THE ROLE AND ORGANIZATION OF PUBLIC HEALTH

Chapter 3

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The preceding chapter set out a brief chronology of theSARS outbreak as it affected Canada. The SARS experienceillustrated a variety of issues, some to do with the healthservices system, but many others to do with public healthand the interface between public health and clinical care.Except in cases of sudden threats to the health of commu-nities such as Walkerton, North Battleford, or SARS,public health operates in the background and is oftentaken for granted. Many Canadians—including healthcare professionals and administrators—accordingly haveonly a limited understanding of what public health is andhow it is organized in Canada. This chapter provides anoverview of the evolution of public health, its organizationand funding in Canada, selected comparisons with otherindustrialized nations, and some preliminary thoughtson domestic directions for change.

3A. What is Public Health?3A.1 The Origins of Public HealthMore than two thousand years ago, the authors of Greekmythology had already drawn a distinction betweencurative medicine and prevention or health promotion.Asklepios, the Greek god of medicine, was reputed tohave had two daughters, Hygiea—the goddess of preventionand wellness, and Panacea, the goddess of treatment.Other distant origins of public health surface in Greco-Roman writings associating different diseases with possiblecauses, together with prescriptions for their avoidance.

Canadians today sometimes confuse public health withpublicly-funded health care. However, until the latenineteenth and twentieth centuries, personal health carewas left for individuals to arrange. Threats to collectivehealth, in contrast, have been taken up as a matter forcommunity control or regulation wherever mechanismsof governance emerged. In Biblical times, for example,communities isolated those with leprosy as potential

sources of contagion. Urbanization in medieval Europelent momentum to concerns about sanitation and disease.The first English Sanitary Act was passed in 1388, dealingwith offal, slaughterhouses, and “corrupting of the air”.Around 1348, the Republic of Venice appointed threeguardians of public health to detect and exclude shipswith passengers affected by pneumonic plague (BlackDeath). In Marseilles (1377) and Venice (1403), travellersfrom plague-infected areas were detained for 40 days toprotect against transmission of infection; this is theorigin of the modern term Quarantine.

From the outset, public health practice has depended onhealth information, and information in turn presupposesthe existence of surveillance systems and organized data.One such source of data was the "bills of mortality"established in London, England in 1532. More than acentury after this system of death records was initiated,John Graunt published his Natural and Political Observationsmade upon the Bills of Mortality (1662), examining deathsin London by age, sex, district and social class. By 1766,the Austrian physician Johan Peter Frank had advocateda comprehensive system of health surveillance as part ofhis proposed “medical police”. In 1790, Dr. Frank arguedthat curative and preventive measures had little impacton populations where people lived in abject poverty andsqualor. This heralded a tradition of concern for livingconditions and social justice that continues today in thepublic health ethos.

In 1842, England’s Edwin Chadwick similarly describedurban squalor, lack of sanitation, and over-crowding; andhe related these to the incidence of disease and death, aswell as contrasting life expectancy in different socialclasses. His work heralded the beginning of the sanitarymovement in Britain. The motives behind the sanitarymovement were mixed as were the arguments for it bypublic health proponents. Some claimed that a moreegalitarian society would be healthier and fairer. Others

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pointed out the need for healthy labouring classes andsoldiers, and the threat of both social instability andcontagion spreading from the teeming industrial slums ofEurope. By 1850, Lemuel Shattuck’s “Report of theMassachusetts Sanitary Commission” also related livingconditions to infant and maternal mortality and morbidityrates. As the sanitary movement spread, communitiesimplemented proper disposal of waste, urban sewagesystems, and supplies of pure water for all, with a dramaticimprovement in population health.

The tool-kit of public health practice still had fewindividual-level interventions apart from measures suchas vaccination against smallpox. Nonetheless, the scienceand information supporting public health was improvingsteadily. In England William Farr started to develop theGeneral Registry Office in 1836, building on the introduc-tion of a national census in 1801 by classifying causes ofdeath. Formal medical certification of death and universaldeath registration commenced in England and Wales ayear later. John Snow—the “father of epidemiology”—published his On the Mode of Communication of Cholera in1849, famously removing the handle of the contaminatedBroad Street pump from whence cholera was spreading.Snow’s action was a landmark in public health interven-tion to contain a disease outbreak. A critical step forwardoccurred in 1856 when Louis Pasteur published hisobservations on the germ theory, allowing microbiologyto advance rapidly. In 1867, Koch published his famouspostulates for establishing a causal connection between aspecific microbe and a disease. Such connecting threadsin public health thinking have proven durable: onlyweeks before release of the present report, The Lancetpublished an article by Kuiken et al arguing that thenovel SARS-associated coronavirus satisfies a modernizedversion of Koch's postulates.1

In this country, Lower Canada established a Board ofHealth in 1832; Upper Canada followed suit a year later.Ontario passed the first provincial public health act inCanada in 1884, and other provinces soon passed similarlegislation. These acts provided for the establishment oflocal boards of health with the authority to remedyhazards to health and to appoint medical officers ofhealth. In these early years, boards often hired medicalofficers of health only when a disease outbreak struck,and dismissed them once the danger was over. Localboards of health were heavily involved in the mid-nineteenth century with quarantine and immunizationas well as combating a series of epidemics of smallpoxand cholera.

As medical science evolved, and local boards of healthprovided infrastructure for implementing inspection andregulation, local public health units in Canada took onother activities. These included pasteurization of milk,tuberculin testing of cows, oversight of isolation tocontain spread of tuberculosis [TB], management of TBsanatoria, quarantine for diverse conditions, and thecontrol of sexually transmitted diseases. The earlytwentieth century brought an increasing emphasis onmaternal and child health. Public health physicians andnurses took a leading role in developing immunizationclinics, well baby clinics, prenatal classes, postnatal visits,and education on parenting and childhood nutrition.

The activism of public health in individual- and family-level interventions was not without occasional territorialtensions. Some general practitioners voiced complaintsthat these salaried and subsidized personnel were takingaway their livelihoods and interfering with the developmentof family-based practices. The First World War none-theless saw a blush of enthusiasm for public health andthe integration of preventive medicine into clinical practice.In 1919, the Government of Canada brought togetherseveral pieces of legislation pertaining to food, drugs andcontrol of infectious diseases, and established a nationalDepartment of Health. This was the same year that theLiberal Party cautiously adopted national health insuranceas a plank in its platform, and the British ColumbiaSocial Welfare Commission began exploring the feasibilityof a state-sponsored health insurance scheme.2 But whileMedicare was several decades away, public healthmeasures were already well-established across Canada.

Following the Great War, mainstream medicine still hadfew specific remedies to palliate or cure disease. Surgicaltechniques were crude, and drugs limited to a handful ofcompounds such as digitalis for congestive heart failure,quinine for malaria, and arsenicals for syphilis. Insulinwould not appear on the clinical scene until 1923. Publichealth, meanwhile, was progressing steadily. Toxoidswere a key breakthrough in immunization strategies; atoxoid is a bacterial toxin treated to render it harmlessbut still capable of inducing immunity to the disease.On into the mid-1920s, diphtheria was the leading causeof death among children. The widespread use ofantitoxin had only a minor impact on the incidence ofthe disease. After the discovery of diphtheria toxoid, theConnaught Laboratories in Toronto produced toxoid on amassive scale and proved its effectiveness with massivefield trials of childhood immunization in Ontariostarting in 1926. The same period saw pertussis toxoidintroduced for case contacts and epidemics. Tetanustoxoid and a string of other triumphs for immunization

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and vaccination—most notably the introduction of aneffective vaccine for polio by Jonas Salk in 1956 and theeradication of smallpox—followed later.

Notwithstanding these triumphs, indeed perhaps in partbecause of them, public health was moving into a back-ground role. The growing effectiveness and technologicalsophistication of clinical medicine captured the publicimagination. After insulin came sulpha drugs andpenicillin, and then a massive armamentarium of anti-biotics, including treatments for tuberculosis. Surgicaland related techniques blossomed. Open heart surgery,dialysis, joint replacement, pacemakers, kidney trans-plantation—these and other innovations featured promi-nently in the mass media of the 1950s and 1960s. Theirmarginal yields at a population level were meaningfulbut relatively small. Increasing societal prosperity andenlightened social policy accompanying economicgrowth were great catalysts for overall improvements inlife expectancy. Across all industrialized nations, publichealth interventions also helped drive communicablediseases down the mortality lists through the middle andlatter parts of the twentieth century.

Public health, as we have already seen, was not solelyabout control of infectious diseases. Pioneers of publichealth in the eighteenth and nineteenth centuriesinvestigated the causes of, and advocated action against,nutritional (scurvy), occupational (cancer of the scrotum),and environmental (lead poisoning) diseases, and urgedmeasures to limit inequalities in health across educationand income levels. Public health practitioners remainedat the forefront throughout the twentieth century inchampioning legislative and regulatory initiatives toreduce the burden of premature and avoidable deathsand injuries along with preventable diseases.

Nonetheless, the shift in mortality and morbidity profilesaway from communicable diseases to chronic non-communicable diseases created challenges for publichealth practice. Coronary heart disease [CHD] is a usefulexample. The decline in incidence of CHD in Canada isunequivocal. The decline antedates introduction andwidespread adoption of effective agents for treatment ofdyslipidemias (e.g., high cholesterol), and the impact ofimprovements in physical activity profiles is uncertain.Some of the decline appears to be attributable to smokingcessation and adoption of healthier diets. To what canwe attribute changes in those risk factors? Familyphysicians and other clinicians are actively engaged incounselling against smoking, and provide pharmaceuticalsupports to facilitate smoking cessation, but public healthpolicy and education have also played a role throughtobacco taxes, anti-smoking advertising campaigns,

production of education materials, and product labelling.Various stakeholders from different levels of governmentsto the Heart and Stroke Foundation are active in encouragingsmoking cessation and promoting the adoption ofhealthier diets. Public health researchers unquestionablyhelped generate the epidemiologic evidence that linkedCHD to these risk factors. But even for a clear-cut casesuch as prevention of heart disease, the positive influenceof public health has been as much indirect as direct.Similar challenges arise in delineating the role of publichealth in areas such as injury prevention or, a fortiori,interventions to redress the profound and persistingvariations in health status across socioeconomic strata in Canadian society.

Not surprisingly, even within the public health community,debates occur between those with more or less expansiveviews of the mandate of public health. But there is littledisagreement on two points. First, existing levels—andallocations—of resources are suboptimal to permit thedeployment of many interventions that have the potentialto avoid premature death or disability. Second, publichealth has essential roles in areas such as health protection(food and water safety), disease surveillance, and outbreakmanagement, and these functions must be given priority.As we have seen with SARS, questions now exist as towhether the Canadian public health system is minimallyequipped and organized to deal with even a modest-sizedoutbreak of a new communicable disease.

In sum, for about a century and a half in Canada, therehas been an organized public health presence, often littlenoticed, but nevertheless contributing to a steadilyincreasing life expectancy and quality of life for Canadians.Various analyses of the improvements in health duringthe twentieth century have highlighted that modernclinical medicine is important, but broad social changesand public health measures deserve the lion’s share ofthe credit for the 25-year increase in life expectancyacross industrialized nations, including the dramaticreduction of infant mortality from 20% to less than 1%in most developed countries.3 Influential social andeconomic changes have included smaller families, higherstandards of living with better nutrition, and adequatehousing. However, public health has played a huge rolein securing safe food and water supplies, implementingpasteurization, and developing and delivering programsof vaccination and immunization. The re-emergence ofinfectious diseases, and the continued scope forprevention of the now dominant non-communicablediseases, both suggest that the yields of prudent newinvestments in public health may be substantial.

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3A.2 Defining Modern Public HealthPractice

Public health developed over the centuries as society’sresponse to threats to the collective health of its citizens,and has an enviable record of contributions topopulation health status. How do we define publichealth practice today?

Public health can be described as the science and art ofpromoting health, preventing disease, prolonging life andimproving quality of life through the organized efforts ofsociety.4 As such, public health combines sciences, skills,and beliefs directed to the maintenance and improvementof the health of all people through collective action. The programs, services, and institutions involved tend toemphasize two things: the prevention of disease, and thehealth needs of the population as a whole.5 This popu-lation focus distinguishes public health from the clinicalenterprise that is governed by the Hippocratic imperativewith its focus on the individual patient. Indeed, delineationof the boundaries of public health in this regard has beenmade explicit in Quebec’s 2001 Public Health Act, viz:“Public health actions must be directed at protecting,maintaining or enhancing the health status and well-being of the general population and shall not focus onindividuals except insofar as such actions are taken forthe benefit of the community as a whole or a group of individuals.”6

This collective approach means that, as even the briefhistory above has illustrated, public health has longincluded a regulatory function. Regulation is an effectivemeans of protecting the public from a variety of hazards,including carriers of infectious diseases, food, drugs,consumer products, pesticides, improper waste disposal,impure drinking water, recreational water, dangerousmotor vehicles, unsafe workplaces, second-hand smoke,and many others. In Canada, all levels of government—federal, provincial/territorial, and municipal—are involvedin the regulatory functions of public health.

The logic of a collective or population-based approach totraditional public health measures, such as communicabledisease control, is self-evident. But a population approachcan also be efficient in dealing with non-communicabledisease prevention. As Geoffrey Rose7 has argued, riskfactors for most diseases are typically distributed across acontinuum. A preventive strategy focusing on high-riskindividuals will deal with the margin of the problem, and has only a trivial impact on the large proportion ofdisease occurring in the majority of people who are atmoderate risk. For example, the number of cardiovascularevents arising in people with slightly raised blood pressure

or moderately abnormal blood lipids greatly exceeds thosearising in the clinically hypertensive or dyslipidemicminority. Population-based strategies that seek to shiftthe whole distribution of risk factors have the potentialto exert a much larger impact at a population level.

However, a preventive measure that brings large benefitsto the community may offer little to each participatingindividual—this is Rose’s ‘prevention paradox’.Changing health habits through individual interventioncan be difficult and inefficient; and the gradual adoptionof new norms (e.g., in diet and exercise) becomes thelogical way forward. At the same time, ethical concernsdictate that clinicians seek out and offer individualizedtreatment to the small minority of persons at greatlyelevated risk. The population approach of public healthand the individualized approach of clinical medicine arethus complementary: the opportunities for each willvary according to the disease and risk factor, and whatinterventions are available. Finding the right balance is important.

When the task of disease prevention and health promo-tion moves away from precisely identifiable risk factors,matters become even more complex. The health ofpopulations and individuals is obviously shaped by awide range of factors in the social, economic, natural,built, and political environments. These factors interactwith each other and with innate individual traits such asgenetics, sex, and age. As researchers have delineated thecomplex webs of causation that influence health-relatedbehaviours and health status, they have articulated apopulation health approach that highlights the need forinterventions such as regulation, education, communitydevelopment and social policy. The extent to whichparticular public health units or professionals embracethese tools varies, but the population health frameworkhas usefully integrated analytical perspectives in thepublic health field.

Public health practice relies heavily on intersectoralpartnerships. Public health professionals must be able towork with a range of disciplines, and form coalitions toadvocate for mitigation of health risks or implementhealth-enhancing changes in various environments. The voluntary sector is a key partner in public healthtoday. This includes non-governmental agencies (such ashealth charities and professional associations), localassociations of all kinds, community development groups,recreational associations, business groups, organizedlabour and other workplace collectivities, together withthe governmental structures which partly support andfund them. These groups may be overtly health-oriented, or may have primary interests in related areas

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such as child development and social welfare. In Canada,the voluntary sector partners with local health agencies,as well as federal and provincial/territorial [P/T] govern-ments in various programs. Joint activities include healthpromotion initiatives, and the provision of services,advocacy and community development. These partici-patory approaches are particularly important forAboriginal populations and other marginalized or hard-to-reach groups.

Over the past decade, many countries have tried todefine the essential functions of their public healthsystems. In Canada, no single accepted list exists,although a report of the national Advisory Committee onPopulation Health (ACPH) recently recommended thefollowing list of essential functions:

• Health Protection. This is a long-standing corefunction for all public health systems. The assuranceof safe food and water, the regulatory framework forcontrol of infectious diseases, and protection fromenvironmental threats are essential to the Public Healthmandate and form much of the body of current publichealth legislation worldwide. Included in this functionis the provision of expert advice to national regulatorsof food and drug safety.

• Health Surveillance allows for early recognition ofoutbreaks, disease trends, health factors, and cases ofillness which in turn allows for earlier interventionand lessened impact. Surveillance also assists in ourunderstanding of the impacts of efforts to improvehealth and reduce the impact of disease. For example,a new strain of Salmonella occurring in many parts ofthe country over a short period of time may indicatecontamination of a widely-distributed food product.

• Disease and Injury Prevention. More than a decadeago, the Centers for Disease Control and Preventionin the USA identified that as much as two-thirds ofpremature mortality was preventable through theapplication of available knowledge. Many illnessescan either be prevented or delayed and injuries can beavoided (e.g., bicycle helmet use). This category ofactivity also includes investigation, contact tracingand preventive measures targeted at reducing risks ofoutbreaks of infectious disease. It overlaps withhealth promotion, especially as regards educationalprograms targeting safer and healthier lifestyles.

• Population Health Assessment entails the ability tounderstand the health of populations, the factorswhich underlie good health and those which createhealth risks. These assessments lead to better servicesand policies.

• Health Promotion. Public health practitioners workwith individuals, agencies, and communities to under-stand and improve health through healthy publicpolicy, community-based interventions, and publicparticipation. Health promotion contributes to andshades into disease prevention (see below) by catalyzinghealthier and safer behaviours. Comprehensiveapproaches to health promotion may involve communitydevelopment or policy advocacy and action regardingthe environmental and socioeconomic determinantsof health and illness.*

The Canadian Institutes of Health Research’s [CIHR]Institute of Population and Public Health recently led agroup of opinion leaders through a process to considerthe future of Public Health, and identified some examplesfor each of these functions delineated in Table 1.

Last, public health also plays a key role in DisasterResponse. Many natural disasters not only place imme-diate demands on the health care system, but mayinvolve secondary threats to population health throughcontamination of food or water supplies or communicabledisease outbreaks.

3B. Governance and Organizationof Public Health in Canada

3B.1 Some Constitutional and Legislative Issues

Chapter 9 provides a more detailed treatment ofconstitutional and legislative issues. This introductoryoverview offers some general context.

Canada’s Constitution Act (formerly the British NorthAmerica Act of 1867) outlines the division of responsi-bilities between provinces and the federal government,and was created at a time when infectious disease andother public health concerns were everyday realities. The Act assigned responsibility for “quarantine and theestablishment of marine hospitals” to the federal govern-ment, and (s. 92) the “establishment, maintenance andmanagement of hospitals, asylums, and eleemosynaryinstitutions in and for the province, other than marinehospitals” to the provinces.

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* The more expansive aspects of health promotion occasionally draw criticism as forms of ‘health imperialism’ or ‘social engineering’.

Sections 92(13) and 92(16) of the Constitution giveprovinces responsibility, respectively, for property andcivil rights and for matters of a local or private nature.Both are relevant to the primary authority that provincialgovernments claim in Canada to pass legislationconcerning public health. Federal authority in publichealth derives from federal powers in diverse areas, suchas the criminal law, matters of national concern as regards“peace, order, and good government”, quarantine andnational borders, regulation of interprovincial trade andcommerce, and international treaty-making. Jurisdiction,in short, is mixed.

In Canada, there are federal legislative provisions for theregulation of food, drugs, and pesticides. The titles of theQuarantine Act and the Importation of Human PathogensRegulations of the Department of Health Act are self-explanatory, and these laws flow logically from theconstitutional division of powers. The Canada Health Actsets out the conditions for receipt of funding for physi-cian and hospital services, but does not cover publichealth. Indeed, only the Department of Health Act offers a

broader public health mandate, and, apart from theabove-noted regulations, its wording is more permissivethan prescriptive. It states that the Minister of Health isresponsible for “the promotion of the physical, mentaland social well-being of the people of Canada, theprotection of the people of Canada against risks to healthand the spreading of diseases, and the investigation andresearch into public health, including the monitoring of diseases.”

The uncertainty about federal powers in public health isunderscored by the state of disease surveillance. Whilethe Statistics Act and the Department of Health Act providethe Government of Canada with a mandate to collectinformation on public health risks of a pan-Canadiannature, Health Canada does not currently have a clearlegal mandate to require provinces/territories to sharehealth surveillance data with each other and the federalgovernment. As was evident in the SARS outbreak, thesetransfers occur voluntarily.8

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Essential Function Programming Examples

Population health • Population/community health needs assessment;Assessment • Health status report, system report card.

Health surveillance • Periodic health surveys;• Cancer and other disease registries;• Communicable disease reporting;• Ongoing analysis of data to identify trends or emerging problems,

(e.g., recognition of increasing syphilis cases);• Report to practitioners of increasing threat, what they need to look for, and intervention

required.

Health promotion • Intersectoral community partnerships to solve health problems;• Advocacy for healthy public policies;• Catalyzing the creation of physical and social environments to support health

(e.g., bike paths, promoting access to social networks for institutionalized seniors).

Disease and injury prevention • Immunizations;• Investigation and outbreak control;• Encouraging healthy behaviours (e.g., not smoking, healthy eating, physical activity,

bicycle helmet use);• Early detection of cancers (e.g., organized programs for breast cancer screening).

Health protection • Restaurant inspections;• Child care facility inspections;• Water treatment monitoring;• Air quality monitoring/enforcement.

T A B L E 1Examples of Programming for Essential Public Health Functions.

For the federal government to exert a stronger coordinatingand supporting role, one logical avenue is through the useof federal spending power. That is, the federal governmentcan involve itself in public health by providing condi-tional funding for public health programs or by enteringinto legal contracts to develop public health initiatives.The Population and Public Health Branch of HealthCanada currently exerts only a limited steering effectthrough its program of grants and contributions. Thesegrants and contributions are not directed to other levelsof government, but to non-profit and non-governmentalorganizations. They target areas such as children’shealth, Aboriginal peoples’ health, diabetes, HIV/AIDS,Hepatitis C, and tobacco control, among others. There isno legislative provision per se for Health Canada’s role inthese programs. Rather, they are established under thebroad rubric of the Minister of Health’s authorities in theDepartment of Health Act, and funded following Cabinetand Treasury Board decisions on policy and fundingrespectively.

Public health activities in each province and territory aregoverned by a public health act (or equivalent) and itsregulations, as well as by other specific legislation (e.g., Ontario’s Immunization of School Pupils Act). Somepublic health acts are decades old. Ontario (1983),Saskatchewan (1994), and Quebec (2002) all have modern-ized legislation, and British Columbia proposes tointroduce a new act soon. The older acts tend to bemainly concerned with infectious diseases and specific inthe powers given to public health officials, while thenewer acts are more flexible. All public health acts haveregulations; these vary from province to province. Theplanning and delivery of services is mostly devolved toregional/local structures, with responsibility usuallyassumed by elected and/or appointed boards.

Environmental health illustrates the potential jurisdictionalambiguities. The federal and P/T governments all havelegislation bearing on environmental health issues. P/Tenvironment ministries may operate water purificationfacilities and test water. Municipal governments maypass by-laws, provide many environmental services, andbe involved in enforcement. Local public health agenciesand/or P/T health ministries are responsible for advisingon human health impacts of environmental problems,for undertaking inspections and enforcement, and forinvestigations of environmental health hazards and healthevents thought to be environmentally caused. Publichealth laboratories undertake some testing, as also dovarious federal, provincial, university or contract labora-tories. Other departments of governments such as natural

resources, transportation and recreation are inevitablyinvolved. Lastly, emergency preparedness and responseauthorities, including P/T ministries of public security, willbe involved in responding to environmental disasters.

3B.2 Organization of Public HealthServices

The situation of primary responsibility for public healthservices at the municipal or local level is rooted in atradition that dates back to the time of Elizabeth I. InCanada, primary legislative authority seems to rest withthe provinces and territories, but local public healthremains the front line for battling outbreaks such asSARS. The following overview accordingly moves fromthe local to P/T to federal levels.

There are four patterns of governance of local publichealth services in Canada.

• Regional Health Authorities/Districts

This is the most common pattern, especially in theWest and increasingly in the Maritimes. Elected and/orappointed boards are responsible for the provision ofhealth services within a defined geographical area.The governance for public health is thus combinedwith that for other health services. The boards areeither elected by local residents, or appointed by theprovincial government, or a mixture of both. Thesystem is a product of the 1990s and still evolving: forexample, the number of regions and their boundarieschange frequently, there is sometimes tension betweenboards and provinces concerning powers, and therehas been a swing away from elected to appointedmembers. Despite the instability of these arrangements,they have the major advantage of promoting theintegration of clinical and public health services underunified governance that is locally responsive to somedegree. Regional structures, however, have not solvedthe problem of under-investment in public health.

• Regional/District Boards

In this case, the boards are responsible for publichealth and/or other community-based services withinan area, but do not have oversight of publicly-fundedpersonal health services. This is the pattern in parts ofNewfoundland, and until recently, in New Brunswick.

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• Quasi-municipal/County

This is the earliest pattern, and continues in Ontario.Local boards are responsible for public health andsome other community services. Boards serve eithersingle or multiple municipalities and counties, and areappointed by the involved municipalities and theprovince. In large cities, the public health board isusually a committee of city council.

• Provincial

In Prince Edward Island, services are delivered at theprovincial level.

Health Canada, through the First Nations and InuitHealth Branch [FNIHB], has a mandate from the federalparliament to provide certain public health services toFirst Nations communities on reserve. Communitieswith “transfer arrangements” with FNIHB have taken onresponsibility for some or most health services whichwould otherwise be delivered by the federal government,i.e., public health services may be delivered by thecommunities themselves. These arrangements aresupported through contribution funding provided by thefederal government.

Local service delivery across Canada is through the healthdepartments of regional health authorities or districts, or(in Ontario) through health units and municipal healthdepartments. The populations served by the relevant unitsrange from 600 to 2.4 million people, with catchment areasfrom 4 square kilometres to 800,000 square kilometres.There are approximately 139 such local/regional agenciesserving urban, rural and isolated areas, covering thepopulation of Canada, exclusive of some Aboriginalcommunities.

Each local/regional public health agency has a positionfor a medical officer of health [MOH] - a licensedphysician with post-graduate training in public health.Smaller health units find it difficult to attract medicalofficers of health or provide the full range of services. In Saskatchewan, partly for this reason, adjacent districtshave arranged to share either the medical officer ofhealth or the entire public health agency.

Each province or territory has a chief medical officer ofhealth [CMOH] or equivalent. The CMOH may also bethe director of the public health branch of the P/Tgovernment, or these may be separate positions. Thesenior public health physician sometimes also holds anAssistant Deputy Minister position. In Quebec, theAssistant Deputy Minister for public health by law is aphysician with a specialist qualification in communitymedicine. The reporting relationships of the CMOHwithin the P/T governments vary considerably, as provinceshave balanced a desire to ensure the independence of theCMOH as a health advocate with the need to integratehis or her portfolio into ministries of health.

Each province and territory also has public health staffwithin the provincial government. These staff typicallyengage in planning, administering budgets, advising onprograms, and providing assistance to local staff for seriousincidents. The British Columbia Centre for Disease Control[BC CDC] was established in 1997 to take responsibilityfor provincial-level management of infectious diseaseprevention and control, including laboratories. Divisiondirectors and other key scientific and medical staff in theBC CDC hold appointments at the University of BritishColumbia, and have protected time to enable academicactivities. A specific effort is made to ground practices inresearch evidence. The BC CDC’s budget flows throughthe provincial Health Services Authority.

Quebec established the National Public Health Institutein 1998 by transferring in staff from several regionalpublic health departments and the ministry; it overseesthe main public health laboratories and centres ofexpertise. Unlike the BC CDC, it has a general mandatethat covers prevention, community development andhealth promotion, healthy living, workplace health, andchronic disease as well as infectious diseases. The Instituteincludes the Quebec Toxicology Centre, the ScreeningExpertise Centre, and the Poison Control Centre.

Many provinces have taken steps to ensure that the localadministration of public health is not compromised byspecial interests and that provincial standards are upheld.These can be summarized as follows:

• Delivery of certain programs and services may berequired for the province to flow funds to the localhealth unit. There may be lists of core or mandatoryprograms, together with a monitoring mechanism, withor without accompanying regulations. Nevertheless,the level of service provision varies both between andwithin provinces/territories.

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• The chief medical officer of health may have thepower to intervene anywhere in the province in anemergency.

• Medical officers of health at the local level may beprovincial employees, reporting formally to the chiefmedical officer of health.

• Local boards of health may require the consent of theminister to hire and/or fire medical officers of health.

• The Minister of Health generally has the power todismiss local boards of health.

At the federal level, the most relevant organization vis-à-vis public health is the Population and Public HealthBranch [PPHB] of Health Canada. The Branch is head-quartered in Ottawa, and has regional offices acrossCanada. Its components include Centres for InfectiousDisease Prevention and Control, Chronic DiseasePrevention and Control, Emergency Preparedness andResponse, Surveillance Coordination, and Healthy HumanDevelopment. PPHB has oversight of the NationalMicrobiology Laboratory in Winnipeg and the Laboratoryfor Foodborne Zoonoses in Guelph. Other branches inHealth Canada, particularly the Health Products and FoodBranch and the Healthy Environments and ConsumerSafety Branch interact with local public health to a lesserextent. Federal agencies such as the Canadian FoodInspection Agency [CFIA] also have a role in public health.

In sum, the provincial/territorial presence predominatesin public health, with most of the delivery of servicesoccurring locally or regionally. The local/regional agencieshave their own governance, but their activities areconstrained by P/T law, regulations, policies, directivesand conditions of funding. Various federal/provincial/territorial committees provide some elements of nationalcoordination. These include the Advisory Committee onPopulation Health and Health Security reporting to theConference of Deputy Ministers of Health, the Council ofChief Medical Officers of Health, the Canadian PublicHealth Laboratory Network, and many more technicalgroups. Domestically, the federal role, apart from specificareas of jurisdiction set out above such as quarantine atnational borders or regulation of food and drugs, hasbeen to support P/Ts and non-governmental organiza-tions with technical advice, expert resources, advancedlaboratory technology, and national surveillance andstatistics. The federal government also funds researchrelevant to public health through various channels,including the CIHR and PPHB. Last, the federalgovernment has a lead role in international liaison, aswill be discussed in Chapter 11.

3B.3 The Challenge of Public Health inRural and Remote Areas

As noted earlier, Canada was fortunate that SARS struckprimarily in Toronto with its comparatively well-developedpublic health and health care infrastructure. In manyparts of the country, capacity to battle public healththreats is limited. The risk of communicable diseases, ofcourse, is also contained by the low population densityof these same areas.

Canada’s northern territories, for example, comprise0.3% of Canada’s overall population, but 39% of itsgeographic area. In the far north, average life expectanciesare lower than for the rest of Canada, owing to higherinfant mortality rates in Nunavut and the NorthwestTerritories, higher lung cancer mortality rates in all threeterritories, and substantially higher rates of death fromunintentional injuries and suicide. The territories havehigher rates of infectious diseases such as tuberculosis andChlamydia, higher teen birth rates, and greater incidencesof smoking and other forms of substance abuse.

More generally, populations residing outside of largeurban centres tend to have lower levels of education,employment, and income. Small local hospitals cannotmaintain infection control with highly specialized staffas occurs in many urban hospitals. Rural hospitalsseldom have rooms with respiratory isolation facilities.And in local public health units, staff multi-task as amatter of course. Public health nurses provide well babyand immunization coverage one day, communitydevelopment and school visits the next. Similarly, publichealth inspectors deal with issues ranging across watersafety, restaurant and event inspections for food safety,potential rabies exposures, enteric disease outbreaks, andenvironmental hazards. In these settings, no functioncan be abandoned to combat an outbreak for more thana few days without introducing new hazards. Most ofthese remote areas have a medical officer of health, butsome positions go unfilled and others are managed bypart-time clinical physicians. Public health inspectorpositions remain unfilled for long periods, and fewsmaller health units can afford to hire personnel withgraduate training in areas such as health promotion orepidemiology. In short, Canadian geography posesspecial challenges in the organization and delivery ofpublic health services.

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3C. Public Health in theBackground

We have seen that public health moved to the backgroundas the technological capacity of clinical medicine grewthrough the latter half of the twentieth century. Inparallel, Canada moved to organize universal prepaymentof physicians’ services and hospital care, initiating fourdecades in which funding of personal health services hastaken ever greater priority over public health. Writing inthe Royal Commission report that laid the foundationsfor Canada’s universal medical care insurance system, Mr. Justice Emmett Hall and his fellow commissionersfocused on plans to improve access to physician services,and offered only a passing reference to public health:“The efforts to improve the quality and availability ofhealth services must be supplemented by a wide range ofother measures concerned with such matters as housing,nutrition, cigarette smoking, water and air pollution,motor vehicle and other accidents, alcoholism and drug addiction.”

In 1974, then Health Minister Marc Lalonde publishedan influential volume entitled A New Perspective on theHealth of Canadians.9 Lalonde argued that health statuswas influenced not only by health services and genetics orbiology, but also by environmental and lifestyle factors.While the “New Perspective” drew positive national andinternational responses, its legacy was clouded on twoscores. First, by highlighting the limits to health carebased on broad population health trends and aggregatemortality statistics, the volume understated the value ofclinical services for relevant outcomes such as disease-specific mortality, function, and quality of life. In part, itre-opened the unhelpful divide between advocates ofmore clinical spending and champions of public andpopulation health. Second, the ‘lifestyle’ terminology,with its emphasis on personal choices, was characterizedby some critics as “victim-blaming” because it down-played the social roots of unhealthy behaviours at theindividual level. The ”New Perspective” did lend momen-tum to health promotion efforts, presaged the need forintersectoral collaboration in public health, and fore-shadowed the population health paradigm that nowholds sway. However, it appears to have had little lastingeffect on federal or provincial spending in public health.

Throughout the latter half of the 1980s, when economicrecession was coupled with escalating health care costs,most provinces and territories published reviews ofhealth and health care. Nearly all of these reports sharedtwo recommendations: improved control over resources,through processes such as integration of services,alignment of incentives, regionalization, and utilizationmanagement; and an increased emphasis on preventionand health promotion. In every province, the first set ofrecommendations was operationalized; the latter receivedmuch less attention.

The scope and importance of the HIV pandemic becameincreasingly evident during the 1980s, sparking world-wide concern about infectious diseases. An expert panelof the US Institute of Medicine conducted an 18-monthstudy, culminating in 1992 in a major report—EmergingInfections: Microbial Threats to Health in the United States.10

Health Canada’s Laboratory Centre for Disease Control(later restructured inside the Population and Public HealthBranch of Health Canada) also organized an Expert WorkingGroup on Emerging Infectious Disease Issues. A multi-disciplinary group of 40 researchers and practitioners metat Lac Tremblant from December 7-9, 1993, producing adeclaration whose opening sentences were prophetic:

“The HIV pandemic has demonstrated that theworld is rapidly becoming a global community.Global interdependence, massive internal andexternal population movements, rapid transpor-tation, increasing trade and changing social andcultural patterns expose large populations to newand different pathogens and pose new threats totheir health and well-being. National boundariesno longer offer isolation or protection from infectiousdiseases, toxic chemicals and hazardous products.”

In its long list of recommendations, the group called for“a national strategy for surveillance and control ofemerging and resurgent infections,” support and enhance-ment of “the public health infrastructure necessary forsurveillance, rapid laboratory diagnosis and timelyinterventions for emerging and resurgent infections,”coordination and collaboration in “setting a nationalresearch agenda for emerging and resurgent infections,”“a national vaccine strategy,” “a centralized electroniclaboratory reporting system to monitor human and non-human infections,” and strengthening “the capacity andflexibility to investigate outbreaks of potential emergingand resurgent infections in Canada.”

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Little action was taken apart from some organizationalchanges, and most of the Working Group’s recommen-dations from 1993 remain entirely valid a decade later.Indeed, we essentially recapitulate many of them in this report.

Mr. Justice Horace Krever provided a more general call toaction in his 1998 report of the “Commission of Inquiryon the Blood System in Canada.” Krever wrote: “Publichealth departments in many parts of Canada do not havesufficient resources to carry out their duties…Continuedchronic under-funding of public health departments is adisservice to the Canadian public…It is recommendedthat the provincial and territorial ministers of healthprovide sufficient resources for public health services.”11

Krever made specific reference to the need for bettersurveillance for infectious diseases, not least those thathad contaminated the blood supply.

On September 11, 2000, the provincial premiers andfederal government reached an agreement on new fundingfor health care. This agreement provided $23.4 billion inadditional funds over a six-year period (from 2000-01 to2005-06) as set out in Table 2. There was no earmarkedfunding for public health infrastructure, although fundsfrom the Canada Health and Social Transfer [CHST]could, of course, be directed to public health by theprovinces.

At the provincial level, recent reports have begun tohighlight the need for specific investments in publichealth. For example, in June 2000, the Quebec govern-ment created the Commission d’étude sur les services desanté et les services sociaux. The Quebec report definesthe health system broadly, encompassing services toindividuals, public programs aimed at prevention, andsocial policies aimed at improving health and welfare.12

Of 36 recommendations, the first is “That prevention bethe central element of a Quebec health and welfarepolicy.” The report explicitly integrates recommendationsabout public health and preventive services with thosefocused on personal health and social services. HealthierTogether: A Strategic Health Plan for Newfoundland andLabrador was released in September 2002 and focusesextensively on a population approach to health.13 Thereport outlines only three broad goals. The first is awellness strategy, the second goal a healthy communitiesstrategy, and the third “to improve the quality, accessi-bility, and sustainability of health and community services.”Throughout the report, there are many references tohealth promotion, health protection, illness and injuryprevention, child and youth initiatives, and the non-medical determinants of health. Five-year targets arelisted in an appendix.

From a national perspective, the Commission on the Futureof Health Care in Canada14, under the direction of theHon. Mr. Roy Romanow was asked to “recommend policies”that would strike “an appropriate balance betweeninvestments in prevention and health maintenance andthose directed to care and treatment.” The Romanowreport devotes one chapter to primary care and preven-tion. His definition of primary care (“services … providednot only to individuals but also to communities as awhole, including public health programs that deal withepidemics, improve water or air quality, or healthpromotion programs designed to reduce risks related totobacco, alcohol and substance abuse”) conflates generalpractice with traditional public health activities.

Three of Mr. Romanow’s recommendations dealspecifically with public health issues. He recommends anational immunization strategy, a physical activity strategy,and strengthening health promotion and preventionprograms, focusing initially on obesity and tobacco use.Funding for these initiatives would come from a PrimaryHealth Care Transfer. The proposed Health Council ofCanada is to monitor these activities, establish commonindicators, and set benchmarks. Mr. Romanow alsorecommends that the federal government take a moreactive role in international health, focusing on publichealth initiatives and the training of health careproviders in developing countries.

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Area of funding Amount

Canada Health and Social $18.9 billionTransfer increases

Medical Equipment Fund $1.0 billion

Health information technology $0.5 billion

Health Transition Fund for $0.8 billionPrimary Care

Early childhood development $2.2 billion

Total $23.4 billion

T A B L E 2Health care funding over six years (beginning in 2000-01), as per the 2000 Health Accord.

One senior public health leader later commented:

“Sadly, the long-awaited Romanow Report did notentirely grapple with—or indeed even mention—theserious plight of public health services in Canada.Instead, it offered some suggestions for investmentsin disease prevention and health promotion, suchas the creation of a central fund for harmonizedimmunization programs and a Centre for HealthInnovation focusing on ‘Health Promotion’. Muchof the report did not sufficiently differentiate thecomplementary roles of primary care and publichealth in achieving disease prevention and healthpromotion goals. As a result, it gives the impressionthat all such activities—even health protection fromhazardous exposure, and the sort of community-based cultural change that we need to tackle theobesity epidemic—can be spearheaded from physicians’offices and ambulatory care centres.”15

The Standing Senate Committee on Social Affairs, Scienceand Technology chaired by Senator Michael Kirby releasedThe Health of Canadians –The Federal Role in October 2002after a two-year study of the Canadian health care system.16

A chapter is devoted to the argument that healthy publicpolicy must include health and wellness promotion,illness and injury prevention, public health and healthprotection, and population health strategies, and that thefederal government can and should play a leadership rolein these areas. Kirby et al focus on two areas of publichealth. The first is a National Chronic Disease PreventionStrategy that incorporates public education efforts, massmedia programs, and policy interventions targetinglifestyle behaviours such as a poor diet, lack of exercise,smoking, excessive alcohol intake, and stress. Kirby et alsuggest that the federal government should commit $125 million annually towards chronic disease prevention.The second area of focus is the deficiency in publichealth infrastructure. The Senate Committee specificallycited inconsistent funding, fragmentation and poorcoordination between jurisdictions, and an overall lack ofaccountability and leadership. Regarding health promo-tion efforts, Kirby et al mention poor coordination betweengovernment and non-governmental organizations andlow funding relative to spending on health care. TheCommittee accordingly recommended additional fundingof $200 million annually to sustain, better coordinate,and integrate the public health infrastructure as well asrelevant health promotion efforts.

The Senate Committee’s recommendations have yet to beoperationalized, notwithstanding another major re-investment in health services by the federal government.Specifically, on February 5, 2003, the First Ministers andthe federal government reached another agreement onincremental funding for health care. This agreementprovided for $34.8 billion in additional funds for healthover a five-year period (2003-4 to 2007-8). Of these,$30.9 billion represent new spending over and above theprevious Health Accord. The funding has been directedas shown in Table 3 below.

The text of the 2003 Health Accord mentions “prevention”once. In a paragraph entitled “Healthy Canadians”, theAccord acknowledges that there is a “collective responsi-bility” to deal with issues like exercise and obesity and topromote better public and environmental health.17 The2003 Accord directs health ministers to continue workingon initiatives to reduce health status disparities, and topursue a National Immunization Strategy. Funding forthese activities appears to come from the “direct HealthAccord initiatives” and “other health reform initiatives”line items. Other programs within these line itemsinclude patient safety, health human resources, andtechnology assessment.

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Area of funding Amount

Canada Health and Social $12 billionTransfer increases

Health Reform Fund $16 billion

Diagnostic/medical equipment $1.5 billion

Health information technology $600 million

Research hospitals $500 million

Direct Health Accord initiatives $1.585 billion

Other health reform initiatives $1.364 billion

First Nations and Inuit Health $1.25 billion

Total $34.8 billion

T A B L E 3Health care funding over five years (beginning in 2003-04), as per the 2003 Health Accord

The Accord proposes that health ministers develop a setof performance indicators by September 2003, andsuggests indicators for the ministers to consider. Theseindicators are divided into four groups: timely access,quality, sustainability, and health status and wellness.Although two of the suggested wellness indicators dealwith obesity and physical activity, public health activitiesare generally overlooked. For example, none of thesuggested indicators discuss vaccination rates, surveillanceof communicable diseases, disease screening, breastfeedingrates, or childhood nutrition. The 2003 federal Budgetprovides $45 million over five years for the NationalImmunization Strategy and a further $45 million for“Wellness-Sport Participation”.

The record of the last several decades is depressingly clear.Even the presence of a major new infectious disease suchas HIV was insufficient to galvanize new investments inand reorganization of public health infrastructure inCanada. Notwithstanding the drumbeat of disease preven-tion and health promotion, governments have steadilycommitted virtually all new health spending to areasother than public health. We turn accordingly to a briefexamination of the funding of public health in Canada.

3D. Funding Public Health in Canada

Tellingly, reliable information on expenditures on publichealth in Canada is not even readily available. The datapublished by the Canadian Institute for Health Information[CIHI] are not suitably disaggregated and thereforeunhelpful. The public health category includes admin-istrative spending for many other parts of the health caresystem. For example, the amount shown for Ontarioincludes the province’s contribution to the CanadianBlood Services and the operating costs of the provincialbreast cancer screening program. Some other provincesprovide no breakdown at all. CIHI intends to publishpublic health expenditures data separate from generaladministrative costs of government ministries, but thiswill not solve the problem of inconsistencies in categoriesof expenditure included in the public health envelope.

3D.1 National Spending on Public HealthFor a view of federal data, Health Canada’s “BudgetQuick Facts” document does list expenditures by branchand business line. Various branches also providedinternal estimates of expenditures on communicablediseases. Expenditures for infectious diseases inside PPHBwere calculated from budgets for individual centres.

For provinces and territories, we were able to obtaininformation on public health budgets from a fewprovinces and prorated these expenditure data to theentire country. Thus, the national estimates providedhere are fairly crude approximations. Data were notavailable for all subcategories. Data for vaccine costswere taken from a survey of provinces and territoriesundertaken by Health Canada last year; costs for thatyear were unusually high as a result of a mass campaignof meningococcal vaccination in Quebec.

Expenditures were estimated for both a narrow definitionof public health (roughly corresponding to the activitiesof official P/T and local public health organizations) and a broader definition (including activities of non-governmental organizations [NGOs] and regulatoryfunctions).

Table 4 provides a summary of estimated public healthexpenditures in Canada. Total public health expendi-tures in Canada (2002 - 2003) are estimated at $2.8 billionby the broad definition, and $2 billion by the narrowdefinition. This corresponds to per capita expendituresof $88 and $65, respectively. CIHI has forecasted 2002health expenditures of $79.4 billion for the public sectoralone and $112.2 billion for the public and privatesectors combined. Public health by the broader andnarrower definitions therefore amounts to 2.5% and1.8% respectively of total health expenditures (publicand private) or 3.5% and 2.6% respectively of publicly-funded expenditures. Public health expenditures forinfectious diseases specifically, are estimated at $787million or $25 per capita. This corresponds to 1.0% ofpublic health care expenditures.

3D.2 Expenditure Trends in OntarioWe attempted to examine public health system fundingtrends in more detail for the Province of Ontario. Ourinterest was piqued by the fact that Ontario has a set ofmandatory programs for local public health units andmeasures compliance with them. The programs representa solid foundation for public health, and thus the relation-ship between program compliance and funding seemedto offer a potential benchmark for analysis.

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Total Expenditures Per Capita As Proportion of Health ($ million) Expenditures $ Care Expenditures

Total Publicly-funded

Broad definition 2,762.4 88 2.5% 3.5%

Narrow definition 2,047.0 65 1.8% 2.6%

T A B L E 4Summary of Estimated Public Health Expenditures - Federal and Provincial/Territorial Departments of Health, 2002.

Direct Grants & Contributions Total TotalSpending for Community-based Broad Narrow

Interventions definition1,4 definition2

Federal [Health Canada] only]PPHB 186.8 200.3 387.5 225.04

Other Branches 497.93 497.9 75.05

Vaccines 25.3 25.3 25.3Subtotal 710.0 200.3 910.7 325.3

P/TOntario 443.76 - 528.310 443.76

B.C. 234.87 - 246.59 234.87

Nova Scotia 28.48 - 29.89 28.4Manitoba 43.08 - 459 43.0Prorated to Rest of Canada11 622.8 653.3 622.8Vaccines 349 349 349Subtotal 1721.7 1851.9 1721.7

Total 2431.7 200.3 2762.6 2047

Notes:1 Local public health plus regulatory functions and grants and contributions for community-based interventions2 Functions corresponding to work done by local official public health agencies3 Healthy Environments and Consumer Safety Branch [HECS], Health Products and Food Branch [HPFB], Pest Management Regulatory Agency

[PMRA], expenditures for the ‘protection & promotion of health’ business line, plus the public health portion of First Nations and Inuit HealthBranch [FNIHB] expenditures

4 Direct spending + estimated portion of grants and contributions5 Estimated public health-like expenditures by FNIHB6 includes municipal portion + provincial public health branch7 BC CDC plus Ministry and transfers to regions minus public health labs and vaccines8 Ministry plus transfers to regions (Nova Scotia: +10% for food safety and related health inspection services)9 Estimate - approximately 5% allowance for health promotion grants and regulatory work10 Addition of health promotion transfer grants + Healthy Babies, Healthy Children Program11 Prorated on a per capita cost basis by region: Manitoba for Alberta and Saskatchewan, Nova Scotia for Maritime provinces and territories,

British Columbia for Quebec. * Best available data as of May 2003.

T A B L E 5Breakdown of Estimated Public Health Expenditures by Federal and Provincial Departments of Health in Canada, 2002*($ millions)

Unfortunately, examining funding trends for the publichealth system in Ontario was problematic for several reasons.Substantial funding by municipalities is not captured byprovincial public accounts or estimates. In the transitionto the current 50:50 cost sharing with municipalities, therewas a brief period of 100% funding of local programmingby municipalities. The province has also introduced alarge and expanding Healthy Babies, Healthy ChildrenProgram. Further, non-public health budget lines appearto be embedded in the public health vote.

The Ontario Association of Local Health Agencies (alPHa)has tried to track funding for local public health depart-ments. Data were available for selected years from 1994-2002. These figures combine provincial and municipalfunding of local public health departments. Figure 1 abovesuggests that local public health funding lagged the growthin overall provincial health care spending during the periodof 1996-2001. Funding as a percentage of total healthspending increased in 2002, but remains below levelsobserved in 1994 and 1995. Per capita spending, unadjustedfor inflation, has clearly increased from 1998 through2002. The total public health budget net of revenue andexcluded items plus unorganized areas ($3.3 million) was$304.4 million in 1998 and $435.9 million in 2002. Percapita spending appears similar to Manitoba but lowerthan British Columbia; however, interprovincial comparisonsmust be drawn cautiously given limitations of the data.

Funding trend data do not addressthe broader issue of whether currentfunding is sufficient to fulfill themandate of the public health system.As noted, Ontario’s Mandatory HealthPrograms and Services offered apotential benchmark. The Programstandards and requirements arereasonably detailed and have astrong service delivery perspective.Starting in 1998, the Public HealthBranch developed a series ofindicators to facilitate local healthdepartments’ reporting on theextent of compliance with theMandatory Programs. The PublicHealth Branch annually compilesinformation from a MandatoryProgram Indicator Questionnaire[MPIQ]. Provincial averages foroverall compliance as evidenced byMPIQ results are reported to haveincreased from 70.9% to 82.6%from the period of 1998 to 2001.The extent to which the additionalfunding is responsible for risingcompliance is unclear.

3D.3 A Modest Investment by Any MeasureCIHI data report that public health and administrationtogether account for 6% of health care spending. Theinvestment in public health is clearly the smaller part ofthat percentage. Convergent validation of the estimatesdeveloped above is derived from Alberta data. As notedearlier, Alberta’s regional health authorities [RHAs] areresponsible for the delivery of both acute and chroniccare, as well as public health programs. In 1999-2000,RHA spending on “promotion, prevention, and protection”accounted for 2.9% of their budgets. This number isconsistent with our estimates that public health spendingamounts to approximately 2% of total health spending.These estimates are also in a range familiar to publichealth practitioners, i.e., between 1.5% and 3% of healthspending. Only by using the broader definition of publichealth and the smaller denominator of public spendingalone does the figure move slightly outside that range to3.5%. The good news is that, because public healthremains a very small part of total health spending, relativelymodest investments could have a transformative impact.The bad news is that there are clearly inconsistencies inpublic health programming and spending within andbetween provinces and territories, with the result thatuniform conditional transfers by the federal governmentto reinforce capacity will be difficult to operationalize.

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F I G U R E 1Local Public Health Funding in Ontario —- Percentage ofMinistry of Health Spending and Per Capita Estimate

Local public health funding is based on provincial and municipal contributions to public healthdepartments in Ontario. The provincial component coincides primarily with the “Official LocalHealth Agencies” line item in Public Accounts. Data are missing for 1997 due to the time-limiteddownloading policy of the provincial government.

Overall spending targets are difficult to set as there arelimited data on spending trends and outputs, let alonehealth status outcomes. The Ontario data are consistentwith the common opinion that absolute levels of publichealth funding have generally increased, but laggedbehind spending on health care in general. This latterpoint has been supported in a submission to the Committeeby the Canadian Medical Association. Comparisons ofexpenditures across jurisdictions are also difficult, as notwo provinces seem to include exactly the same activitieswithin the public health funding envelope. For example,in several western provinces, most or all of immunization,including vaccine and delivery costs, is provided throughpublic health, whereas in Ontario and Quebec most immu-nizations are given in physicians’ offices and delivery isfunded through the medical insurance plan.

If one takes British Columbia as a benchmark, andcalculates the incremental funding required to bring allprovinces up to the per capita spending apparent forBritish Columbia, governments would need to spend anadditional $408 million per annum. But this figure isimprecise. Some services included in the British Columbiapublic health envelope may be funded through differentenvelopes in other provinces, and we have no way ofbeing certain that British Columbia’s spending in anyway represents a ‘gold standard’ for public health. Theincremental spending proposed does not consider thepotential differences in delivery costs due to geographically-dispersed populations, variable proportions of higherneeds populations, or fixed system costs that are partlyindependent of population size. We turn therefore tointernational comparisons for additional enlightenment.

3E. International ComparisonsFor comparative purposes, the Committee asked HealthCanada to obtain information on the organization,governance and funding of public health in selectedforeign countries, with an emphasis on national agencies.We have reviewed material on the USA, the UnitedKingdom, Australia, New Zealand, Sweden, Finland, andNorway. We found the organization and governance ofpublic health to be particularly informative for the USA,United Kingdom, and Australia, and review these below.

3E.1 United States of AmericaThe USA combines a large population (297 million), thehighest average per capita income on the globe, dramaticincome-related and ethno-racial health status disparities,geographic challenges that are only slightly less dauntingthan those in Canada, and a federal system of govern-ment that includes 57 separate governments at thestate/territorial/district level.

The Institute of Medicine has recently published a compre-hensive and critical review of public health infrastructurein the United States.18 As the Institute’s report high-lights, the health care context is different from otherdeveloped countries: the Department of Health andHuman Services, through its Medicare and Medicaidprograms (the latter a joint venture with the states) is thelargest insurer in the country. However, absent universalhealth care insurance, the majority of Americans obtaininsurance privately, with about 40 million uninsured,relying on a patchwork of state, local and voluntaryprograms for service. This tends to confuse the publichealth picture, as public health programs at the state andmunicipal level are often an amalgam of populationhealth and clinical prevention programs and curativecare for the indigent and uninsured populations.

The US constitution gives states primary responsibilityfor health. The federal government has a limited role inthe direct delivery of public health services, but doesprovide leadership, has some regulatory authority, andcontributes operational and financial resources. Theultimate authority for public health in the USA rests withthe Secretary of Health and Human Services. The AssistantSecretary for Health is the principal advisor to theSecretary on public health and related scientific issues.Presently, the Acting Assistant Secretary is Dr. RichardCarmona, who is also the Surgeon General. There is alsoan Assistant Secretary for Public Health EmergencyPreparedness.

The lead agency for public health activity at the federallevel is the US Department of Health and HumanServices [DHHS] (see Appendix 3.1 for an organizationalchart). The DHHS oversees several key agencies includingthe Centers for Disease Control and Prevention [CDC],referenced in the two previous chapters. Numerouscommittees in both the House of Representatives andSenate have jurisdiction over HHS activity. The roles ofDHHS include:

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Policy making: For example, the DHHS, through itsHealthy People initiative, sets goals and objectives forhealth promotion and disease prevention.

Financing public health activities: Whereas much ofthe CDC budget flows through to the states and territories,the Institute of Medicine [IOM] notes that other spendingby DHHS in the public health sphere goes not to publichealth activities as we understand them, but to personalhealth care services through Medicaid.

Public health protection: The federal government isheavily involved in this area through the Food and DrugAdministration [FDA], and the Centers for Medicare andMedicaid Services which regulates health care providersand laboratories.

Collecting and disseminating information:Numerous federal agencies collect key health data.

Capacity building for population health: The federalgovernment is expected to ensure that state and localgovernments have the resources (human, financial,organizational, etc.) to carry out their responsibilities. Inpractice, state public health agencies are chronicallyunder-funded. When states do receive additional fundsfrom the federal government, they sometimes use theseresources to reduce the proportion of state expensesdirected towards public health activities, i.e., the fundssubstitute for, rather than increase, existing state-levelpublic health spending.

Direct management of services: These allocationsinclude Medicaid, Medicare, funding of the IndianHealth Service, and some community health centres.

Faced with a constitutional division of powers similar tothat in Canada, the DHHS must work with State, Localand Tribal governments to fulfill its mission of protectingthe health of all Americans. The US Public HealthService [PHS] combines eight HHS agencies with theOffice of Public Health and Science [OPHS] that housesthe Office of the Surgeon General. The Surgeon Generaldirects the PHS Commissioned Corps—a quasi-militaryunit of 6,000 uniformed public health professionals.

The federal government has constitutional responsibilityfor preventing entry of disease into the USA and, underthe Interstate Commerce clause of the Constitution, forpreventing the interstate spread of disease. The USA has specific legislation (the Public Health Threats andEmergencies Act, 2000, also known as the Frist/KennedyAct) aimed at countering bioterrorism through theimprovement of public health infra- and infostructure at

state and local levels. Other relevant legislation governsimmunization and vaccine purchase, and includes severallong-standing “categorical” programs to fund specificnationwide programs, usually with an emphasis on thepoor or on children and youth, often in partnership withstates.

Apart from the CDC, other agencies under the umbrellaof the DHHS in the USA are listed below. The list showstheir 2002 HHS budget authority in parentheses; theseagencies may receive additional funding from non-HHSsources:

• Food and Drug Administration (US$1.3 billion)

• Health Resources & Services Administration (US$6.2 billion)

• Indian Health Service (US$2.9 billion)

• National Institutes of Health (US$23.6 billion)

• Substance Abuse & Mental Health Services (US$3.1 billion)

• Agency for Healthcare Research & Quality (US$0.3 billion)

• Centers for Medicare & Medicaid Services (US$388 billion)

• Administration for Children & Families (US$47.3 billion)

• Administration on Aging (US$1.3 billion)

The Centers for Disease Control and Prevention [CDC]was founded in 1946 to combat malaria, typhus andother communicable diseases. As noted in Chapter 1,CDC initially stood for “Communicable Disease Center.”The CDC was renamed the Center for Disease Control in1970, and added “Prevention” to its name (but not theacronym) in 1992. It is an operating division of theDepartment of Health and Human Services, and thelargest federal agency outside Washington, D.C. TheCDC has always been based in Atlanta, but over 2,000 ofthe approximately 8,600 full-time equivalent employeeswork elsewhere; this includes postings in 47 state healthdepartments, with 120 CDC employees overseas. SomeCDC staff are also members of the Commissioned Corpsof the PHS. The CDC’s current mission is “to promotehealth and quality of life by preventing and controllingdisease, injury, and disability.” The federal governmentcreated the Agency for Toxic Substances and DiseaseRegistry [ATSDR] in 1980. The director of the CDC alsoserves as the administrator of the ATSDR; the CDC andthe ATSDR submit a joint budget request.

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The CDC has 12 centres, institutes and offices. TheDirector is always a public health physician and thesenior staff are predominantly health professionals andscientists. The CDC maintains a very high public profile,and has a strong ‘corporate brand’. Its director reports tothe Secretary for Health and Human Services through theDeputy Secretary.

The CDC exerts considerable influence at state and local levels. In part this is due to the CDC’s EpidemicIntelligence Service [EIS]. The EIS was a forerunner ofsimilar programs in Canada and elsewhere. The EIS is at once a training program in field epidemiology,surveillance and disease control, and a significant part of the CDC’s ability to respond rapidly to outbreaksanywhere in the USA or abroad. It helps to ensure thatthe CDC can dispatch teams to assist or lead localinvestigations into disease outbreaks.

Many of the state and local staff were trained in the CDC EIS. Most states also have CDC staff stationed inkey state agencies.

The CDC is the clear international leader in the areas ofsurveillance systems, databases, outbreak investigation,and communicable disease epidemiology. The speedwith which the CDC and the PHS Corps can respond toan emergency infectious outbreak is unmatched globally.

The programs of the CDC are directed towards two majorfunctions. It provides infrastructure support to the statesand local health agencies. It also serves as the nationalcommand centre for health emergencies, including new or re-emerging infectious diseases and bioterrorism.The CDC engages in research, offers technical advice tomultiple nations, and helps with program developmentin the USA and around the world.

The infrastructure programs are set out below:

The National Public Health Standards Programdevelops capacity and performance standards, providesfor evaluation against these standards and providesgrants and technical assistance to state and local healthauthorities to address deficiencies. Although states arefree to reject the CDC’s performance standards, theCDC’s funding of state-level programs gives it substantialinfluence.

The Health Alert Network links all state and localhealth departments to secure communication systemsthrough the development of architecture, technicalassistance and grant-supported projects.

The Public Health Workforce DevelopmentInitiative includes a comprehensive strategy for life-longlearning for public health practitioners, and has twoarms: the Public Health Training Network and theNational Laboratory Training Network.

The National Public Health Laboratory System,beginning with standardization and enhanced testing,aims to develop policies and public-private partnershipsthat would enable improved and more timely reportingof laboratory results.

The Public Health Information Network is thearchitecture for a comprehensive system for the captureand exchange of surveillance information. It providesdesktop access to important information for publichealth practitioners.

The Public Health Emergency Fund is available forfederal action on public health emergencies.

The situation with surveillance in the USA is not dissimilarto Canada with respect to legal authority. Mandatoryreporting of infectious diseases occurs at the state or evenlocal level in the USA. Although the CDC and theCouncil of State and Territorial Epidemiologists jointlymaintain a list of nationally notifiable infectious diseases,reporting to the CDC is voluntary. On the other hand,the CDC performs a crucial role in disease surveillance,offering leadership and coordination, education, laboratorytesting, and information technology, as well as directfunding. In the last category, for example, the NationalCenter for Infectious Diseases distributed US$31.2 millionto states in 1998 through various grants for surveillance.Other CDC departments also provide funding to statesfor surveillance. In 2002, bioterrorism funding enabledthe CDC to disburse almost US$1 billion to states, ofwhich approximately US$183 million was for surveillanceand epidemiology. In short, given constitutional limitsand recent legislation that prevents the imposition ofunfunded mandates on states by federal regulators, theCDC essentially purchases a national surveillance systemthrough earmarked state-level funding and partnerships.

In the USA, the Healthy People 2010 Objectives (publishedevery ten years) contain quantifiable objectives, andprogress towards them is measured. This stands incontrast to Canada, where an overarching public healthstrategy for the nation has never been articulated.

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Essential public health services have been defined. TheCDC offers programs and funding to review state/localperformance; a framework for organizing, assessing anddeveloping public health staff care competencies; and apotential framework for new/revised public healthlegislation. Again, the contrast to Canada is striking.Direct transfers to P/T governments earmarked for publichealth do not occur in this nation, leading to inter-jurisdictional inconsistencies along with limited nationalcoordination. The federal presence in public health isalso much reduced.

The enacted CDC budget for the 2002 fiscal year (FY 2002)is outlined in the CDC’s budget request for FY 2004.Allocations for 2003 had not been formally enacted atthe time of the 2004 budget request; nevertheless, as2004 requests are generally similar both in total and bycategory to actual 2002 and expected 2003 enactments,this report presents data for 2002 only.

The CDC’s total 2002 budget of approximately US$6.5 billion excludes approximately US$1.2 billiontransferred from the CDC’s terrorism budget to theDepartment of Homeland Security for accumulation of a“strategic national stockpile” and the smallpox vaccinationprogram. The CDC receives funding via several mecha-nisms (e.g., the Labor-Health and Human Services-Education regular appropriations bill, the Veteran Affairs-Housing and Urban Development regular appropriationsbill, the Public Health and Social Services EmergencyFund, etc.). Budget details are presented by program inTable 6.

Although responsibility for public health rests with thestates constitutionally, the degree of commitment to publichealth by states and territories varies greatly. A few statesinvest heavily, and others hardly at all. State healthdepartments are usually headed by a professionally-qualified director or commissioner. However, this officialmay have responsibility not only for public health, butalso for Medicaid, professional licensing and other healthcare matters, and perhaps child welfare and some socialservices as well. In the interests of brevity, we shall notreview state-specific arrangements in detail here. Sufficeit to say that the provision of local and regional publichealth services appears more variable in the US than inCanada. While some larger cities have very effectivepublic health units, there are also several thousand local(usually county-based) agencies, many too small to beeffective or attract qualified staff. Resources areconstrained by local ratepayer interest, as a substantialportion of the funding for local agencies comes frommunicipal or country-level taxes and revenues.

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Program Expenditure Percent(US$, 000)

Birth Defects and Disabilities $89,946 1.4%

Chronic Disease Prevention and Health Promotion $746,731 11.4%

Heart Disease and Stroke $37,378Diabetes $61,683Cancer $268,627Arthritis and Other Chronic Diseases $20,812Tobacco $100,973Nutrition, Physical Activity,

and Obesity $27,505Health Promotion $15,235School Health $58,443Safe Motherhood/Infant Health $50,697Oral Health $10,814Prevention Centers $26,176Youth Media Campaign $68,388

Environmental Health $153,397 2.3%

Epidemic Services and Response $80,156 1.2%

Health Statistics $126,750 1.9%

HIV/AIDS, STD and TB Prevention $1,156,826 17.6%HIV/AIDS – Domestic $689,169HIV/AIDS – International $168,720STDs $166,534TB $132,403

Immunizations (state programs, public health clinics) $627,239 9.6%

Infectious Disease Control $348,181 5.3%

Injury Prevention and Control $149,502 2.3%

Occupational Safety and Health $275,808 4.2%

Preventive Health and Health Services Block Grant $134,958 2.1%

Public Health Improvement $148,306 2.3%

Emergency Response and Recovery $12,000 0.2%

Office of the Director $49,077 0.7%

Buildings and Facilities $296,000 4.5%

ATSDR $78,203 1.2%

Terrorism (Nonbuildings and Facilities) $1,101,439 16.8%

Upgrading State and Local Capacity $940,174Upgrading CDC Capacity $143,225Anthrax $18,040

Vaccines for Children (Medicaid, uninsured, native, etc.) $989,535 15.1%

User Fees $2,226 0.0%

Total $6,566,280 100.0%

T A B L E 6Budget for the Centers for Disease Control andPrevention, USA, 2002 (US$).

The first line for outbreak management remains at thelocal and then state level in the USA. The CDC must beinvited to offer support, but thereafter it plays particularlystrong roles in outbreak investigation and strategicadvice. The CDC’s influence and surveillance systemsalso ensure that, with few exceptions, it enters the frayearly in any serious outbreak. Just as in Canada, juris-dictional tensions occur. However, the conspicuousposition of the CDC in US outbreaks arises from its ownfirepower, its funding of activities by other governmentaljurisdictions, the role that it plays in training andcapacity-building, direct secondments of federalpersonnel into state/territorial agencies, and, not least,limits in capacity at the local or regional level.

3E.2 United KingdomAlthough the United Kingdom does not have a federalconstitution, three separate health systems are inoperation for England and Wales, Scotland, and NorthernIreland. Each is a variation on the basic model of theNational Health Service [NHS].

Britain was a pioneer in many aspects of public healthduring the nineteenth century. Its strong municipally-based public health programs were largely absorbed intothe NHS when the latter was created in 1948. Since then,public health has been closely integrated with other NHSfunctions. Furthermore, public health physicians in theUnited Kingdom have wide-ranging roles. They are notonly engaged in public health as we understand it, butalso in planning, commissioning and managing thequality of the NHS clinical services.

The basic organizational unit of the NHS is the PrimaryCare Trust. Many public health services are provided atthis level. Since April 2002, the trusts are accountable to 28 Strategic Health Authorities, each with a regionaldirector of public health. The public health directors inthe Strategic Health Authorities are charged with thedevelopment of a cross-governmental and cross-sectoralapproach to the determinants of health. Public healthpolicy informs and is informed by regional work oneconomic regeneration, education, employment andtransport. The directors give high priority to partnershipswith primary care physicians. They are accountable forhealth protection (including control of communicablediseases and environmental hazards) across the region,and play a role in emergency and disaster planning andmanagement. The public health directors are also often apoint of contact for concerns about clinical standards. In essence, serious lapses in clinical quality are regardedas tantamount to iatrogenic disease outbreaks, and may

be investigated accordingly in tandem with clinicalgovernance. Each region has its own characteristics andpublic health priorities.

Intriguingly, the Cabinet includes not only a Minister ofHealth but a Parliamentary Under Secretary of State forPublic Health, essentially a junior minister, with specificresponsibilities for a strategy to improve the health of thepublic and for policies on issues such as tobacco controland food safety. The government published a greenpaper and subsequent white paper (Saving Lives: OurHealthier Nation) setting out the government’s strategy for public health policy. In contrast to the Canadiansituation, the white paper identified five priority areas for reducing mortality and morbidity and 25 quantifiedtargets for achieving reductions in mortality and morbidityover given timescales. Work in progress is addressingtargets for addressing health inequalities and tacklingsome of the social and environmental determinants ofhealth. Public health activities are subject to nationalhealth frameworks: each Strategic Health Authoritymeasures the performance of the primary care trusts withinits boundaries, and the performance of Strategic HealthAuthorities in turn is assessed centrally. In sum, Britainis making an effort to create an accountable hierarchy ofperformance measurement in public health, a structureparallel to its innovative system of performance measure-ment for clinical or personal health services.

The UK government recently formed a Health ProtectionAgency. It drew together the Public Health LaboratoryService (including the Communicable Disease SurveillanceCentre), the Centre for Applied Microbiology andResearch, NHS staff responsible for communicable diseasecontrol and emergency planning, and units responsiblefor chemical exposures and poison control. The staff inthis agency number 2,700 in 9 regional offices. Thissecond line of defence against outbreaks is an importantinnovation to which we shall return.

The government operates other agencies designed todrive a research agenda in public health and translateevidence into action. The Health Development Agency hasan annual budget of about C$23 million. Focused onknowledge translation, the agency finances systematicreviews, gathers evidence and makes it available to publichealth authorities, advises on good public health practice,and supports the information needs of front-line publichealth workers. It has a particular interest in healthpromotion and works closely with both local public healthagencies and community groups. The Department ofHealth also funds the Policy Research Programme to helpensure that public health policy, plans, and practices arebased on reliable evidence about population needs and

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effective interventions. All of the research is directlycommissioned (costing around C$67 million per annum).More generally, the Department of Health will spendapproximately C$1.21 billion in 2002/03 through thePolicy Research Programme and NHS R&D Programme.While the NHS R&D Programme has a strong appliedclinical and health services focus, a meaningfulproportion of the research spills over to inform publichealth issues. The British Medical Research Council isfunded separately for investigator-initiated researchacross the full range of health research.

3E.3 AustraliaAustralia is similar to Canada with its vast land mass,modest population (now about 19 million), and federalsystem of government. Australia’s federation is comprisedof six states and two territories. The Commonwealth(federal) government has a broad policy leadership andfinancing role in health matters, while the states andterritories are largely responsible for the delivery ofpublic hospital and community services. Australia hasmoved back and forth with various configurations ofprivate-public mix in financing and delivering personalhealth services. Currently, it operates a nationalcompulsory tax-based system of public health insurance(known as Medicare), graduated on the basis of incomeand general taxation, that provides access to medical andhospital services for all Australians. The Commonwealthhas recently introduced a number of key policy initiativesto increase participation in parallel private healthinsurance. The Commonwealth also provides manage-ment and control of communicable diseases, and regulatesfood, therapeutic goods, and chemicals.

The Commonwealth Department of Health and AgedCare coordinates surveillance, prevention, managementand control of communicable diseases, and regulation offood and therapeutic products. However, funding ofpublic health differs from funding of hospital andmedical services. While the Commonwealth (under theAustralia Health Care Agreements) pays 75% of totalfunding for public hospital services, it pays for half of thepublic health services funding (30% via direct expenditureand 22% via payments to States and Territories). Thestates and territories contribute the remainder. Based on1999/2000 data, A$931 million was spent on core publichealth activities (less than 2% of health expenditure inAustralia).

Joint public health activities conducted by theCommonwealth and State/Territories Health Authoritiesare coordinated through the National Public HealthPartnership, a sub-committee of the Australian HealthMinister’s Conference. States and territories vary in theorganization of their public health services, with differingnumbers of local and regional public health units,variable integration with community health centres, andconsiderable variation in the role of NGOs or stand-alonefoundations.

In February 2003, all Health Ministers signed amemorandum of understanding to continue the NationalPublic Health Partnership [NPHP] for the period 2003-2007. The memorandum sets out the objectives of theNPHP, clarifies the roles and responsibilities of therespective parties to the multilateral agreement anddescribes the arrangements for implementation. TheNPHP Group is comprised of a senior representative fromCommonwealth, State and Territory Health Departments(voting members), senior representatives of the AustralianInstitute of Health and Welfare and the National Healthand Medical Research Council (non-voting members) andtwo observers (the New Zealand Ministry of Health andthe NPHP Advisory Group). The NPHP has alreadyestablished subgroups in areas such as communicablediseases and AIDS.

The Program priorities for the NPHP are clearly identified.They include: 1) improving public health practice; 2) developing public health information systems; 3) reviewing and harmonizing public health legislation;4) implementing public health workforce initiatives; 5) strengthening national public health research anddevelopment capacity; 6) improving the coordination ofnational public health strategies; 7) developing standardsfor the delivery of core public health strategies; and 8) improving Aboriginal and Torres Strait Islander health.Lessons for Canada from these collaborative arrangementswith explicit priorities are self-evident.

The Commonwealth contributes towards the capacity ofstates and territories through Public Health OutcomeFunding Agreements [PHOFAs]. Base funding is providedfor major national health priorities. PHOFAs includespecific outcome reporting requirements. This year, theCommonwealth Department of Health & Welfareprovided funds for SARS screening at airports, vaccines,and improved prevention in primary care.

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The NPHP has made substantial efforts to integrate thepreventive work of general practitioners with other primarycare services and community services. These steps shouldhelp to integrate the personal service continuum withbroader public health programming. In particular, theNPHP is working with the General Practice AdvisoryCommittee to improve the adoption of preventive andearly intervention approaches by general practitioners,thereby rationalizing the complementary role of clinicaland population strategies for prevention. Research onpopulation health issues and epidemiologic study issupported at the Commonwealth level through twomechanisms. The National Health and Medical ResearchCouncil [NHMRC] provides independent, expert adviceto government in health issues and research grants. As well, the Public Health Education and Research Programfunds Australian tertiary institutions to strengthen post-graduate education and training, including preparationof public health practitioners and research training inpopulation health.

3F. Some Reflections andConclusions

SARS is simply the latest in a series of recent bellwethersfor the fragile state of Canada’s federal/provincial/municipal public health systems. The pattern is nowfamiliar. Public health is taken for granted until diseaseoutbreaks occur, whereupon a brief flurry of lip serviceleads to minimal investments and little real change inpublic health infrastructure or priorities. This cycle must end.

Canadians have seen high-profile disease clusters arisingfrom the contamination of water supplies in Walkerton,Ontario and North Battleford, Saskatchewan. Both hadtragic effects. Last year, the nation faced an outbreak ofWest Nile virus. West Nile virus is another zoonosis, arisingfrom a reservoir of infected birds and transmitted tohumans by mosquito bites. The virus appeared in NorthAmerica in New York City in 1999, and was detected inCanada by the summer/fall of 2001. Canada recordedabout 300 confirmed cases in 2002, some with severe orfatal effects. Variant Creutzfeld Jacob Disease (the humanform of Bovine Spongiform Encephalopathy or BSE) hasalso sparked public anxieties and exacted an economic toll.

The SARS outbreak was moderate in size, in part becauseeffective actions were taken to contain its spread and alsobecause the causative agent is actually less contagiousthan some other respiratory and enteric viruses. Its socialand economic impact, however, was enormous, and itscollateral clinical consequences are still being measured.

SARS has highlighted how communicable diseases,particular those caused by hitherto unknown agents, cantap primal anxieties, prompt enormous interest on thepart of the media, and provoke some unsavoury publicresponses (e.g., incidents of harassment and scapegoatingof the Asian community in Toronto). The SARS outbreakthereby underscores the need for public health to play aleadership role in analyzing risks and communicatingeffectively about them. Yet, as the chronology in the last chapter demonstrated, neither the analytical capacitynor the communications strategies were anywhere near optimal.

Many involved have acknowledged the potential conse-quences of two public health crises happening simulta-neously. What if SARS had struck just as public healthstaff were fully engaged in coping with a bioterrorismattack or an accelerated caseload of infections with West Nile virus? In the absence of a robust public healthsystem with built-in surge capacity, every crisis forcestrade-offs—attention to one infectious disease at theexpense of others, or infectious disease prevention at theexpense of food safety, chronic disease prevention, andother public health responsibilities. In the latter respect,if Canada expends most available public health resourceson relatively rare events such as SARS or West Nile virus,we run the risk of winning a few high-profile battleswhile losing the war for health. A host of partiallypreventable non-communicable diseases continue toexact a tremendous toll on the health of Canadians,while avoidable injuries cost the nation billions of dollarsin direct health spending and indirect costs. Publichealth has much to contribute apart from containmentof communicable diseases.

The chronology in Chapter 2 highlighted the impact ofSARS in Canada’s richest and largest city in the nation’srichest and largest province. Globe and Mail columnistMargaret Wente has tartly commented: “Thanks to near-heroic efforts by public health officials, we managed tofight off a SARS fire spreading at lightning speed with anorganization about as sophisticated as an improvisedbucket brigade.”19 Support to fight the outbreak wasrequired from other jurisdictions, including scores ofvolunteers from the USA.

The capacity of other provinces varies but Ontario isassuredly not the ‘weakest link’ in the P/T public healthchain. In this respect, an F/P/T report on Public HealthCapacity was prepared for the Conference of DeputyMinisters at their request, and presented in June 2001.20

It was never formally accepted for publication anddissemination. Some of the key findings highlightpotential areas of concern for all Canadians including:

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• an overall erosion of the public health system, withsurvey respondents in key positions noting the reducedcapacity to address ongoing and emergent challengesto public health such as water quality safety andmanagement of infectious diseases;

• significant disparities in public health capacity nowexist across Canada;

• concerns that the relative low priority given to longer-term disease and injury prevention strategies isincreasing threats to the health of Canadians andundermining the sustainability of the health caredelivery system;

• a lack of written multi-year plans covering the fivecore areas of public health practice in more than halfthe jurisdictions;

• insufficient efforts in staff development and growingrecruitment/retention difficulties;

• uncertain capacity of jurisdictions to deal with morethan one emergency at a time, or to deliver some coreprograms, particularly to northern and Aboriginalcommunities; and

• limited access to health information and erodingleadership on key public health issues.

The SARS outbreak has affirmed these observations. It illustrates an urgent need to strengthen not only thefederal role, but also the P/T public health infrastructure.The effectiveness of the public health system dependscritically upon capacity at local and provincial/territoriallevels. In turn, this demands a well-trained, adequate,and fully prepared workforce, and information andsurveillance systems that can detect health threats rapidly,analyse and interpret data and communicate the resultinginformation to health care providers and the generalpublic as needed. The same infrastructure that will helpcombat the next outbreak of SARS or a similar communi-cable disease will also provide Canadians with enhancedhealth protection and preventive capacity to reduce theburden of non-communicable diseases.

The 2000 and 2003 Health Accords provided majortransfers of funds to the provinces for health spending.These transfers offer provinces a resource base that, ifthey choose, can be tapped to enhance public healthinfrastructure [PHI]. And, given the very small percentageof publicly-funded health spending directed to publichealth functions, the levels of investment that wouldhave a transformative effect on public health capacity arecomparatively small—ranging by province from tens ofmillions to the low hundreds of millions annually. Anew allocation or re-allocation equivalent to the budget

of a single mid-sized general hospital could hugelyaugment PHI for larger provinces. However, theCommittee is under no illusions about the continuingcompetitive spending pressures on provincial andterritorial governments. In the chapters that follow, weare recommending that a substantial majority of the newfederal spending on public health be directed to initiativesand programs that will create a seamless, strengthened,and collaborative F/P/T public health system.

In shaping new programs and structures, what generallessons can Canadians learn from public health systemsin other countries?

First and foremost, the US, the UK and Australia each havea coherent chain of policy, stretching from legislation,national goals and priorities, national strategies, programsto sustain the public health infrastructure (includinghuman resources), means of reaching agreement betweenstakeholders, and specific funding programs. There arequantifiable targets with timelines, and accountabilitymechanisms. In contrast, Canada does not have nationalhealth goals or strategies. Even the extant nationalindicators arising from the Health Accords are focused on the personal health care system.

Second, many countries have agencies for public healthled by a recognized expert in the field. Embeddingpublic health functions inside the usual bureaucracy mayenhance the crosswalk to other health activities, buttends to blur the professional career path for those withspecial training in the relevant disciplines, impede theagility of responses to public health emergencies, andaugment the politicization of inter-jurisdictional activity.A distinct agency can still be held to account through avariety of mechanisms, and its credibility, for better orworse, is enhanced by its distance from the usualmachinery of government. Furthermore, these agenciesin other nations help build PHI by continually andgenerously investing in the training and continuingeducation of skilled personnel. This must be a highpriority for any Canadian public health agency.

Third, the scope of public health agencies varies. Someare focused on infectious diseases alone; others have ageneral mandate. We see the rationale for single-focusagencies, and commend the work of British Columbia’sCentre for Disease Control as a provincial exemplar inthe infectious disease field. Federally, Canada already hasa Centre for Infectious Disease Prevention and Controlunder the auspices of PPHB. The Committee believesthat any new national agency must encompass a fullspectrum of public health activities through a variety ofcomponent centres, as exemplified by the USA’s CDC,

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and intriguingly, Quebec’s National Institute of PublicHealth. The scope of the agency nonetheless requirescareful assessment as we shall show in the next chapter.

Fourth, the Committee has been struck by the fact thatother federations, such as Australia and the USA, alsoface challenges from the divergent capacity of differentprovinces or states and territories. The Australian and US response is to confront the challenges of regionalpluralism with earmarked funding, mechanisms to fosterinter-jurisdictional collaboration and coordination, andagreement on explicit performance standards. Canadaneeds a more consistent public health system withmaximum inter-jurisdictional collaboration on essentialfunctions. Governments in other nations have providedexamples of steps that can be taken to meet this need forour citizens.

In seeking to foster a stronger and more integratednational public health system, the Government of Canadacan variously use legislation and regulation, provide infor-mation and advice, deliver programs itself, or make transferpayments to individuals, organizations, and other levelsof government. Each of these has a role to play.

As summarized in Chapter 9, new legislation and regulationcould be dovetailed with the recognized need for Ottawato revise and consolidate all of its public health andhealth protection legislation. A national public healthsystem would also be facilitated by a stronger nationalpresence, established arm’s-length from Health Canada butaccountable to the Minister of Health and Parliament,that would provide credible information, advice, andtechnical support to provinces and territories. The USA’sCDC is exemplary in these respects. SARS has shown thatan outbreak in one province (or nation) affects all others.Every province and territory would benefit from moreeffective support for and coordination of public healthactivities. A strong federal presence is particularly impor-tant in supporting smaller provinces faced with epidemics,and is critically important in international liaison.

Direct program delivery by the federal governmentavoids skirmishing over cash transfers and accountability,but the federal government cannot effectively deliverlocal public health services nor does it have jurisdictionto do so. As in the USA, the federal government inCanada could instead become more directly involved insurveillance in support of provinces and territories. TheCommittee is also impressed by the ability of the USCDC to maintain a highly mobile, professionally-trainedemergency response structure capable of reacting rapidlyto outbreaks of infectious disease or other healthemergencies. In an ideal world, a new Canadian agency

would support a network of expertise, have sufficientcredibility, enjoy collegial relations, and move swiftlyacross bridges of inter-jurisdictional agreements to helpin local outbreak investigations and management. Thisis one reason why, as will be elaborated in Chapter 5, weenvisage a network focused on infectious diseases alongwith a system of secondments and sharing of personneldesigned to create a culture of collaboration.

Transfers are the other policy instrument in the federaltool-kit. As noted above, the federal government currentlyoperates a program of grants and contributions throughPPHB. This system moves approximately $200 millionper annum primarily to NGOs, and aims at addressingvarious determinants of health through programs in areassuch as prenatal nutrition, Aboriginal early childhooddevelopment, healthy living, and prevention of variousnon-communicable diseases. This set of transfers shouldbe aligned with a new national public health strategy.But what is clearly needed as well is a serious investmentdirected at the support of provincial, territorial, andmunicipal public health infrastructure. To this end, boththe American and Australian examples are important.Their systems of grants and related agreements withstates and territories, incorporating clear targets andreporting mechanisms, exemplify the approach that anew Canadian agency could use to build capacity inaccordance with both a national public health strategyand the needs of specific P/T jurisdictions.

The Committee is concerned that new funding forprovinces and territories not displace current spending,and end up transferred within provincial health budgetsto become another drop in the ever-leaking acute carebucket. New funding should neither preferentially under-write those provinces that have chosen to invest at levelsmuch below others nor disadvantage provinces such asBritish Columbia and Quebec that have innovated andinvested in public health. Instead, we recommend that a new federal agency allocate these funds in such a waythat program expenditures roll up to reflect, with someallowance for year-over-year variation, approximatepopulation size, consistent with the Social UnionFramework Agreement.

The national agency should be free to set floors fordovetailed provincial activity or matching conditionsbefore a particular provincial public health branch canreceive earmarked program funds. The agency may alsochoose to underwrite all costs for particular provincial/municipal programs. What the Committee views ascrucial, however, is that there be no bulk transfer orpassive payments. The monies should be disaggregatedinto separate program grants, and different provinces

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should receive funds for different purposes to promoteachievement of a stronger and more consistent publichealth infrastructure. Overall target setting for inter-jurisdictional division of funds thereby becomes a mecha-nism whereby provinces are both assured of receiving areasonably fair share of support for their own priorities,and given incentives to set priorities for re-investment inconcert with the national agency.

Fifth, the areas of infectious disease surveillance andoutbreak management need specific support and attention.Ideally, outbreak management should be harmonizedwith other provisions for health emergencies and thesearrangements in turn dovetailed with broader strategiesfor emergency preparedness and response. To ensurethat these areas receive priority and avoid F/P/T tensions,it seems intuitively appealing to create a new networkwith earmarked funding inside the agency’s envelope forP/T contributions. This would be a uniquely Canadianapproach to reconcile some of the inter-jurisdictionaluncertainties that arise with public health not just in ourfederation, but in other federal states as well.

Sixth, Australia, the UK, and the USA all have embeddeda strong research and science component in their publichealth activities. These countries provide a solid founda-tion in epidemiology, surveillance and health statistics,to inform public health practice. The UK is the inter-national leader in its efforts to ground public healthpolicies and services in solid evidence. Canada needsmore applied public health research and evaluation,more systematic reviews and public health practiceguidelines, better training in the generation and interpre-tation of public health evidence, and better means ofstoring, maintaining and accessing the relevant knowledgefor public health practice. These issues have beenhighlighted in a document produced by the Institute ofPopulation and Public Health within the CIHR. Any newagency must have a combination of in-house capacityalongside funding to contract out R&D functions topartners such as the CIHR. The challenges go beyondpublic health and demand a review of our scientificcapacity with respect to infectious diseases research;further comments on this matter follow in Chapter 10.

Last, in one nation after another, we see efforts madeacross jurisdictions to exchange and share data andinformation. Public health practitioners were pioneeringusers of health information in the eighteenth andnineteenth centuries. More recently, public health, likethe personal health care system, has been unable to takefull advantage of innovations in information andcommunication technologies. Three levels of governmentare involved in public health, and as the SARS outbreakdemonstrated, public health must be connected to whatis happening in clinics, hospitals, and other parts of thehealth enterprise. Thus, information must move rapidlyto and from the clinical and public health frontlines.Both professionals and the media have been strongly and justifiably critical of the difficulties in sharinginformation across levels of government that becameevident in the recent outbreak of SARS. Special effortsmust be made not only to invest in informationtechnology, but also to generate the intergovernmentalagreements and information standards that will giveCanada a leading-edge public health information system.These must be an integral part of rolling out any newfunding, whether for general public health renewal, orearmarked for infectious disease surveillance and outbreakmanagement. Alongside these more informal agreements,and notwithstanding any federal legislative renewal, onecan also envisage a process to upgrade and harmonizepublic health legislation across Canada, facilitating thefunction of a truly seamless system to protect and promotethe health of our citizens, wherever they live.

These are not tall orders. They presuppose in the firstinstance only a visible and continuing commitment onthe part of all those who govern us to the principle that,whatever other differences may inevitably separate us in this sometimes-fractious federation, the health ofCanadians is paramount. Beyond that, the investment ofnew monies needed to transform public health is modestcompared to numerous other spheres of public spending,not least the personal health services sector. The singlequestion that the Committee would put to all healthministers, finance ministers, and first ministers isaccordingly simple: If not now, when?

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References1. Kuiken, Thijs, et al, “Newly discovered coronavirus as

the primary cause of severe acute respiratorysyndrome”, The Lancet, 2003, 362: 263-70.

2. Naylor, C. David, “Private Practice, Public Payment:Canadian medicine and the politics of healthinsurance, 1911-1966,” McGill Queen’s UniversityPress, Montreal, 1986: 35-37.

3. McKeown, Thomas, “The role of medicine: dream,mirage or nemesis?”, Oxford: Basil Blackwell, 1979.

4. Public Health in England, “The Report of theCommittee of Injury into the Future Development ofthe Public Health Function,” Cmnd 289, London:HMSO, 1988.

5. Report of the Premier’s Advisory Council on Health(Donald Mazankowski, Chair), “A Framework for Reform,”2001. (www.premiersadvisory.com/reform.html)

6. Public Health Act R.S.Q., 2001 c60, s5.

7. Rose, Geoffrey, “The population mean predicts thenumber of deviant individuals,” British Medical Journal,1990; 301:1031-4.

8. Wilson, Kumanan, “The complexities of multi-levelgovernance in public health”, (unpublished).

9. Lalonde, Marc (Minister of National Health andWelfare), “A New Perspective on the Health ofCanadians,” Ottawa: 1974.

10. Lederberg, Joshua, Shope, Robert E. and Oaks,Stanley C. (eds.), “Emerging Infections, MicrobialThreats to Health in the United States,” Committeeon Emerging Microbial Threats to Health, Instituteof Medicine), National Academy Press: WashingtonD.C, 1992.

11. Krever, Horace, “Commission of Inquiry on theBlood System in Canada,” Volume 3, p. 1073,released November 26, 1997.

12. Government of Quebec, “Emerging Solutions,”Commission d’étude sur les services de santé et lesservices sociaux, June 2000.

13. Government of Newfoundland and Labrador,“Healthier Together: A Strategic Health Plan forNewfoundland and Labrador.” Department of Healthand Community Services, released Sept. 10, 2002.(www.gov.nf.ca/health/strategichealthplan/pdf/HealthyTogetherdocument.pdf)

14. Romanow, Roy, “Building on Values: The Future ofHealth Care in Canada,” Commission on the Futureof Health Care in Canada, November 2002.

15. Frank, John and di Ruggiero, Erica, “Public Health inCanada: what are the real issues?”, Canadian Journalof Public Health, 2003, 94(3): 190-192, CIHR Instituteof Population and Public Health, Toronto.

16. The Standing Committee on Social Affairs, Scienceand Technology (Michael Kirby, chair), “The Healthof Canadians—The Federal Role,” Volume Six:Recommendations for Reform (Chapter 13), Ottawa,October, 2002.

17. Health Care Renewal Accord 2003. (www.hc-sc.gc.ca/english/hca2003/)

18. The Institute of Medicine, “The Future of the Public’s Health in the 21st Century,” publishedNovember 2002, National Academies Press.(www.nap.edu/catalog/10548.html)

19. Wente, Margaret. Globe and Mail, May 5, 2003, p. A15.

20. Federal/Provincial/Territorial Advisory Committee on Population Health, “Review of Public HealthCapacity in Canada,” Report to the Conference ofDeputy Ministers of Health, June 2001.

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Appendix 3.1US Department of Health and HumanServices Organizational Chart

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The SecretaryDeputy Secretary

Chief of Staff

Executive Secretary

Commissioner, Food and Drug Administration

(FDA)

Administrator, Health Resources and

Services Administration (HRSA)

Director, Indian Health Service

(IHS)

Director, National Institutes of Health

(NIH)

Administrator, Substance Abuse and Mental Health Services Adminstration

(SAMHSA)

Director, Program Support Center

(PSC)

General Counsel

Assistant Secretary for Public Health

Emergency Preparedness

Director, Center for Faith-Based and

Community Initiatives

Director, Office for Civil Rights

Inspector General

Chair, Departmental Appeals Board

Assistant Secretary, Administration for

Children and Families (ACF)

Assistant Secretary, Administration on Aging

(AoA)

Administrator, Centers for Medicare &

Medicaid Services (CMS)

Director, Agency for Healthcare Research and Quality

(AHRQ)

Director, Centers for Disease

Control and Prevention (CDC)

Administrator, Agency for Toxic Substances

and Disease Registry (ATSDR)

Assistant Secretary for Health

Assistant Secretary for Administration

& Management

Assistant Secretary for Budget, Technology,

& Finance

Assistant Secretary for Planning & Evaluation

Assistant Secretary for Legislation

Assistant Secretary for Public Affairs

Director, Intergovernmental Affairs, & Secretary’s

Regional Representatives