Strengthening the Pan-Canadian Public Health System

Key Concepts

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Letter from the Minister of State for Public Health

Over the past three years, concerns have grown about the capacity of Canada's public health system to anticipate and respond effectively to public health threats. The SARS outbreak, the ongoing challenges posed by the spread of West Nile disease, the BSE crisis and other events have underscored the urgency for decisive action. Recent reports by the National Advisory Committee on SARS and Public Health chaired by Dr. David Naylor, and by the Senate Standing Committee on Public Health, have helped clarify some of the major challenges confronting Canada's public health system. More importantly, both reports have proposed thoughtful and positive solutions for improving Canada's ability to manage outbreaks of infectious diseases. These proposed solutions complement the strong consensus that exists among all governments in Canada on the need to move forward together to strengthen national public health infrastructure and to work toward a national public health strategy. It is time for action.

On December 12, 2003, the Prime Minister appointed me to serve as Minister of State for Public Health. My immediate priority is to oversee the creation of a new federal public health agency of Canada that reflects the February 2, 2004, Speech from the Throne commitment to:

"...establish a strong and responsive public health system, starting with a new Public Health Agency of Canada that will ensure that Canada is linked, both nationally and globally, in a network for disease control and emergency response..." and "...appoint a new Chief Public Health Officer for Canada."

This preliminary Discussion Paper has been designed to enable me to share with interested Parliamentarians, public health stakeholders and concerned Canadians some of the initial planning assumptions for building a stronger national public health system, establishing a new Public Health Agency of Canada and appointing the Government of Canada's first-ever Chief Public Health Officer for Canada. I am specifically seeking your counsel and advice on 3 key issues:

• Inter-Governmental Cooperation & Public Health
• Agency Mandate & Mission
• Transparency & Accountability

Time is of the essence; recent reports about the spread of the Avian Flu Virus in some parts of Southeast Asia are a sobering reminder of the need to act now to shore up Canada's public health system. My intention is to proceed in a deliberate and expeditious way to give effect to the Throne Speech commitments.

Please provide any comments you or your organization might have on any or all of the preliminary issues raised in this discussion document:

• Via your Member of Parliament
• Through the Public Health Agency website
• By writing to me: The Honourable Carolyn Bennett, P.C., M.P.
  Brooke Claxton Building
  Tunney's Pasture
  Ottawa, Ontario K1A 0K9

To support informed discussion, submissions that have been received in an electronic format will be posted on the Health Canada website (with the consent of their authors). Please visit the Health Canada website for information on upcoming opportunities to contribute to the development of the new Public Health Agency of Canada .

The Health Canada website also provides links to the final report of the National Advisory Committee SARS and Public Health and the final report of the Senate Standing Committee on Public Health.

As proposals for strengthening our public health system and developing the new Agency are refined and clarified, I am committed to providing additional opportunities for your input and comment.

I look forward to learning of your views on these matters.

The Honourable Carolyn Bennett, P.C., M.P.
Minister of State for Public Health

CONTENTS

• Part A: Background & Planning Assumptions
• Part B: Issues for Discussion
  • I. Inter-Governmental Cooperation & Public Health
  • II. Agency Mandate & Mission
  • III. Transparency & Accountability
• Annex: Questions for Discussion

Part A: Background & Planning Assumptions

Building on a Foundation of Consensus

At the September 2003 Conference of Federal/Provincial/Territorial (FPT) Ministers of Health, Ministers acknowledged the need to:

"... make public health a top priority by improving public health infrastructure, and increasing institutional, provincial, territorial and federal capacity that builds on current strengths and successes across the country."

They also agreed to work collaboratively on such issues as:

• clarifying roles and responsibilities for preventing and responding to public health threats, in a manner respectful of federal, provincial and territorial jurisdiction;
• creating a national network of centres of public health science;
• ensuring the adequacy of health human resources and strengthening capacity to respond to regional and national public health emergencies; and
• enhancing national surveillance and information infrastructure.

Toward A Pan-Canadian Public Health Network

To build on this consensus, federal, provincial and territorial governments are working toward the creation of a Pan-Canadian Public Health Network. This Network could initially complement and - if it proves effective - eventually subsume, certain of the existing mechanisms and arrangements for intergovernmental collaboration on public health matters. The Network could serve as a forum for:

• ongoing dialogue on public health issues;
• coordinating responses to public health emergencies;
• developing national public health strategies;
• facilitating the development of national standards and agreements on issues such as resource and data sharing, accreditation of health professionals; and
• encouraging the development of centres of public health expertise across the country.

The development of the new Public Health Agency of Canada must take account of this broader effort to strengthen and improve coordination across the public health system. Accordingly, in addition to an overall mandate to serve as a focal point within the federal government on public health matters, the new Agency will also be expected to make an important contribution to the development of an effective Pan-Canadian Public Health Network.

Direction from the National Advisory Committee & the Senate Committee Reports

In their respective reports, both the National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health concluded that the federal government should create an Agency with specific responsibilities for public health in areas of federal jurisdiction. They proposed an Agency legally and visibly separate from Health Canada, but operating under the direction of, and accountable to, the federal Minister of Health. The reports envisaged an Agency with the authority necessary to act promptly in public health emergencies and sufficiently autonomous to enable it to engage and collaborate with provincial/territorial and local health authorities on public health matters.

The National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health reports further concluded that the federal government should appoint a senior official to serve as Canada's "Chief Public Health Officer" (CPHO). In their view, the CPHO would provide dedicated and authoritative leadership on public health issues generally and during public health emergencies. This individual would also serve as the primary interlocutor with his/her provincial and territorial counterparts through the existing Council of Chief Medical Officers of Health. Finally, both reports proposed that the CPHO also serve as the Chief Executive Officer for the new Agency.

Proposed Elements of a Canada Public Health Agency

Keeping in mind the overall goal of a strengthened national public health system and the establishment of an effective Pan-Canadian Public Health Network, the following assumptions will guide the development of a new Public Health Agency of Canada :

The Agency would:

• be established by statute;
• operate within the Health Canada Portfolio, but be separate from Health Canada;
• be managed by a Chief Public Health Officer;
• have appropriate advisory structures to provide for ongoing and timely expert advice from the medical, health and scientific communities, from community and advocacy groups, and from other related sectors;
• act as an important focal point within the Pan-Canadian Public Health Network; and
• be accountable to the Minister of Health who would retain ultimate responsibility for matters of public health within the Health Canada portfolio and be accountable to Parliament for what is done in and by the Agency.

The CEO/Chief Public Health Officer would:

• manage and lead the Agency;
• provide timely, objective and evidence-based advice to the Minister on all matters pertaining to public health and national readiness for public health threats;
• develop and implement policies, plans, programs and decisions approved by the Minister to protect the health of Canadians;
• interact with the public health community and with public health experts, both in Canada and internationally;
• contribute to the efforts of the Pan-Canadian Public Health Network to strengthen Canada's public health system;
• provide leadership in advancing Canada's interests in international agencies focussed on public health matters;
• ensure the Agency carries out its tasks in accordance with its mandate; and
• (during public health disasters and emergencies), help coordinate national public health response.

The Agency priorities would be to:

• support national readiness for public health threats, with particular emphasis on the adequacy of, and capacity to deploy, health professionals where and when they are needed in response to public health threats;
• promote excellence in the management of public health in Canada and throughout the world; and
• oversee federal efforts to:
  • strengthen national capacity to identify and reduce public health risk factors; and
  • develop, implement and assess policies and programs that support efforts and strategies to enable Canadians to live a healthier life.

Help Shape the Future of Canada's Public Health System

The three Sections that follow highlight various issues related to the objectives of developing a Pan-Canadian Public Health Network and building a new Public Health Agency of Canada, under the direction of a Chief Public Health Officer for Canada, as an important component of this Network. Please provide any comments you or your organization may have on any or all of the issues raised in these materials, as well as any other suggestions or advice you may have in relation to these efforts.

Part B: Issues For Discussion

Issue I: Intergovernmental Cooperation & Public Health

At the September 2003 Conference of Federal/Provincial/Territorial (FPT) Ministers of Health, Ministers acknowledged the need to:

"... make public health a top priority by improving public health infrastructure, and increasing institutional, provincial, territorial and federal capacity that builds on current strengths and successes across the country."

They also agreed to work collaboratively on such issues as:

• clarifying roles and responsibilities for preventing and responding to public health threats, in a manner respectful of federal, provincial and territorial jurisdiction;
• creating a national network of centres of public health science;
• ensuring the adequacy of health human resources and strengthening capacity to respond to regional and national public health emergencies; and
• enhancing national surveillance and information infrastructure.

In addition, the National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health reports both highlighted weaknesses in Canada's ability to anticipate and respond to outbreaks of infectious diseases and other public health threats and structural inadequacies within Canada's broader system of public health response. Both reports concluded that:

• there is an essential need for the federal government to improve its own public health capacity;
• there is an essential need for better FPT coordination on public health issues and especially in responding to public health threats/emergencies; and
• more effective approaches are needed on all aspects of public health, not just emergency response.

Addressing these challenges will require a coordinated approach involving all governments, and it is clear that better FPT coordination is essential to the effective management of broader public health issues. To this end, the federal government is committed to working closely with provinces/territories on the development of new collaborative public health strategies and in working on national public health priorities.
As a reflection on this need for collaboration, FPT Deputy Ministers of Health have already been tasked with working toward the development of a national public health strategy.

Going beyond this work, there is a need to develop new modes of consultation and cooperation that would:

• provide a forum for the coordination and oversight of national public health initiatives;
• allow jurisdictions to work together and establish consensus-based priorities, which would help all governments focus and refine their public health investments and resources;
• help define and clarify jurisdictional roles and responsibilities with respect to public health, and seek to reduce duplication and overlap between jurisdictions;
• improve information and data sharing between jurisdictions;
• allow for the exchange of information on best practices and guidelines to assist governments to work within their respective jurisdictions;
• improve inter-jurisdictional coordination of public health labs, programs and services;
• establish codes of practice or other standards that could be applied by individual jurisdictions, as appropriate, within their own domain; and
• provide for joint analysis and expert/stakeholder/community/public discussion on emerging public health issues or trends.

Improved Planning & Priority Setting

In building these new modes, it should be noted that a wide variety of FPT committee structures already exist that could be refined and focussed for the purposes described above. These include meetings that already regularly occur between Ministers and Deputy Ministers of Health and between Health Canada and the Council of Chief Medical Officers.

There are also a variety of areas where collaboration between the federal government and provinces/territories, or between the provinces and territories themselves, could be improved by building formal agreements that set out the rules of collaboration on public health issues. Among the areas where such "formal" arrangements might be of benefit are:

• rules on sharing public health information, including arrangements for timely access to information in times of emergency, best practices in data collection, and protection of privacy;
• arrangements to provide assistance/share resources in times of emergency;
• consensus-based standards and best-practices in areas like immunization;
• arrangements to allow for the inter-jurisdictional practice of designated public health professions (to ease their work in non-resident provinces); and
• interchange agreements allowing for the temporary secondment of public health professionals to other jurisdictions for the purposes of training/experience.

In reflecting upon the above options, the following considerations should be noted:

• any new arrangements must respect the authority and jurisdiction of each government to manage public health operations within their own domain;
• how each province and territory exercises its public health responsibilities, establishes priorities and manages its public health infrastructure varies significantly, and this precludes a "one-size fits all" approach to public health.

The development of a Pan-Canadian Public Health Network, as described earlier in this Discussion Document, would help to give expression to these objectives.

Questions for Discussion

What are the challenges inherent in achieving greater collaboration in public health in a federal system where responsibility for public health is shared?

What should be the "ground rules" for future federal-provincial-territorial cooperation in this area?

Are there "gaps" in Canada's existing public health system that could be addressed through the collaborative approach described above and through the development of a Pan-Canadian Public Health Network? If so, what are the priority areas where this approach should be contemplated?

Is there merit in seeking to build a process of citizen/stakeholder engagement into future intergovernmental arrangements in area of public health? If so, how should it be structured?

Issue II: Agency Mandate & Mission

Background

Canada's public health system comprises everything governments in Canada do to protect and improve the health of Canadians. While responsibility for public health is shared among the federal and provincial/territorial governments, the provinces and territories have front-line responsibility for responding to health threats that occur within their jurisdiction. However, both orders of government conduct monitoring and surveillance activities to identify and respond to potential threats to the health and safety of Canadians. Also, both exercise regulatory duties and implement policies, programs and educational efforts to protect population health and to promote informed health choices. Moreover, responsibility for public health does not rest within a single federal, provincial or territorial department or agency, but is typically a government-wide responsibility. The effectiveness of Canada's overall public health system has a direct impact on the health of Canadians and on the sustainability of our health care system.

Collaboration to Strengthen the Public Health System

At the September 2003 Conference of Federal/Provincial/Territorial (FPT) Ministers of Health, Ministers agreed to make public health a top priority. They also concurred on the need to improve public health infrastructure and to build on existing strengths across the country in order to improve overall institutional, provincial, territorial and federal capacity. Finally, Health Ministers tasked their deputies to work toward a national public health strategy.

Developing a pan-Canadian Public Health Network that could complement existing FPT mechanisms, and that could serve as a forum for intergovernmental dialogue, collaboration and coordination, would constitute an important step forward toward these objectives.

The National Advisory Committee and the Senate Standing Committee Prescription

The National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health reports both highlighted weaknesses in Canada's ability to anticipate and respond to outbreaks of infectious diseases and other public health threats and structural inadequacies within Canada's broader system of public health response. In response to these concerns, the Government of Canada announced in the February 2, 2004, Speech from the Throne its intention to establish a new Public Health Agency of Canada and to appoint a Chief Public Health Officer for Canada.

Toward a new Canada Public Health Agency

As part of an overall effort to strengthen Canada's public health system and as a component of an eventual Pan-Canadian Public Health Network, a new Public Health Agency of Canada would be designed to:

• support national readiness for public health threats, with particular emphasis on the adequacy of, and capacity to deploy, health professionals where and when they are needed in response to public health threats.;
• promote the management of public health in Canada and throughout the world; and
• oversee federal efforts to:
  • strengthen national capacity to identify and reduce public health risk factors; and
  • develop, implement and assess policies and programs that support efforts and strategies to enable Canadians to live a healthier life

Agency Mandate and Functions

There are a wide range of factors that influence the health and life expectancy of Canadians. An individual's genetic background, their income and level of education, their marital status, the conditions under which they live and work, their own sense of personal security and of citizenship - all of these factors make a difference!

The point here is that the main "determinants" that will decide whether or not an individual is healthy and will have a long life, are ones that affect society as a whole. Various departments and agencies of government, through their policies and programs, play an important role in influencing these determinants. Clearly, boundaries matter. It would be unrealistic to incorporate within the new Public Health Agency of Canada all that the federal government does to protect and promote public health. The challenge is determining what role the new Agency can and should play relative to that of other federal government departments and agencies, provincial and territorial authorities and the roles and responsibilities of other public health stakeholders, including health professionals, the scientific and research communities, advocacy groups and others.

Questions for Discussion

What should the new Agency's priorities be in terms of issues, target populations, programs, health protection and promotion, improving public health capacity and reducing public health risk factors?

What criteria should be used to determine the mandate and functions of the new Agency?

What contribution can/should the Chief Public Health Officer for Canada make in relation to advancing Canada's interests in international organizations like the World Health Organization or the Pan-American Health Organization?

Issue III: Transparency & Accountability

Background

Promoting health and quality of life for Canadians by preventing and controlling disease, disability and injury must be at the heart of any renewed national public health system. There is also a need for a trusted source for credible, timely and accessible information that enables governments, health professionals and ordinary Canadians to make informed choices that support good health. The National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health reports proposed a federal public health agency of Canada that could contribute to these objectives.

While the agency contemplated by the National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health could undertake health promotion and education activities directly, it would also need to establish strong and effective partnerships with a variety of groups and organizations. These include, among others, provincial and territorial officials; health professionals, administrators and the health policy community; the scientific and academic communities; Parliamentarians and elected officials; community groups and organizations; and, foreign governments and international agencies like the World Health Organization. These partnerships would contribute to the agency's effectiveness by making it easier to:

• monitor emerging health risks;
• coordinate, with provinces and territories, responses to real or potential health emergencies;
• share and apply information and knowledge on public health; and
• leverage the "reach" of the agency's health promotion and public education efforts.

But there is also another important group that the agency envisaged by the National Advisory Committee on SARS and Public Health and the Senate Standing Committee on Public Health would need to partner with in order to ensure its success: Canadians!

Canadians must have confidence that any agency that is established with their tax dollars to protect their health and safety has the tools, resources and strong leadership it requires to fulfill its mandate. Canadians also must have an opportunity to contribute, on an ongoing basis, to such an agency's success and to ensure it is effective and accountable.

Recognizing this imperative for accountability, a number of mechanisms can be contemplated to ensure that the new Public Health Agency of Canada operates in an open and transparent manner. Before reviewing these mechanisms, it is important to note that Ministerial accountability is an important principle of our democratic electoral system. Consistent with this principle, Ministers may not delegate to un-elected officials authority to make major policy decisions that may have major economic, social or political consequences that could affect federal-provincial-territorial relations or that may impact on Canada's international interests. Thus, while one of the objectives for creating a new Public Health Agency of Canada and for appointing a Chief Public Health Officer for Canada is to have a clear focal point of accountability for decisions affecting public health and for preparing for public health emergencies, the new Agency and Chief Public Health Officer will be accountable to the federal Minster for Health.

Among the mechanisms that could support transparency and accountability objectives for the new Agency are:

Advisory Structures

The new Agency must develop effective advisory structures that ensure that the interests and perspectives of the medical, scientific and stakeholder communities, of Members of Parliament and of Canadians themselves, are brought to bear on the policies, programs and priorities of the Agency.

Annual Reports

The Agency will be required to table an Annual Report to Parliament detailing its financial performance, operations and activities. The report could also contain information on a wide range of issues relating to public health including, among others, emerging health threats, international "best practices" in public health and reports on the health status of Canadians or of vulnerable populations.

Accountability/Transparency

The Agency will be governed by the same accountability framework and rules that apply to other federal government departments and agencies. This means that Parliamentary Committees and the Auditor General could have authority to review the Agency's overall policy, program, operational and financial performance.

Engaging Canadians

In addition to tabling an Annual Report, the new Agency will need to develop other mechanisms to enable Canadians to influence the direction of the Agency, share their views on public health issues and obtain timely and relevant information on potential health risks and how to mitigate them.

Questions for Discussion

What types of advisory structures and mechanisms should the new Agency establish to ensure appropriate oversight into its operations and activities by expert stakeholders, Members of Parliament and Canadians themselves?

Are there specific issues or matters on which the Agency should report annually to Canadians?

What types of requirements or mechanisms would contribute to the good governance of the Agency?

What mechanisms should the Agency consider establishing to engage Canadians on an ongoing basis in its deliberations and in shaping its future directions?

Annex - Questions For Discussion

Questions for Discussion - Issue I

What are the challenges inherent in achieving greater collaboration in public health in a federal system where responsibility for public health is shared?

What should be the "ground rules" for future federal-provincial-territorial cooperation in this area?

Are there "gaps" in Canada's existing public health system that could be addressed through the collaborative approach described above and through the development of a Pan-Canadian Public Health Network? If so, what are the priority areas where this approach should be contemplated?

Is there merit in seeking to build a process of citizen/stakeholder engagement into future intergovernmental arrangements in area of public health? If so, how should it be structured?

Questions for Discussion - Issue II

What should the new Agency's priorities be in terms of issues, target populations, programs, health protection and promotion, improving public health capacity and reducing public health risk factors?

What criteria should be used to determine the mandate and functions of the new Agency?

What contribution can/should the Chief Public Health Officer for Canada make in relation to advancing Canada's interests in international organizations like the World Health Organization or the Pan-American Health Organization?

Questions for Discussion - Issue III

What types of advisory structures and mechanisms should the new Agency establish to ensure appropriate oversight into its operations and activities by expert stakeholders, Members of Parliament and Canadians themselves?

Are there specific issues or matters on which the Agency should report annually to Canadians?

What types of requirements or mechanisms would contribute to the good governance of the Agency?

What mechanisms should the Agency consider establishing to engage Canadians on an ongoing basis in its deliberations and in shaping its future directions?