Ontario's proposal to end provincial funding for public health: What is at stake?
Larry W. Chambers, MSc, PhD
CMAJ 1997;156:1001-3
[ résumé ]
Dr. Chambers is Epidemiology Consultant with the HamiltonWentworth Regional Public Health Department and Professor in the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
Reprint requests to: Dr. Larry W. Chambers, Department of Public Health Services, 25 Main St. W, 4th floor, Hamilton ON L8P 1H1; chambers@fhs.csu.mcmaster.ca
© 1997 Canadian Medical Association (text and abstract/résumé)
Abstract
The Ontario government intends to introduce legislation requiring municipalities to assume full funding of public health and other locally administered social programs. This bodes ill for the future of public health services in Ontario. The author points out that public health programs in the US are supported by government funding and by a network of state-funded schools of public health. The Ontario government can ensure the survival of a strong public health system only by guaranteeing funding to municipalities, supporting professional education in public health and introducing legislation to ensure the delivery of mandatory public health programs.Hamilton, Ont.
Résumé
Le gouvernement de l'Ontario a l'intention de présenter une mesure législative pour obliger les municipalités à prendre en charge le financement complet de la santé publique et d'autres programmes sociaux administrés à l'échelon local. C'est de mauvaise augure pour l'avenir des services de santé publique en Ontario. L'auteur signale que les programmes de santé publique aux États-Unis bénéficient d'un financement gouvernemental et ont l'appui d'un réseau d'écoles de santé publique financées par les États. Le gouvernement de l'Ontario ne pourra assurer la survie d'un solide système de santé publique qu'en garantissant du financement aux municipalités, en appuyant la formation professionnelle en santé publique et en présentant des mesures législatives pour assurer la prestation de programmes obligatoires de santé publique.
In January of this year the government of Ontario announced its intention to introduce legislation requiring the province's municipalities (or regions) to assume full funding of public health programs and various other locally administered social services. In return, primary and secondary education will be paid for directly by the province. The province's 42 boards of health will be responsible for funding public health programs out of $225 million raised from municipal property taxes.[1]
Although the level of provincial funding has not been revealed, the Ontario government plans to retain responsibility for certain province-wide programs as determined by a social and community health services implementation team. Comprised of representatives from the provincial and municipal levels of government, the team is working out the details of programs and financing.[1] At the same time, the Harris government is proposing to make changes to the boundaries, structure, funding and governance of municipalities through additional legislation; this creates further uncertainty about the role of municipalities in public health.
These plans reverse the $225 million funding agreement made under Ontario's Health Protection and Promotion Act of 1983,[2] by which the province agreed to provide to the 42 boards of health 75% of funding for mandatory public health programs (including disease surveillance, vaccination, infectious disease control, food safety and water quality control, family health, prevention of sexually transmitted diseases, rabies control, prevention of noncommunicable diseases and injuries, and so on) and 100% of funding for priority activities such as AIDS programs. For Metropolitan Toronto, the province pays 40% of the cost of mandatory programs and the municipalities pay 60%.
Before the 1983 Act was implemented, mandatory public health programs were not identified in law. The province paid roughly 50% of the cost of municipal programs, and many municipalities were known to put roads and other capital-works projects ahead of public health services. Even since 1983, many local public health boards have been unable to spend their full allocation from the province because they cannot get local politicians to approve their share (25%) in municipal budgets.
Policy-makers in Ontario have been taking a favourable view of health care trends in the US, such as "managed care" and "integrated care," the separation of care funders from care providers and the movement toward greater private-sector involvement; such enthusiasm is evident in the government's move to curtail payment for "nonessential" physician services. However, Dr. David A. Kessler, Commissioner of the US Food and Drug Administration, has pointed out that even though the American public is "anti-government" it has high expectations of government with respect to health promotion and protection.[3] Most US states do not leave 100% funding of public health services up to municipal governments. In 1996 the Institute of Medicine of the National Academy of Sciences urged states and municipalities to fund the following core functions of public health:
- as part of a community health improvement process, collecting, analysing, interpreting and communicating information about health conditions, risks (e.g., environmental health risks) and assets (e.g., high rates of literacy and voluntary health associations) in a community,[4]
- identifying and working with all of the entities in a community that influence health to create, implement and evaluate plans and policies for public health in general and priority health needs in particular in a manner that incorporates scientific information and community values,[4,5] and
- ensuring that "high-quality services, including personal health services needed for the protection of public health in the community are available and accessible to all persons."[5]
Equivalent functions have been articulated by the Canadian Public Health Association.[6]
Local public health units are key among health care agencies in the community in that they have a mandate to focus on health issues affecting the population as a whole. As such, they view health not as an end in itself but as a resource for the community and its members. The determinants of the health of a population include the social and physical environment, individual lifestyles, the health status and function of individuals, the productivity and wealth of individuals and of society as a whole, and the health care system. In keeping with the World Health Organization's Charter of Health Promotion,[7] public health units endeavour to promote health by:
- advocating (i.e., communicating effectively to policy-makers in all sectors),
- enabling (i.e., involving consumers and laypeople in building their capacity for intelligent and equal involvement with professionals),
- mediating (i.e., recognizing and working with organizations, groups and individuals from many cultures, including not only ethnic cultures but professional and organizational cultures as well),
- building public policy on health,
- creating supportive environments with respect to families, the educational system, social networks, socioeconomic status, work setting and level of prosperity of the community,
- strengthening community action on health issues,
- developing the skills of individuals, and
- reorienting health care services to improve the population's health through optimal uses of resources, such as by improving hospital discharge planning for elderly and very ill patients and for new mothers, and by assessing community health needs in planning services.
In the US, a network of state-funded schools of public health as well as large federally funded research and development agencies such as the Centers for Disease Control and Prevention "ensure [that there is] a competent workforce for public health" and provide "new insights and innovative solutions to health problems."[8] Thus, even with its private insurance systems, the US strongly supports government-funded public health services, education and research.
Ontario's Health Protection and Promotion Act gives to local boards of health the authority to support public health education and research. In 1986 the Ministry of Health began funding the Teaching Health Unit Program.[9] Under this program the ministry transfers $6.3 million annually to 8 of the 42 local public health units to provide education for future public health practitioners and existing staff. There is no other provincial public health training program in Canada and no school of public health. Each teaching unit is affiliated with 1 or more universities and integrates education and research into its service activities. Building blocks to this integration have included the recruitment and training of appropriate staff, close collaboration with university faculty, and research and development of public health programs. The Teaching Health Unit Program was not mentioned in the government's announcement of the proposed changes to social services funding. The social and community health services implementation team should ensure that this
program, clearly a valuable investment for the whole province, continues to be funded.
If Ontario wishes to "keep up" with the US it should consider carefully that country's support for public health activities, including its support for schools of public health. The provincial government can ensure the survival of a strong public health system in Ontario only by guaranteeing funding to municipalities for public health, supporting the Teaching Health Unit Program as it furthers public health research, education and development[10] and introducing legislation giving greater powers to the province to enforce mandatory public health program requirements within municipalities. The people of Ontario should be assured of continuing public health services at the level of excellence currently known throughout the province.
References
- Ecker announces new plan for social and community health services [news release]. Toronto: Ministry of Health; 1997 Jan 14.
- Health Protection and Promotion Act RSO 1990 c H7.
- Kessler DA. Television interview. The lead [Newsworld]. Toronto: Canadian Broadcasting Corporation; 1997 Jan 30.
- Institute of Medicine. Improving health in the community: a role for performance monitoring. Washington: National Academy Press; 1997.
- Institute of Medicine. Healthy communities: new partnerships for the future of public health. Washington: National Academy Press; 1996:2.
- Canadian Public Health Association. Focus on health: public health in health services restructuring. Can J Public Health 1996;87(1 suppl I):I1-I26.
- World Health Organization. World Health Organization Charter on Health Promotion. Can J Public Health 1986;77:425-7.
- Baker EL, Melton RJ, Stange PV, Fields ML, Koplan JP, Guerra FA, et al. Health reform and the health of the public: forging community health partnerships. JAMA 1994;272:1276-82.
- Provincial Teaching Health Unit Steering Committee. Public health research, education and development partnership: reinventing the Teaching Health Unit Program [final report]. Toronto: Ontario Ministry of Health; 1997.
- Proposal for the Public Health Research, Education and Development Program. Toronto: Ontario Ministry of Health; 1997.
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