CIHR - Institute of Population and Public Health
John Frank - Scientific Director
Erica Di Ruggiero - Assistant Director
Brent Moloughney - Project Consultant
Project Advisory Group:
The Ad Hoc Committee on the Future of Public Health in Canada
This document would not have been possible without the direction and input from the project's ad hoc committee. It should be noted that no attempt was made to achieve consensus from all Committee members on all of the content and recommendations of this document. The project sponsors take full responsibility for its content.
The key informants from other countries were an invaluable source of information to better understand the current state of public health system development elsewhere in the world. No particular observation regarding other countries' systems should, however, be attributed to the key informants.
A draft version of this document was circulated to attendees at a national Think-Tank on the future of the public health system in Canada that was sponsored by the CIHR Institute of Population and Public Health. The discussions at the Think-Tank, held on May 10th, 2003 in Calgary, as well as the specific suggestions made by participants, to improve this document were extremely valuable.
Public health measures have been responsible for many of the major improvements in the health of Canadians. Today, Canadians are healthier and live longer than they ever have previously. In the past several decades, the risks to health have been changing. The leading causes of death for all ages are now chronic diseases and injuries. Today's public health challenges include epidemic numbers of obese adults and children, continued high smoking rates, and increasing rates of asthma in children. The threat of infectious diseases has not disappeared, with old foes re-emerging (e.g. syphilis, community water-borne disease outbreaks) and new ones appearing (West Nile, SARS, bioterrorism).
There has been increasing concern regarding the state of Canada's public health system. High profile inquiries have addressed specific events (e.g. Walkerton outbreak) or topics (e.g. Krever Commission). However, current concerns are of a much broader nature. In response, an ad hoc committee of public health leaders from across the country has come together to bring attention to the state of Canada's public health system and how it can be better structured and resourced to improve the health of Canadians. This paper presents a brief synthesis of pertinent issues with suggested actions for the future.
Public health is the science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society. The public health system's programs, services, and institutions emphasize the prevention of disease, the promotion of health, and the health needs of the population as a whole. The public health and health care systems share the same goal of maximizing the health of Canadians, and it is just as critical to have a well functioning public health system, as it is to have a strengthened health care system. Furthermore, both systems much work well together in responding to threats to the public's health.
The public health system provides and supports a wide range of program and policy interventions including: the development of health status reports; disease surveillance and responses to outbreaks; health promotion to advocate for and facilitate healthier public policies, improve skills, and support individual and community-level behaviour change; immunization programs; and inspection of restaurants and child care facilities. The essential functions of the Canadian public health system have never been officially defined although a national working group has recommended the following list:
The public health "system" in Canada might be better described as a grouping of multiple systems with varying roles, strengths and linkages. Each province has its own public health legislation although the age and content of these vary considerably. Most legislation focuses on the control of communicable diseases, although most preventable disability and death is now due to chronic diseases and injuries. Quebec has the most recently updated legislation and it provides a comprehensive approach to public health addressing all of its essential functions. Federal legislation is limited to the Quarantine Act, (which dates predominantly back to 1872), and a variety of health protection-related Acts. Overall, the legislation does not identify the federal government's mandate, roles, and responsibilities in public health.
It is unclear how much money is actually spent on public health in Canada. CIHI estimates are confounded by the inclusion of substantial administrative costs of provincial health Ministries. Ontario budget data suggests that about 2.3% of the provincial health budget is spent on public health. In all provinces/territories but Ontario, public health services are funded by the province/territory. In Ontario, public health services are cost-shared on a 50:50 basis with municipalities.
In most provinces and territories, public health is delivered through regional health authorities or the provincial/territorial government. The primary public health entity within Health Canada is the Population and Public Health Branch (PPHB). The Branch is primarily responsible for policies, programs and systems relating to prevention, health promotion, disease surveillance, community action and disease control. Health Canada's health protection responsibilities are located in two other branches and one agency.
There is little information available on the functioning of Canada's public health system. Since there is no accepted list of expected system functions, it is difficult to assess the extent that these are being fulfilled. As an initial step, a working group of the Advisory Committee on Population Health assessed the capacity of the Canadian public health system in 2001 through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed upon it. Significant disparities were observed between "have" and "have not" provinces and regions in their capacity to address public health problems. This is particularly important since these provinces often have the highest rates of unhealthy behaviours and chronic diseases. The capacity report's findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada.
The pervasive concern regarding Canada's public health system prompted a review of alternative international models for organizing and funding essential public health programs and services that Canada might want to consider in restructuring its national, provincial/territorial, regional and locally-based public health programs and services. Background documents and key informant interviews were conducted for the following countries: England, Australia, New Zealand, and the United States. The development of the provincial public health system in Quebec was also reviewed.
Concern for public health systems was present in all of the jurisdictions reviewed. The impact of health system restructuring, chronic system underfunding and inattention, a shift in focus from communicable to chronic diseases, as well as the need to address emerging threats such as bioterrorism, had prompted countries to take steps to improve their public health system's infrastructure.
Countries have taken action to define the essential or core functions of the public health system and developed mechanisms to assess their implementation. National level leadership has been critical to articulate the key issues and challenges facing public health and implement comprehensive strategies to address the deficiencies in the system's infrastructure. In all of the countries reviewed, the federal government funds a substantial portion of the public health system infrastructure. A major challenge for public health is arguing for spending now to prevent something in the future. A major economic report from England however, highlighted the potential cost savings to the health care system if adequate investments were made in prevention and health promotion. Nevertheless, the aim of prevention is to spare people from avoidable misery and death, not always to save money on the health care system.
Public health is focused on the health of populations. To do so effectively requires a critical mass of technically expert staff. This has implications for the size of the population base of public health agencies. Achieving the critical mass of expertise to address the breadth of public health issues has prompted the development of central resources to support the fulfillment of essential public health functions. These agencies also play a significant role in system infrastructure development including targeting increased skills for the public health workforce, improving information management, and addressing research and development. A strong governmental public health system is an essential, but insufficient factor to address population health issues. Inter-sectoral partnerships have been important in the development of strategies to improve the public health system in other countries. A major challenge has been the lack of interest in decision-makers to address public health system infrastructure unless faced with a specific health issue or crisis. The challenge for public health leaders is to successfully acquire funding for new/improved issue-related programming while simultaneously attempting to build the necessary infrastructure to support programs.
Based on the collective experience of Committee members, the results of the previous Canadian key informant survey of public health capacity, and the findings from the review of other countries' efforts to improve their public health systems, the following key infrastructure elements of a national public health system need to be achieved:
With sufficient leadership, commitment and resources, Canadians across this country can have a well-functioning public health system. Different parts of the country have developed particular strengths in their public health system, and the system evolution that must occur can build upon these existing strengths. In many ways, Quebec has the most comprehensively developed provincial public health system in the country. While there are many positive attributes of the Quebec system, it is not realistic to expect that all of these could be replicated in a substantial number of provinces and territories. Other mechanisms of system development need to be explored. The changes that need to occur across the country are substantial and will not occur without a dedicated process to achieve the vision outlined above. While there are many potential places one could start, for discussion purposes, some immediate potential action steps include:
There are a variety of options on how these actions could be pursued. Some items may work best with a specific level of government taking the lead, while others could work with a variety of approaches (e.g. national public health partnership, lead governmental or non-governmental agency, etc.). The Committee felt that it was not appropriate to specify implementation processes or action plans, prior to achieving consensus of what needs to be accomplished.
The public health system exists to safeguard and improve the health of Canadians. Great progress has been made in the past century, but many challenges remain. The dawn of a new century is an opportune time to strategically and explicitly build the infrastructure for a strong public health system that will adequately serve all Canadians.
