A Plan of Action
Final Report of the Ontario Expert Panel on SARS and Infectious Disease Control
Introduction to Final Report (Continued)
We wish to highlight our firm conviction and belief that the need for change centres on a renewal of the public health system, not just the creation of structures or new agencies. Ultimately, the core faith of Ontarians, and indeed Canadians, in government rests on performing certain essential functions well. Historically, one of these essential functions has always been the protection of the population from disease. Therefore, basic public health and core infection control need to be thought of in this light as functions that reflect part of the social contract between the public and its government, and not simply as another fiscal pressure on a burdened health system. Even in an era of fiscal restraint, we must remind ourselves and others of the cost of ignoring the essentials.
In essence, the Panel envisions the creation of a new Ontario Health Protection and Promotion Agency as only one element of a much larger renewal effort that must be supported by broader changes at the local, regional, provincial, and national levels in order to achieve the required public health system for Ontarians.
In addition to being a key focus of our Initial Report, this conviction has also been reflected in the work of Dr. Naylor and the National Advisory Committee on SARS and Public Health,1 the work of Senator Kirby and the Senate Committee,2 and in the earlier work of the Walkerton Inquiry3 (in terms of local capacity). All of these reports emphasize the importance of addressing the weaknesses in the foundations of the public health system and infection control capacity, and not simply redirecting existing resources and functions into a new central structure. In our view, if the provincial and/or federal governments only create new public health agencies and simply redirect existing resources into these agencies, we will have built some of the structure, but not the foundations. And, sadly, we will not have learned the appropriate lessons from SARS.
1 Canada. National Advisory Committee on SARS and Public Health, Naylor D. Learning from SARS : renewal of public health in Canada: a report of the National Advisory Committee on SARS and Public Health. [Ottawa] : Health Canada; 2003.
2 The Standing Senate Committee on Social Affairs, Science and Technology, Kirby M. Reforming health protection and promotion in Canada: time to act. November 2003. [Online] Available at :http://www.parl.gc.ca/37/2/parlbus/commbus/senate/Com-e/SOCI-E/rep-e/repfinnov03-e.htm. Accessed November 5, 2003.
3 O’Connor DR (Hon.). Walkerton Commission of Inquiry Reports. Toronto, Ont : Ontario Ministry of the Attorney General; 2002. Also available online at :http://www.attorneygeneral.jus.gov.on.ca/english/about/pubs/walkerton/. Accessed October 23, 2003.
A key opportunity for comprehensive public health renewal remains, as it has always been, at the local level where resources will have the greatest impact and where the day-to-day strengths and weaknesses of our system are felt in communities. While more mundane and less glamorous than the creation of a new agency, the task of revitalization at the local level is essential in improving the core services directly provided to Ontarians in their communities and in their facilities.
For this reason, the Panel believes that discussions concerning public health renewal in Ontario should flow from recognizing the need to strengthen basic functions such as infection control, surge capacity, and essential public health functions in the overall system, and not merely from the desire to create an agency per se. What Ontario requires now is a sustained, consistent, and ongoing focus on strengthening the essential functions of public health and infection control. This will be true both on the ground and at the agency level.
The Panel believes it is important to provide a degree of context to the changes proposed. It is necessary to first grasp the breadth of activities required for an effective public health system before we can approach an understanding of the changes required and the place of an agency in the bigger picture.
A public health system entails a clear vision for health protection and promotion along with articulated goals and objectives as well as the appropriate system infrastructures (human and financial resources, organizational structures) and strategies. There has been considerable work undertaken around the world to try to articulate what the parameters, and thus functions of a public health system, should entail. In the U.S., the Essential Public Health Services (EPHS) concept was developed by a working group of leading public health agencies in the mid-nineties.4 In 1995, following pilot testing in various states, the EPHS was formally adopted. Building on this work, the Pan American Health Organization (PAHO), the Regional Office for the Americas of the World Health Organization, adapted the EPHS and developed the Essential Public Health Functions (EPHF).5 Table 1 provides a summary of these services and functions.
4 Centers for Disease Control and Prevention. National Public Health Performance and Standards Program. The essential public health services. September 3, 2003. [Online] Available at :http://www.phppo.cdc.gov/nphpsp/10EssentialPHServices.asp . Accessed February 24, 2004.
5 Pan American Health Organization (PAHO). Public health in the Americas. Conceptual renewal, performance assessment and bases for action. Washington, D.C.: PAHO; 2002. [Book description available online at : http://www.paho.org/English/DPI/pr020923e.htm]
Table 1 : Overview of Essential Public Health Services and Essential Public Health Functions
|Essential Public Health Services (U.S.)||Essential Public Health Functions (PAHO)|
Although quite similar, EPHF as articulated by PAHO more clearly delineate a disaster/emergency function for public health. Full details of what these functions and services entail is included in Appendix 2.
EPHF/EPHS encompass a vision of the key components of an effective public health system, recognizing the need for multiple actions and interventions to be undertaken by different parties (government, nongovernment, academia, research, etc.) and at various levels (local, provincial, federal). There has been some work done in Canada to try to articulate essential public health services. A recent position paper by the Association of Local Public Health Agencies (alPHa) highlights the need for Ontario Public Health Units to undertake core public health activities that are consistent with EPHS.6
6 Association of Local Public Health Agencies (alPHa). The future of public health in Ontario : alPHa Board of Directors position paper. 2003. [Online] Available at :http://www.alphaweb.org/docs/ph_future_paper_final_version- 17_12_2003-10_30_55.pdf. Accessed March 19, 2004.
From a process perspective, EPHF/EPHS can also serve as a benchmark against which progress towards a public health system that supports specific health goals can be measured. To this end, the US Centers for Disease Control and Prevention (CDC) has taken these functions a step further and uses them as the foundation for public health performance and standard setting (see textbox).
In both the Initial and Final Reports, the Panel makes specific recommendations in many of the EPHF/EPHS areas to support public health renewal. These focus on the creation of specific structures and networks to support public health action, affording greater independence by the Chief Medical Officer of Health to speak independently, undertaking a capacity assessment of local Public Health Unit staffing levels and mix to work towards greater breadth and maximization of resources, as well as further promoting collaboration among public health and other sectors.
As part of its Public Health Performance and Standards Program,7 the CDC has developed specific tools based on EPHF for state and local authorities, as well as for public health governing bodies to determine current performance and capacity; identify areas for system improvement; strengthen partnerships; and ensure that a strong public health system is in place to respond effectively to day-to-day public health issues and public health emergencies.
7 Centers for Disease Control and Prevention. National Public Health Performance and Standards Program. September 3, 2003. [Online] Available at: http://www.phppo.cdc.gov/nphpsp/index.asp. Accessed February 24, 2004.
The Panel is acutely aware that an effective agency and a strengthened system can only be achieved through partnerships and collaboration. This collaboration will entail partnerships within the health system and across sectors, as well as among government departments within the province, with other provinces and, critically, with the efforts of the federal government. For this reason, in our Initial Report the Panel both endorsed and called for a comprehensive response from the federal government to the recommendations set out in the Naylor Report. From the 2004 Federal Budget, it is now clear that some important first steps have been taken to pave this path of renewal.8 The Panel notes that while these initial steps are positive, they are clearly limited and need to go further and be both sustained and supplemented.
8 Canada. Department of Finance Canada. Budget 2004. New agenda for achievement. Budget themes : the importance of health. March 23, 2004. [Online] Available at :http://www.fin.gc.ca/budget04/PDF/paheae.pdf. Accessed March 24, 2004.
We trust, though, that with partnership and commitment at the provincial level, and a comprehensive approach at the federal level, real progress can be made. Presently in Canada, there is a rare opportunity to converge federal and provincial interests. If it is actively pursued, this convergence will result in real and lasting change. This opportunity must be seized and not lost.
There are clear synergies and opportunities for collaboration between the proposed federal approach to strengthening Canada’s public health system and the proposed course for Ontario. These synergies centre on a number of areas including :
Establishment of a Public Health Agency
The proposed Canadian Public Health Agency will serve as the focal point within the federal government on public health matters. At the present time, discussion on the Canadian Public Health Agency has focused on the management of infectious diseases, emergency preparedness and response, as well as the prevention of chronic diseases. The national agency will also contribute to the development of a pan-Canadian public health network. Furthermore, of key importance to the Panel is the recent announcement in the 2004 Federal Budget of additional funding to develop and implement improved data collection standards and the development and implementation of a national surveillance system.9 The proposed Canadian Agency and processes to support public health across the country will support and contribute to public health renewal in Ontario.
9 Canada. Department of Finance Canada. Budget 2004. New agenda for achievement. Budget themes: the importance of health. March 23, 2004. [p.7]. [Online] Available at :http://www.fin.gc.ca/budget04/PDF/paheae.pdf. Accessed March 24, 2004.
The vision for the proposed Ontario Health Protection and Promotion Agency echoes well with the developing vision of the Canadian Public Health Agency and potentially could translate it into the day-to-day life of the provincial domain. The degree to which potential operational alignments can be built in at the agency design level by both levels of government early on in the process will be important, and a far easier task than attempting to undertake modifications and role clarifications after the fact. The Panel envisions that once the agencies are operational, there will be considerable technical and scientific liaison between both. Furthermore, the collaboration and relationship with the Canadian Agency will support the proposed Ontario Health Protection and Promotion Agency in effectively carrying out its mandate.
Given Ontario’s strategic location and position as well as its core critical mass of academic, scientific, research, and clinical expertise, the Panel feels that in addition to coordination and collaboration, there are benefits to exploring the co-location of the proposed Canadian Public Health Agency in Ontario. That said, regardless of the location of the hub, Ontario’s efforts must supplement and link whatever the outcome of national discussions.
Emergency Response and Health Human Resources
Both levels of government are undertaking a number of activities to enhance emergency response capacity, including the support for Emergency Preparedness Units/Offices, as well as Emergency Response Teams and equipment. Ontario is collaborating with the federal government in many of these endeavours. However, there are also important opportunities to collaborate in the recently announced expansion of the Canadian Field Epidemiology Program. The gaps in human resource training in Ontario are very clear. Coordination with the federal government in this Program could be an enhanced contribution to Ontario’s work in health human resources training and any effective models developed within provinces should have the potential and the mechanisms to be shared beyond the boundaries of any single jurisdiction.
Centres of Excellence
There have also been announcements regarding the establishment of regional centres of excellence in public health and laboratory facilities to advance understanding and action in key areas such as communicable disease epidemiology. This announcement presents a key opportunity for collaboration, particularly given the Panel’s recommendations with respect to the mandate of the Ontario Health Protection and Promotion Agency and the proposed Provincial Communicable Disease Committee along with the Regional Communicable Disease and Infection Control Networks.
Expanding Laboratory Capacity
In its Initial Report as well as this Final Report, the Panel has identified the clear need for an enhanced Central Public Health Laboratory capacity within Ontario, as well as the need for enhanced coordination with other components of the public health system. To this end, the need for continued and enhanced coordination with the National Microbiology Laboratory and the rapid development of an enhanced national public health laboratory network remain of key importance. The recent announcement of increased funding to support laboratorybased research will no doubt provide opportunities to support proposed research and laboratory functions needed in the province.
Aboriginal Public Health
No communities in Canada have experienced and continue to experience poorer health status than the Aboriginal communities. The Panel is aware of the litany of statistics that attest to the negative impact that a range of health determinants continue to play in the Aboriginal communities on- and off-reserve across Ontario.
Often overlooked in the rush to document the health status inequities, there are successes including numerous creative and effective programs in some areas that have achieved real progress. It is also clear from experience that the direct involvement of the Aboriginal communities in the design, development, and delivery of the required solutions is a prerequisite for their success.
Public health services and responsibilities within First Nations communities reside in a particularly complex and tangled jurisdictional field that currently structures the way in which healthcare is funded, regulated, and delivered in these communities.
In the area of public health and infection control, there is a critical need for a tri-partite plan. This is particularly true in the need to develop contingency plans for infectious disease outbreaks in First Nations communities.
The Panel proposes that mechanisms to support continued collaboration with the federal government be further refined and focused (i.e., F/P/T committees), with the recognition of specific areas and issues of mutual interest. Such endeavours should not only centre on technical liaison and exchanges, but also on specific collaboration activities to advance respective public health priorities. The timing for collaboration is not only ideal, but if anything, overdue.
The Panel also proposes that Ontario, the federal government, and First Nations leaders initiate discussions on a formal protocol pertaining to govern public health emergencies at the First Nations level, with a view to completing a protocol within twelve months.
We remain committed to the observations and recommendations put forward in our Initial Report, and see this Final Report as a further step towards public health renewal in Ontario. In both Reports, we have discussed and made recommendations regarding the rest of the healthcare system in Ontario, and we urge an equal consideration of these issues.
The time for change in Ontario is now : a new provincial government with a fresh mandate and a stated commitment to public health; a federal government that has already indicated some willingness to move forward in public health; and a healthcare system that is crying out for change. Within six months of each other, three reports at both the national and provincial levels have all put forward a consistent vision for a revitalized public health system that cannot be ignored. We have already lived through a fall and winter, hoping that SARS would not return. With the new year came more news of avian influenza outbreaks across Asia and fears of the possibilities of human transmission should the virus mutate. The question we pose is whether we are any more ready now to tackle an unknown public health enemy than we were one year ago? The honest answer is yes. We acknowledge the progress that has been made at both the federal and provincial levels, but we must rephrase the question, are our systems as ready as they need to be for the future?
As we noted in our Initial Report, improving our collective capacity to deal with emergencies such as SARS is a collective debt we owe to those who died from the disease, to those who lost loved ones, and to the healthcare providers who valiantly dealt with the disease. It is a debt that we owe to those who have shared their stories with us, and to those who continue to suffer from the experience. Improving our capacity to handle health emergencies is a down payment on the future – it is an investment for those who fight the next major health emergency or crisis, so that they may have access to the tools, supports, and process that we lacked during the SARS outbreak.
We hope that the thoughts, considerations, and recommendations that we have put forward both in our Initial and Final Reports are taken seriously. These must be truly considered as a foundation for substantial change, which is crucial to the effectiveness of our healthcare system in a rapidly changing global environment. We hope that this change moves ahead in partnership and collaboration, and in the spirit of those who fought so hard and offered so much to protect the health of everyone in Ontario. Now is the time for words to begin to be deeds.
10. The federal government, First Nations leaders, and the Ontario Ministry of Health and Long-Term Care should initiate discussion on a formal protocol relating to public health emergencies at the First Nations level with a view to completing a protocol within one year.
11. Ontario should vigorously pursue opportunities for co-location and collaboration between the proposed Canadian Public Health Agency and the Ontario Health Protection and Promotion Agency.