Building an Innovative Foundation: A Plan for Ontario's New Public ...

Report of the Agency Implementation Task Force

Building an

Innovative

Foundation: A Plan for Ontario’s New

Public Health Agency

October 2005 PART ONE

ISBN 0-7794-9044-4 (Print) ISBN 0-7794-9045-2 (PDF) © Queen's Printer for Ontario, 2005nt

cover

Table of Contents Agency Implementation Task Force Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii Letter of Transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Glossary of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Chapter 1 Context 1.1 1.2 1.3

Operation Health Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Agency Implementation Task Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Validating Our Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Chapter 2 The Benefits of an Agency for Ontario 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

Setting the Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Opportunity to Build on the Learnings of Other Jurisdictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Alignment with Key Healthcare Reform Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Ensuring Collaboration and Maximizing Use of Resources While Minimizing Duplication . . . . . . . . . . .10 Ensuring Government Can Do What It Does Best . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Ensuring Flexibility and Ability to Respond in an Ever Changing Environment . . . . . . . . . . . . . . . . . . . . . .13 Strengthening Research and Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Ontario Will Become a Centre of Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Chapter 3 Agency Development and Implementation Recommendations 3.1 3.2 3.3 3.4 3.5

Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Mandate, Vision, Mission, Values, and Philosophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Roles and Responsibilities of the Ministry of Health and Long-Term Care vis-à-vis the Agency . . . . . .19 Program Functions, Areas and Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Relationships and Principles for Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Chapter 4 Next Steps 4.1 4.2

Agency Implementation Task Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Ministry of Health and Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Appendices Appendix 1: Agency Implementation Task Force – Terms of Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Appendix 2: Research and Knowledge Transfer Sub-committee – Terms of Reference . . . . . . . . . . . . . . . . .37 Appendix 3: Agency Implementation Task Force, Reference Panel – Terms of Reference . . . . . . . . . . . . . . .39

Report of the Agency Implementation Task Force – Part One

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Building an Innovative Foundation: A Plan for Ontario’s new Public Health Agency

Agency Implementation Task Force Members CO-CHAIRS

MEMBERS

Geoff Dunkley

Michael Christian

Former Associate Medical Officer of Health, Ottawa Public Health Unit

Fellow, Infectious Disease and Critical Care Medicine, McMaster University

Donald Cole Terry Sullivan

Associate Professor, Department of Public Health Sciences, Faculty of Medicine, University of Toronto

President and Chief Executive Officer, Cancer Care Ontario

Ken Deane President and Chief Executive Officer, St. Joseph's Health Centre

Mae Katt Nurse Practitioner, Anishnawbe Mushkiki, Thunder Bay Aboriginal Community Health Centre

Alan Meek Professor, Ontario Veterinary College, University of Guelph

David L. Mowat Deputy Chief Public Health Officer, Public Health Practice and Regional Operations, Public Health Agency of Canada

Linda O'Brien-Pallas Professor, Faculty of Nursing, University of Toronto

Ruth Sanderson Health Unit Epidemiologist, Middlesex-London Health Unit

Andrew Simor Head, Department of Medical Microbiology, Sunnybrook and Women's Health Sciences Centre

Penny Sutcliffe Medical Officer of Health / Chief Executive Officer, Sudbury and District Health Unit

Ron Yamada Founder and Executive Vice President (retired), MDS Incorporated

Jennifer Zelmer Vice President of Research and Analysis, Canadian Institute for Health Information

Acknowledgements The Agency Implementation Task Force would like to thank the Strategic Planning and Implementation Branch of the Public Health Division, Ministry of Health and Long-Term Care, for its support and excellent work in the preparation of this report, specifically: Phil Jackson Camille Lemieux Paulina Salamo Helen Bedkowski Liz McCreight Barbara Slater The Task Force would also like to acknowledge the valuable input provided by the following: ■ Institut national de santé publique du Québec. ■ British Columbia Centre for Disease Control. ■ Participants in the roundtable discussions. ■ Members of the Agency Implementation Task Force, Reference Panel.


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Letter of Transmittal Dr Sheela Basrur Chief Medical Officer of Health and Assistant Deputy Minister Public Health Division, Ministry of Health and Long-Term Care Hepburn Block, 11th Floor 80 Grosvenor Street Toronto, ON M7A 1R3

October, 2005

Dear Dr. Basrur: he Agency Implementation Task Force is pleased to present you with Part One of its report outlining necessary initial recommendations for the timely implementation of a Public Health Agency for Ontario, focused upon governance, program areas and functions. We believe that time is of the essence in moving forward to establish the Agency. Implementation of these recommendations is required to meet the present government’s clear commitment to create an independent agency by 2006/07 as part of a “sweeping plan to rebuild the public health system by bold system-wide changes that will make the public health system stronger, more responsive and sustainable for future generations.”

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We firmly believe the Agency must be an independent organization with dedicated resources that will provide public health leadership through the advancement and application of science and knowledge. This new organization will be the linchpin for a revitalized public health system in Ontario and will become an attractive scientific, technical and training hub. The Agency will establish a firm post-SARS legacy in Ontario, one that will support healthier Ontarians and ensure we are well prepared to anticipate and respond effectively to new and emerging public health challenges. A strong Public Health Agency for Ontario will respond to the expectations of the public as well as those of healthcare providers and practitioners, and will bolster public confidence through a revitalized capacity to promote and protect the health of our citizens. We urge the government of Ontario, through the Ministry of Health and Long-Term Care, to move swiftly on our recommendations and grant the Agency sufficient funding and resources, including a critical mass of skills and expertise, to allow it to be fully responsive to the needs of government, the field and all Ontarians. Part One of our report lays the necessary foundation upon which the government can move forward immediately to begin to realize the Agency while Task Force members continue with their work. Part Two of our report will build on this foundation and provide further recommendations related to operating structure and phased start-up of the Agency. Sincerely, Members of the Agency Implementation Task Force cc:

Honourable George Smitherman, Minister of Health and Long-Term Care Honourable Jim Watson, Minister of Health Promotion

Geoff Dunkley (co-chair)

Terry Sullivan (co-chair)

Michael Christian

Donald Cole

Ken Deane

Mae Katt

Alan Meek

David L. Mowat

Linda O’Brien-Pallas

Ruth Sanderson

Andrew Simor

Penny Sutcliffe

Ron Yamada

Jennifer Zelmer


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Glossary of Acronyms

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AITF

Agency Implementation Task Force

BCCDC

British Columbia Centre for Disease Control

CDC

Centers for Disease Control and Prevention (U.S.)

CEO

Chief Executive Officer

CMOH

Chief Medical Officer of Health

HPA

Health Protection Agency (U.K.)

INSPQ

Institut national de santé publique du Québec

MHPSG

Mandatory Health Programs and Service Guidelines

MOHLTC

Ministry of Health and Long-Term Care

NGO

Non-governmental organization

PHAC

Public Health Agency of Canada

PIDAC

Provincial Infectious Diseases Advisory Committee

Part One – September 2005

Recommendations AGENCY FOUNDATIONS n Part One of its report, the Agency Implementation Task Force (AITF) is putting forward fifteen initial recommendations for the development and implementation of a Public Health Agency for Ontario (Agency). In addition, the AITF is proposing the following mandate, vision, mission and values for the Agency:

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Mandate To provide scientific and technical advice for those working to protect and promote the health of Ontarians.

Vision We will be an internationally recognized centre of expertise dedicated to the promotion and protection of the health of all Ontarians through the application and advancement of science and knowledge.

Mission We are accountable to support healthcare providers, the public health system and government in making informed decisions and taking informed action to improve the health and security of all Ontarians through the transparent and timely provision of credible scientific advice and practical tools.

Values The core values supporting the Agency’s work should be: responsiveness, relevance, credibility, collaboration and innovation. The Vision, Mission and Values of the Agency should be reviewed once the Agency is operational and periodically thereafter.

The AITF urges the Ministry of Health and Long-Term Care (MOHLTC) to immediately move forward to implement the following recommendations, in order that the government can fulfill its commitment to have the Agency in place by 2006/2007. 1. The MOHLTC should establish a dedicated internal team, in the fall of 2005, to operationalize the Agency based upon the AITF recommendations put forth in Part One of its report. (a) The MOHLTC should establish an expert advisory transition body, in early 2006, to assist the internal MOHLTC team with the phased implementation of the recommendations of the AITF.

2. The Agency should be established through special purpose legislation. (a) The Agency should be a scheduled agency of the MOHLTC. (b) The Agency should be granted the necessary powers to access and hold third party funds to enhance its capacity. (c) The Agency should be granted the necessary powers to hold data in a privacy-sensitive manner. 3. The government should establish memoranda of understanding between the Agency and the MOHLTC, the Ministry of Health Promotion and other relevant ministries, clearly articulating the roles and responsibilities of each. 4. The Agency should be funded by the MOHLTC on a multiyear basis, subject to annual review. (a) The Agency should be provided with sufficient resources to ensure it houses a critical mass of skills and expertise to effectively fulfill its mandate. (b) The Agency should have the ability to enter into flexible human resource arrangements such as crossappointments and secondments. (c) The Agency should receive annual funding of at least $45 million as recommended in the Walker Report, over and above any existing base funding and over and above any costs associated with recommendations put forth as a result of the public health laboratory review. 5. The Agency should have the ability to develop formal partnership agreements with appropriate academic and research centres, as well as informal partnerships as appropriate. (a) All partnerships in which the Agency engages should be guided by a formal framework governed by the principles articulated in Part One of the AITF report. 6. The Agency should be functionally arm’s-length from the MOHLTC and be governed by a Board of Directors. (a) A Board of Directors for the Agency should be in place by mid-2006.


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(b) Members of the Board of Directors should be selected through a transparent, non-partisan process involving appropriate external expert advice. (c) Membership of the Board of Directors should represent a suitable breadth of skills and competencies reflective of the Agency’s mandate including a public health presence and a public representative. (d) Clear reporting relationships should be established whereby the Chair of the Board of Directors is directly accountable to the Minister of Health and Long-Term Care, who is in turn accountable to the legislature for the Agency’s activities. (e) A series of standing committees should report to the Board of Directors, including Strategic Planning, Scientific Advisory and Audit. The membership of these committees should include a majority of non-Board members. (f) The Strategic Planning committee should be tasked with recommending a multi-year strategic plan to be approved by the Board of Directors that aligns with both government and field priorities. 7. The Chief Medical Officer of Health should regularly attend Agency Board meetings as an observer, but not sit as a member of the Agency Board of Directors. 8. The Chief Medical Officer of Health should be directly involved in the strategic planning process for the Agency through membership on the standing Strategic Planning committee of the Board of Directors. 9. The Board of Directors should select and hire the Chief Executive Officer of the Agency through a transparent recruitment and selection process. (a) The Chief Executive Officer of the Agency should possess scientific and public health leadership skills. 10. The Agency should submit annual performance plans to the MOHLTC, the results of which should be documented in annual performance reports. (a) Periodic external reviews of the Agency should be carried out to assess and evaluate its performance.

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AGENCY ROLES AND RESPONSIBILITIES 11. The Agency’s primary clients should be healthcare providers and practitioners, Public Health Units, and government. 12. The Agency’s initial program areas should be: infectious diseases; health promotion, chronic disease and injury prevention; environmental health; and emergency management support. 13. The Agency should provide the following functions or services as part of its program areas: surveillance and epidemiology; research; knowledge exchange; specialized laboratory diagnostics; professional development; and communication. 14. The Agency should be directly linked with a reformed and strengthened public health laboratory system. (a) The implementation of AITF recommendations contained in Part One of its report should be closely aligned with the recommendations emanating from the public health laboratory review. (b) Agency-based laboratory diagnostics should: (i) Be co-located with the Agency itself. (ii) Be supported by a comprehensive provincial Laboratory Information System. (iii) Provide specialty functions such as confirmatory and molecular diagnostics and disease surveillance. (iv) Provide increased research capability.

GOVERNMENT ROLES AND RESPONSIBILITIES 15. The MOHLTC should maintain the lead role and retain lead responsibility in the following areas: (a) Policy development. (b) Ensuring compliance and accountability with standards and guidelines. (c) Public health human resource planning, assessment and training. (d) Emergency management activities (with Emergency Management Ontario and other relevant ministries). (e) General health communication to practitioners, professionals, the public and the media. (f) Funding of Public Health Units and healthcare facilities, and ensuring accountability for the use of these funds. (g) Maintaining direct relationships with federal departments such as Health Canada and with the Public Health Agency of Canada through established federal/provincial/territorial processes, except where such responsibility is delegated to the Agency.

Introduction n carrying out its mandate, the Agency Implementation Task Force (AITF) will present

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two reports to the Ministry of Health and Long-Term Care (MOHLTC). This report, Part One, provides an overview of the deliberations and recommendations to date. It sets

out the vision and lays the foundations for a new Public Health Agency for Ontario. It also outlines a proposed governance model, including the recommendation that the Agency be established as a scheduled agency of the MOHLTC. Furthermore, the recommendations in this report delineate accountability relationships between the Agency and the MOHLTC as well as principles to guide partnerships. Part One also provides the MOHLTC with high level recommendations regarding the functions and program areas to be undertaken by the Agency. However, additional work remains to further define the scope of the Agency’s operations. Some of this work will be guided by recommendations put forth as part of the public health laboratory review currently underway, as well as by developments such as the transition associated with the newly established Ministry of Health Promotion. To this end, the AITF believes that further delineation of the Agency’s functions and program areas must be undertaken as the Agency begins to materialize through the establishment of founding legislation, and the appointment of a Board of Directors as well as a Chief Executive Officer.


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Chapter 1

Context ublic health renewal has been called for in a number of recent reports, which have documented with great clarity the need to invest in and rebuild our capacity to promote and protect the health of Canadians. These reports have commented that public health is in need of revitalization and investment at both the provincial and national levels. They include the following:

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National Advisory Committee on SARS and Public Health, Learning from SARS: renewal of public health in Canada (Naylor Report).1 SARS Commission, Interim report: SARS and public health in Ontario (first Interim Report of Justice Archie Campbell).2 Ontario Expert Panel on SARS and Infectious Disease Control, For the public’s health: final Report of the Ontario Expert Panel on SARS and Infectious Disease Control (Walker Report).3 Meat Regulatory and Inspection Review, Farm to fork: a strategy for meat safety in Ontario (Report of Justice Roland Haines).4

Common to all of the above reports is recognition of the need to establish an arm’s-length body with a primary focus on excellence in the provision of technical and scientific public health support to the health system. Such a body would be similar to those already in place in British Columbia, Québec and the United Kingdom. The experience of these and other jurisdictions has shown a clear benefit in having a dedicated body that bridges the gap between science and practice.

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Operation Health Protection

In response to the recommendations contained in the Walker Report and the first Interim Report of Justice Archie Campbell, the Minister of Health and Long-Term Care released Operation Health Protection — an action plan to prevent threats to our health and to promote a healthy Ontario on June 22, 2004. A key strategic priority of this three-year action plan is a landmark commitment to the creation of a new arm’s-length Public Health Agency for Ontario (Agency), dedicated to the prevention and control of disease and the promotion of health. The stated goal of the Agency, as articulated in Operation Health Protection, is to “strengthen Ontario’s capacity to provide scientific and technical advice for and within the health sector in the areas of health protection and promotion.”5 The present government’s commitment is to establish an agency by 2006/07, with a formal board structure in place before 2006/07.

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Operation Health Protection made a commitment to establish the Agency Implementation Task Force (AITF) as an advisory body to the Ministry of Health and Long-Term Care (MOHLTC) on the development and implementation of the Agency. The AITF was struck in January 2005 with the following responsibilities: ■ ■

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To validate the Agency’s proposed mandate, key functional areas, structure and governance. To recommend operational public health responsibilities for the Agency and delineate its roles and responsibilities in relation to those of the MOHLTC, academia, the broader health system, and the Public Health Agency of Canada and its collaborating centres. To recommend a comprehensive three-year implementation plan for the Agency, including infrastructure, financial requirements, human resources and transition planning.

The full terms of reference for the AITF can be found in Appendix 1. The AITF has met regularly since early 2005 and is now two-thirds of the way through its mandate. In Part One of its report, the AITF is sharing its initial recommendations for the development and implementation of the Agency.


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Deliberations have occurred on the following: the Agency’s proposed vision, mission and values; governance; principles for partnership; and recommended key program areas and functions. These discussions have been predicated on the need for the Agency to have a significant degree of independence in order to effectively carry out its mandate, but also maintain sufficient links with both the field and government so as to add value in a coordinated, focused and organized manner.

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The AITF has also identified the primary groups that the Agency should serve: healthcare professionals and practitioners; healthcare facilities, institutions and organizations; Public Health Units; and the provincial government.

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Validating Our Work

To validate the proposed program areas and functions of the Agency, several strategies were used: 1 Searching the literature to determine best practices. 2 Learning extensively from the direct experiences of other jurisdictions. 3 Consulting with various existing public health agencies in relation to their programs and functions. 4 Consulting with experts on governance in the public sector. 5 Conducting roundtable discussions with participants representing a wide variety of expertise, knowledge and experience, including Public Health Units, hospitals, community health settings, the voluntary sector and academia. Roundtables were convened on the following topics: health promotion, chronic disease and injury prevention; infectious diseases; and environmental health. The outcomes of the three roundtables were consistent with one another and validated the role of the Agency as discussed in Chapter 3 of this report. Roundtable participants viewed the role of the Agency as follows: ■

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Building core technical capacity across the continuum of healthcare by: identifying gaps in capacity and putting in place networks of expertise or communities of practice (for example, in epidemiology); facilitating strong connections between these hubs and the field; developing online resource tools, training opportunities and continuing education initiatives; and liaising formally and informally with experts locally, nationally and internationally. Bridging and coordinating networks, linkages and communication channels in order to share information and data. Developing practical tools based upon evidence and science; for example, specific tools to support Public Health Units in implementing the Mandatory Health Programs and Services Guidelines.6


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Shaping research agendas such that public health research, including applied and intervention-based research, is undertaken. Providing leadership in partnership development and networking, as well as collaboration provincially, nationally and internationally, in order to build technical capacity on the ground, provide leading-edge scientific and technical support, and encourage and leverage research in areas of need. Providing system-wide and cross-sectoral integration of research, knowledge, policy and practice.

As evidenced by the above, the AITF has spent considerable time validating its direction with a cross-section of leaders in the field. This validation was overwhelmingly consistent in terms of pointing out a clear need for the Agency to engage in the programs and fulfill the functions that the AITF is recommending. This validation not only points to the need for the Agency as recommended in the Walker Report, but confirms that the Agency will not be duplicating existing programs and functions and will provide added value in terms of filling gaps, developing competencies and building on and creating synergies between existing organizations. Research and knowledge exchange will be key pillars of the Agency. To this end, a Research and Knowledge Transfer subcommittee of the AITF has been established, which has been working to draft recommendations related to the Agency’s work in these areas. The sub-committee also reports to and supports the work of the local Public Health Capacity Review Committee (see Appendix 2 for the terms of reference of the Research and Knowledge Transfer Sub-committee). As well, the AITF has made a concerted effort to share information with various health system stakeholders to allow opportunities for broader input into the process of designing the new Agency. Stemming from this, the first meeting of a Reference Panel was held mid-July 2005, establishing a forum for the AITF to provide stakeholders with an update on its activities and to hear a variety of perspectives on a wide range of issues related to the creation of the Agency. The terms of reference for the Reference Panel, can be found in Appendix 3. Finally, the AITF has benefited greatly from the advice and lessons learned from discussions with the British Columbia Centre for Disease Control (BCCDC) and the Institut national de santé publique du Québec (INSPQ), as well as the U.S. Centers for Disease Control and Prevention (CDC) and the U.K. Health Protection Agency (HPA).

Chapter 2

The Benefits of an Agency for Ontario he crucial questions that the AITF has worked to answer in its deliberations to date are “How best to build an Agency that is appropriately arm’s-length and that has a strong working relationship with the government and the field?” and “What are the unique contributions that an Agency will provide for Ontario?” In answering these questions, the AITF has been guided by the following principles: the need for transparency; the need to promote confidence in the public health system; the need to attract and retain expertise; and the need to nurture a scientific and research oriented environment. Further, through reflecting on these questions, the AITF arrived at the recommendations found in Chapter 3 of this report.

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2.1

Setting the Stage

Public health concerns are not new to Ontario. In the recent past, West Nile virus, Walkerton water issues, meat inspection concerns in Aylmer, and of course SARS, have come to the fore and highlighted that emerging and ongoing threats to the health of Ontarians are constantly present. Other current concerns include: bioterrorism threats such as anthrax and smallpox; worrisome trends in chronic disease risk factors such as obesity; and an increasing global concern with emerging infectious diseases such as avian influenza and its potential transmission to humans as a highly pathogenic strain that is increasingly feared as the next trigger for a pandemic. There are also escalating demands on the public health system, evidenced by increasing national and international focus on issues such as: the increasing burden of illness caused by chronic and non-communicable diseases; the resurgence of tuberculosis; the growing threat of antibiotic-resistant organisms in both healthcare and community settings, for example methicillin-resistant Staphylococcus aureus; more pathogenic facility-acquired infections; for example, Clostridium difficile; and zoonotica diseases, such as Lyme disease, which

have been reported to account for approximately 70% of all new and emerging infectious diseases in humans. Finally, as the province and society as a whole begin to invest more heavily in promoting health and preventing illness, there is a demonstrated and clear need for evidence-based behavioural science to ensure these initiatives are effective and affordable. We need to know what works, what doesn’t, and why before scarce healthcare dollars are spent: evidence matters. It is essential that Ontario be prepared to address these concerns in the most effective, efficient, timely and scientific manner possible. For example, the need for reliable, high-quality surveillance data and information in order to effectively and proactively deal with the next influenza pandemic and other threats cannot be overemphasized. In recent decades, decreasing attention to public health has resulted in a depletion of public health capacity; fortunately, it appears that the tide has turned both provincially and nationally, and public health is experiencing a rejuvenation. As part of this renewal, there is a critical need to provide the scientific, technical and human resource supports for the system as well as for its components, such as Public Health Units. It is into this landscape of renewal that the AITF has been placed, and it is with great optimism that the recommendations found in this report are made. Over the two years since the SARS outbreaks, a series of reports have discussed how to best ensure that Ontario, and indeed Canada, is sufficiently prepared for future inevitable public health threats. Each has called for enhanced capacity in public health as well as for the establishment of a scientific and technical centre of public health expertise. Released in October 2003, the Naylor Report recommended that a Canadian Agency for Public Health be established as an arm’s-length legislated service agency to provide leadership and action on public health matters.1 The report called for increased resources for this agency ($100 million per annum over funds presently being spent on core federal public health

a Communicable from animals to humans.


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functions), as well as funding to provinces and territories to strengthen public health programming. The report also indicated that priority should be given to infectious disease surveillance and programs to support the personnel required to implement surveillance activities. In response to the Naylor Report and in order to deliver on the federal government’s commitment to protect the health and safety of all Canadians, the Public Health Agency of Canada (PHAC) was established in September 2004 through Order-inCouncil, rather than as a legislated service agency as recommended. The activities of PHAC focus on preventing chronic diseases and injuries as well as responding to public health emergencies and infectious disease outbreaks.

technical public health functions in a manner that is flexible and agile, as well as appropriately independent. Building on the Walker Report, the government of Ontario set out its commitment to revitalize public health in the 3-year action plan Operation Health Protection.5 A cornerstone of Operation Health Protection is the establishment of an independent agency with the following core functions: ■ ■ ■ ■ ■

Part of the structure of PHAC includes its six National Collaborating Centres (NCCs). Key functions of the NCCs include: drawing on regional, national and international expertise to complement the contributions of individuals and organizations throughout the public health system; fostering collaboration, strengthening relationships and creating important new linkages among researchers, the public health community and other stakeholders; and furthering the development of enhanced and improved programs, policies and practices by sharing knowledge and working cooperatively with a wide variety of stakeholders in the health care community.

Released in November 2003, the report of the Standing Senate Committee on Social Affairs, Science and Technology, chaired by Senator Michael Kirby, stated the following with respect to a federal public health agency: “In summary, the Committee is firmly convinced … that a new agency operating at arm’s-length would contribute to enabling quicker, more efficient and nimbler responses in the face of health emergencies. It would also improve the chances for greater cooperation amongst all levels of government, thereby furthering the capacity to protect and promote the health of Canadians.”2

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The AITF has used each of these reports as a touchstone and foundation for its work, particularly Operation Health Protection.

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Two Canadian provinces currently have specialized public health bodies in existence: Québec and British Columbia. The INSPQ was founded to engage in knowledge development and management, in order to support and transform public health practices. The activities of the INSPQ include: ■

The Walker Report was also released in April of 2004, setting out the vision of a revitalized public health system in Ontario in great detail. Among the recommendations made in the Walker Report was the establishment of a legislated public health agency in Ontario that is at arm’s-length from government and has a formal board structure.4 Walker also indicated that an agency would serve to organize and align scientific and

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Opportunity to Build on the Learnings of Other Jurisdictions

Much can be learned from the successes of other national and international jurisdictions. Many either have in place or are currently taking steps to establish more focused and specialized bodies dedicated to the provision of technical and scientific public health support. (see page 9, A History of Specialized Public Health Organizations Around the Globe).

In April of 2004, Mr. Justice Archie Campbell submitted his first Interim Report to the Minister of Health and Long-Term Care. In clearly describing the dearth of public health capacity in Ontario at the time of the SARS outbreaks, Justice Campbell recommended that an Ontario Centre for Disease Control be created independent of the MOHLTC, that would have a critical mass of public health expertise, strong academic links and central laboratory capacity.3

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Enhanced and specialized public health laboratory services. Infectious diseases (including infection control and communicable disease capacity). Emergency preparedness assistance and support. Health promotion, chronic disease and injury prevention. Risk communications. Research and knowledge exchange.

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Promoting the development, sharing and use of knowledge in public health. Developing and promoting research in collaboration with research organizations and funding agencies. Informing the Minister of the impact of public policies on the health status of the people of Québec. Informing the public of its health and well-being, and of emerging problems, their causes and effective prevention methods and solutions. Working with universities in preparing and updating public health training at the undergraduate, graduate and postgraduate level, including designing and implementing continuing education programs.6

The BCCDC is that province’s centre of excellence for the prevention, detection and control of communicable disease, as well as a

A History of Specialized Public Health Organizations around the Globe Quebec Institut national de santé publique du Québec (INSPQ)

BC Centre for Disease Control (BCCDC)

US Centers for Disease Control and Prevention (CDC)

UK Health Protection Agency (HPA)

Hong Kong Centre for Health Protection (CHP)

EU European Centre for Disease Prevention and Control (ECDC)

Date of creation

1998

1997

1946

2003

2004

May 2005

Type of Entity

Fully arm’s-length Authority derived from special legislation (An Act Respecting Institut National de Santé Publique du Québec, 1998)

Arm’s-length (degree) Established as a Society (corporate body) and accountable to the Provincial Health Services Authority – somewhat arm’s length

Part of government Part of the Department of Health and Human Services

Fully arm’s-length Authority derived from special legislation (Health Protection Agency Act 2004)

Part of government Part of Hong Kong’s Department of Health (the Controller for the CHP reports to the Director of Health)

Fully arm’s-length Authority derived from special legislation (Regulation of the European Parliament and of the Council, 2004)

Mandate

To improve the coordination, development and use of expertise in public health, and to develop knowledge and share information in public health.

To support a comprehensive program of communicable disease and environmental health prevention.

To promote health and quality of life by preventing and controlling disease, injury and disability.

To protect health and reduce the impact of infectious diseases, chemical hazards, poisons and radiation hazards.

To achieve effective prevention and control of diseases in Hong Kong in collaboration with major local and international stakeholders.

To identify, assess and communicate current and emerging threats to human health from infectious diseases (may be broadened to noninfectious diseases after a scheduled review in 2007).

Focus

• Surveillance and population health assessment • Health promotion • Disease and injury prevention • Health protection • Administration of public health laboratories, toxicology centre, provincial audiological and radiological screening service

• Hepatitis services • Epidemiology services • Laboratory services • Sexually transmitted disease/AIDS control • Tuberculosis control • Drug and Food Information Centre • Food protection • Radiation protection

• Health promotion and prevention of disease, injury and disability • Preparedness, including protection from infectious, occupational, environmental and terrorist threats

• Infectious diseases • Chemicals and poisons • Radiation • Emergency response • Local and regional services • Research • Risk communications

• Surveillance and epidemiology • Emergency response and information • Infection control • Program management and professional development • Public health laboratory • Public health services

• Networking public health authorities to foster coordination and collaboration. • Linkages with international partners (e.g. World Health Organization, CDC)

provider of specialty health support and resource services such as drug and poison information services, radiation protection services, food protection services and a series of clinics for the public.7 The BCCDC collaborates with the University of British Columbia in the advancement of academia, research and teaching. The best known of the international public health bodies is the CDC in the United States.8 Established immediately post–World War II as a Communicable Disease Center, the CDC is part of the Department of Health and Human Services and has achieved credibility, public trust and a degree of earned autonomy by building highly respected scientific and technical

expertise. Although building such credibility and autonomy while operating as part of government is possible, it takes many years to achieve and may be easily undermined by changes in government that can lead to political interference.9 The CDC currently has a much broader mandate to promote health and quality of life. The CDC works with partners throughout the nation and the world to: monitor health; detect and investigate health problems; conduct research to enhance prevention; develop and advocate sound public health policies; implement prevention strategies; promote healthy behaviours; foster safe and healthful environments; and provide leadership and training.


9

More recently, the United Kingdom (U.K.) has established a legislated agency, the HPA, with the role to protect health and reduce the impact of various hazards.10 This role involves the following: ■ ■

■ ■ ■

■

Advising government on public health protection policies and programs. Delivering services and supporting the National Health Service and other agencies to protect people from infectious diseases, poisons, and chemical and radiological hazards. Providing an impartial and authoritative source of information and advice to professionals and the public. Responding to new threats to public health. Providing a rapid response to health protection emergencies, including the deliberate release of biological, chemical, poisonous or radioactive substances. Improving knowledge of health protection through research, development, and education and training.

Similarly, the European Union11 and Hong Kong12 have moved to create specialized bodies. The U.K. also has in place specialized public health observatories (PHOs)13, created in 1999/2000. Each of the ten PHOs is responsible for a geographic area of England and Wales, collecting and analyzing public health data and monitoring the performance of local health authorities. A number of PHOs are co-housed with academic institutions, such as the University of Durham Queen’s Campus, John Moores University in Liverpool and the Institute of Public Health in Cambridge. The PHOs fulfill the following functions in their respective regions: ■ ■ ■ ■ ■ ■ ■

Monitor health and disease trends and highlight areas for action. Identify gaps in health information. Advise on methods for health and health inequality impact assessments. Draw together information from different sources in new ways to improve health. Carry out projects to highlight particular health issues. Evaluate progress by local agencies in improving health and reducing inequality. Look ahead to give early warning of future public health problems.

Clearly, other jurisdictions have heeded the call for housing a critical mass of expertise in public health at arm’s-length from government. As the largest of the Canadian provinces, Ontario should follow this same call.

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2.3

Alignment with Key Healthcare Reform Initiatives

The current Ontario government has committed to broad sweeping reform of the health system: the implementation of Local Health Integration Networks (LHINs); the creation of a quality of care accountability framework grounded in legislation14 together with a Health Quality Council; the establishment of Family Health Teams; and the development of a strategy for System Information Management. Among the principles driving each one of these initiatives are improved integration and benchmarked quality of care. The AITF sees the Agency as adding value to these endeavours in several ways, most significantly though being a significant integrator across the healthcare spectrum by acting as a scientific and technical resource in the delivery of information, programs and services. These will be provided not only to Public Health Units and practitioners, but also to healthcare providers and practitioners broadly including hospitals, community health centres, long-term care facilities and other organizations and non-governmental organizations, as well as to government. The Agency will provide advice, tools and information using common language and common science, further ensuring integration and increased quality of care. We need to be working from the same page, and that page needs to be based on evidence and science that spans across existing silos. Finally, through provision of coordinated services such as surveillance and associated epidemiologic analyses, the Agency will act as a centralized source of data and information upon which to establish reliable benchmarks.

2.4

Ensuring Collaboration and Maximizing Use of Resources while Minimizing Duplication

The value and importance of an integrated approach is increasingly evident. The recent history of healthcare delivery and research has resounded with examples of the “silo” approach, whereby institutions, organizations, researchers and practitioners work in relative isolation from one another. More recently, networking principles have taken hold, in the form of research consortia and disease-specific networks organized on a regional level. However, Ontario continues to lack a resilient central hub of scientific and technical expertise in public health for healthcare providers, professionals and government. Through establishment of the Agency, the AITF sees a clear opportunity for a collaborative and consistent approach to the delivery of programs and services provincially, locally or regionally, supported by tools and knowledge generated by the Agency. For this to be a success, however, the AITF cannot

stress strongly enough that adequate capacity, in terms of human and financial capital, as well as access to data and information, must exist within the Agency. The Agency will prove to be a solid investment through its coordination of functions, information and tools. It will also achieve cost avoidance by establishing the critical mass of resources and expertise required to be prepared for unforeseen events that may take an economic toll on Ontario. The extensive costs incurred as a result of the SARS outbreaks are sobering evidence of the need for this enhanced capacity. The Agency will provide the locus for the establishment of partnerships with academic institutions, academic health science centres, research bodies and governmental and nongovernmental organizations. In this way, expertise already within Ontario can be networked effectively and expert resources used efficiently. Further, networking acts to minimize “reinventing the wheel,” whereby efforts are duplicated in the absence of a centralized coordinating body. In addition, partnerships act to build upon and enhance existing capacity, rather than building entirely from the ground up. Ontario is a leader in many areas of health-related research; the AITF feels that this role can only be augmented through the creation of the Agency. Partnerships, collaboration, and a venue through which public health research priorities can be identified and aligned will foster an Ontario-wide research environment rather than one grounded in specific academic institutions or organizations. The Agency will be an innovative structure to create bridges among practitioners, researchers and government. Further, the Ontario government invests a significant amount in research funding, and the creation of a new Ministry of Research and Innovation signals an increased government commitment to the “knowledge industry” in the province. The Agency will help to leverage the greatest results from that investment. Establishment of a dedicated and focused central resource for public health will also allow multiple sectors of government to draw upon the same scientific base. In addition to the MOHLTC, the new Ministry of Health Promotion, the Ministry of the Environment (with jurisdiction over water and air safety) and the Ministry of Agriculture, Food and Rural Affairs (with jurisdiction over food safety) would, the AITF believes, all benefit in fulfilling their given mandate from the consistent expertise and advice provided by a single agency. An example is the threat of an influenza pandemic from an avian source. The Ministry of Natural Resources would require support in relation to the surveillance of migratory birds who may be carrying the H5N1 strain of influenza, the Ministry of Agriculture, Food and Rural Affairs would require support in relation to surveillance of domestic flocks who may contract H5N1 from wild fowl and the

MOHLTC would require support in relation to the risk of transmission of H5N1 to humans. We need a comprehensive and consistent analysis of risk, as well as coordinated access to the latest science and risk assessments across multiple ministries; the Agency will be ideally equipped to perform this bridging function.

2.4.a

Formalizing a successful approach to integration across the healthcare sector – building on work to date

In Ontario, the Provincial Infectious Diseases Advisory Committee (PIDAC) was established in June 2004 as part of Operation Health Protection. PIDAC is advisory to the Chief Medical Officer of Health (CMOH) on scientific and technical matters relating to the prevention, surveillance and control of infectious diseases. Membership brings together experts from acute care, long-term care, public health, occupational health and safety, and community-based settings — portions of the healthcare sector that have not traditionally worked together at the same table. To date, PIDAC has demonstrated itself to be flexible, responsive, credible and relevant while remaining outside of the infrastructure of the MOHLTC; for example, it provided expert advisory support during the spring 2005 rubella outbreak in southwestern Ontario. PIDAC is composed entirely of volunteer experts who maintain full-time careers outside of their commitments to the committee. The situation is similar for the Scientific Advisory Committee (SAC), which supports the Emergency Management Unit within the MOHLTC. On an ongoing and long-term basis, the expectation that these individuals can continue in this voluntary manner is unreasonable. As such, there is a need to formalize the infrastructure to support expert resources such as PIDAC and the SAC through mechanisms of compensation and formal affiliation; for example, cross-appointments whereby an individual can maintain stable relationships with multiple organizations, or secondments. There is a need to move beyond episodic and ad hoc mechanisms by which government accesses science in order to guide decision-making, and toward permanence and resilience.

2.4.b

Filling gaps efficiently

The AITF acknowledges the existing level of knowledge, expertise, and program and service delivery in public health across the province. However, a number of glaring gaps exist that would be remedied by creating the Agency. Among these is a need for a significantly enhanced system of surveillance for various infectious and chronic diseases, whether targeted or ongoing. Examples of current gaps include: animal health issues given the importance of zoonotic diseases in human health; infectious diseases that are not reportable under legislation; antibiotic-resistant organisms in healthcare facilities and in


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community settings, such as methicillin-resistant Staphylococcus aureus; facility-acquired infections such as Clostridium difficile; chronic diseases such as type 2 diabetes; and emerging threats such as childhood obesity. Furthermore, there is a need to better analyze comprehensive surveillance data and to use this analysis to advise government in a timely manner on the need for: policy change; development of and support for new programs; implementation of specific interventions such as immunization campaigns; and determination of research needs. Another significant gap is the need for practical, up-to-date and relevant tools for use by the field; for example, guidelines, best practices and outbreak protocols. The Agency would provide the venue to carry out or support these activities. It is good news that the federal government has established PHAC; however, the bulk of day-to-day public health activities, including outbreak response, are handled at the provincial and local levels. It is for this reason that many of the larger U.S. states, such as Minnesota and Florida, have their own specialized bodies and why the INSPQ and BCCDC have proven so valuable in their respective provinces. An Ontario Agency will provide necessary provincially relevant capacity and infrastructure to support the field and front-line healthcare workers, as well as to collaborate at the provincial level. While there will be areas of common interest, PHAC has a number of roles that will not be undertaken by the Agency, such as national coordination, national data collection, liaison with international organizations and other nation states, and provision of highly specialized services such as the National Microbiology Laboratory. In addition, the Agency would provide an ideal venue through which Ontario can further work collaboratively with PHAC via its NCCs.

2.4.c

Ensuring Ontario’s rich expertise can benefit Ontarians

Ontario is home to numerous expert resources, housed in existing public health, clinical, research and academic, and veterinary medical settings. Many of these experts are worldrenowned and are frequently called upon by other jurisdictions, both nationally and internationally. By establishing a consolidated agency, a hub will be created where such experts can work in an atmosphere of excellence and generate relevant and leading-edge knowledge and information for Ontario, and thereafter for the rest of Canada and the world. The Agency will therefore serve as a magnet which will attract additional expertise and innovation, and thereby have a ripple effect through the establishment of research and development clusters. 12


2.5

Ensuring Government Can Do What It Does Best

Clarity of roles is a critical success factor. Across numerous jurisdictions, the role of government is being increasingly focused on health stewardship and away from direct provision of health services. Government is the expert in policy generation, leading to the enactment of legislation where appropriate, as well as in funding and managing programs, and ensuring accountability and the effective use of funds in the interests of Ontarians. These are not roles to be undertaken by the new Agency. Government is, by necessity, more bureaucratic and process-oriented, and must manage competing interests; conducting science forms only a small component of its activities. Government does have a role in identifying broad research priorities, investing strategically and effectively in research and creating an environment for research excellence and innovation across all sectors. However, innovation and science, essential to Agency success, thrive best in a flexible infrastructure. As stated succinctly in the Naylor Report, “…the current placement of public health functions within a department of government puts public health professionals inside a very large organization and a highly process-oriented culture with a particular orientation to the political issues of the day…the processes by which policy is developed and communicated may be suboptimal for the provision of specialized public health services.”15 Further, the Walker Report stated: “…an agency structure functioning distinctly from the Ministry could offer a greater degree of agility to several of the critical analytical and response functions currently housed at the Ministry.”16 Clearly, the values of the Agency recommended by the AITF in this report would be best fulfilled outside of government. Civil servants frequently need to be more generalist in their scientific and technical knowledge in order to effectively carry out the broad nature of their jobs. On the other hand, a flexible and relevant response capacity requires access to very specific types of expertise. This type of expertise can be housed within or accessed through an agency structure by way of cross-appointments or partnerships. In addition, the Agency would serve as a resilient hub of expertise in the face of changing governments. As witnessed in the past, in the face of budget cuts scientific and technical capacity is often the first to be compromised. As such, the AITF feels that situating scientific and technical resources at arm’s-length from government will assist in bringing a greater focus to government functions while ensuring that a relevant and responsive resource is available when required. Creating the Agency will achieve the best of both worlds: a body linked to government that is both accountable and appropriately independent. This approach is different from that taken by the federal government, which initially established the Public Health Agency of Canada as part of the public service reporting to the federal Minister of Health.

2.6

Ensuring Flexibility and Ability to Respond in an Ever Changing Environment

Effective and rapid response to health-related threats is dependent upon access to accurate scientific information. Scientific knowledge is ever-changing, and new threats to health can arise at any time. Therefore, in order to ensure currency of knowledge and respond to emerging threats, flexibility and timely access to expertise (whether in-house or otherwise) and to research capability is required. By creating a body with an organizational structure geared to moving effectively and quickly, flexibility and the ability to react rapidly can be maximized. The AITF will be addressing the appropriate organizational design of the Agency to facilitate such flexibility in the next phase of its work. The AITF urges that, in order to ensure flexibility and responsiveness, the Agency be directly linked with the public health laboratory system as committed to in Operation Health Protection and as implemented in virtually every other jurisdiction that has established an arm’s-length public health body.b Such proximity will ensure that essential diagnostic information is linked to epidemiologic capacity, thereby facilitating efficient and effective surveillance of emerging or reemerging diseases. The Agency will provide an environment in which laboratory experts can interface regularly with clinical and public health peers as well as engage in relevant research. This will assist in the recruitment of medical microbiologists and other critical personnel. Therefore, the AITF strongly recommends that its work and implementation of its recommendations be closely aligned with the public health laboratory review currently underway. The Agency will offer providers and practitioners across Ontario access to the best expertise and appropriate supports through many means, including, web-based technology and videoconferencing. It is a reality that many Ontario healthcare providers and practitioners currently seek such expertise through remote means, using resources such as the CDC or specialists in academic health science centres that are geographically dispersed. Once established, the Agency will be able to provide access to Ontario-based and relevant expertise through a central hub which will provide services and knowledge across the province. Flexibility and responsiveness will also be maximized in an agency structure by ensuring that necessary surge capacity for the field is in place to address urgent, emergent or unforeseen public health issues. In these, as in all circumstances under

which it would provide support to the field, the Agency will not supplant or replace, but rather augment, complement and support local or regional capacity. Surge capacity can be enhanced through use of innovative human resource policies such as cross-appointments, secondments, employee-sharing agreements with facilities and institutions, and affiliate scientist arrangements. The Agency will therefore better prepare Ontario for unforeseen future public health emergencies and priorities, through a number of mechanisms such as planning and preparedness, response activities and generation of new knowledge to better understand risks. Ultimately, this will result is a safer, more secure and healthier Ontario.

2.7

Strengthening Research and Innovation

Innovation results from the timely application of scientific findings. Knowledge that is not applied or used effectively is an investment without a return. With the creation of the Ministry of Research and Innovation, Ontario has signaled the importance of “competing and winning in the marketplace of ideas.”17 The importance of research and development in the health sector as a driver of economic development is evidenced by the investments that many countries, such as the U.S., U.K., Germany and Japan, are making in the development of health research networks or clusters. Clustering, with its ability to draw together complementary skills, can achieve a critical mass that allows the level of expertise to be exponentially increased. Clusters have the ability to build networks and partnerships between industry, researchers, universities, clinicians and other stakeholders. The AITF envisions that the Agency, together with its partners, will become a cluster for public health research and innovation. The Agency will not be a fund-granting body for external research; however, the AITF recommends that there be a core Agency research budget to allow for such things as seed funding of necessary public health research in collaboration with Agency partners. The Agency will also link with and complement the important work already underway by research leaders throughout Ontario in universities, hospitals and Public Health Units, as well as with projects such as the Medical and Related Sciences (MaRS) complex. The Agency will incorporate many of the critical success factors that the literature has identified in successful research and development clusters, notably:

b The INSPQ, BCCDC, HPA and CDC all have laboratory services included among their core functions.


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■ ■ ■ ■ ■ ■ ■ ■

Functioning networks and partnerships between industry, researchers, academia and stakeholders. A strong innovation base with research and development activities. Expertise in various disciplines. A physical infrastructure. Access to sources of funding. The ability to foster innovation. The ability to develop cohesive policy objectives. The presence of a supportive community that includes public acceptance, understanding and engagement in life-sciences activities.18

This ability to form a public health and laboratory cluster will allow the Agency to act as a magnet for research funding and thereby leverage research dollars from external third-party sources to the benefit of the province as a whole. Indeed, a significant percentage of the overall funding for the INSPQ flows from such sources, brought in by its research activities and collaborations. The Agency, in conjunction with its partners, will have the ability to bring together a critical mass of researchers from different backgrounds in a multidisciplinary approach, which will have access to databases, biobanks, bioinformatics and advanced laboratory processes. These resources that the Agency can leverage will lead to a whole that is stronger than the sum of its parts, both scientifically and economically, with discoveries in one area having applicability in others. This has been clearly demonstrated in other jurisdictions through cluster projects such as the Kobe Medical Industry Development Project19 in Japan and the Minnesota Medical Alley20. In addition, the intersection of different fields and spheres of activity, including industry, will provide new opportunities and bridge organizational and functional boundaries.

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2.8

Ontario Will Become a Centre of Excellence

The Agency has the promise to attract leading scientists and act as a catalyst for partnerships. The AITF feels that Ontario should strive to be an internationally recognized leader in public health, in light of the strong commitment of the current government to public health renewal. Through establishment of an agency that is able to function independently and to forge relationships and partnerships, Ontario will have in place a credible, reliable and objective source of knowledge, information and data that will serve the needs of Ontarians and be regarded by those outside of Ontario as an example of excellence. Further, the Agency will serve as a receptor for new technology. By way of an agency structure that builds and nurtures key areas of expertise, Ontario will achieve national and international prominence and visibility, and thereby attract the highest caliber healthcare professionals, academics and researchers. A smaller and less process-oriented infrastructure will also allow for enhanced professional flexibility, providing further incentives for scarce expertise to remain in Ontario, or in many cases to return to Ontario. As an example, a public health expert would have the flexibility to engage in research activities (including pursuing research funding from outside agencies), maintain clinical practice or engage in teaching responsibilities if she or he chose to do so, through cross-appointments, secondments and partnership arrangements, all the while maintaining a direct link with the Agency. This, in turn, will ensure that the requisite critical mass of expertise is in place to provide the programs and services included within the mandate of the Agency (see Chapter 3 for a detailed discussion of the proposed program areas of the Agency). In cultivating Ontario as a centre of excellence in public health knowledge, research and services, the current government will be building a crucial and enduring legacy that will serve the people of Ontario and ensure public confidence in Ontario’s public health system.

Chapter 3

Agency Development and Implementation 3.1

Governance

he AITF has spent considerable time deliberating on key aspects related to the development and implementation of the Agency. A cornerstone of these deliberations is the recommended governance structure for the Agency. Establishing the Agency as an arm’s-length scheduled agency of the MOHLTC is a critical foundation, which will support the timely establishment of a Board of Directors and facilitate securing a Chief Executive Officer – essential elements in moving forward to operationalize the Agency.

T

Governance is the process whereby organizations make their important decisions, determine who they will involve in the decision-making process and how they will be accountable for those decisions. In determining the recommended governance structure of the Agency, the AITF consulted with experts and researched principles of good governance for non-profit corporations developed in a number of jurisdictions. The governance model that is being recommended is consistent and aligned with best practice principles set out in the following:

The AITF urges the MOHLTC to take immediate action on the recommendations put forth in this chapter, in order to meet the government’s commitments under Operation Health Protection to establish a formal Board structure before 2006/07 and the Agency by 2006/07. Furthermore, the AITF recommends that sufficient resources be allocated to the Agency so that it can achieve its mandate. To that end, the AITF endorses the projected costing for the Agency put forth in the Walker Report of $45 million, over and above any existing base funding and over and above any costs associated with recommendations put forth as a result of the public health laboratory review.

■ ■ ■ ■ ■ ■

Meeting the expectations of Canadians: review of the governance framework for Canada’s crown corporations.1 Public appointments processing guide.2 Agency establishment and accountability directive.3 Corporate governance guidelines for building high performance boards.4 Principles for good governance in the 21st century. 5 Appointment guidelines governing boards and other public sector organizations.6

The key principles underlying good governance are independence, accountability, transparency and legitimacy.

3.1.a

Recommended governance model

The recommended governance model, including reporting relationships, is set out in Figure 1. The role of the CMOH in relation to the Agency is critical in ensuring alignment between government objectives and expectations and Agency priorities. It is therefore important that there be a close working relationship and communication between the CMOH and the Agency, while allowing the CMOH to carry out the responsibilities of her or his government position without conflict of interest.


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FIGURE 1.

Recommended governance model AGENCY Standing Committees

MOHLTC

Board

Board Chair reports to Minister

Minister of Health and Long-Term Care

Strategic Planning Scientific Advisory

CMOH/ADM CEO

Audit

3.1.a.i

Independence

In order for the Agency to be credible as a non-partisan, nonpolitical provider of scientific and technical advice, the AITF recommends that it be functionally and operationally autonomous from the MOHLTC. A body at arm’s-length from the government was recommended in the Walker, Campbell and Naylor reports,7–9 was a commitment in Operation Health Protection10 and aligns with the successful experience of the INSPQ. An arm’s-length approach will also ensure that the scientific and technical integrity of the Agency remains insulated from possible political interference, a concern which has been recently raised in relation to the CDC and its role as part of government. The INSPQ provides a good model; it was set up by specialpurpose legislation that ensconces in detail the mission, governance and functions of the organization in a statutory expression. This ensures that it will remain at arm’s-length to the government in order to be an independent scientific and technical body. In addition, a very detailed memorandum of understanding between the INSPQ and the Ministry of Health and Social Services exists that sets out a clear delineation of responsibilities. This arrangement has served the INSPQ well in the seven years of its operation, and is the foundation for the great success and prestige that the INSPQ maintains despite political changes and transitions at the Ministry level in Québec.

Public Health Division

accountable to the legislature for the activities of the Agency. While it is understood that the Agency will serve both the field and several government ministries, a single accountable Minister should be in place. In keeping with good governance principles, an accountability framework with performance indicators should be developed in order to ensure that the Agency is accountable for the efficient and effective operationalization of its mandate. Other recommended accountability mechanisms are: annual performance plans to be submitted by the Agency to the MOHLTC with results documented in annual performance reports; and periodic external reviews to assess and evaluate Agency performance.

3.1.a.iii

The Agency must have systems and structures in place to ensure that there is transparency in the application of and compliance with internal policies, as well as in all types of transactions. Stakeholders, government and the public should have the means, via regular reports, of ensuring that the Agency is accountable for delivery of its mandate and activities and is using its resources effectively. It is also critical that Agency recommendations and reports are based on peer reviewed science and are not subject to undue influence or expediency.

3.1.a.iv 3.1.a.ii

Accountability

The AITF recommends that the Agency be established as an agency of the MOHLTC. The recommended governance model sets out clear lines of responsibility and clear reporting relationships. The Chair of the Board is directly accountable to the Minister of Health and Long-Term Care, who in turn is

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Transparency

Legitimacy

The AITF deliberated on how best to establish the Agency and considered several options, including the following: ■ ■ ■

Special purpose legislation Regulation under the Development Corporations Act11 An affiliation agreement

Due to the importance of legitimacy and permanence to the Agency, the AITF strongly recommends that that it be created through special purpose legislation, and that this legislation be put into place as soon as possible. This legislation should include the following: the right of the Agency to hold third party funds; the right of the Agency to hold personal health information as a “health information custodian” under the Personal Health Information Protection Act, 2004;12 and the ability of the CMOH to delegate to or direct the Agency as required. The AITF will provide further detail regarding the legislation establishing the Agency in Part Two of its report. As well, in order to enhance accountability and clarity of role definition, the relationship of the Agency with the provincial government should be articulated in detail through one or more memoranda of understanding.

3.1.b

Board of Directors

The Board of Directors will be responsible for the overall stewardship of the Agency. It will provide strategic direction for the Agency and approve strategic plans based upon alignment with MOHLTC priorities and consultation with the field. In addition, the Board will oversee management performance and play a primary role in selection and hiring of the Chief Executive Officer (CEO). The AITF recommends that the Agency be accountable to the MOHLTC via the Chair of the Board, who will report directly to the Minister of Health and Long-Term Care. The AITF further recommends that Board members be selected through a transparent and nonpartisan process. Transparency could be achieved through the establishment of a recruitment committee or governance committee, either as an ad hoc or standing committee of the Board. This committee could solicit candidates through a transparent search model using a variety of methods such as: advertisements in newspapers and journals; self or peer referrals; or the use of professional search consultants. Candidates would then be assessed based upon clearly defined and publicly available criteria. A list of selected candidates would then be forwarded to the Minister for approval. As well, in keeping with best-practice guidelines, it is recommended that the appointment term for members be staggered to ensure that there is overlap and continuity in the Board. The Board should be relatively small (seven to thirteen members including the Chair) and members must represent a suitable breadth of skills and competencies; for example, legal, financial, business, scientific/technical, communication and knowledge transfer. The Board should include public health expertise and a public representative. Finally, the Board should consider member representation from other public health agencies, both nationally and internationally. In Part Two of its report, the AITF will provide greater detail regarding criteria for selection of Board members and recommended skill sets.

The AITF urges a staged approach to the development of the Board, which would involve establishing and articulating the final Board structure from the outset, but populating that final structure with only a small core number of members in the early stages of the implementation of the Agency. This approach means that a founding Board can be established that includes members with the necessary start-up expertise who can remain on the Board once the start-up phase is complete. It will allow for minimal delay in getting the Agency up and running, for continuity and stability in Board membership and leadership, and for clarity and permanence of the Board structure from the initial stages. The AITF strongly recommends that the necessary underpinnings to establish the founding Board for the Agency be in place by early 2006 to support the timely operationalization of the Agency and meet the government’s commitment as articulated in Operation Health Protection.

Board standing committees As part of the recommended governance model, standing committees advisory to the Board of Directors should be established. Such committees should include, at minimum, a Strategic Planning committee, a Scientific Advisory committee and an Audit committee. The membership of these standing committees should include a majority of non–Board members. ■

Strategic Planning Committee The purpose of this committee is to advise upon the strategic direction of the Agency, including recommendation of a strategic plan to the Board. The membership of this committee should include key MOHLTC representation, particularly the CMOH, as well as client groups. As a member of this committee, the CMOH will ensure that the Agency’s strategic plan is informed by MOHLTC priorities. Regional representation should also occur as appropriate.

■

Scientific Advisory Committee The purpose of this committee is to provide scientific and technical steering advice to the Board. Membership should include clinical, academic and public health experts, who can be drawn from across the province, Canada and, as appropriate, internationally.

■

Audit Committee The purpose of this committee is to ensure accountability in the financial workings of the Agency. In accordance with good governance principles, both internal and external Agency auditors should report directly to this committee. Membership should be independent of management and include a requirement of financial literacy, and skills and abilities in financial risk management.


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3.1.c

Chief Executive Officer

The CEO will report to the Board of Directors and be responsible for the management and performance of the Agency, as well as for implementation of the strategic plan and ensuring that performance plans or agreements are achieved. The CEO will be responsible for the day-to-day operations of the Agency and provide scientific guidance to the Agency’s work. The Board should select and hire the CEO, ensuring that the recruitment and selection processes are fully transparent. The AITF addressed the question of whether the CEO should be a scientist or a clinician/practitioner, and whether the medical leadership of the Agency should be integrated into the role of CEO or remain separate from it. The AITF feels strongly that the Agency CEO should possess scientific and public health leadership skills.

The AITF strongly recommends, however, that the CMOH regularly attend Board meetings as an observer. The CMOH should also have the power, articulated in legislation, to mobilize Agency resources or to undertake and produce reports, when required in order to meet priorities and address urgent and emergent issues, In addition, a good day-to-day working relationship between the senior management of the Agency (including the CEO), the CMOH and the Public Health Division is essential. The Agency must also work well with the remainder of the MOHLTC and other government ministries on an ongoing and collaborative basis. The need for regular communication and dialogue between government and the Agency has been identified as a key success factor by both the BCCDC and the INSPQ.

3.1.e Because the work of the first CEO will be to oversee implementation of the Agency structure, this individual should have the ability to support the recruitment of skilled individuals to foster academic partnerships and, most importantly, a willingness to be a champion for the Agency in its early days. CEO selection should occur via a transparent process. The AITF will provide further detail on recruitment of the Agency CEO in Part Two of its report.

3.1.d

Chief Medical Officer of Health

The CMOH must have a role that ensures alignment between government objectives and expectations and Agency priorities. Among other things, the CMOH should participate directly in the strategic planning process through membership on the standing Strategic Planning Committee of the Board. The CMOH should also have direct involvement in the establishment of a performance plan or agreement between the government and the Agency, which would align with the Agency’s strategic plan. The CMOH could also have the authority, delegated from the Minister, to “contract” with the Agency through this performance plan or agreement as part of the annual budget process. The AITF feels that the CMOH should not sit as a Board member for the following reasons: ■

■

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As a public servant, the CMOH has duties to act in the best interest of the government that may conflict with the fiduciary duty of a Board member to act in the best interest of the Agency. For example, a Board member may need to challenge the Minister of Health and Long-Term Care with respect to a financial direction, a situation that would pose a clear conflict for the CMOH as Assistant Deputy Minister (ADM). The CMOH will be the ADM responsible for decisions potentially affecting the funding of the Agency by the MOHLTC; therefore, he or she will hold a position of power, both perceived or actual, that has the potential to influence the decision-making process at the Board level and thereby the independent nature of the Board.


Minister of Health and Long-Term Care

The Minister would be accountable to the legislature for the activities of the Agency as set out in the founding legislation applicable to the Agency and would provide broad policy direction to the Agency.

3.2

Mandate, Vision, Mission, Values, and Philosophy

Definition of the mandate, vision, mission, values and philosophy is key in setting the direction, tone and foundations upon which the Agency will operate. Environmental scans, experience from other jurisdictions, stakeholder consultations and both formal and informal discussions have contributed to the development of these basic principles, providing the AITF with a strong foundation on which to make recommendations for the Agency. As with any progressive organization, it is understood that the vision, mission and values of the Agency may evolve over time in order to ensure that it can continue to be responsive to, and anticipatory of, future requirements and innovations. As such, the AITF recommends that these be reviewed once the Agency is operational and thereafter as required.

3.2.a

Mandate

The AITF endorses the mandate for the Agency as articulated in Operation Health Protection: To provide scientific and technical advice for those working to protect and promote the health of Ontarians.

3.2.b

Vision

The following sets out the overarching aspiration of the Agency, which will be pursued through its daily functioning: We will be an internationally recognized centre of expertise dedicated to the promotion and protection of the health of all Ontarians through the application and advancement of science and knowledge.

3.2.c

Mission

The mission statement of the Agency sets out what it intends to accomplish on a functional level: We are accountable to support healthcare providers, the public health system and government in making informed decisions and taking informed action to improve the health and security of all Ontarians through the transparent and timely provision of credible scientific advice and practical tools.

3.2.d

Values

To support the Agency’s mandate, vision and mission, the AITF recommends a set of core values to guide it.

Responsiveness The Agency will meet the needs of its clients across the continuum of the health system by providing timely analysis and practical support through the development and translation of applied research, training and advice. The Agency will have a field response capacity, both in-house and through partnerships, to support, assist and augment local and provincial health system capacity.

Relevance The Agency will translate research into action-oriented advice and tools for evidence-based public health programs, policies and practices. The Agency will base its priorities on close consultation with healthcare providers, the public health system and government to ensure its services continue to meet current and emergent needs.

Credibility The Agency will be guided by the best available evidence and science in order to consistently provide quality information and services in an independent and unbiased manner. Collaboration The Agency will build partnerships and will draw upon the best available expertise provincially, nationally and internationally. The multidisciplinary staff of the Agency will respect, support and promote one another’s creativity, expertise and well-being.

Innovation The Agency will be at the forefront of knowledge generation and knowledge exchange in Ontario and beyond. The Agency will provide leadership through being anticipatory and proactive with regard to threats to and opportunities for the health of Ontarians.

3.2.e

Guiding principles

The AITF spent a considerable amount of time looking at guiding principles that will direct and sustain the Agency in carrying out its mandate. In order to be relevant and proactive, the Agency’s work will not be redundant or duplicative but will complement and build on existing capacity and expertise in Ontario. The work of the Agency will be guided by a population health approach that supports improvement in the health of all Ontarians throughout their lives and commits to supporting a reduction of inequities in health status between population groups. The Agency recognizes that there are multiple factors contributing to a disparity in health status among populations, including material and social inequities. Ontario has a demographic and cultural diversity of populations, including First Nations and francophone populations. Recognition of this diversity will further guide the Agency.

3.3

Roles and responsibilities of the Ministry of Health and Long-Term Care vis-à-vis the Agency

Clarity of roles and responsibilities between the Agency and government is essential to avoid confusion and ensure that roles are complementary and accountable. It is also imperative that the necessary resources and capacity remain within the Public Health Division of the MOHLTC in order to ensure that there is an effective and complementary skill set to receive, integrate and act upon the advice and support provided by the Agency. A functional and effective interaction on a day-to-day basis between the Agency and the MOHLTC, as well as adequate and appropriately skilled receptor capacity within the MOHLTC, have been identified as essential in discussions with both the INSPQ and BCCDC. The AITF recommends the following assignment of roles and responsibilities between the MOHLTC and the Agency.

3.3.a

Policy development

The MOHLTC will maintain the lead responsibility for policy development. The Agency will inform and contribute to the policy development process through the provision of scientific and technical advice to the MOHLTC.

3.3.b

Compliance and accountability

The primary responsibility for enforcement of compliance and for the Mandatory Health Programs and Services Guidelines (MHPSG)13 will remain with the MOHLTC. The Agency would support the MOHLTC in enforcement of compliance with standards and assist the field in adhering to these standards through development of best practices, templates and tools. In addition, the Agency will play a role in reviewing and supporting the revision of the MHPSG so that they remain current, through provision of scientific and technical advice.


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3.3.c

Public health human resource planning, assessment and training

The MOHLTC will continue to hold overall responsibility for public health human resource strategies. The Agency will play several key roles in relation to public health human resources, including the following: ■

■

Taking the lead in surveying and reporting on public health training gaps and identifying cutting edge solutions to these issues. Acting as a skills-development site for public health professionals, scientists and researchers.

3.3.d

Emergency management

The lead responsibility for emergency management will remain within relevant ministries of the Ontario government, including the MOHLTC. The Agency will strengthen this capacity by providing technical and scientific advice and support to government before, during and after an emergency with health impacts. In addition, where required, the Agency will be staffed and structured to provide rapid on-site field support including surge capacity (see section 3.4 for a more detailed discussion). Adequate legislative authority should be provided in support of the roles of both government and the Agency in relation to emergency management.

3.3.e

Communication

The MOHLTC will retain lead responsibility for general health communication to practitioners, the public and the media. The Agency will have a role in risk communication and, as directed by the MOHLTC, assume other communication responsibilities when required, such as during an emergency. The Agency will carry out many of its activities for its client groups through the use of various communication vehicles and channels; however, the Agency will not be responsible for direct communication with the public.

3.3.f

Relationship to Public Health Units, hospitals, long-term care facilities and community health centres

The MOHLTC will continue to hold the lead responsibility for funding of Public Health Units and other healthcare facilities and ensuring accountability for the use of these funds. The role of the Agency with respect to Public Health Units, hospitals, long-term care facilities and community health centres will be focused on: the provision of specialized scientific and technical support, including surge capacity and training support; synthesis of best practices, guidelines and practical tools; and provision of expert advice.

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3.3.g

Relationship to federal government and other agencies

The MOHLTC will continue to hold lead responsibility for direct relationships with Health Canada and PHAC, through established federal/provincial/territorial processes (F/P/T). The MOHLTC could delegate responsibility, as appropriate, to the Agency in relation to a particular F/P/T activity. The Agency will have ongoing relationships and liaisons with a number of federal, provincial and, as appropriate, international agencies such as PHAC, Health Canada, Environment Canada, the BCCDC and the INSPQ. Furthermore, the Agency would provide the perfect platform for housing PHAC’s National Collaborating Centre in Public Health Methodologies and Tools, currently located within the MOHLTC.

3.4

Program Functions, Areas and Clients

The AITF envisions that the Agency’s operations will consist of a series of specific Functions to be carried out within a number of Program Areas, for Agency Clients. These three interconnected variables are depicted in Figure 2 on page 21. Proper delineation of the functions and program areas of the Agency are integral to its success. As such, the AITF has given considerable thought to these, building on the recommendations put forward by the Walker Panel as well as the commitments under Operation Health Protection. In addition, the functions and program areas proposed have been validated through discussions with other jurisdictions and roundtables with stakeholders from the field. It is important to define what the Agency will and will not do, and to be cautious not to duplicate existing capacity. In each of the functions and program areas recommended below, the Agency will bring important added value to both the field and government by enabling: ■

■

Common science: the Agency will be able to provide a single window of expertise from which various stakeholders and government ministries can obtain evidence-based information and science. This will effectively establish a scientific bridge and horizontal integration at a scientific and technical level between existing silos; for example, the Ministries of Health and LongTerm Care, Environment, Agriculture Food and Rural Affairs, and Natural Resources will all be able to access a common scientific base that they can use for their specialized purposes. Common language: the Agency will translate science into practical tools and information. This will allow different portions of the healthcare sector, such as Public Health Units, hospitals, long-term care homes and community-based healthcare providers, to have common understandings of scientific information using common definitions.

FIGURE 2.

Agency Functions, Program Areas and Clients Go

PROGRAM AREAS

ver

Inf

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us

He

alt

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en t

hc

alt

pro v

CLI

he alt

EN

hu

ide

dis

rs

nit

s

TS

ea

ses hp ch ron romo t inju ic dis ion, ea ry pre se a ven n tio d n En vir on me nta l he alt h

He

are

Pu blic

Surveillance and epidemiology Research Knowledge exchange Specialized laboratory diagnostics Professional development

Em

Communication

erg en c

y

management support

FUNCTIONS ■

Communities of practice: the Agency will enhance existing communities of practice and nurture additional ones by supporting collaboration, information exchange and sharing of best practices.

3.4.a

Functions

The functions are the “how” of Agency operations, the types of FUNCTIONS services it will provide to its clients in relation to any or all of the program areas outlined above. The AITF recommends that the following functions be phased-in and carried out by the Agency.

3.4.a.i

Surveillance and epidemiology

Coordinated centralized epidemiologic capacity is essential to provide quality surveillance data to support each of the proposed program areas of the Agency. The Agency must have the capacity to carry out provincial surveillance activities, whether ongoing or targeted in nature, in an efficient and technically robust manner. Collection, analysis and dissemination of comprehensive, readily comparable data can better inform actions and interventions required in the field, identify emerging trends and threats, and inform the setting of goals for Ontario’s public health system.

Epidemiology is the study of the distribution and determinants of health-related-states and events in populations and the application of this study to the control of health problems.14 Health surveillance entails the tracking and forecasting of any health event or health determinant through the continuous collection of high-quality data, the integration, analysis and interpretation of those data into surveillance products (i.e., reports, advisories, warnings) and the dissemination of those surveillance products to those who need to know.15 Further, establishing a centralized infrastructure for the collection, analysis and dissemination of data and information back to the field will complement and support the knowledge exchange function of the Agency. The Agency will also provide a mechanism to support and, where appropriate, consolidate surveillance activities already underway through Public Health Units or other agencies. In addition, the Agency should take the lead in developing and bridging new and existing surveillance networks dealing with both human and animal health, through coordinating crosssectoral and database linkages that will result in improved information sharing.


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The Agency could assume a leadership role in defining surveillance priorities, such as syndromic surveillancec and the provision of real-time alerts. Through the roundtable process, the AITF heard that how surveillance is defined will directly impact upon overall Agency priorities and decision-making. The AITF acknowledges that there is presently a shortage of epidemiologic capacity in Ontario and urges that this be remedied through ensuring a critical mass of epidemiologic expertise both within the Agency and in the field. This would best be accomplished through a gap analysis, identifying the epidemiologic competencies and skills, as well as types of surveillance and data, required to provide appropriate support and advice across the health continuum. This gap analysis could be carried out as an early task of the Agency. Where it does exist, current epidemiologic and surveillance capacity will not be replaced by the Agency, but rather built upon to ensure that it is both cohesive and collaborative through such things as standardized indicator development and performance measurement. Establishing a core capacity of epidemiologic expertise within the Agency will allow for collection of data on diseases and risk factors, as well as issues for which there is no existing mandate or infrastructure to carry out surveillance; for example, nonreportable infectious diseases such as antibiotic resistant organisms and facility-acquired infections, risk factor surveillance for chronic diseases, animal health, and surveillance for targeted congenital anomalies. It will also provide quality data to better assist in determining the burden of certain diseases in Ontario, assess the impact of selected risk factors on disease, and generate and support useful research and programs. In addition to the skills and human resource capacity required to provide a vigorous surveillance and epidemiology function within the Agency, it is essential that the technological infrastructure be put in place to allow the Agency, government, academia, laboratories and others in the field to share information on an ongoing basis and have access to common databases in a privacy sensitive manner. In so doing, the Agency would better support access to meaningful analysis and interpretation of data through standardized mechanisms, such as online resource tools that meet specified standards. Participants at roundtables identified a clear need to link surveillance data with what is happening at the field level in order to effectively determine the impact and cost-effectiveness of interventions, such as immunization campaigns, and a solid information technology infrastructure linked to the Agency will support this.

There will be numerous beneficiaries of a strengthened surveillance and epidemiologic capacity within the Agency: government, which will have access to quality data upon which to base new policy generation; the field, who will have access to consistent, credible and reliable data; researchers and academia, which will have access to a centralized and standardized source of surveillance data; and the public, whose health will be better protected as a result.

3.4.a.ii

Research

Ontario is fortunate to have significant research strength and expertise in public health. The AITF believes that the Agency can be a vehicle for aligning and fostering research excellence by working with partners to create a provincial research cluster that will attract expertise and effectively leverage research dollars. The AITF endorses the view of the Research and Knowledge Transfer sub-committee that the Agency’s research function needs to be intimately tied to knowledge exchange endeavours. This is consistent with the roundtable process, in which participants indicated that the key research roles for the Agency should include: provision of a system-wide and crosssectoral integration of research, policy and practice; and maximization of applied public health research capacity. The AITF believes that these activities should take place in the context of a philosophy of continuous quality improvement, which would include understanding and evaluating the impact of research and knowledge exchange efforts. Through partnerships with academia (including veterinary medicine), Public Health Units, academic health science centres and others, the Agency should serve as the hub for a provincial public health research infrastructure and bring leadership, coherence and relevance to the research agenda. Given the mandate of the five current Public Health Research, Education and Development (PHRED) programs with respect to public health research, knowledge synthesis, education, dissemination and diffusion, the Agency should have strategic partnerships with the PHREDs to enhance province-wide access to their products and services. For example, the Agency could facilitate a process for identifying and focusing research priorities as well as assist in filling research gaps, both provincially and nationally. In this way, the Agency can ensure that research responds to questions and requirements relevant to the needs of public health in Ontario. The Agency should also conduct and facilitate outcomedirected public health research through:

c The term “syndromic surveillance” applies to surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response (CDC, Division of Public Health Surveillance and Informatics).

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■

■ ■

■

A focus on applied research that will inform health policy and front-line practice, including high quality evaluations of public health interventions, research on effective knowledge exchange, and research to support public health human resource planning. Ensuring a flexible research infrastructure with “reserve capacity” to respond to emerging issues. Building capacity and strengthening links with healthcare providers, public health practitioners and policy makers, by providing research mentorship and learning opportunities for graduate students and field staff. Maximizing the use of limited resources and demonstrating accountability.

While the Agency should have strong relationships with research funding bodies, the AITF does not believe that it should be a fund granting body for external investigator-initiated research.

3.4.a.iii

Knowledge exchange

Improved planning that meets defined needs and achieves defined goals depends upon better access to a consistent and coherent knowledge base. A central role for the Agency in knowledge exchange will increase awareness of important public health issues and raise the profile and the credibility of the Agency. Considerable knowledge generation and synthesis is currently being carried out in Ontario, but often in a fragmented manner such that duplication of effort can occur at the same time as gaps abound. In its role as a knowledge broker, the Agency will facilitate access to the best available evidence in a relevant and timely manner that takes into account local circumstances and knowledge. The Agency will have a role both in the generation of new action-oriented knowledge, stemming from applied research and surveillance activities, and in the synthesis and translation of existing knowledge, accomplished through processes such as systematic literature reviews, advisory expert panels, and development of best practices, guidelines and consensus statements. Participants at the roundtable discussions identified the development of provincially applicable best practices, guidelines and protocols, which can be tailored to meet specific local needs, as an early win for the Agency. The Agency will serve as an integrating vehicle to provide consistent, evidence-based and credible knowledge to the field as well as to government. Through appropriate skills capacity in-house and in collaboration with partners, the Agency will be able to translate scientific and technical information (including research) into tools that are appropriate for use by its diverse clients.

An effective knowledge exchange function requires an equally strong information technology infrastructure and communications capacity to support it. The Agency will need quality surveillance data, appropriate technology, state-of-theart information from around the world, and strong provincial, national and international links. It should facilitate access and uptake of information and evidence using both physical and virtual media. In addition, targeted methodologies for knowledge access and uptake should be developed wherever possible.

3.4.a.iv

Specialized Laboratory Diagnostics

A comprehensive review of the Ontario public health laboratory system is currently underway, the results of which will inform the role of the Agency in relation to laboratory diagnostic functions. In anticipation of these recommendations, the AITF sees a definite need for laboratory diagnostic capacity within the Agency, those aspects which are only partially undertaken or provided through the current public health laboratory system. In addition, the AITF recommends that Agency-based laboratory diagnostics: ■ ■

■ ■

Be co-located with the Agency itself. Be supported by a comprehensive provincial Laboratory Information System, linking the laboratory system and the field with the ability to provide real-time data and automated reporting. This urgent recommendation was echoed in discussions at the roundtable sessions. Provide specialty functions such as confirmatory and molecular diagnostics, enhanced disease surveillance. Provide increased research and partnership capability.

The final alignment of laboratory diagnostic functions of the Agency will be outlined further in the final report of the AITF, based upon the recommendations emanating from the public health laboratory review. The AITF feels strongly that proximity between diagnostic services and clinical, research and public health expertise is essential to ensure that the Agency values of responsiveness, relevance and innovation can be fulfilled. Research, knowledge exchange and surveillance functions often cannot be effectively accomplished without direct access to and linkages with laboratory data. Through the Agency, a critical mass of laboratory expertise can be assembled as a result of networking, partnerships and a clustering of research and innovation opportunities. In turn, this will result in greater capacity for Ontario to respond to unforeseen events, and for Ontario to become a leader in diagnostic innovation.


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3.4.a.v

Professional Development

The AITF sees professional development as a cross-cutting function of the Agency, with training support potentially being made available to providers and practitioners in the areas of surveillance and epidemiology, applied research, knowledge exchange, laboratory diagnostics, and communications. However, the Agency will not have a primary role as an education or training institution, nor will it displace academic institutions in providing healthcare professions training programs. Rather, it will provide services such as skillsenhancement training, clinical placements, practicums and continuing education initiatives for front-line healthcare professionals.

3.4.a.vi Communication Communication is required to carry out Agency consultations, collaboration and leadership roles and also in order to accomplish knowledge exchange. At the same time, communication requires content-supported knowledge and its translation. As such, communication and knowledge exchange are effectively inseparable. In order to carry out its knowledge exchange function, the Agency will require multimodal vehicles for communication to effectively reach all of its client groups in a manner that is relevant to each of their needs. There are a variety of types of communication; the AITF sees the Agency as having a role in two of these. First, the Agency should have a primary role in risk communication. Risk communication is the exchange of information between concerned stakeholders about an actual or perceived risk in relation to an outcome of a behaviour or an exposure; for example, information about the expected type of outcome, the intensity and duration of the outcome, and what is known or unknown about the outcome. Risk communication should come from a trusted and credible source and be validated by other trusted and credible sources. Effective risk communication helps people make choices about taking a particular action or about adjusting to something that is happening or has already happened.16 With its surveillance, research and knowledge exchange capacity, the Agency will be in the best position to provide the credible scientific and technical expertise to inform and support risk communication activities. In addition, the Agency should play a supportive role in crisis communication. Effective crisis communication entails the process of communicating in the midst of an emergency with the goal of de-escalating the crisis through information. It should be integrated into an overall crisis-response plan as part of an incident command system with a clear chain of command. Crisis communication should also be tested prior to an

emergency through planned exercises. It also requires an effective working relationship with the media.17 The Agency’s role in crisis communication would come in the form of scientific and technical advice to the government, which would have the lead for crisis communication during an urgent or emergency situation. The government could, at its discretion, delegate certain direct crisis communication functions to key individuals or experts within the Agency.

3.4.b

Emergency management support

The AITF feels that emergency management support is both a function and a program area of the Agency. Best practices in emergency management aim to reduce the potential impact of a disaster by making long-term plans to mitigate consequences and improve preparedness. Emergency management activities take place at three stages: before, during and after the emergency.d The AITF recommends that the Agency fill a supporting role in relation to emergency management, with government retaining the lead. During a health-related emergency, the chain of command should follow a well-defined incident management system with clearly predetermined roles and responsibilities, and leadership resting with the appropriate areas of government. Proposed roles for the Agency in relation to overall emergency management include: support for hazard, risk and vulnerability assessments; support of mitigation and preparedness activities; provision of surge capacity; access to technical and scientific expertise and support during an emergency; and support for planning based on lessons learned from an emergency. Each of these roles would be accomplished through the various proposed functions of the Agency described below, exercised within the centralized chain of command in place for Ontario. Surge capacity would include human resources and technical resources such as diagnostics. The Agency would provide surge capacity to the field only when local capacity is exceeded or when specialized expertise not available at the local level is required. The AITF feels that the primary areas of focus of the Agency in relation to emergency management support should be infectious diseases, bioterrorism and environmental disasters such as spills. The Agency would also provide support whenever there are public health implications of other disasters, such as floods.

d See also National Framework for Health Emergency Management, F/P/T Network on Emergency Preparedness and Response, 2004.

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3.4.c

Program Areas

The program areas the Agency will assume are the “what” of Agency PROGRAM operations. The following are the AREAS program areas for the Agency recommended by the AITF.

3.4.c.i

Infectious diseases

The final report of the Walker Panel pointed clearly to the need for a centralized resource to better coordinate a more comprehensive and systematic approach to infectious diseases in Ontario, a position reflected in Operation Health Protection and fully supported by the AITF. As a program area, infectious diseases would encompass the surveillance, prevention and control of these diseases in both healthcare and community settings. Significant recent improvements have been made to the infectious disease landscape in Ontario. The Provincial Infectious Diseases Advisory Committee (PIDAC) was established in June 2004 as part of the commitments under Operation Health Protection, to be an advisory body to Ontario’s CMOH on the surveillance, prevention and control of infectious diseases. PIDAC brings together experts from areas of healthcare that have not traditionally worked together in a consistent manner, such as acute care, Public Health Units, long-term care and academia. Currently, PIDAC is comprised of a main committee together with four theme-based subcommittees as follows: ■ ■ ■ ■

Infection prevention and control (in healthcare facilities, including long-term care homes) Surveillance Infectious disease prevention and control (in community based settings) Immunization

Each subcommittee makes evidence-based expert recommendations in multiple areas including, for example: standards, guidelines and best practices; professional development activities; benchmarks and core indicators; research priorities; and appropriate epidemiologic and surveillance activities. The AITF sees PIDAC as being a prototype for the projected role of the Agency in infectious diseases, which will include engaging in each of the functions discussed above, namely surveillance and epidemiology, research, knowledge exchange, specialized laboratory diagnostics, professional development, communication and emergency management support. The Agency will provide the necessary infrastructure and capacity to support these activities in a comprehensive manner. In addition, the AITF recommends that PIDAC, or a similar expert advisory body, have a role within the Agency in the

infectious disease program area, and that similar expert advisory bodies be considered for each of the other program areas discussed below. Another key infectious disease initiative committed to in Operation Health Protection is the implementation of regional networks dedicated to infection prevention and control. The first four networks have now been established. The mandate of regional networks is to maximize coordination and integration of activities related to the prevention, surveillance and control of infectious diseases across the healthcare spectrum on a regional basis. Further, regional networks will strengthen the coordination between infection prevention and control activities at acute and non-acute facilities and Public Health Unit communicable disease control activities. The role of networks in integration across the healthcare spectrum fits well with that of the proposed Agency, and therefore the AITF feels that there should be clear linkages between the networks, as they develop, and the Agency. A third relevant initiative in Operation Health Protection is the development of core competency education in infection prevention and control for all front-line healthcare workers. The goal is to provide standardized, evidence-based, current and easily accessible infection prevention and control training tools for front-line healthcare workers based upon up-to-date core competencies validated through PIDAC. This initiative is the first of its kind in Canada. Given the recommended role of the Agency in knowledge transfer and exchange, the AITF feels that initiatives such as this one should be housed within the Agency.

3.4.c.ii

Health promotion, chronic disease and injury prevention

Health promotion is a public health strategy distinct from disease prevention and health protection strategies. Health promotion begins with the positive concept of health, recognizing that health is about much more than “a lack of illness”. A key component of health promotion is the recognition that being in control or empowered promotes and supports individual and community health. Strategies range from interventions to influence individuals’ decisions about lifestyles or behaviours (for example, counseling or education campaigns about tobacco use, healthy eating, and physical activity) to advocacy, policy and legislative work to affect the socialenvironmental context in which individual decisions are made (for example, municipal zoning decisions affecting access to trails or green space). The scope of health promotion work is broad and spans the lifecycle, including maternal and child health, healthy growth and development, youth and teens, adults and seniors. Effective health promotion initiatives partner with diverse sectors and occur in many settings, such as workplaces, schools, clinics and community-based organizations. The outcomes of effective health promotion


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interventions extend beyond reduction of disease and ill health to positive states such as healthy growth and development, healthy sexuality and supportive environments. Chronic diseases are the leading cause of death and disability in Canada. In Ontario, the estimated burden of illness from such diseases amounts to 55% of total healthcare expenditures, including: cardiovascular and respiratory disease; cancer; and musculoskeletal, endocrine, neurological and psychiatric disorders.18 This number does not take into account indirect costs such as those incurred by families. Given the burden of indirect and direct costs associated with chronic diseases in Ontario, they should form part of the Agency’s key program areas. Preventable injuries, such as falls, motor vehicle accidents, drowning, pedestrian injuries, poisoning and fire, have also become an increasing public health threat. The annual cost of these unintentional injuries is estimated to be $2.9 billion in Ontario.19 Injury prevention is another key program area for the Agency.

Operation Health Protection commits to incorporating health promotion, together with chronic disease and injury prevention, as part of the Agency’s work beginning in its first year of operation.20 The AITF deliberated extensively on whether health promotion should form part of a distinct program area, acknowledging that it is a cross-cutting strategy that should be part of all of the Agency’s activities. At the same time, not including it as a program area may result in health promotion being “lost,” particularly in light of other jurisdictions’ difficulties in trying to incorporate health promotion into their mandate. For example, the BCCDC has faced numerous challenges in trying to incorporate heath promotion as part of its mandate in recent years. Ontario has significant capacity in the fields of health promotion, chronic disease and injury prevention. At the provincial level, with the support of the MOHLTC, the Ontario Health Promotion Resource System (OHPRS) supports practitioners by building capacity through the provision of training, consultation, resources (print and electronic), network-building opportunities and referrals. A number of health and disease-specific nongovernmental organizations are also major players in this field. Even with this existing capacity and expertise, the field and government have a defined need to harvest the best evidence available in the fields of health promotion, chronic disease and injury prevention, and translate this into useful tools and practical information for evidence-based practice and policy. Furthermore, roundtable participants identified the need for centralized support in non-communicable disease and risk factor surveillance. As a central resource, the Agency will fill this need and maximize synergies with existing resources in the field such as OHPRS. To this end, the AITF suggests that a

26


review of the OHPRS be undertaken to explore how best to align its role with that of the Ministry of Health Promotion, the MOHLTC and the Agency in the area of health promotion. Lastly, the Agency can set a health promotion agenda for Ontario, by advising on emerging issues, leveraging its credibility and supporting a provincial response.

3.4.c.iii Environmental health Chemical, physical and biological factors have great impacts on human health; attention to these factors in our water, food and air is of paramount importance in the prevention of a range of communicable and non-communicable diseases, and the promotion of health and well-being. Environmental health issues became very much top of mind following the province’s recent experiences with the breakdown in safe water and food systems. In addition, there is a growing demand for specialized capacity within the public health sector, to respond to existing and emerging environmental issues.21 Although neither addressed in the Walker Report nor a distinct commitment in Operation Health Protection, the AITF sees environmental health as an important program area for the Agency. The public health field has been involved in food issues for many years, and more recently has begun to address broader environmental health issues, particularly those related to air and water. These endeavours, although not carried out consistently throughout the province, have been critical in developing and establishing initiatives to support local and regional environmental health priorities and needs. Environmental health focuses on complex problems and requires the contributions of many specialties and areas of expertise. Working collaboratively with other players in the area of environmental health, such as the Ministry of the Environment, the Ministry of Agriculture, Food and Rural Affairs, and Public Health Units, the Agency could be a hub for resources dedicated to environmental health issues. The Agency could develop surveillance and information management capacity related to such areas as environmental issue identification and the effectiveness of various prevention and control strategies. Creating an environmental health program area would allow the Agency to direct research and influence policy in what is a developing area of focus, help Ontario anticipate and prepare for emerging environmental health challenges, and provide researchers with the ability to link environmental health knowledge and evidence with other fields such as genomics, urban planning and ecology. Further, the Agency would act as the source of scientific and technical expertise to inform such things as a much-needed program standard within the MHSPG for environmental health and the development of tools and methods for risk assessment and evaluation related to environmental hazards and associated effects on health.

While this area is still being defined by the AITF, at the present time it is envisioned that this program area will start by encompassing issues related to the health impacts of poor food and water quality.

3.4.d

Clients

■ ■

Healthcare providers, including clinicians, public health professionals, academics, healthcare facilities and institutions Public Health Units Government

FIGURE 3.

Relationships and Principles for Partnership

A new Agency for Ontario will need to operate within the following context:

CLIENTS

Clients are the direct beneficiaries of the Agency’s work; the people and organizations for whom the Agency will carry out its functions. In keeping with the recommended mandate of the Agency, its clients will include the health sector in the broadest sense. To this end, the AITF recommends that the primary client base for the Agency should be as follows: ■

3.5

■ ■ ■

An accountability framework – see governance discussion in subsection 3.1. A series of formal and informal partnerships – see discussion below. A series of mutually beneficial relationships and partnerships – see Figure 3 below.

Meaningful partnerships are the cornerstone of effective coordination and collaboration. The AITF recognizes that the Agency will not function in a vacuum and that it is a part of an existing and evolving matrix. In order to effectively meet its mandate, the Agency will therefore need to establish partnerships with academia, research bodies, nongovernmental organizations and key health organizations (such as Public Health Units) in order to have broad connections and affiliations, and draw on the best available expertise provincially, nationally and internationally. To facilitate this, the AITF envisions the Agency as having the flexibility to work with partners in a variety of ways including formal processes such as contracts and memoranda of understanding and more informal processes such as affiliate scientist positions and cross-appointments.

Agency Relationships

Abbreviations:

MOHLTC

BCCDC (British Columbia Centre for Disease Control) ICES (Institute for Clinical Evaluative Sciences) INSPQ (Institut national de santé publique du Québec) MCSCS (Ministry of Community Safety and Correctional Services) MCYS (Ministry of Children and Youth Services)

Other Gov. Ministries

Core MOU and funding

MCSCS, MCYS, MEDT, MNR, MOE, MOHP, MRI, MTCU, OMAFRA

Other Public Health Bodies

MEDT (Ministry of Economic Development and Trade) MNR (Ministry of Natural Resources)

Agency

MOE (Ministry of the Environment)

(e.g., BCCDC, INSPQ, PHAC)

MOHLTC (Ministry of Health and Long-Term Care) MOHP (Ministry of Health Promotion) MRI (Ministry of Research and Innovation) MTCU (Ministry of Training, Colleges and Universities) OMAFRA (Ministry of Agriculture, Food and Rural Affairs)

Patnerships (e.g., universities, academic health science centres, CIHI, ICES, NGOs)

Clients Public Health Units Health care providers Government

PHAC (Public Health Agency of Canada)


27

The AITF envisions that, through its partnerships, the Agency as a whole will be greater than the sum of its parts in areas such as: leveraging research dollars from granting agencies and other external sources; recruiting top-notch scientists, researchers and healthcare professionals; supporting and strengthening innovation and research capacity; and providing educational materials and opportunities to healthcare professionals. As such, the AITF proposes that the following principles guide the development of partnerships in which the Agency will engage: ■

■

■

■

■

■

■

28

Clarity: the objective(s) of the partnership will be clear, welldefined and directly aligned with the objectives and strategic priorities of the Agency. Rules governing the partnership should similarly be clear and well-defined. Credibility: organizations with whom the Agency partners will have a demonstrated track record in contributing to a key area of knowledge and expertise relevant to the mandate of the Agency. Transparent: the purposes of, approaches to, and mechanisms of entrance into partnerships will be transparent and open to the parties concerned. Results-based: partnership arrangements will include clear and measurable performance expectations, with results that are of value to both parties and that are monitored/evaluated accordingly. Governed by exit rules: partnership arrangements will exist for a clear and defined period of time, be renewable, be based upon the achievement of stipulated objectives and/or results, and have clearly stated terms for both engagement and disengagement. Practical: partnership arrangements will incorporate mechanisms for practical, cost-effective and timely resolution of disputes. Mutually beneficial: partnerships will be structured in a manner that ensures they are sustainable over time with provision of benefits to both parties.


Chapter 4

Next Steps The recommendations included in Part One of the AITF report represent a significant body of work and fulfill many of the tasks assigned to the AITF at its inception earlier this year. These recommendations provide the government with a launching point and foundation to immediately put in place the necessary infrastructure to ensure that the Agency is operational by 2006/2007. As the AITF approaches the end of its mandate, it will continue its deliberations simultaneously with the government as it works to fulfill its commitment to the Agency. The AITF will submit its final report to MOHLTC by end of 2005, which will build upon the recommendations found in Part One. Outlined below are key next steps for the AITF, as well as recommended concurrent actions for the MOHLTC.

T

Over the next four months, the AITF will shift the focus of its deliberations to finalizing its recommendations for the operationalization of the Agency, particularly with respect to the development of a phased implementation plan and the establishment of a founding Board structure. The AITF will also continue to engage stakeholders through at least one more Reference Panel meeting and other sessions with experts as necessary.

4.1


In fulfilling its mandate, the AITF will develop a high-level implementation plan for the Agency that will delineate and recommend the following: priorities for the first three years of operations; a proposed overall operating budget; a capital plan including funding requirements; proposals for location; and phasing-in of program areas, functions and services. This implementation plan will be informed by key recommendations in the areas discussed below. The AITF also recommends that an expert advisory transition body be established in early 2006 to assist the MOHLTC with operationalization of the recommendations of the AITF. The functions of this body should include identification of key individuals with a role in the early phases of the Agency (such as the initial CEO or Board Chair), and identification and cultivation of partnerships for the Agency linked to its functions and program areas. This transition body will require expertise in the following areas, among others: ■ ■ ■ ■ ■

Organizational design Legal Human resources Each of the recommended program areas and functions Establishment of partnership arrangements, particularly with academic institutions

4.1.a

Infrastructure development

The AITF will further delineate the recommended program areas and functions as required, to ensure that roles and responsibilities are clearly defined and the Agency’s mandate with respect to the program areas is aligned with existing public health structures and mandates. The AITF will recommend a preliminary organizational structure for the Agency, taking into account the following elements: ■ ■ ■ ■

Best practices in organizational design, including learnings from other jurisdictions and similar organizations. Units of program and service delivery suitable to the scope of the program areas and functions to be carried out by the Agency. Potential issues related to decentralization and regional presence. Relevant recommendations contained in the public health laboratory review.


29

4.1.b

Governance

Building upon the recommended governance structure presented in Part One, the AITF will develop recommended Board member and CEO recruitment and selection processes. Specifically, the AITF will provide recommendations regarding the following: ■

■

Board of Directors: – Competencies and skill sets required for Board members and the Chair. – Selection criteria and selection process for Board members. – Suggested term of service and method for staggering appointments. CEO: – Competencies and skill sets required. – Selection criteria and selection process.

The key priorities for the internal MOHLTC team in the short term include the following: ■

■

■

■

4.1.c

Principles for partnership

The AITF will develop a recommended partnership framework for the Agency that will further delineate the various types and levels of partnerships with, for example, the field, academia and non-governmental organizations. ■

4.2

Ministry of Health and Long-Term Care

As the AITF continues with its work, it recommends that the MOHLTC start to move forward immediately to establish and set in motion critical enablers for the Agency. Specifically, the AITF recommends that the MOHLTC establish a dedicated internal team to operationalize the Agency based upon the recommendations in Part One of its report. This internal team will need to link with experts in a number of areas to support the operationalization of the Agency, including the recommended expert advisory transition body discussed above.

30


Begin to develop of a human resources plan for the Agency, including recruitment strategies, competency and skills analysis, and delineation of a staffing model that includes human resource requirements, recommended skill sets and appropriate staffing mix. Plan for an information technology infrastructure that builds on and complements current endeavours such as iPHIS, publichealthontario.com and ehealthontario.com. Undertake a number of financial planning exercises, including the creation of start-up and projected operational budgets, and begin the process of capital planning, including proposed facility design and site analysis. Begin drafting of founding legislation for the Agency, building upon principles of accountability and transparency as well as lessons learned from other jurisdictions, in particular Québec. The MOHLTC must also set in motion the recommendations for the establishment of the founding Board, and recruitment and retention of the initial CEO after the initial Board Chair is in place. Develop partnership agreements to guide the establishment of formal and informal partnerships, building on the partnership framework recommended by the AITF; further delineate roles and responsibilities between the Agency and other relevant ministries, including the MOHLTC; begin development of a memorandum of understanding between the Agency and the MOHLTC; and begin development of memoranda of understanding between the Agency and other government ministries, as necessary.

References Chapter 1

Chapter 2

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. [online]. Accessed August 22, 2005 from: http://www.phac-aspc.gc.ca/publicat/ sars-sras/naylor/.

1


2

Ontario. SARS Commission, Campbell A. Interim report: SARS and public health in Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ministry_reports/ campbell04/campbell04.html.

2

The Standing Senate Committee on Social Affairs, Science and Technology, Kirby M. Reforming health protection and promotion in Canada: time to act. 2003, p. 22 [online]. Accessed August 22, 2005 from: http://www.parl.gc.ca/37/2/parlbus/commbus/senate/ com-e/soci-e/rep-e/repfinnov03-e.pdf.

3

Expert Panel on SARS and Infectious Disease Control (Ont.), Walker D. For the public’s health: a plan for action: final report of the Ontario Expert Panel on SARS and Infectious Disease Control. [Toronto, Ont.]: SARS Expert Panel Secretariat. Ontario. Ministry of Health and Long-Term Care; 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/walker04/walker04_mn.html.

3

Ontario. SARS Commission, Campbell A. Interim report: SARS and public health in Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ministry_reports/ campbell04/campbell04.html.

4

Expert Panel on SARS and Infectious Disease Control (Ont.), Walker D. For the public’s health: a plan for action: final report of the Ontario Expert Panel on SARS and Infectious Disease Control. [Toronto, Ont.]: SARS Expert Panel Secretariat. Ontario. Ministry of Health and Long-Term Care; 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/walker04/walker04_mn.html.

4

Haines RJ. Farm to fork: a strategy for meat safety in Ontario: report of the Meat Regulatory and Inspection Review. Toronto, Ont.: Ministry of the Attorney General; 2004. [online]. Accessed August 22, 2005 from: http://www.attorneygeneral.jus.gov.on.ca/ english/about/pubs/meatinspectionreport/.

5

Ontario. Ministry of Health and Long-Term Care. Operation Health Protection: an action plan to prevent threats to our health and promote a healthy Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004, p.12. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/consumer_04/oper_healthprotection.html.

5

Ontario. Ministry of Health and Long-Term Care. Operation Health Protection: an action plan to prevent threats to our health and promote a healthy Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ministry_reports/ consumer_04/oper_healthprotection.html.

6

Ontario. Ministry of Health and Long-Term Care. Mandatory health programs and services guidelines. Toronto, Ont.: Ministry of Health and Long-Term Care; 1997. [online]. Accessed August 24, 2005 from: http://www.health.gov.on.ca/english/providers/pub/ pubhealth/manprog/mhp.pdf.

6

Institut national de santé publique du Québec. (2005). INSPQ Developing knowledge, sharing information. [online]. Last updated August 2005. Accessed August 25, 2005, from http://www.inspq.qc.ca/english/.

7

British Columbia Centre for Disease Control. (2005). BC Centre for Disease Control home page. [online]. Last updated August 2005. Accessed August 25, 2005, from http://www.bccdc.org.

8

US Department of Health and Human Services. Centers for Disease Control and Prevention. About CDC: Home Page. [online]. Accessed August 25, 2005 from: http://www.cdc.gov/.

9

McKee M, Novotny TE. Political interference in American science: why Europe should be concerned about the actions of the Bush administration. European Journal of Public Health. 2003;13(4):289-91.


31

10

Health Protection Agency. About the Health Protection Agency. [online]. Accessed August 25, 2005 from: http://www.hpa.org.uk/.

11

Regulation (EC) No 851/2004 of the European Parliament and the Council of 21, April 2004 establishing a European centre for disease prevention and control. The European Parliament and the Council of the European Union. Official Journal of the European Union. I.142/1; 2004. [online]. Accessed August 26, 2005 from: http://europa.eu.int/eur-lex/pri/en/oj/dat/2004/l_142/ l_14220040430en00010011.pdf.

Chapter 3 1

Treasury Board of Canada Secretariat. Meeting the expectations of Canadians: review of the governance framework for Canada’s crown corporations. [Ottawa, Ont.]: Government of Canada; 2005. [online]. Accessed August 23, 2005 from: http://www.tbssct.gc.ca/report/rev-exa/gfcc-cgse_e.asp.

2

Public Appointments Secretariat. Public appointments processing guide. Toronto, Ont.: Government of Ontario; 2005.

12

Centre for Health Protection. [online]. Accessed August 26, 2005 from: http://www.chp.gov.hk/

3

Management Board Secretariat. Agency establishment and accountability directive. Toronto, Ont.: Corporate Policy Branch, Government of Ontario; 2000.

13

Association of Public Health Observatories. Welcome to the network. 2004. [online]. Accessed August 26, 2005 from: http://www.apho.org.uk/apho/

4

Canadian Coalition for Good Governance. Corporate governance guidelines for building high performance boards. 2005. [online]. Accessed August 23, 2005 from: http://www.ccgg.ca/web/ ccgg.nsf/web/ccgg_guidelines_v1_january_2005/$FILE/CCGG_ Guidelines_v1_January_2005.pdf.

5

Graham J, Amos B, Plumptre T. Principles for good governance in the 21st century. [Ottawa, Ont.]: Institute on Governance; 2003. [online]. Accessed July 23, 2005 from: http://www.iog.ca/ publications/policybrief15.pdf.

6

Board Resourcing and Development Office. Appointment Guidelines Governing Boards and Other Public Sector Organizations. Office of the Premier, Government of British Columbia; 2004. [online]. Accessed August 23, 2005 from: http://www.fin.gov.bc.ca/oop/brdo/ AppointmentGuidelines_PublicAgencies04.pdf.

7

Expert Panel on SARS and Infectious Disease Control (Ont.), Walker D. For the public’s health: a plan for action: final report of the Ontario Expert Panel on SARS and Infectious Disease Control. [Toronto, Ont.]: SARS Expert Panel Secretariat. Ontario. Ministry of Health and Long-Term Care; 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/ pub/ministry_reports/walker04/walker04_mn.html.

8

Ontario. SARS Commission, Campbell A. Interim report: SARS and public health in Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care, April 2004. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/campbell04/campbell04.html.

9


14

Commitment to the Future of Medicare Act, 2004. S.O. 2004, c. 5. [online]. Accessed August 25, 2005 from: http://www.elaws.gov.on.ca/ DBLaws/Statutes/English/04c05_e.htm.

15

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, p. 4. [online]. Accessed August 22, 2005 from: http://www.phac-aspc.gc.ca/publicat/sars-sras/naylor/.

16

Expert Panel on SARS and Infectious Disease Control (Ont.), Walker D. For the public’s health: a plan for action: final report of the Ontario Expert Panel on SARS and Infectious Disease Control. [Toronto, Ont.]: SARS Expert Panel Secretariat. Ontario. Ministry of Health and Long-Term Care; 2004, p.79. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/walker04/walker04_mn.html.

17

Government of Ontario. Office of the Premier of Ontario. Premier McGuinty fine tunes his cabinet at mid-term. (2005). Ontario Government news release, June 29, 2005. [online]. Accessed August 25, 2005 from: http://ogov.newswire.ca/ontario/GPOE/ 2005/06/29/c7145.html?lmatch=&lang=_e.html.

18

A practical guide to cluster development: a report to the Department of Trade and Industry and the English RDAs by Ecotec Research & Consulting. (2005). U.K. Department of Trade and Industry. [online]. Accessed August 25, 2005 from: http://www.dti.gov.uk/clusters/ecotec-report/dti_clusters.pdf.

19

City of Kobe. Kobe Medical Industry Development Project. 2004. [online]. Accessed August 25, 2005 from: http://www.city.kobe.jp/ cityoffice/27/kigyo/opport/kobe-proj04.html.

20

Medical Alley/MNBIO. About us. 2005. [online]. Accessed August 25, 2005 from: http://www.medicalalley.org/about/insitute.shtml.

32


10

Ontario. Ministry of Health and Long-Term Care, Operation Health Protection: an action plan to prevent threats to our health and promote a healthy Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004, p.12. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/consumer_04/oper_healthprotection.html.

11

Development Corporations Act, R.S.O 1990, c. D.10. [online]. Accessed August 25, 2005 from: http://www.elaws.gov.on.ca/DBLaws/Statutes/English/90d10_e.htm.

12

Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A. [online]. Accessed August 25, 2005 from: http://www.e-laws.gov.on.ca/ DBLaws/Statutes/English/04p03_e.htm.

13

Ontario. Ministry of Health and Long-Term Care. Mandatory health programs and services guidelines. Toronto, Ont.: Ministry of Health and Long-Term Care; 1997. [online]. Accessed August 24, 2005 from: http://www.health.gov.on.ca/english/providers/pub/ pubhealth/manprog/mhp.pdf.

14

Norman GR, Streiner DL. PDQ epidemiology.2nd ed. Hamilton, Ont.: B.C. Decker; 1998, p.1.

15

National Health Surveillance Network Working Group, Integration Design Team. Proposal to develop a network for health surveillance in Canada. [Ottawa, Ont.]: Health Canada; 1999, p.6. [online]. Accessed August 26, 2005 from: http://www.phac-aspc.gc.ca/csc-ccs/pdf/Propos17.pdf .

16

Margo Edmunds. Risk communication strategies for public health preparedness. John Hopkins Center for Public Health Preparedness; 2005. [online]. Accessed August 26, 2005 from: http://www.jhsph.edu/preparedness/training/online/riskcomm.html.

17

Ibid

18

Ontario. Ministry of Health and Long-Term Care. Ontario’s health system performance report. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004, p. 33. [online]. Accessed August 25, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/pirc_04/pirc_04.pdf .

19

SmartRisk. The economic burden of unintentional injury in Ontario. Toronto, Ont.: SmartRisk; 2003, p. 30. [online]. Accessed August 25, 2005 from: http://www.smartrisk.ca/ContentDirector.aspx?tp=78&dd=3.

20

Ontario. Ministry of Health and Long-Term Care. Operation Health Protection: an action plan to prevent threats to our health and promote a healthy Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004, p. 12-13. [online]. Accessed August 22, 2005 from: http://www.health.gov.on.ca/english/public/pub/ ministry_reports/consumer_04/oper_healthprotection.html.

21

OPHA Environmental Health Working Group. Building environmental health capacity within public health. [Toronto, Ont.]: Ontario Public Health Association; 2004. [online]. Accessed August 25, 2005 from: http://www.opha.on.ca/ppres/2004-02_res.pdf.


33

34


Appendix 1 Ontario Health Protection and Promotion Agency — Agency Implementation Task Force: Terms of Reference Background As outlined in Operation Health Protection, the Ministry of Health and Long-Term Care (MOHLTC) is committed to the establishment of a Health Protection and Promotion Agency (Agency) by 2006/07. An Agency Implementation Task Force will be struck to provide advice to the Ministry of Health and Long-Term Care on the design, development and implementation of the Agency.

Purpose The Task Force will advise the MOHLTC on the operationalization of the Agency. This advice will centre on a number of areas such as validation of core activities, organizational and functional operations, development of an implementation plan, relationships with other public health organizations, as well as capital and ongoing operating budget requirements.

■

■

■

■

■

Responsibilities The responsibilities of the Agency Implementation Task Force will be to: ■ ■ ■

■

Validate the Agency’s proposed mandate, key functional areas, structure, governance and oversight. Recommend operational public health responsibilities for the Agency, and delineate its role and responsibilities in relation to those of the MOHLTC and academia and the broader public health system, the Federal Public Health Agency and its collaborating centres, etc. Recommend a comprehensive three-year implementation plan for the Agency (including infrastructure, financial requirements, human resources, transition, arrangements etc.).

The Task Force may wish to establish sub-committees and/or undertake consultations with Ontario health care providers and other stakeholders in developing its recommendations. The Task Force will also commission studies. The studies to be commissioned may include, but need not be limited to: ■

Development of various Memoranda of Understanding (including joint planning workshops) and other agreements between Agency and MOHLTC, Agency and the broader public health system, and between Agency-MOHLTC-Health Canada-Canadian Public Health Agency.

■

Governance model for Agency – to provide specific recommendations for the Agency’s Board (membership, terms, structure), Chief Executive Officer and senior management level requirements as well as relationships with the MOHLTC. Site analysis – to provide specific recommendations for the site requirements for the Agency, including co-locating specialized Laboratory Services within Agency. Fiscal analysis and modelling for the Agency – to provide specific recommendations with respect to the appropriate levels of funding for the Agency to fulfill its mandate. Competency analysis and modelling – to delineate the core human resource requirements along with salary ranges, including transition planning between the MOHLTC and the Agency. Framework to establish the Agency’s research partnership model and operations – to provide specific recommendations with respect to the breadth and scope of the Agency’s research mandate (and possible partnership agreements with academia). Communications protocols and systems – to provide specific recommendations on how the Agency should fulfill its communications mandate (risk communication, dissemination of epidemiological and surveillance information, internal and external communications, etc.). Phased implementation options – to provide specific recommendations with respect to a multi-year roll-out for full implementation of the Agency. These recommendations will be informed by several reviews and work (i.e., Governance Review, Site Analysis, Laboratory Operational Review, the Research and Knowledge Transfer Sub-committee of the Capacity Review Committee, Communications, Human Resources, etc.).

Membership The Chief Medical Officer of Health will appoint the Co-Chairs and the members of the Task Force. The Co-Chairs will be professionals with recognized public health expertise and experience in the provision of strategic advice. Membership will include provincial and national experts representing the proposed functional areas of the Agency (e.g., research, laboratory, infection diseases, health promotion, chronic disease and injury prevention, etc.) as well as a member with financial expertise.


35

Accountability Through the Co-Chairs, the Task Force will report to the Chief Medical Officer of Health and Assistant Deputy Minister of the Public Health Division. An ad-hoc intra-Ministerial Committee will be established to liaise with this committee.

Staff support The task force will be supported by staff from the Strategic Planning and Implementation Branch (SPIB) of the Public Health Division of the Ministry of Health and Long-Term Care.

Term of appointment Task Force members shall be appointed for a term of one year. This term may be extended, upon the needs of the Ministry of Health and Long-Term Care.

Time frame The Task Force will complete its work over a one year period, recognizing that the Ministry of Health and Long-Term Care is committed to the establishment of the Agency in 2006. The Task Force will present interim recommendations to the Ministry of Health and Long-Term Care in the Summer of 2005. A Final Report will be presented in the Fall of 2005.

36


Appendix 2 Research and Knowledge Transfer Sub-committee: Terms of Reference Background In June, 2004, the Minister of Health and Long-Term Care released Operation Health Protection – A Three Year Action Plan to Prevent Threats to our Health and to Promote a Healthy Ontario. This Action Plan confirms the commitment of the Ministry of Health and Long-Term Care (MOHLTC) to implementing the recommendations of the Expert Panel on SARS and Infectious Disease Control as per the following strategic directions: ■ ■ ■ ■ ■ ■

Creating the Ontario Health Protection and Promotion Agency Renewing the Public Health System Health Emergency Management Infection Control and Communicable Disease Capacity Health Human Resources Infrastructure for Health System Preparedness

Research and knowledge transfer has been identified as a priority for the creation of the Ontario Health Protection and Promotion Agency and in the renewal of the public health unit system.

Ontario Health Protection and Promotion Agency An Agency Implementation Task Force (AITF) has been established to provide advice to the MOHLTC, via the CMOH, on the design, development and implementation of the Ontario Health Protection and Promotion Agency.

function would be undertaken through creating, reinforcing and strengthening partnerships with research, academia, and healthcare institutions to support the generation of evidencebased public health policies and practices.

Public Health Renewal One of the key goals of renewing the public health system is to review the organization and capacity of local Public Health Units and the Public Health Education, Research and Development (PHRED) Program. This review will inform the development of long-term strategies to enhance capacity to plan and implement optimal public health programs and services that effectively respond to the needs of Ontarians. This review is being supported by the Capacity Review Committee (CRC). CRC advises the CMOH and, through her, the MOHLTC on options to improve the function and configuration of the local Public Health Unit system. The advice to be provided encompasses the following: ■

■

The responsibilities of the AITF will be to:

core capacities required (such as infrastructure, staff, etc.) at the local level to meet communities’ specific needs (based on geography, health status, health need, cultural mix, health determinants, etc.) and to effectively provide public health services (including specific services such as applied research and knowledge transfer); issues related to recruitment, retention, education and professional development of public health professionals in key disciplines (medicine, nursing, nutrition, dentistry, inspection, epidemiology, communications, health promotion, etc.); identifying operational, governance and systemic issues that may impede the delivery of public health programs and services; mechanisms to improve performance management systems and programmatic and financial accountability; strengthening compliance with the Health Protection and Promotion Act, associated Regulations and the Mandatory Health Programs and Services Guidelines; organizational models for Public Health Units that optimize alignment with the configuration and functions of the Local Health Integration Networks, primary care reform and municipal funding partners; and staffing requirements and potential operating and transitional costs.

Validate the Agency’s proposed mandate, key functional areas, structure, governance and oversight. Recommend operational public health responsibilities for the Agency, and delineate its role and responsibilities in relation to those of the MOHLTC, academia, the broader health, the Federal Public Health Agency and its National Collaborating Centres. Recommend a comprehensive three-year implementation plan for the Agency (including infrastructure, financial requirements, human resources, transition, arrangements, etc.).

■

The Co-Chairs of the AITF are Dr. Terry Sullivan and Dr. Geoff Dunkley.

■

A core function proposed for the Agency is research and knowledge transfer. Operation Health Protection noted that this

The Chair of the CRC is Dr. Susan Tamblyn and the Vice-chair is Mr. Brian Hyndman.

■ ■

■

■ ■

■


37

Purpose The Research and Knowledge Transfer Sub-Committee will support the AITF and the CRC by sharing its expertise and making recommendations to produce the following deliverables: ■

■ ■

■

An assessment of lessons learned from existing and former models of public health research and knowledge transfer in: – Ontario (e.g., the Public Health Research, Education and Development (PHRED)/ Teaching Health Unit Program). – Other jurisdictions (i.e., British Columbia, Quebec, etc.) An assessment of gaps and analysis of needs with respect to public health research and knowledge transfer. An environmental scan of other key sources of research and knowledge transfer for public health units, such as universities, ICES, CIHI, Health Intelligence Units, Ontario Health Promotion Resource System members. Recommendations for an appropriate vision to inform the design of the mandate and structure for a research and knowledge transfer system, including the potential roles of the Health Protection and Promotion Agency, that support and enable more effective public health programs and policies and that is anchored in public health needs.

The Research and Knowledge Transfer Sub-committee will be Co-chaired by Mr. Brian Hyndman, Vice-chair of the CRC and Ms. Jennifer Zelmer, AITF member.

Terms of Membership 1 The Research and Knowledge Transfer Sub-Committee will report to the AITF and CRC via its Co-chairs. 2 The Research and Knowledge Transfer Sub-Committee will have a sunset date of December 31, 2005 unless the CRC, the AITF and the MOHLTC agree to extend this term. 3 The Research and Knowledge Transfer Sub-Committee will operate by consensus to the fullest extent possible. 4 The Research and Knowledge Transfer Sub-Committee members will be reimbursed for travel expenses as per Management Board Guidelines. 5 All documentation produced by the Research and Knowledge Transfer will be the property of Her Majesty the Queen in right of Ontario.

Support to the Sub-Committee The Research and Knowledge Transfer Sub-Committee will be supported by the Strategic Planning and Implementation Branch (SPIB) of the Public Health Division of the MOHLTC.

Process The Research and Knowledge Transfer Sub-Committee will convene at the call of the Co-chairs, Mr. Brian Hyndman and Ms. Jennifer Zelmer.

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Appendix 3 Agency Implementation Task Force Reference Panel: Terms of Reference Background In June, 2004, the Minister of Health and Long-Term Care released Operation Health Protection – A Three Year Action Plan to Prevent Threats to our Health and to Promote a Healthy Ontario. This Action Plan confirms the commitment of the Ministry of Health and Long-Term Care (MOHLTC) to implementing the recommendations of the Expert Panel on SARS and Infectious Disease Control as per the following strategic directions: ■ ■ ■ ■ ■ ■

Creating the Ontario Health Protection and Promotion Agency Renewing the Public Health System Health Emergency Management Infection Control and Communicable Disease Capacity Health Human Resources Infrastructure for Health System Preparedness

An Agency Implementation Task Force (AITF) has been established to provide advice to the MOHLTC, via the CMOH, on the design, development and implementation of the Ontario Health Protection and Promotion Agency. The responsibilities of the AITF will be to: ■ ■

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Validate the Agency’s proposed mandate, key functional areas, structure, governance and oversight. Recommend operational public health responsibilities for the Agency, and delineate its role and responsibilities in relation to those of the MOHLTC and academia and the broader public health system, the Federal Public Health Agency and its collaborating centres, etc. Recommend a comprehensive three-year implementation plan for the Agency (including infrastructure, financial requirements, human resources, transition, arrangements etc.).

The Co-Chairs of the AITF are Dr. Terry Sullivan and Dr. Geoff Dunkley.

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Provide a forum to update public health practitioners/associations on the activities of the AITF. Provide a forum for public health practitioners/associations to share their knowledge and expertise relating to public health and issues that emerge from the AITF. Provide feedback to the AITF on specific matters related to the development of the Ontario Health Protection and Promotion Agency.

The Co-chairs of the Reference Panel will be Dr. Terry Sullivan and Dr. Geoff Dunkley.

Terms of Membership 1 The RP will have a sunset date of December 31, 2005, unless the AITF and the MOHLTC agree to extend this date. 2 The RP will operate by consensus to the fullest extent possible. 3 The RP members will be reimbursed for travel expenses as per Management Board Guidelines. 4 The proceedings of the RP are intended to occur in an atmosphere where all members, including the Co-Chairs, can speak freely and where discussions and materials shared among the participants are kept confidential and are not discussed or distributed outside the proceedings of the RP. Any reports of the proceedings prepared by the Chair of the AITF will not attribute the contents of the discussions to any person. RP members must respect these confidentiality requirements unless disclosure is required by law. If a RP member believes that he or she may be required to make a disclosure by law, the RP member will notify the Chair prior to such disclosure being made. 5 Participation in the deliberations of the RP shall not be construed as limiting the ability of any organization to make whatever representations they so choose to other processes currently in place. 6 All documentation produced by the RP will be the property of Her Majesty the Queen in right of Ontario.

Support to the Reference Panel The AITF is creating a Reference Panel (RP) to advise and assist in meeting its mandate.

The RP will be supported by the Strategic Planning and Implementation Branch (SPIB) of the Public Health Division of the MOHLTC.

Purpose The purpose of the RP is threefold:

Meetings The RP will convene for a minimum of two meetings.


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