Background to the Public Health Human Resources Strategy

• Historic events and decisions
• Recent events and decisions: Public health infrastructure
• Recent events and decisions: HHR planning
• Health Care System Reform: The Romanowand the Kirby Reports
• Public-Health System Reform: the Naylor and other SARS Reports
• Health-Care System Reform(2003 +)
• The Advisory Committee on Population Health and Health Security (ACPHHS):

The work of the Public Health Human Resource (PHHR) Strategy in implementing the Pan-Canadian Framework for Public Health Human Resources Planning (1511KB) can be understood by considering historic events and decisions that influenced the evolution of the Canadian health-care system (including public health

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), in general, and the critical events that led to developing the PHHR Strategy, in particular.

Historic events and decisions

The development of the Canadian health-care system was driven by the shift from infectious to chronic diseases and the implications of the medical model of health, including the rise of curative/preventive health technologies and the dominance of physicians and hospitals for treating patients, the provision of publicly funded universal insurance to reduce financial barriers to obtaining health care, and the public’s expectation of being able to access health-care services when disease strikes.

Also, while comparatively comprehensive data are compiled counting the medical workforce and the work of fee-for-services practitioners, relatively little are reported for unregulated public health professionals, such as public health inspectors and the environment health work that they perform as salaried employees.

These factors influenced policy-makers to focus more on the provision of curative/preventive services and the physicians, nurses, and allied HHRs required to produce them. Hence, it is not surprising that analysis to inform HHR planning:

• focused mostly on future requirements for physicians and nurses and
• estimated future requirements by applying prevailing patterns of care to changes in population size and, more recently,distribution by age/sex).

In the past, HHR planning for public health has not been coordinated with that of the broader health-care system, even for common areas, such as medicine (community medicine as a specialty) and nursing (public health nursing as a specialty). For example, the decision to eliminate the rotating internship and the restrictions placed on reentry positions may have unintended consequences for the public health workforce.

The following sections distinguish between events and decisions in the public health and the broader health care systems that have influenced the (separate) trajectories of PHHR and HHR planning. The collaboration of the Advisory Committee on Population Health and Health Security and the Advisory Committee on Health Delivery and Human Resources to produce the Report, Building the Public Health Workforce for the 21st Century – A Pan-Canadian Framework for Public Health Human Resources Planning, 2004(link), however, is a recent development suggesting greater coordination between PHHR HHR planning activities.

Recent events and decisions: Public health infrastructure

Lac Tremblant Declaration (1994):
Proceedings and Recommendations of the Expert Working Group on Emerging Infectious Disease Issues Lac Tremblant Declaration. Canadian Communicable Diseases Report. 1994;20(S2):10-9.

In 1994, the Expert Working Group on Emerging Infectious Disease Issues, a working group of some 40 scientists convened by Health Canada, released the Lac Tremblant Declaration, which noted numerous concerns with capacity to respond to emerging and resurgent infectious diseases, including:

• jurisdictional issues, a lack of coordination, incompatible information systems and lack of timely analysis of data;
• lack of federal leadership and inadequate federal funding; and
• limited surveillance capacity and a shortage of epidemiologists.

The Lac Tremblant Declaration called for a national strategy to support and enhance capacity of the public health infrastructure for disease surveillance and outbreak management.

A new focus on public health capacity (Conference of Deputy Ministers of Health, 2001)
At the request of the Conference of Deputy Ministers of Health, the Federal/Provincial/Territorial (F/P/T) Advisory Committee on Population Health examined the health protection and promotion infrastructure in Canada. While no formal report was released, the advisory committee noted a clear shortfall in PHHR planning and development.

Auditor General’s Review of F/P/T Collaborative Framework (1999, 2002):
1999 Report of the Auditor General to Parliament, September and November 1999.

• Chapter 14 - National Health Surveillance: diseases and injuries.
• Chapter 15 - Management of a Food-borne disease outbreak.

2002 Report of the Auditor General to Parliament, 2002 Status Report.

Chapter 2 – Health Canada – National Health Surveillance.

In the 1999 reports and the 2002 Status Report, the Auditor General of Canada raised critical questions about F/P/T collaborative frameworks and Canada’s capacity for infectious disease surveillance and outbreak management, with implications for PHHR Strategy.

Recent events and decisions: HHR planning

National and provincial HHR forecasting exercises traditionally have focused on professional disciplines, the broad health-care system, and projected changes in population demographic structure ( Evans 1984) – even in recent forums calling for integrated HHR planning have not noted public health (for example, The 2003 Canadian Health Services Research Foundation Roundtable on Integrated HHR Planning).

Public health and the scope of its activities (1974 to 1996):

Whereas the traditional activities of infectious disease surveillance and outbreak management are regulated public health services,

• The 1974 Lalonde Report, A New Perspective on the Health of Canadians,
• The 1986 Ottawa Charterfor Health Promotion
• The 1986 Epp Report, Achieving Health for All: A Framework for Health Promotion,
• The 1994 F/P/T Advisory Committee Report, Strategies for Population Health
• The 1996 Hamilton and Bhatti Report, An Integrated Model of Population Health and Health Promotion
  broadened public health in terms of its focus (infectious and chronic diseases; health), types of intervention (prevention and health promotion), and unit of intervention (individuals and populations). How P/T jurisdictions (and regions, where applicable) responded has created differences across Canada in the organization and provision of public health.

Establishment of Canadian Institute for Health Information (1994):
Concerns about the scope, quality, and availability of national health care data led to the establishment of CIHI in 1994. As an independent, Canadian, not-for-profit organization, CIHI has become a focal point for collaboration among major health players—from provincial governments, regional health authorities and hospitals to the federal government, researchers and associations representing health care professionals for:

• developing and maintaining national databases and registries on health human resources, health care services, and health spending;
• developing knowledge about the determinants of population health; and
• disseminating information on the health of Canadians and the performance of the health-care systems (health indicators, reports, and special studies).

Although CIHI is advancing its ability to count the public health workforce in the medical, nursing, and laboratory technician registries, further work is required. For example, whereas community medical specialists are counted, non-specialist public health physicians (e.g., general physicians with public health training) are not distinguished. Similarly, while CIHI has advanced its ability to estimate expenditure on public health, analysis is limited by problems of disentangling the cost of health administration and lack of agreement among the jurisdictions on the operational definition of public health and the scope of its activities and workforce.

National Forum on Health Care (1997):
Contributions of the National Forum on Health Care include:

• emphasizing the broad determinants of population health and measurement linking the development of mental and social well-being, quality of life, life satisfaction, and other measures beyond traditional morbidity and mortality to income, employment and working conditions, education and other factors known to influence health;
• fostering national consensus for evidence-based policy development and decision making based on the values that Canadians have about health and health care;
• roadmap initiatives to build a national health information system, include funding CIHI to expand/enhance its national health-care data holdings and to establish the Canadian Population Health Initiative; and
• calling for the establishment of the Canadian Institute for Health Research, of which the Institute for Population and Public Health, along with the Canadian Public Health Association, are key collaborators working with PHAC to implement the PHHR Strategy.

Health Care System Reform: The Romanow and the Kirby Reports

• Romanow Report, Building on Values: The Future of Health Care in Canada (2002):

• Standing Senate Committee on Social Affairs, Science and Technology Response to the Romanow Report, Reforming Health Protection and Promotion in Canada: Time to Act (2003):
  

Although high priority was placed on redressing access to physicians and nurses (Chapter 4, Investing in Health Care Providers), the Romanow Report did not specifically address public health workforce concerns.

In responding to the Romanow Report, however, the Standing Senate Committee on Social Affairs, Science and Technology examined Canada’s ability to respond to public health emergencies arising from infectious disease outbreaks. The Committee recommended that:

• Human Resource Development Canada (now Human Resources and Skills Development), as part of its human resources sector studies of physicians and nurses in Canada, examine current and future needs of health professionals in the field of health protection and promotion;
• the federal government take immediate action to encourage the development of on-the-job training programs to assist health professionals in acquiring the necessary skills pertaining to health protection; and
• the federal government, in collaboration with P/T to increase enrolment in existing university and community college programs in the field of health protection and promotion and, then, undertake the establishment of a "Virtual School of Public Health.”

Kirby Report,The Health of Canadians – The Federal Role Final Report. The Standing Senate Committee on Social Affairs, Science and Technology. Chair: The Honourable Michael J.L. Kirby (2002).

In noting disease trends that threaten the health of Canadians, the Kirby Committee recommended that “the federal government ensure strong leadership and provide additional funding to sustain, better coordinate and integrate the public health infrastructure in Canada as well as relevant health promotion efforts" (Chapter Thirteen: Health Promotion and Disease Prevention).

The HHR Strategy (Chapter Eleven: Health Human Resources) noted “the only long-term solution to the human resources crisis remains the development of a national strategy that focuses on training enough physicians and other health professionals in Canada to meet the country’s needs, as well as meeting increasing physician productivity.” To accomplish this goal, the Kirby Report recommended that the federal government work with other concerned parties to create a permanent National Coordinating Committee for Health Human Resources to:

• disseminate up-to-date data on human resource needs;
• coordinate initiatives to ensure that adequate numbers of graduates are being trained to meet the goal of self-sufficiency in health human resources;
• share and promote best practices with regard to strategies for retaining skilled health care professionals;
• coordinating efforts to repatriate Canadian health care professionals who have emigrated to other countries;
• recommend strategies for increasing the supply of health care professionals from under-represented groups, such as Canada’s Aboriginal peoples, and in under-serviced regions, particularly the rural and remote areas of the country; and
• investigate the potential for greater coordination of licensing and immigration requirements between the various levels of government.

Public-Health System Reform: the Naylor and other SARS Reports.

Naylor Report, Learning from SARS: Renewal of Public Health in Canada. A report of the National Advisory Committee on SARS and Public Health chaired by Dr. David Naylor (2003).

The Naylor Report identified several systemic deficiencies, including PHHR capacity (Chapter 7 – Public Health Human Resources), which impaired the ability of the public health system to respond to SARS. Key recommendations include:

• create a Canadian Agency for Public Health structured as a legislated service agency, with a Chief Public Health Officer of Canada as the chief executive of the new agency reporting directly to the Minister of Health;
• establish a National Health Strategy with specific health targets and benchmarks for F/P/T governments to monitor; and
• develop a Pan-Canadian Public Health Human Resources Strategy for F/P/T governments to implement to renew and sustain public health human resources (including public health nurses, public health physicians, infections control practitioners and microbiologists).

The Naylor Report noted no attempt to improve public health will succeed that does not recognize the fundamental importance of providing and maintaining in every local health agency across Canada an adequate staff of highly skilled and motivated public health professionals.

The Walker Report, For the Public’s Health: A Plan of Action. Final Report of the Ontario Expert Panel on SARS and Infectious Disease Control, chaired by Dr. David Walker (2004).

The Walker Report made 53 recommendations and one overarching counsel to ensure that federal and Ontario actions to improve public health and emergency preparedness are coordinated and complementary. Key recommendations include:

• design a Public Health Human Resource Revitalization Strategy to increase capacity and training of public health professionals, and to review recruitment and retention issues;
• increase enrolment in key public health professions; and
• establish a centralized public health agency in Ontario that is integrated into a comprehensive national public health framework.

Campbell Report, SARS and Public Health in Ontario. Interim report of the SARS Commission chaired by the Honourable Mr. Justice Archie Campbell (2004).

The interim Campbell Report made 21 recommendations for reforming the Ontario public health system, including:

• a new mandate with safe water, safe food, and protection against infectious disease priorities;
• leadership and resources to execute the mandate; and
• creating an Ontario Centre for Disease Control, independent of the Ministry of Health, to support the Chief Medical Officer.

Health-Care System Reform (2003 +)

In the 2003 First Minister’s Accord on Health Care Renewal, the F/P/T governments made a commitment to work together to improve HHR planning and management. In the 2004 Ten-Year Plan to Strengthen Health Care, First Ministers reaffirmed their commitment to both collaborative HHR planning and strengthening public health.

The Health Human Resources Strategy (2003) and Planning Framework (2005):

The HHR Strategy, one of the initiatives out of the 2003 First Ministers’ Accord on Health Care Renewal, builds upon the recommendations of the Romanow and the Kirby Reports.

The F/P/T Advisory Committee on Health Delivery and Human Resources (ACHDHR) is the major conduit for the collaborative work undertaken to develop the HHR Strategy. In reporting to the Conference of Deputy Ministers of Health (CDMH), the ACHDHR provides the link for the work of the Health Human Resource Planning Subcommittee (HHRPSC) to gain approval for implementation by the F/P/T community. The mandate of the HHRPSP is to provide strategic evidence-based advice, policy and planning support on HHR planning matters to the ACHDHR and to serve as a linkage between the ACHDHR and the three initiatives of the HHR Strategy together with their working groups, including developing A Framework for Collaborative Pan-Canadian Human Resources Planning.

Health Council of Canada (2003):

The Health Council of Canada, which was established in response to the Romanow Report, is an independent organization mandated to monitor and report on the progress of health care renewal in Canada.

In summarizing the 2005 national summit on HHR, the Health Council of Canada’s Report, Modernizing The Management of Human Resources in Canada: Identifying Areas for Accelerated Change:

• reported shifts in funding to support population health care goals rather than health services with corresponding changes in HHR planning for the mix and skills of the workforce, especially the workforce concerned with public/population heath; and
• noted the development of the Pan-Canadian strategy on the public workforce.

The Advisory Committee on Population Health and Health Security (ACPHHS):

Similar to the above ACHDHR, the ACPHHS is the major conduit for the collaborative work undertaken to strengthen public health. In reporting to the Conference of Deputy Ministers of Health (CDMH), the ACPHHS provides the link for the work of its task group to gain approval for implementation by the F/P/T community.

The Joint Task Group on Public Health Human Resources (JTG PHHR): reporting to the CDMH through both the ACHDHR and the ACPHHS.
Emerson and Pringle Report, Building the Public Health Workforce for the 21st Century – A Pan-Canadian Framework for Public Health Human Resources Planning (2004).

In recognition that PHHR planning for the public health system is part of broader HHR planning for the broader heath-care system, the Emerson and Pringle Report was developed by the JTG PHHR (joint with the ACHDHR and ACPHHS). As such, this framework for PHHR planning is consistent with the ACHDHR Framework for Collaborative Pan-Canadian Health Human Resources Planning (see, above) and it is congruent with the ACPHHS Report, Improving Public Health System Infrastructure in Canada.

As for HHR planning, the framework for PHHR planning accounts of population needs for public health within the context of how public health and broader health-care systems are organized. As such, jurisdictions will implement PHHR planning within the context of:

• the development of their own public health policies and service models;
• according to the resources available to support this activity; and
• within the context of a larger health-care system that shares information and works together to develop the optimum number, mix, and distribution of public health providers to meet population health needs.
  

 

For more information, contact publichealthpractice@phac-aspc.gc.ca
or call toll free: 1-877-430-9995.