officer of health (MOH). This pertains particularly
to the above listed public health programs and does not address
issues related to so called "professional supervision" of
nurses practising in an expanded role, issues related to access
to treatment services provided by physicians nor to the role of
physicians in the Non-insured Health Benefits program [Where a
physician maintains clinical knowledge and skills, the supervision
of the clinical practice of nurses working in an expanded role
- that is, as "nurse practitioners" - may be undertaken.
Such arrangements would have to be made on an individual basis].
Medical officers of health play key roles in the administration
of provincial Public Health Acts, in which their responsibilities
are usually elaborated in detail.
Role of the Medical Officer of Health
In Canada, all communities are under the jurisdiction of an MOH.
The roles of medical officers of health vary from jurisdiction
to jurisdiction but always include responsibilities related to
public health and safety. Authority to enforce provincial legislation
must be given to physicians by the relevant provincial Ministers
of Health.
The functions of the MOH generally include the following:
- responsibility for communicable disease control;
- working with
other stakeholders to assess environmental health concerns
and to intervene as necessary;
- providing leadership in emergency
situations where there is a potentially negative impact on
public health;
- overseeing health surveillance activities;
- undertaking in-depth
epidemiological studies where necessary;
- acting as consultant
on health promotion and disease prevention;
- developing, recommending
and implementing public policies in support of improved health;
- managing programs, including planning, implementation and
evaluation;
- education of other health care providers.
Mandatory Roles under FNIHB Transfer Initiative
The complete role and responsibilities of an MOH working with
a transferred community will vary from one place to another depending
on legislation and prevailing standards and practices. Many of
the functions outlined above may be included upon mutual agreement
between the physician and the community representatives. However,
the community must allocate the appropriate resources and ensure
that the MOH is willing and able to provide the following services
related to public health and safety:
1. Immunization
1.1 Schedule
- formulating routine immunization schedules for children and
adults;
- making decisions pertaining to the use of vaccines in exceptional
circumstances (e.g. outbreaks or epidemics);
- where legislated immunization requirements are in place for
school entry and day care entry, providing advice to staff on
the adequacy of the immunization status of children;
- recommending immunization schedules for workers in various
community occupational settings;
- recommending immunization schedules for individuals with other
special concerns (e.g. immuno-compromised patients, travellers
etc.).
1.2 Supervision of Program Delivery
The MOH will ensure that appropriate guidelines are in place for
the following:
- vaccine acquisition, transport, storage and handling;
- the acquisition of informed consent;
- pre-immunization counselling;
- immunization procedures;
- record keeping;
- emergency procedures (in the event of adverse reactions to
vaccine administration).
- The MOH may also ensure that processes are in place for education
and certification of nurses and for quality assurance. In Quebec,
immunization is a delegated medical act. In that instance, the
MOH may be required to formally delegate the function. In most
jurisdictions, however, these matters are the responsibility
of public health nursing. In some places, immunization is recognised
as an advanced nursing skill requiring the demonstration of competence
by nurses before thay can undertake immunization procedures.
1.3 Surveillance
The MOH will:
- ensure that record keeping allows for regular reviews of immunization
coverage. Community coverage will be reviewed at least annually
with appropriate action as needed;
- be notified in a timely fashion of all significant adverse
events. The MOH will ensure that these are followed up as necessary,
including the linkage of information to the provincial/territorial
and national surveillance systems.
2. Communicable Disease Control (other than immunization)
2.1 Surveillance
The MOH will:
- ensure that procedures are in place for the timely reporting
of all reportable diseases and outbreaks;
- review communicable disease reports in a timely, on-going fashion
and on a quarterly basis;
- annually write a communicable disease summary for submission
to the health agency and to FNIHB;
- promptly notify FNIHB of any communicable disease outbreaks
where an emergency response may be required.
2.2 Laboratory
The MOH will:
- make recommendations on appropriate laboratory specimens to
be submitted for diagnosis and follow-up of communicable diseases;
- ensure that appropriate procedures are in place for collection,
storage and handling of samples used in the diagnosis of communicable
diseases;
- provide advice on the interpretation of laboratory reports.
Advice on diagnosis and treatment will normally be given to local
family physicians and to nurses providing limited treatment services.
2.3 Screening
The MOH will make recommendations on screening for communicable
diseases, including:
- screening for
STDs (Sexually Transmitted Disease);
- screening in occupational health settings (e.g. for tuberculosis);
- screening in schools, day care centres,
National Native Alcohol and Drug Abuse Program (NNADAP)
treatment centres
etc.;
- screening for tuberculosis. (This will be done in consultation
with provincial TB Directors where the latter are on contract
to provide TB services).
2.4 Case finding / Diagnosis
The MOH will:
- provide advice on case finding activities;
- provide advice on the diagnosis of communicable diseases;
- propose case definitions for surveillance purposes;
- encourage the use of appropriate diagnostic procedures related
to the case definitions.
2.5 Case Management / Follow-up
For patients with a reportable disease, the MOH will advise on
the following matters and make certain that procedures are in place
to ensure that:
- appropriate treatment has been instituted;
- patient education / counselling has taken place;
- an appropriate interview has taken place to determine the source
of infection;
- where appropriate, an interview has taken place to identify
and undertake preventive therapy and/or testing of possible contacts;
- where necessary, mechanisms are in place to ensure that therapy
is completed.
The MOH will ensure that appropriate action is taken in situations
where a person with a communicable disease may, by his/her actions,
be placing others at risk.
2.6 Contact Tracing
The MOH will make recommendations on the identification, counselling,
testing and follow-up of contacts of patients with communicable
diseases. The MOH will ensure that community health nurses are
trained in the appropriate procedures before undertaking contact
tracing.
2.7 Source of Infection
Where indicated, the MOH will ensure that appropriate follow-up
has been undertaken to reduce the risk of communicable disease
in the future. This will involve extensive liaison with EHOs, community
health representatives (CHRs), community health nurses, physicians
and others.
2.8 Outbreak management
The MOH will assume the lead in outbreak situations. The role
will include the following:
- determining when an outbreak has occurred;
- undertaking appropriate investigation of the outbreak;
- ensuring that all key stakeholders are involved and kept aware
of developments;
- taking appropriate measures to control outbreaks.
3. Environmental Health
The MOH will work with other personnel - particularly EHOs - to
give assistance by:
- providing advice on the possible health effects of environmental
factors;
- investigating health concerns to determine potential associations
with environmental factors.
4. Public Health Legislation
All public health legislation (and a variety of related legislation)
includes provisions related to communicable disease control and
environmental health. Medical officers of health designated by
the legislation have specific duties and authority related to these.
In some jurisdictions this authority may be delegated to an MOH
employed by a community. In others, the community-employed MOH
will have to collaborate closely with the provincially-authorised
MOH in certain situations if the law is to be applied.
5. Emergency Response
The community's emergency response plan must be reviewed and approved
by the MOH. The MOH will play a key role in the following situations:
- emergencies involving communicable diseases or having the potential
for giving rise to outbreaks;
- environmental situations where there is an imminent risk to
health;
- situations involving the rapid relocation of residents of communities.
Availability
A qualified medical officer of health should be available by phone
at all times and should be able to visit the community if urgent
situations arise. Since many communities will be hiring medical
officers of health on a part-time basis, the following points may
be considered:
- payment of a retainer fee to ensure availability;
- possession of cellular phones;
- on-call arrangements with:
- other medical officers of health
working with First Nations communities;
- provincial / municipal
medical officers of health;
- FNIHB medical officers.
Professional Requirements - description of training
The medical officer of health must satisfy the following professional
requirements:
- A degree in medicine recognised by the provincial medical
licensing body;
AND
- a licence to practise medicine in the province
in which the community is located. This is the case for medical
officers employed or retained by or under contract to First Nations.
[If employed by FNIHB, however, licensure in any province or
territory is sufficient provided that the work is restricted
to the federal jurisdiction];
AND
- liability protection;
AND
- either: a) a fellowship of the Royal College
of Physicians of Canada in community medicine - FRCP(C); OR b)
a recognised masters degree in public health; OR c)
10 years experience which was primarily in public health; OR d)
a formal arrangement for supervision by a physician who fulfills
criteria a), b) or c);
AND
- a demonstrated, basic understanding of public
health principles.
Most family physicians do not have the specialised training to
enable them to undertake the responsibilities of an MOH. Special
arrangements for supervision would have to be made if this were
the only available option.
Cost
The daily fee for a qualified MOH is in the range $450 - $750
(1996). Annual salaries, with benefits, vary from $90 000 to $130
000 (again, 1996). Retainer fees should depend on responsibilities.
Operating costs (accomodation, telephone, travel, liability protection,
membership fees, continuing education etc.) must also be taken
into account.
Options
Regional Transfer Officers can identify the level of resources
available for transfer. This is usually a per capita proportion
of the zone or regional resources devoted to the medical officer.
Most communities will not have the funds available nor the need
to employ a full-time MOH. Communities must be able to demonstrate,
however, that the services which are provided by medical officers
of health are available to the community.
The following options may be considered:
- Employment of a full-time MOH. This is likely to be possible
only by health agencies of tribal councils or other large groupings
of communities.
- Pooling of resources with other communities to hire or contract
with an MOH on a full- or part-time basis.
- Daily fee or part-time employment with arrangements made for
full-time coverage or continuous availability.
- Contract with a provincial/municipal MOH.
- Continued use of FNIHB medical officers (funds not transferred).
- Purchase of MOH services from FNIHB. In this case, funds are
transferred to the community which then purchases services based
on a memorandum of understanding.
- Contract with a university Community Medicine Department.
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