Report: A Public Health Agency for Canada

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

III. A Public Health Agency for Canada

Building from the recommendations of the Naylor and Kirby Reports, the Working Group believes that there is considerable merit in establishing a dedicated, sole purpose Public Health Agency for Canada that would bring together the existing resources and capacities now found within Health Canada on matters related to public health. In addition to serving as a focal point for leadership and accountability on public health matters within the federal government, the Agency would lead and coordinate the federal government's contributions to the Pan-Canadian Public Health Network described in the previous section of this report.

A. Agency Structure and Operating Principles

A Distinct Agency

In the wake of the Naylor and Kirby Reports, there has been considerable discussion within the policy community over the degree to which such an agency should be at arms'-length from the existing structure of Health Canada. To some degree, this discussion has been clouded by varying views and interpretations of the possible roles and responsibilities of a CPHO and a dedicated public health agency. At one end of the spectrum is the argument that an agency should perform the duties of an "Auditor General for Public Health" and play an advocacy or ombudsman role in addressing public health matters. The proponents of this view see the need for a public health agency that has a high measure of autonomy from Health Canada - in effect a body that has a high degree of independence and is free to criticize government action or inaction. At the other end of this spectrum is the argument that a new entity is needed to rationalize and integrate the broad range of existing public health services within federal domain into a single, dedicated and sole purpose entity. Advocates of this position challenge the need to take such an agency outside the existing structure of Health Canada.

It is the view of the Working Group that, while there is merit in both of these options, the two cannot be easily or appropriately mixed. While the "Auditor General" approach suggested in the first option would provide a useful "challenge function" in assessing and potentially improving the existing activities of the Government in public health, in practical terms, an agency taking on such a role could not play a direct role in the delivery of public health programs and services is assesses. The second of these options would require any new agency to maintain a close relationship with both the Minister of Health and Health Canada, as it should be in a position to offer advice to the Minister on public health policy issues (as a matter of principle, policy matters remain a prerogative of Cabinet, and Ministers do not delegate policy matters to independent organizations) and ensure that its activities are closely coordinated with those of other agencies within the Health portfolio.

Particular consideration must be given in this context to the degree to which any new agency should be able to act autonomously to protect the public interest in times of emergency. While the Working Group agrees that there is an essential need to ensure that any agency can act quickly and effectively in times of emergency, this is quite different from a need for independence. Among the key decisions that may need to be taken in times of emergency would be critical decisions to close borders - including those between nations and potentially between individual provinces and territories. It would seem inappropriate and impractical to delegate such a responsibility to an independent agency given the practical economic, international and political ramifications that could ensue. Indeed, in times of war, critical decisions on the deployment of troops and the disposition of resources remain with Cabinet. In this context, it seems implausible that Cabinet would delegate its responsibilities under the Emergencies Act, the Emergency Preparedness Act, the Quarantine Act, or other legislation. Beyond all of these considerations, it should be noted that only a portion of the work of a new public health agency should deal with public health emergencies; an effective agency will need to take command of the full range of public health issues, such as the development and coordination of new programs and approaches concerning chronic disease and health promotion. Indeed, in dealing with matters like diabetes and obesity, the Government will be forced to make trade-offs between new initiatives in these areas and other social policy priorities. This would make the delegation of such responsibilities to an independent agency both implausible and impractical.

In light of the foregoing, it is the view of the Working Group that:

• There is an essential need for a new agency that can provide a more focused, intensive and science-based perspective in the management and delivery of existing public health services within Health Canada and more broadly within the federal system.
• This new agency must play a leadership role in the design and delivery of public health policies, programs and services, starting with those programs and services already managed by Health Canada.
• The new agency should possess the clinical expertise and acumen necessary to detect patterns of clinical symptoms and signs at the earliest possible stage and to advise on their management.
• In the above context, any new agency should be in pith and substance a new policy, program and service delivery agency, rather than an independent advocate or Auditor General for public health.
• Accordingly, the new agency should operate within the Health portfolio and report directly to the Minister of Health. The Minister of Health should retain ultimate accountability for the consequences of decisions that are made (or not made) by the agency in relation to public health matters.
• Notwithstanding this relationship, the agency must be guided by a commitment to respect the ability of its personnel to exercise professional values, ethics, judgement and discretion in undertaking their respective roles and duties.
• Finally, the agency must be guided by a strong commitment to inclusiveness in decision-making and it should be a model for accountability, transparency and citizen engagement in the public affairs.

Operating Principles

Building from the above, the Working Group believes the following principles should guide the activities of the Public Health Agency of Canada and its relationship to others:

1. The work of the Agency should support and encourage a broad vision of public health. It should recognize that effective public health strategies must involve the assessment of population health, health surveillance (including clinical assessments of emerging illnesses), health promotion, disease and injury prevention and protection from health threats.
2. The work of the Agency should be evidence-based, and the Agency should be guided by the highest level of scientific expertise and inquiry in all aspects of its work. It should place special emphasis on knowledge translation and applying research in practice, as well as on the development of best practices. The Agency should forge strong and effective relationships with other members of the scientific and academic research community, including the Canadian Institute for Health Information, the Canadian Institutes of Health Research, Statistics Canada, provincial laboratories and agencies, universities and other academic/research institutions, and international science bodies.
3. The Agency should be respectful of the fact that public health issues are a shared responsibility of federal, provincial/territorial governments, and recognize that local governments also play key roles in the delivery of public health services.
4. The Agency should seek to set the highest possible standard of public transparency in its decision-making.
5. The Agency should be pioneering in its efforts to develop inclusive approaches to public health. It should work with other governments and government agencies - and also with academia, the expert community, research organizations, stakeholders and Canadians - in shaping its policies, programs and services.
6. The Agency should seek to educate Canadians on public health issues, and it should be a conduit between international developments and local action.
7. The Agency should respect the legal and legislative responsibilities of other federal departments and agencies.
8. The Agency should develop and maintain a professional staff of the highest caliber and empower this staff to play an effective and strategic role in shaping the federal government's contribution to public health.

B. Mandate and Functions

Core Mandate

It is the Working Group's view that the Agency should play an appropriate national role in public health and lead federal efforts with respect to:

• Preventing, identifying and managing public health emergencies.
• Infectious disease monitoring and control.
• Chronic disease and injury monitoring and control.
• The development, implementation and assessment of policies, programs, services and strategies that encourage population health, health promotion and wellness.
• Managing and strengthening public health monitoring and surveillance capacity.
• Facilitating the establishment of common public health goals and targets and report annually on progress towards their achievement.

Specific Roles

Building from the core functions and mandate described above, the Working Group believes the specific functions of the Agency should include:

• Leadership: The Agency should play a leadership role in coordinating, managing and undertaking the responsibilities for public health now under the auspices of Health Canada. This should include:
  • Supporting emergency planning and preparedness. Undertaking national surveillance and applied public health research (working in collaboration with other key agencies, such as the Canadian Institutes of Health Research and the Canada Health Infoway Inc.).  
  • Supporting public health training.  
  • Acting as the lead federal agency for the provision of program and policy advice on public health issues.  
  • Developing and maintaining MOUs with other federal departments so as to coordinate effective federal management of public health matters (see below).  
  • Working with the provinces/territories and the stakeholder community to develop effective national public health approaches. Developing effective public health information systems and communicating with Canadians on public health.

• Public Health Science and Research: The Agency should lead and coordinate federal research on public health issues. It should:
  • Work closely with other academic, scientific and research organizations with a view to strengthening national and international collaboration in public health research.  
  • Be a model for evidence-based decision-making.  
  • Act as a repository for global research on priority public health issues.  
  • Be guided by the highest level of scientific expertise and inquiry in all aspects of its work.
  • Place special emphasis on knowledge translation and applying research in practice, as well as on the development of best practices.  
  • Provide for peer review of its activities, where this is appropriate.
  • Encourage academic excellence amongst its staff, and facilitate academic cross appointments, where this is appropriate and feasible.  
  • Establish durable training links with the academic community through the sponsorship of bursaries, research chairs, etc.

• Emergency Preparedness and Response: A priority of the Agency should be to coordinate existing Health Canada responsibilities regarding public health emergencies, and to collaborate more broadly with other government departments on emergency preparedness. This should include:
  • Overseeing federal public health emergency planning, particularly the management of immediate national threats.  
  • Supporting national preparedness for public health emergencies, including, where appropriate and necessary, the provision of training, information, emergency facilities, supplies and expertise. Taking a leadership role in the establishment of standards, objectives, quality guidelines and codes of practice in preparation for and response to emergencies.  
  • Collaborating with other jurisdictions on the development of a "Health Alert System" based on the proposals set out in the Naylor Report which would (a) clarify the roles and responsibilities of each level of government, (b) provide for the timely provision of advice and information, and (c) allow for a rapid, graduated and systematic approach to public health emergencies.  
  • Providing advice on travel medicine and migration health (that takes account of advisories, bulletins and alerts issued by expert international advisory bodies and agencies, including the World Health Organization and the U.S Centres for Disease Control).  
  • Administering the Quarantine Act and other related legislation (e.g. Emergencies Act and Emergency Preparedness Act) on behalf of  
    the Minister of Health.
  • Administering the Importation of Human Pathogens Regulations. Developing policy and advice on bio-safety, including certification of containment level, shipping and handling, emergency response.  
  • Funding/managing the National Emergency Stockpile.

In undertaking these specific responsibilities, there must be no question about the Agency's capacity to act in times of emergency. Through the course of its work, the Working Group heard views from a variety of experts that existing emergency legislation is dated. Indeed, some legislation, such as the Quarantine Act has been "on the books" in largely unaltered form for over 100 years. As part of a process of ongoing legislative review, Health Canada has committed to establishing new health protection legislation, and the recent Speech from the Throne specifically committed the Government to a new Canada Health Protection Act. Departmental officials have advised the Working Group that consultations on this new legislation have commenced with a view to having a new bill introduced in Parliament in 2005. As an interim step that will coincide with the development of the Agency, the Department is also planning updates to the Quarantine Act later this year.

• Monitoring and Surveillance: The Agency should:
  • Undertake monitoring and national surveillance, with a priority on infectious disease.  
  • Undertake targeted research to enable the assessment and detection of new, emerging and persistent threats to health or patient safety.
  • Undertake and support laboratory diagnosis for new and emerging diseases and hazardous exposures.  
  • Provide specialized microbiology laboratory services and oversee the management and administration of federal laboratories.  
  • Collaborate with Canada Health Infoway Inc. in the development of a detailed strategy for implementation of the monitoring and surveillance initiatives announced in the 2004/5 federal budget.  
  • Collaborate, as appropriate, with the Canada Patient Safety Institute on patient safety issues.
  • Support and take a leadership role in the Canadian Public Health Laboratory Network.
  • Fund, undertake, participate and evaluate public health knowledge management, synthesis and transfer systems.  
  • Act as a repository and coordinator of international scientific information on public health intervention effectiveness, and on related program and service guidelines and best practices. This should include disseminating information on guidelines and best practices and encouraging their utilization within the professional community.  
  • Take a leadership role in the national promotion of quality and development of standards for population and public health.
  • Partner with provincial and territorial bodies (such as the BC Centre for Disease Control and Quebec National Institute of Public Health) to stimulate and support the development of new monitoring and surveillance initiatives across the country.

• Training and Outreach: The Agency should conduct and support public health training and provide advice and assistance to external agencies and government departments to assist their activities in the field of public health. The Agency should:
  • Work with the provinces, territories and national professional bodies on the development of a national health human resources strategy for population and public health.  
  • Support and expand the development of the Canadian Field Epidemiology Program as well as national access to training and scholarships in epidemiology (including field investigation) and other core disciplines in public health (such as biostatistics and social sciences for health promotion and disease prevention, health economics and policy analysis, etc.).  
  • Fund and oversee federal grants and contributions to external community-based and expert organizations on public health matters.

• Intergovernmental and International Collaboration and Public Health: The Agency should work with international agencies and other nations, as well as with provinces and territories, to develop and facilitate national and international strategies and approaches on public health issues. The Agency should:
  • Work with other authorities to develop and articulate a coherent long- term public health strategy for Canada.  
  • Work with provinces and territories on the development of the Pan-Canadian Public Health Network described above that would coordinate, integrate, and strengthen the existing services and activities of all jurisdictions.  
  • Provide appropriate advice and support on public health issues as appropriate to other federal government departments and agencies, provincial and territorial governments, non-governmental organizations, health professionals, international agencies and other nations.  
  • Collaborate, as appropriate, with international partners like the World Health Organization and the United States Centers for Disease Control and Prevention on public health matters.

• Advice on Policy and Program Development: The Agency should play a leadership role in the provision of advice to Ministers on program development in the field of population and public health. The Agency should:
  • Undertake policy/program research and support policy development on public health issues.  
  • Monitor emerging programs and policy trends in public health throughout the world.  
  • Provide policy advice to the Minister of Health on public health programs and services.
    
    (Note: These functions relate exclusively to the field of public health. The Working Group believes the Department of Health should retain lead responsibility for general health policy at the federal level).

• Communications: Communications must be an essential component of the Agency's work. Specifically, the Agency should:
  • Coordinate risk communications activities and emergency communications in the field of public health.  
  • Act as point of contact with international and national agencies for information sharing, particularly in times of emergency.  
  • Promote public awareness and understanding of public health issues, working with the Health Council of Canada and other organizations, where appropriate.  
  • Be a focal point for citizen engagement on public health issues.  
  • Provide, via the Minister of Health, regular reports to Parliament on the state of public health, including reporting on public health threats and measures being taken or planned to be taken to address those threats.

• Information Management and Informatics: The Agency should:
  • Seek to improve the transparency of decision-making and support activities designed to promote public awareness on public health issues, as well as improved integration, where appropriate, of clinical and public health services (e.g. in disease outbreaks and chronic disease prevention).  
  • Develop information systems and information standards for public health by working with Statistics Canada, the Canadian Institute of Health Information, Canada Health Infoway Inc. and other agencies that respect Canadians' expectations of privacy.  
  • Seek to strengthen Canada's ability to distribute public health information in a timely manner and provide Canadians with the information they need to make informed choices about their health.

Strengthening and Building from the Base

In general terms, the responsibilities described above presently fall within Health Canada's Population and Public Health Branch (PPHB). The Working Group believes there is considerable merit in seeking to build beyond this base and to including other program areas within the mandate of the Agency. In particular, the Working Group believes the following matters should be further assessed over time for possible inclusion in the Agency:

• Nutrition and exercise/healthy body weights.
• Tobacco and other psychotropic/addictive substance control and prevention.
• Radiation protection initiatives.
• Occupational health and safety (within federal authority).
• Environmental health (e.g. air/water).
• First Nations and Inuit public health programs and services.

It is the Working Group's view that specific consideration should not be given to adding these items to the mandate of the Agency until the Agency is "up and running" and has demonstrated its capacity to effectively deal with the core mandate items previously described (emergency preparedness and response, infectious disease prevention and control, chronic disease and injury prevention and control, public health promotion). It is also the Working Group's view that an operational and organizational review of these core mandate items should commence as soon as the Agency is established. A more detailed proposal for such a review is set out below.

The following tests are offered by the Working Group to assist in the further evaluation and assessment of options to expand the Agency's mandate in the future:

• Public Health Interest Test: The degree to which any new items fit within the general definition of public health. "Public health" is commonly described "as the science and art of promoting health, preventing disease and prolonging life through the organized efforts of society via programs, services and institutions that emphasize the prevention of disease, the promotion of health, and the health needs of the population as a whole." ²

• "Strengthening the Core" Test: The degree to which new items may have a direct and demonstrable impact on:
  • Public health emergency preparedness.
  • Infectious disease prevention and control.
  • Chronic disease and injury prevention and control.

• Regulatory Powers Test: The degree to which new items involve large- scale regulatory management and oversight (e.g. product safety approvals). It is the view of the Working Group that the Agency's primary focus should be on strategic program, service and policy development and delivery as it relates to public health. Before assuming any new responsibilities or mandates that have a significant regulatory component associated with them, a careful assessment of whether these new roles might divert the Agency from its core policy and program functions should be undertaken.

• Efficiency Test: The degree to which the addition of further items to the mandate of the Agency would improve overall efficiency in the development and delivery of government programs and responsibilities, and/or serve to reduce duplication and overlap.

Beyond the simple application of these tests, the Working Group believes that, when assessing the merit of proposals to transfer other existing Health Canada functions to the Agency, there should be a determination of how any such move might impact on the Department's ability to maintain strong and effective capacity in the areas of:

• Health policy and management.
• International health liaison.
• Federal/Provincial/Territorial relations on health.

Indeed, it is the Working Group's view that the Deputy Minister of Health must retain overarching responsibility for advising the Minister on the broad aspects of health policy development and the management in all aspects of his or her portfolio. Accordingly, there is a need for a close and cooperative relationship between the Deputy Minister of Health and the CPHO. In this context, the Agency's responsibilities in these aforementioned areas should be specifically limited to public health program and service delivery issues (e.g. development of a national public health or immunization strategy).

C. Organizational and Human Resource Management Issues

Agency Core Structural Characteristics

As noted previously, it is the Working Group's view that the new Agency should be a distinct entity operating within the Health portfolio and reporting to the Minister of Health. Building from this model, the Working Group believes the following characteristics should lay at the foundation of the Agency's structure:

• A Departmental Corporation, operating at arms-length from Health Canada. The Naylor Report outlines various corporate models and ultimately proposes that the most appropriate corporate framework for an Agency would be a "departmental corporation model"³ or "legislated service agency". The Naylor Report outlines the general advantages and characteristics of such a model as:
  • Headed by a Chief Executive Officer reporting directly to the Minister. Supported by a "board" with members appointed by the Governor in Council.
  • Subject to Ministerial discretion.
  • Potential flexibility in staffing matters.
  • Managed on the basis of a corporate business plan.
  • Focus on performance and accounting for results.
  • Greater financial and administrative authorities than traditional departments.  
  • Oversight by the Auditor General and subject to the Official Languages Act, Privacy Act and Access to Information Act as well as Federal Identity Program requirements.

The Working Group supports this view, as this model provides legal and practical independence from Health Canada, while retaining a clear, rigorous management and accountability regime under the Financial Administration Act that is essentially the same as that under which federal departments must work. The Working Group believes that creating the Agency as a Crown corporation would send a misleading signal that it has a quasi-commercial purpose, which it should not. It is also our view that the establishment of a Special Operating Agency within Health Canada would not allow the Agency or CPHO to exercise needed autonomy or independent judgment.

• Professional Leadership through a Chief Public Health Officer who would report directly to the Minister of Health. It is the Working Group's view that the CPHO must be the Chief Executive Officer of the Agency. Consistent with the principle of Ministerial accountability within which our system of government operates, the CPHO should report directly to the Minister of Health. The Working Group believes that elected officials must ultimately be accountable to Parliament and to Canadians for decisions that are made, as well as for the consequences of decisions that are not made, which may affect the health and well-being of Canadians, intergovernmental relations or Canada's international interests. These responsibilities should not be delegated to un-elected officials or independent agencies.

• A Part of the Health Portfolio. It is the view of the Working Group that the new Agency should not be operated as a "silo of public health". Its activities, policies, programs and services must be coordinated in an effective way with the other health programs and services now operated by the Government of Canada. Moreover, the Government must retain an overarching perspective on the full and broad context of health in Canada. As noted previously, this means that the creation of this new Agency should not undermine Health Canada's overarching responsibility for coherent policy development and management in all aspects of health care. In this context, it is the Working Group's view that the Agency should maintain a clear and transparent relationship with Health Canada and other agencies within the Health portfolio via formal MOU(s) that clearly spell out respective roles and responsibilities. If and when public health emergencies occur, or when the health of Canadians may be at stake, there should be no ambiguity as to the responsibilities and accountabilities of the Agency. Moreover, the Working Group believes that these MOUs should be available for expert scrutiny and they should be regularly updated as circumstances require.

• Professional Judgment, Values and Ethics and a New Standard in Accountability, Transparency and Engagement. As noted previously, the new Agency should be staffed by experienced professionals who are encouraged to use their professional judgment, values and ethics to excel in their respective fields. The Agency should be a model for evidence- based and scientific decision-making, and should have mechanisms built into its fabric that allow for the peer review of its research and activities where this is appropriate. Agency employees should adhere to the Code of Public Service Values and Ethics and the work of the Agency should be transparent, inclusive and reflective of a high standard of accountability to Canadians.

• Shared Administrative Services, Where Appropriate. In order to gain the confidence of Canadians, the new Agency must adhere to the highest standards of modern comptrollership. Where economies of scale can be identified without compromising the integrity of its operations, the Agency should share services with Health Canada and with other departments and agencies.

Building an Organizational and Program Structure

As noted previously, the Working Group believes that the foundation of the new Agency should be the responsibilities now managed by Health Canada's Population and Public Health Branch (PPHB) for emergency preparedness and response, infectious disease prevention and control, chronic disease and injury prevention and control, and public health promotion. Accordingly, the Agency should assume responsibility for the services and resources now located within PPHB.

Health Canada's Main Estimates for 2003-04 indicate that PPHB has about 1,132 Full-Time Equivalent (FTE) positions and its total operating budget is $404.2 million, comprised of 2 core elements:

Operating costs:	$157.1 million (2003/04)
Transfer Payments (i.e. Grants and Contributions)	$246.9 million (2003/04)

Beyond PPHB's direct staff complement, which is located in the National Capital Region (about 940 employees) and in Laboratories in Winnipeg, Manitoba (about 151 employees), and Guelph, Ontario (about 41 employees), the Branch provides direction to Health Canada's regional field staff in offices across the nation.⁴

It is the Working Group's view that all of PPHB's current resources should be transferred to the new Agency. In this context, the Agency should assume responsibility for all of the existing Centres, Laboratories and Directorates that now constitute PPHB, including the existing Centres for Surveillance Coordination, Healthy Human Development, Chronic Disease Prevention and Control, Infectious Disease Prevention and Control, and Emergency Preparedness and Response, as well as the National Microbiology Laboratory and the Laboratory for Foodborne Zoonoses. PPHB's Strategic Policy, Management Planning and Operations, and Business Integration and Information Services Directorates should also be transferred to the Agency.

Building from this base, the Working Group believes that the CPHO, with direction from the Minister of Health, should ultimately play a leading role in shaping the optimal organizational structure of the Agency for which he/she will have accountability. To assist the CPHO in undertaking this review, the Working Group offers the following observations:

• The senior management group of the Agency should include a number of experienced public health professionals capable of exercising professional judgment on critical issues such as emergency response, infectious disease prevention and control, chronic disease and injury prevention and control, and management of laboratories and research.
• This cadre of senior professionals should be committed to bringing an overarching focus and discipline on science within their respective areas of responsibility and throughout the Agency. They must establish an organizational culture that provides for policies, programs and interventions that are evidence-based and outcomes-driven. An effective, forward-looking, science-driven organization must be the goal; entrenching the status quo within a "new house" will not suffice.
• The Agency must have a strong and effective capacity in the areas of public health policy, communications and citizen engagement, as well as finance and administration.
• The Agency should have a strong regional presence and it should seek to build public health capacity across the nation. As a starting point, the Agency should maintain and build upon PPHB's existing relationship with Health Canada's field staff.

Organization/Program Review

As we hope is evident from the above observations, it is the Working Group's strong view that the creation of the Agency should not be a simple effort to "re- brand" Population and Public Health Branch. Indeed, the new Agency must embody a new way of doing business focused around the core operating principles that are set out earlier in this paper.

In this context, the Working Group believes that a detailed review of the programs and resources transferred to the Agency from Health Canada should be undertaken as quickly as possible once the Agency is "up and running". This review should be overseen by the CPHO and should involve the Agency's senior executive team. It should be undertaken under the direction of the Minister, and it should be timed so as to allow the "early harvest" of core changes in time for their integration into the 2005/06 budget. The Working Group believes this review should be undertaken with advice from and in collaboration with representatives of the public health community. Specific priorities for review should include:

• Agency organizational and management structure.
• Strengthening the existing national laboratory network.
• Building the regional presence of the Agency.
• Ensuring that the Agency has a strong and well-grounded foundation in science, research and evidence-based decision-making.

Determining the optimal regional presence of the new Agency will be particularly important. As noted previously, PPHB presently has a working relationship with about 250 FTEs associated with Health Canada's regional offices. While the focus of these employees is presently on matters related to the administration of grants and contributions, the Working Group believes that a significant potential exists to directly and significantly expand the Agency's regional presence and to build a strong regional Agency staff with an effective capacity in:

• Policy analysis and program evaluation.
• Analysis and the provision of advice on regional public health issues.
• Coordination of "on the ground" resources within the federal domain, such as resources under PPHB's field epidemiology program.
• Linking with regional public health laboratories, research centres, public health experts and the research community.
• Liaison with provincial and territorial public health officials.

Beyond the functional review of organization, programs and services we propose above, it should be noted that the Naylor Report and other reports have called for a detailed review of the grants and contributions which are presently managed by PPHB. Others have also suggested a similar review, on the premise that such a review could potentially identify savings that could be re-profiled for other priorities. While the Working Group similarly believes there is merit in a review of these grants and contributions, it notes that many of these grants are small ($5- 10,000) and are directed to community-based organizations. It is our assessment that the benefits that may accrue from establishing clear performance criteria for future grants and contributions may, in many cases, outweigh any potential savings that may be identified within the existing program.

As such, the Working Group recommends that a program review of PPHB's existing community-based grants and contribution initiatives be undertaken quickly, with a view to having this review completed by December 2004. The purpose of the review should be to propose recommendations on any needed restructuring of the program to improve efficiency, efficacy and cost savings, and to recommend performance assessment criteria for future grants. The review should be led by a dedicated team reporting to the Minister of Health with appropriate representation from Health Canada, Treasury Board and, depending on how quickly it is created, the Agency itself. This team will need to directly engage existing PPHB field/regional staff in this effort, as appropriate.

The Agency as a "Separate Employer"

The Naylor Report and others have argued that there is considerable merit in the new Agency being a "separate employer", as this would allow for greater flexibility in the recruitment and appointment of staff. The Naylor Report specifically notes:

"It seems desirable for the organization to have the authorities of a separate employer under the Public Service Staff Relations Act to allow it to address unique recruitment and retention challenges in an environment of global competition for scarce scientific and public health expertise".

The Working Group agrees in principle with this view. Fundamentally, the new Agency must have flexibility to deal with issues like "upscale" hiring and the capacity to consider new collaborative arrangements with academic institutions (e.g. sabbaticals, locums, allowing employees to hold joint positions within universities and the Agency, etc.).

This being said, it should be recognized that there are also potential challenges associated with this approach:

• On a practical basis, there will likely be only a small number of positions within the Agency where the flexibility brought about by this status would have a demonstrable, positive impact. "Separate employer" status would likely not have a significant positive impact on the "line-function" positions within the Agency (laboratory technicians, clerks, administrative personnel, etc.) which constitute the majority of staff.
• Some flexibility already exists within the existing rules of the Public Service for greater use of "upscale" hiring and formal relationships with academic institutions regarding joint appointments/sabbaticals, etc. Potentially, this flexibility could be more effectively utilized and could potentially achieve many of the same results as separate employer status.
• If not managed properly, proposals relating to "separate employer" status could be a source of considerable anxiety for the staff.
• "Separate employer" status would also require the Agency to develop and maintain a broader and more sophisticated level of expertise and capacity on administration/human resources issues (e.g. collective bargaining) than would otherwise be the case.

In light of the foregoing, the Working Group proposes that:

• In the first instance, PPHB be designated as a "new department" under the Financial Administration Act. Employees of PPHB would automatically become employees of the Agency and their status as federal employees would not be changed.
• As part of the transition towards the new Agency, consultations should be held with the unions on the merits and appropriateness of seeking "separate employer" status. Early discussions with Privy Council Office (PCO), Treasury Board and the new Public Service Human Resources Management Agency should also be held in this regard, and the terms of the new Human Resources Modernization Act should be taken into account.
• A final determination as to whether the Agency should be a "separate employer" should be made following further assessment by the CPHO, and in conjunction with the consideration of legislation for the Agency.

Irrespective of whether the Agency becomes a "separate employer", the Working Group believes that efforts should be made in developing the Agency's human resources plan to:

• Provide flexibility for upscale hiring of professional staff where this is deemed necessary and appropriate.
• Allow for greater linkages with academic institutions including coordination of sabbaticals, cross-appointments between academic and staff positions, etc.

D. Ensuring Effective Accountability and Transparency

As an operating assumption, and building from the government's Management Accountability Framework, the Working Group believes that the new Agency should be a model for accountability and transparency in the public service. The Agency should not hesitate to "push the envelope" in creating new mechanisms and processes which ensure accountability and transparency for public institutions. It should have the tools for citizen and expert consultation, and it should seek to build the confidence of Canadians in the effectiveness of our public health system by utilizing these tools.

The Working Group believes that accountability and transparency of the Agency should occur through:

• The provision of public reports and studies which allow for the assessment of the Agency's performance against clearly articulated goals and objectives.
• The establishment of an independent Advisory Board that would operate in a transparent manner.
• The establishment of additional advisory committees and processes.
• New mechanisms which embed the concept of citizen engagement "into the DNA" of the Agency, building from the mechanisms for citizen engagement that were utilized by the Romanow Commission and other processes.

Reports and Studies

As a general rule, all formal reports and studies prepared by the Agency should be publicly available. The establishment of the Agency also provides an opportunity to establish requirements for new reports that will improve public knowledge and decision-making on public health. In this context, the Working Group proposes that the Agency be required to develop and release:

• Regular reports outlining the state of public health in Canada.
• "Performance Reports" which assess the Agency's effectiveness in dealing with critical public health challenges and the overall performance of its programs, services and activities.
• Annual Operating Plans that set out future Agency plans and activities for transparency and certainty.

These reports could be developed as separate documents, or could be combined where this is appropriate. In addition, in some cases, this work should appropriately be done collaboratively with the work of other agencies (e.g. Health Council of Canada)⁵. In any case, the Working Group believes that, on a regular - and where appropriate annual - basis, Canadians must be provided with information on the following:

• An assessment of overall national performance in relation to clearly defined targets for reducing the incidence of specific chronic and infectious diseases and injuries, and for improving the health outcomes of specific vulnerable population groups. These targets should be defined by the Agency in collaboration with provincial/territorial health officials, the public health stakeholder community and Canadians.
• A comparative assessment of public health capacity and outcomes between regions of the country and subpopulations, as appropriate.
• A comparative assessment of the state of public health in Canada vis-à- vis other nations and international standards.
• A "Watching Brief", summarizing major advances in public health science as well as emerging public health challenges and their implications - globally, nationally and by province, territory or region.
• A State of National Readiness status report in relation to public health emergency planning (e.g. covering issues such as intergovernmental coordination, progress toward legislative harmonization, strengthening monitoring and surveillance functions, improving laboratory capacity, health human resources planning for public health emergencies, etc.).
• An audited financial report, as well as a detailed expenditure report, outlining Agency programs and investments, criteria for evaluating their effectiveness, and assessment reports concerning these programs and investments and the efficiency and efficacy of the Agency.

The "performance reports" described above should be designed to "push the envelope" by critically assessing the programs and investments of the Agency against meaningful benchmarks and progress on specific public health outcomes. They would provide clear criteria for assessing programs and services, and would seek to assess the Agency's work against these benchmarks. The Working Group notes that annual reports now prepared by regional health authorities in Alberta, notably the Calgary Region Health Authority, could serve potential templates or models for these reports.

To ensure transparency and accountability, the Working Group proposes that:

• The basic elements of the reports described above should be laid out in legislation.
• The Minister of Health should be required to table these reports in Parliament upon their completion by the Agency.

A Formal Advisory Board

The Working Group believes that an effective, senior Advisory Board on Public Health should support the Minister, CPHO and Agency. In assessing the options for defining the role and structure of the Board, the Working Group noted the following:

• As noted previously, it will be important to respect the need for a direct and effective relationship between the CPHO and the Minister of Health.
• In light of this relationship, the Board should not have a direct formal authority over, or fiduciary responsibility in, managing the ongoing activities of the Agency.
• While the Board must be advisory in nature, there is merit in it having some form of "challenge function" which would allow it to review and assess the reports, activities and performance of the Agency as a mechanism of "sober second thought".
• There is merit in a Board that has the capacity to judge the effectiveness and performance of the Agency and the CPHO and to provide advice and assessment on these matters directly to the Minister.

Based on these considerations, the Working Group believes there is merit in the establishment of a senior Advisory Board with the following features:

• The Advisory Board would report to the Minister of Health or Minister of State, as appropriate.
• The Advisory Board would support the "good governance" of the Agency and provide advice to the Minister and, as appropriate, the CPHO.
• The Governor in Council would appoint the Board Chair, based on advice from the Minister.
• All other full Board members would be Governor in Council appointments, based on advice from the Minister of Health.
• A regionally balanced 12-15 member Board that is broadly reflective of Canadian cultural and linguistic diversity should be appointed. Members would be selected from the health expert community, the scientific and research communities, the public health stakeholder community, and the general public.
• The Board should also include one representative of First Nations and Inuit peoples. The National Aboriginal Health Organization (NAHO) should be asked to design an appropriate process for the selection of this representative.
• Other Board members would be selected so as to ensure there is an appropriate balance of representation from each region/province/territory within the country.
• Appointments to the Board would be for a set term (perhaps 5 years), with appointments staggered between years so as to ensure orderly transitions in Board membership.
• The CPHO would be a full Board member and would normally attend all Board functions and meetings.⁶
• The Agency/CPHO would provide any organizational, administrative or technical support the Board requires.
• As a means of ensuring effective coordination of policies, programs and services, the federal Deputy Minister of Health and the Chair of the Provincial/Territorial Council of Deputy Ministers of Health would have "observer status"⁷ on the Board.
• Under extraordinary circumstances the Board Chair could seek permission from the Minister to hold a formal Board meeting without the CPHO or the observers being present. In these circumstances, the Board would be required to inform the CPHO/observers of the reason for the exclusion prior to requesting Ministerial consent.

The specific role of the Board would be to:

• Review and provide advice on the Agency's performance and the reports described above.
• Provide advice on Agency activities.
• Provide advice on public health issues in general.

While the Board would not formally approve the reports or plans of the Agency it would have the ability to provide advice directly to the Minister on the efficacy and content of these reports and plans. Additionally, the Minister may wish to use the Board as a mechanism to regularly review the performance of the CPHO⁸.

All Board activities should be transparent. In this context, Board minutes (other than those dealing with internal staffing or personnel matters that might affect privacy rights, issues that might compromise public security, or matters that are of a commercially confidential nature) should be made publicly available in a timely fashion.

The Board should be required to meet a minimum of three times annually. At least one of these sessions should be a public "town hall" meeting in which the Board would invite presentations from the expert and stakeholder communities, as well as the public, on specified issues as determined by the Board, the Minister and/or the CPHO. A report of these annual "town hall" sessions should be presented to the Minister and made publicly available.

The composition and role of the Board could be laid out in legislation establishing the Agency.

Other Expert Advisory Processes

Beyond the formal Advisory Board structure described above, the Working Group believes that there is a need for the Agency to maintain existing expert advisory processes and arrangements and where necessary, to establish new mechanisms through which it can engage the experts, stakeholders and the public on an ongoing basis. Options in this regard include:

• The establishment of an informal cadre of experts who could act as a sounding board to the CPHO. This group would be somewhat similar to the expert advisors who assisted the Working Group. The cadre could come together to discuss issues in a collective way under the direction of the CPHO, or the CPHO may wish to engage individual experts on an ad hoc basis". Individual experts would sign confidentiality agreements that would allow them access to sensitive materials.
• The establishment of expert/scientific panels or reference groups on key issues/diseases (e.g. an expert panel on diabetes).
• The establishment of "consensus conferences" involving national and international experts to provide feedback and input in designing new programs and services.
• Ad hoc "sober second thought" committees to provide advice in dealing with emergencies or new outbreaks of infectious disease.
• Federal/Provincial/Territorial reference groups, established in collaboration with provinces and territories on specific issues and involving experts, stakeholders and/or the public.

The above represents a list of potential options that should be considered further by the CPHO in shaping the ongoing activities of the Agency. The decision to use any of these processes should rest with the CPHO in consultation with the Minister and Board.

Citizen Engagement

Beyond the advisory processes described above, it will be important that the Agency maintain effective mechanisms for direct citizen engagement. Citizen engagement will assist in ensuring that the policies, programs and services offered by the Agency are relevant to Canadians. Citizen engagement will also be critical to an effective risk communications strategy.

Building from the mechanisms for citizen engagement used by the Romanow Commission, Canadian Blood Services and others, it is the view of the Working Group that citizen engagement by the Agency should occur through the following:

• Electronic Interactivity and the Web: The Agency should explore all modern methods of interactivity, and should at a minimum maintain an effective and interactive web site on public health. The web site should contain any advisories, news releases or reports prepared by the Agency, as well as Board minutes, audit findings and other documents. The web site should also allow Canadians to interact with the Agency by email.
• Toll Free Line: As part of its risk communications plan the Agency should maintain a 1-800 line, which would allow Canadians access to vital information on emergencies, travel advisories, etc.
• Direct Engagement: As noted previously, the Board of the Agency should include representation from the general public, and there is a potential role for public representation in the expert/stakeholder advisory processes described above. Additionally, as described above, it is proposed that the Board hold at least one "town hall" meeting annually.
• Public Consultations: Public consultations, focus groups and public opinion surveys should be regularly conducted as part of the Agency's efforts at program and policy formulation.
• Community Liaison Committees: In a manner consistent with similar initiatives undertaken by Canadian Blood Services, the Agency should establish community liaison committees in each province and territory. These committees could be coordinated with support from the Agency's regional field staff. The purpose of these committees would be to provide input on Agency policies, programs and services, provide a forum for the discussion of public health issues at the local level, and build effective relationships "at the front line". Agency regional staff could provide leadership in this regard.

As with the expert advisory processes described previously, the above represents a list of potential options for citizen engagement that should be considered further by the CPHO in shaping the ongoing activities - and in particular the risk communications strategies - of the Agency. The decision to use any of these processes should rest with the CPHO, in consultation with the Minister and Board, where appropriate.

E. Strengthening Formal Relationships

Managing the Agency-Health Canada Relationship

Clearly, the relationship between the Agency and Health Canada must be clear, transparent, and appropriately managed. It will be critical that the CPHO and the federal Deputy Minister of Health have a clear, effective and collegial relationship that will allow them to both provide advice and seek direction from the Minister in an efficient and transparent way. By necessity, there will also be some duplication and overlap between the responsibilities of the CPHO/Agency and Deputy Minister/Department in areas like policy development and liaison with provincial and territorial governments and the international community.

Additionally, as noted previously, savings and cost efficiencies could potentially be achieved by having the Agency and Health Canada share certain administrative services where this is appropriate. The above considerations led the Working Group to conclude that an Agency-Health Canada MOU should be developed which clearly sets out the coordination process and respective roles and responsibilities of both entities in the areas of international relations, intergovernmental relations and policy development. The premise behind this arrangement should be that the Agency takes a lead role in shaping and coordinating strategic policy advice and acting as the lead interface on intergovernmental and international relations on specific public health matters, while Health Canada retains an overarching responsibility for broad health policy and related international and intergovernmental relations.

The Agency-Health Canada MOU should also contain a communications protocol which sets out the respective responsibilities and authorities of the Department's Communications Directorate and Agency communications staff as they relate to:   (a) general corporate communications and utilization of Health Canada's "brand", logos, web sites and other identifiers; (b) respective roles in health promotion communications; and, (c) roles in inter-agency coordination and emergency/risk communications.

Additionally, this MOU should allow for the sharing of administrative resources in the areas of HR management, finance, informatics, and legal services, where this has merit.

The Working Group notes that the above MOU could also serve as a model for the portfolio management of corporate services, given the potential creation of a drug agency in the near to medium term. Such an MOU should also include a requirement for regular periodic review, and it should be regularly updated to reflect any future changes in the Agency's mandate and operating requirements.

Other Federal Departments and Agencies

As noted previously, the Working Group believes that the new Agency can play a critical role in coordinating the federal government's overall approach to public health and emergency preparedness and in developing a "public health lens" by which decisions and actions can be assessed. In this context there would be considerable merit in establishing formal MOUs between the Agency and key federal departments and agencies and other quasi-governmental groups including:

• Agriculture.
• Environment.
• Fisheries & Oceans (Coast Guard).
• Foreign Affairs.
• National Defence.
• Public Safety and Emergency Preparedness.
• Canada Border Services Agency.
• Canada Food Inspection Agency.
• Canadian Institutes for Health Research.
• Canadian Institute for Health Information.
• Canada Health Infoway Inc.
• Royal Canadian Mounted Police.

These MOUs would set out formal roles and responsibilities with respect to:

• Border control and quarantine.
• Risk and emergency communications.
• Emergency response.
• Migration health.
• Provision of advice and shared services (e.g. laboratory support).
• Relationships and points of contact with international agencies and other nations.
• Coordination and targeting of public health research efforts.
• Federal/Provincial/Territorial relations.

In conjunction with these MOUs, the CPHO may also wish to consider the need for establishing some form of ad hoc coordinating committee of interested departments and agencies that would meet routinely to share information and coordinate activities in the area of public health emergency response. Any efforts in this area should be closely coordinated with any broader efforts by the Privy Council Office and/or the Department of Public Safety and Emergency Preparedness related to emergency coordination.

International Collaboration

Beyond the inter-departmental MOUs described above and those which will be developed with the provinces and territories under the auspices of the Pan-Canadian Public Health Network, there may also be some merit in exploring MOUs with international agencies which play a direct role in public health, as well as MOUs with the public health agencies of other nations. These agreements could potentially provide a foundation for resource sharing in times of emergency, common codes of practice in data collection and analysis, and provide a forum for collaboration and consultation on the joint management of key risks like BSE. A first priority in examining possible agreements would be an MOU with the US Centers for Disease Control and Prevention. The Working Group believes the Agency should discuss the merits of such an agreement with DFAIT and Health Canada early in its mandate, with a view to approaching the US and commencing discussion of such an arrangement at the earliest possible opportunity.

F. Location and Regional Presence

The Working Group has taken note of the considerable interest in having the Agency sited outside Ottawa and in using the creation of the Agency as an opportunity to build regional presence in public health. In this context, the Naylor Report noted:

The Committee does not believe that the agency should be centralized in a single new location. This would involve a transition from the current arrangement, be disruptive for staff, and fail to capitalize on the full range of opportunities for partnership in P/T and municipal jurisdictions. We assume, moreover that there will be some expansion of core functions in Ottawa, aligned with the funding recommendations and national public health strategy [proposed in the report]. But the agency must be seen to reach across Canada in tangible and visible ways. ⁹

In this context, the Working Group notes the following:

• Public discussion on the creation of the Agency has been confused by a misperception among some that this will involve considerable new investments in "bricks and mortar". To this end, the Government of Canada has already received several proposals to have the Agency sited in specific locations or co-located with provincial public health offices and laboratories.
• In reality, the creation of this Agency will not involve any significant amount of new "bricks and mortar", nor was the creation of such a new physical presence anticipated in the proposals put forward in the Naylor or Kirby Reports.
• Based on the model described in this document, the Agency will be primarily constituted from existing Health Canada staff and specifically the staff of PPHB. With the exception of the regional field staff described above, virtually all of these individuals presently reside and work in the National Capital Region or are associated with existing laboratories in Winnipeg and Guelph.
• Relocating large numbers of PPHB staff to other centres would be complex, expensive and potentially disruptive. Moving existing laboratories would be particularly problematic. Moreover, it is not clear if existing professional staff would be prepared to transfer to a new location. As noted previously, recruitment for some of these positions already represents a challenge and this challenge could become greater if staff were moved to or consolidated at another site.
• The CPHO will need a close and ongoing working relationship with the Minister of Health, the Deputy Minister of Health and other senior federal officials. In particular, a close physical presence between the CPHO/Agency and the Minister will be necessary in times of emergency, when fast decisions and effective communications will be critical.

Notwithstanding the above considerations, the creation of the Agency and related Pan-Canadian Public Health Network will present opportunities for building the federal government's regional presence and capacity in public health. In this context, the Working Group believes that:

• As a priority in the development of the Pan-Canadian Public Health Network, federal/provincial/territorial Ministers and officials should review Canada's existing national public health capacity and infrastructure, with a view to identifying gaps or new requirements in the area of laboratories, services and research capacities that could be addressed over time with services delivered at new sites and locations beyond existing labs. This strategy might also involve the creation of new "regional centres of excellence".
• As part of the organizational review of the Agency described above, a detailed strategy for building the Agency's regional capacity and presence should be developed. In developing this strategy the Agency/CPHO should consult with:
  • Experts and stakeholder groups.
  • Provinces and territories.  
  • Regional academic institutions.
  • Existing regional field staff.

G. Legislation

As part of its mandate, the Working Group was asked to contemplate the legislative provisions that would underpin the formation of the Agency.

It is the Working Group's view that:

• There is merit in new legislation which provides a clear and solid legislative foundation for the Agency.
• This new legislation should be developed in tandem with the transition to the new Agency over the next few months. Legislation should not be completed and presented to Cabinet until the organizational review proposed earlier in this paper has been completed under the direction of the CPHO.
• New legislation related to the Agency should be coordinated with the development of the proposed Canada Health Protection Act as well as the updates to the Quarantine Act noted earlier in this report.

In light of the foregoing, the Working Group understands that, as a provisional step, the new Agency could be established by Order in Council. This would allow for the new Agency to be established quickly, while at the same time ensuring that the results of the proposed operational review are reflected in legislation. This approach would also afford an appropriate opportunity for consultations on such a bill.

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² See Naylor Report, Chapter 3.

³ A departmental corporation is a distinct agency with a statutory, non-commercial mandate. It is legally separate from the department. As such, it differs from a special operating agency (SOA), which is an entity that is legally part of a department, but has a distinctive management and accountability framework tailored to its specific needs. The head of a departmental corporation reports to a Minister; the head of an SOA to a Deputy Minister.

⁴ Health Canada presently maintains six regional offices that are the main delivery point for PPHB funding programs (e.g. Community Action Program for Children, Canada Prenatal Nutrition Program, AIDS Community Action Program, Population Health Fund, etc.). Over 250 full-time employees (FTEs) within these offices, under the operational responsibility of Health Canada's Regional Directors General, are designated in support of PPHB programs and services. Additionally, the Northern Secretariat of Health Canada's First Nations and Inuit Health Branch (FNIHB) provides a coordinated approach to FNIHB's program delivery in the territories, and has a direct service relationship with PPHB.

⁵ The reports we propose should be developed in close cooperation with the Health Canada, the Health Council of Canada, Statistics Canada, and the Canadian Institute for Health Information and the Canadian Institutes of Health Research, so as to reduce duplication and overlap with other current or planned reports.

⁶ There may be cases where it would be inappropriate for the CPHO to attend Board meetings and/or should abstain from voting as a "full member" of the Board, such as occasions when the Board is developing advice for the CPHO or is developing an assessment of the CPHO's performance for consideration by the Minister.

⁷ "Observer status" would mean that the DM of Health/provincial-territorial representative would be normally entitled to participate in Board meetings and functions and would receive Board documents. Observers would not, however, have the right to participate in any decisions taken by the Board, and in exceptional circumstances determined by the Chair (such as the review of personnel performance) might be excluded from Board meetings.

⁸ Any process for review of the performance of the CPHO should be well defined and transparent. Such a process should only be undertaken at the discretion of the Minister.

⁹ See Naylor Report, P. 79-80.

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