Report: A Public Health Agency for Canada

Working Group on a Public Health Agency for Canada April, 2004

I. A Pan-Canadian Public Health Network

Building a Foundation for Intergovernmental Harmony and Cooperation

The management and provision of public health services in Canada is a matter of shared jurisdiction by federal and provincial/territorial governments. While the Constitution of Canada confirms the federal government's authority in relation to critical components of national public health policy such as quarantine, and the federal government takes a leading role in matters like the provision of the National Microbiology Laboratory in Winnipeg, provincial and territorial governments are chiefly responsible for the "on the ground" delivery of public health services. This means that intergovernmental collaboration in public health is essential.

As the Naylor Report notes, the recent SARS crisis demonstrated that critical gaps exist in the intergovernmental coordination of public health issues. Clearly, these gaps must be addressed in building a durable, national approach to public health.

There are three basic models that could potentially be applied in building such an approach:

• Federal Direction: This model, occasionally prescribed within the policy community, is based on the premise that public health matters - particularly emergencies - are so important that the federal government should simply use its powers for "peace, order and good government" to unilaterally direct how public health matters should be addressed, and to ensure they are fully addressed.
• Joint Management: This model, also occasionally advocated within the policy community, is based on the premise that efficiencies and practical advantages could be gained by establishing some form of joint management and administrative entity, which would combine and jointly administer the public health responsibilities of both orders of government.
• Strengthened Collaboration: This model would involve a concerted effort by all jurisdictions to collaborate on the development of effective national approaches to public health issues, and where necessary it would allow for the pooling of resources.

It is the Working Group's view that the first of these options - unilateral federal direction over public health - is neither appropriate nor practical. Functionally, many aspects of public health service delivery are tied to the delivery of other health services - such as primary health care services - that are clearly within the domain of provincial and territorial governments. It is unlikely that these services could be appropriately "unbundled" in a way that would allow the federal government to assert unilateral control over the administration of public health "on the ground". Beyond this, there is no question that aspects of public health delivery are clearly within provincial and territorial domain: any effort by the federal government to unilaterally assert authority over provincial and territorial jurisdiction would bring with it further intergovernmental discord and would make the effective and coordinated delivery of services even more problematic.

The notion of moving to a "joint management" approach to public health could prove similarly problematic. This approach would involve the development of some form of new "national" entity that would subsume federal and provincial/territorial authorities and to which both orders of government would theoretically cede their responsibilities for public health. To date, Canadian experience with such arrangements has been limited and primarily focused in information gathering/narrow policy issues (e.g. Canadian Institute for Health Information, Canada Health Infoway Inc., Canada Patient Safety Institute) or regulatory matters (e.g. Canada-Newfoundland and Canada-Nova Scotia Offshore Boards). The Working Group concluded that such a model would take considerable time to develop and would be complicated by:

• The need to obtain agreement across all jurisdictions.
• The significant and legitimate variation that exists between jurisdictions in the way they manage public health issues and determine public health priorities.
• Federal/provincial/territorial jurisdictional concerns and related funding challenges.
• The impracticality of seeking to separate the oversight of "front line" public health services from the general health delivery structures now managed by provinces and territories.
• The practicality and appropriateness of governments ceding their authority over some matters (e.g. border, quarantine) to an arm's-length, jointly-managed agency.

As a result of the above considerations, the Working Group focused its attention on options to develop stronger and more effective intergovernmental collaborative mechanisms for public health. The Working Group concluded that the following basic rules were essential to shaping and implementing any new approach:

• Respect for the jurisdictional responsibilities and authorities of each level of government regarding matters of public health.
• Respect for the right of each jurisdiction to determine how to best exercise its public health responsibilities, establish priorities and manage its public health infrastructure.
• A focus on realistic, meaningful and measurable outcomes that improve the efficiency and efficacy of public health services, particularly those related to emergency response.

In this context, the Working Group believes there is merit in establishing a Pan-Canadian Public Health Network which knits together the infectious disease network and other intergovernmental processes discussed in the Naylor Report. The Network would be a new intergovernmental framework focused around a "rules-based" approach to federal/provincial/territorial relations. Improved processes of intergovernmental dialogue would be developed and then guided by a series of formal agreements that specify the "rules of intergovernmental engagement" on specific public health issues.

In parallel with the development of this Network, the Working Group believes there is a need to align federal resources and responsibilities for public health in a Chief Public Health Officer/Public Health Agency which are effectively designed to "get the federal house" on public health in order and ensure clear and effective leadership at the professional level within the federal public service. Proposals and recommendations relating to the CPHO and Agency are set out in Sections II and III of this report.

Network Mandate

The Pan-Canadian Public Health Network would function as a comprehensive mechanism for intergovernmental collaboration, coordination, oversight, and joint policy development on public health issues. It would:

• Develop and maintain agreements to govern intergovernmental collaboration in public health.
• Seek to establish consensus-based priorities that enable governments to better coordinate their efforts in order to more effectively target their respective 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.
• Oversee a process for developing, approving and implementing common standards, guidelines and the sharing of best practices.
• Promote and oversee a process of applied research and its translation into policies, programs and practice.
• Over time, and where appropriate, seek to build new cooperative and collaborative mechanisms and approaches on public health matters.

In the above context, the Network would become a mechanism for better coordinating and organizing existing federal/provincial/territorial bodies and dialogue on public health. It would also become the locus for the development of new national policy initiatives such as the development of a Pan-Canadian Public Health Strategy (based on the September 2003 consensus of Ministers of Health). Building from the concept of "networks" as set out in the Naylor Report, the Canadian Public Health Laboratory Network, as well as other initiatives such as the Canadian Pandemic Influenza Plan, could be also managed by the Network.

Network Design Features & Elements

The Network would be a new collaborative federal/provincial/territorial mechanism. The Working Group proposes that there be a formal charter for the Network, set out in a joint intergovernmental statement, memorandum of understanding (MOU), or agreement. This charter would affirm the Network's mission, operating assumptions and directions.

The basic structure of the Network would be as follows:

• The federal government and each provincial and territorial government would participate in the Network through a specified representative or agency.
• The Network would be accountable to the federal/provincial/territorial Council of Ministers of Health and individual members would be accountable to their own respective governments/Ministers.
• The Network would be led by a Coordinating Committee co-chaired by a federal representative and a provincial or territorial representative, and comprised of a designated representative from each jurisdiction. The federal lead official and federal co-chair of the Network would be the Chief Public Health Officer (CPHO) for Canada. Provincial Medical Officers of Health could also be encouraged to have a leading role in the Network.
• The Coordinating Committee should meet at least twice a year and could, with the concurrence of provincial and territorial governments, eventually replace any other intergovernmental bodies deemed appropriate.
• The Coordinating Committee would establish new collaborative mechanisms or working groups where they are necessary. It should also establish advisory groups involving the academic, scientific, stakeholder or public community to provide advice on specific issues where this has merit and seek to build stakeholders and academic/scientific institutions directly into its ongoing activities.¹
• Federal/Provincial/Territorial Ministers would designate officials who could provide administrative support to the Network. Ideally, each participating government should assume its share of the costs associated with this "secretariat" to underscore the collaborative nature of the Network. Efforts would be made to keep new costs to a minimum.

It is also proposed that Ministers undertake a review of the effectiveness of the Network every 5 years with a view to directing improvements in its operations and activities.

MOUs/Agreements

It is proposed that a series of intergovernmental MOUs or agreements on public health matters, setting out the rules that would apply between provincial and territorial governments, as well as between provincial and territorial governments and the Government of Canada, be the foundation upon which the Network rests. These agreements would be formal arrangements, consistent with Social Union Framework Agreement principles, specifying detailed commitments and rules.

The exact list of agreements to be negotiated, and their substance, should be determined collaboratively by federal/provincial/territorial governments. The Working Group proposes that, as a starting point, agreements be contemplated on the following priorities:

• Information sharing, data standards and privacy.
  • This work should be closely coordinated with other on-going efforts to negotiate intergovernmental agreements on data sharing in health.
• Inter-jurisdictional practice of accredited health professionals.
  • Specific priority should be given to MDs, RNs/BNs, and other specified public health professionals.
• Emergency coordination and sharing of resources.
  • A specific protocol should be developed on how risk communications should be coordinated between jurisdictions, as well as arrangements which would allow for the sharing of assets and personnel between jurisdictions (at cost recovery) in times of emergency.
• Training and training standards.
• Interchange of health professionals.

The Working Group believes there would be merit in federal/provincial/territorial Ministers of Health formally directing officials to develop the agreements noted above as a priority over the next year. Ministers may wish to contemplate a formal "launch" of this process, perhaps timed in conjunction with a public statement of commitment to the Network.

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¹ While the potential should exist to build others (e.g. stakeholders, academic institutions) more formally into the Network over time, the Network must be primarily an intergovernmental mechanism, and other partners should not be added at the expense of building durable intergovernmental trust and collaboration.

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