Public health has been in the news a lot lately, whether it’s for the intensity of influenza season and norovirus infections, or whooping cough outbreaks leading to infant deaths. As happens with significant infectious disease outbreaks, there’s a surge of interest in public health, which will last until the outbreaks calm and cities stop declaring flu emergencies. But public health does a great deal more than what is visible during influenza season, and it is increasingly being asked to do even more, all with only a tiny sliver of the healthcare budget. This funding proportion, and the entire method for funding public health, needs to change.
In Nova Scotia, Public health is described as being: “the art and science of improving and protecting health and preventing illness, injury and diseases through the organized efforts of society.” Other jurisdictions have similar statements. More specifically, public health work typically involves variations of these functions:
- Collecting and analyzing health information, for example from health surveys, research studies, and community meetings, and using that evidence to support programs, policies and services.
- Working with partners, such as different levels of governments, non-profit organizations, businesses, and community groups, to tackle complex health-related issues. Results could include inter-agency collaboration when providing services, or implementation of social policies influenced by diverse perspectives.
- Addressing aspects of the environment (natural and human-made) that impact health
- Protecting people from health hazards such as unsafe water, food, and air
- Protecting people from certain infectious diseases
- Some direct services, such as immunizations, vision screening, dental programs, and pre-natal support
The “more” that public health is being asked to do is seen in the increasing focus on addressing the broader societal and economic factors that impact health – areas like food security, housing, climate change, and many others. Provinces across the country are clearly setting these expectations, which is a welcome trend, but this changing and expanding mandate is not reflected in the funding public health receives.
Obtaining the exact amount that is dedicated to public health is a difficult task. There are often multiple funding sources, including from various levels of government, and through grants and partnerships with other organizations. There are also activities that are incorrectly classified as public health; for example, medical management of someone with diabetes to prevent complications. There are also activities that influence public health, such as spending on affordable housing and education, but are not categorized as public health. Some regions and provinces have attempted to calculate an amount specific for public health. In British Columbia the Chief Medical Officer of Health stated that “public health and prevention initiatives receive only 3 per cent of the provincial health budget,” while in Nova Scotia, the amount is about 1.5% of the healthcare budget.
One example where the paucity of funding in Canada is most apparent is in surveillance infrastructure. Surveillance is the method by which public health assesses the health of communities. Just as clinical medicine uses tests to provide essential information needed to make a diagnosis and determine treatment for individuals, surveillance allows public health to develop plans to improve the health of entire communities. Surveillance is fundamental to the purpose of a public health system. It lets us answer essential questions: Where are we seeing health differences? Why are we seeing them? And most importantly, What can we do to address those differences?
There are numerous examples here in Canada where public health officials have used surveillance to uncover health disparities and then used this information to address them. These are just a few:
- In Saskatoon, analysis determined that low-income neighbourhoods had lower immunization rates; practices were implemented to change that differential.
- In northern Saskatchewan, data related to factory emissions is used by public health to determine the impact on communities in order to inform actions that needed to be taken to protect people’s health.
- In Cape Breton, Nova Scotia, a comprehensive early childhood data system is being used to assess differences in child health across the island and determine where programs, policies, and advocacy efforts should be focused.
- In Toronto, data was used to analyse the health and economic costs of not investing in active transportation; this information was used to make city-wide recommendations.
Despite the need of this type of work, in many parts of the country public health lacks the infrastructure to carry out these steps effectively. This may mean not having adequate information databases, which is disturbing given that strengthening information systems was a key recommendation after several national and provincial reviews of SARS. Even if data is available, public health often lacks the resources to hire or train people with expertise to collect and analyze the information, despite being expected to act on it. Data collection and analysis may seem like an academic debate, but is essential to improving the health of Canadians. Without the resources for effective surveillance, the very foundation of an evidence-based approach to public health, the capacity of public health and its partners is lessened.
Irrespective of the percentage of healthcare funding public health receives, it is clear that public health receives a small amount of funding as compared to acute care. This ratio is not in line with the growing evidence regarding the long-term benefits of prevention.
Admittedly, it is difficult to argue for increased resources at time of extensive government cuts. However, strengthening public health could occur through a strategic allocation of healthcare dollars, or by removing public health from the healthcare funding pot altogether. There are many models of countries that have reoriented their healthcare and other institutions to focus on creating healthy communities rather than treating the outcomes of unhealthy ones. Short-term, public health funding should be at least maintained, if not increased. Long-term, thoughtful healthcare planning needs to occur in a way that prevention is seen as a priority, rather than an afterthought.
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HI Dr. Dutt- My name is Colleen Davison. I am originally from Washabuck, CB so just in your back yard! I am a Public Health Professor at Queen’s University now. I have been reading your blogs and twitter posts for a past while and today used some of this material in my Foundations of Public Health class part of the MPH at Queen’s University. You will see some posts from our great students. Thanks for being an engaged Public Health Practitioner leading by example!
Hello Dr. Dutt.
We agree that public health funding within the healthcare system is limited and should be increased. Public health is essential to improve health outcomes of populations as a whole. An emphasis on prevention is a primary goal of public health, rather than placing focus on curing existing diseases. We realize that limited financial resources is an issue and in order to more efficiently allocate healthcare funding, proper public health training should be mandatory and standardized in all Canadian health professional programs (medical, nursing, dentistry etc.). One difficulty is that the timeframe for preventative public health outcomes is often longer and tends to be deprioritized when it comes to allocation of scarce resources. We hope to see future improvements within the healthcare system alongside a shift towards a more preventative approach to health.
As public health sciences student from Queen’s University we were wondering if based on your experience if the funding between provinces is representative of the public health needs. How do you think the Public Health funding could be increased over time to reach an acceptable balance between health care funding and Public Health funding. If that is unrealistic given how much weight is given to clinical care: How do you think we could separate PH funding in Canada so that it becomes its own entity?
Thank you for your post! I agree that Public Health funding is very limited given its fundamental role in Canada’s health system. I am interested in understanding the strategies other countries haven undertaken to re-allocate funding, and encourage healthy public policy and prevention efforts. Hypothetically, how would you propose that a country split Public Health into its own sector, separate from healthcare? What would this mean for the main stakeholders currently involved in our healthcare system?
Great read! As Master of Public Health Students, overall we agree with what you have stated throughout the article. However, have you noticed any changes that have occurred since Justin Trudeau has been elected into Parliament? With the new government and the new Federal Minster of Health’s focus on addressing healthy communities, are any changes evident at the Provincial level? If so, do you agree with the new changes? With the increasing aging population and their increased burden on the health system, it is a tough time to move funding from treatment and care. Where do you think more funding for Public Health should come from and what area of Public Health requires the most funding?
Thank you for your article Dr. Dutt! I would be curious to hear your thoughts on the opportunities and barriers presented to public health by the shifting of governments, particularly at the federal level? Do you have hope that we are better positioned to make disease prevention, and health protection a priority in Canada, or does the change up present new bureaucratic barriers?
I would also be curious to hear your thoughts on where there is room to shift money in the greater federal/provincial budget for public health. From your experience is this a reordering of priorities at the level of health care systems, and decisions made by health boards and even hospitals, or is this further up the food chain, in terms of the expectations of funding agencies?
Talking about funding approaches is a sensitive issue. It is however the elephant in the room. While the current health system has benefited from large reductions in demand on health services through reduced rates of cardiac disease, lower trauma, and improvements in child wellbeing amongst others, these are loosely defined as opportunity costs (or gains). The savings are not counted as a benefit, and what current investments can accrue in future avoided costs are real, but require up front investment for long term gain.
While numerous reports have touted the benefits of investment in prevention, the annual budgeting process provides little to no incentive to make such investments. This year’s balanced budget for which minimal outcry on failing to access services drives decision making in organizations that do not necessarily perceive that they are of themselves sustainable (subject to political redefinition, amalgamation, regulatory whims).
Public health funding within one regional health structure crept upwards from 3.1% of the budget to just over 3.8%, only to have changes in administrative direction dismiss those efforts, stagnate and eventually reduce funding. Proportional funding has slipped to about 2.8%, absolute inflation adjusted funding has dropped, and further reductions are anticipated.
In this environment, Dr Dutt’s stimulating a dialogue on looking at different funding models is a welcomed foray into the recognizing the elephant. J Ross’ review of past efforts at funding models speaks to some of the attempts to institutionalize public health within global structures, and with varying success that is not discussed.
Were we running our health system to ensure that our children and their children had the greatest opportunity to optimize their contributions to society, we would be sure to have given adequate priority to maintaining health in parallel to treating disease. Meanwhile, short sighted thinking is selling off our children’s inheritance to put out today’s fires. Keep up the dialogue so that a rationale approach can be postulated that balances these needs.
No disagreement here. As I said in a previous comment, public health needs to work with what it has to be as effective as possible.
In recognition of that need, the Nova Scotia public health system has been going through an extensive review in recent years, and has clearly identified priorities and shifted the ways in which some work had been previously done – all essentially within the existing budget. Ontario had also gone through a process of developing public health standards that public health units were required to meet, with the caveat that there would be no increased funding to aid in meeting those standards. Some local examples from Nova Scotia include Cape Breton reassessing its school dental program this year, and in the Halifax area, the ways in which support for pregnant women and infants is provided is being studied in order to inform future planning. Evaluation needs to be constant and ongoing, and some areas of public health have been doing this well, others could be improved.
I’d still like to have this discussion be about how to best use health-related funding to achieve better health outcomes by focusing on prevention. This is more than about having “laudable ideas” – rather it’s about using what is known about illness prevention to inform the funding process.
This approach has been outlined in much more detail than what I have done in this short blog post by the Provincial Health Officer for British Columbia, Dr. Perry Kendall, in his report “Investing in Prevention Improving Health and Creating Sustainability”. There are numerous examples of how prevention saves healthcare dollars, whether that is through harm reduction programs that lead to less healthcare system, or guaranteed housing for people with low incomes leading to better health outcomes, just to name a few.
Other countries have prioritized prevention more than Canada has, both within healthcare and in other ares such as education, and as a result have better health outcomes than Canada. There are practical, concrete ways in which our approach to health can be reoriented to better serve all of us.
(Dr. Kendall’s report: https://legacy.email.nshealth.ca/owa/redir.aspx?C=96effd5d994d44499c78e974fc808cfb&URL=http://www.health.gov.bc.ca/library/publications/year/2010/Investing_in_prevention_improving_health_and_creating_sustainability.pdf)
You ideas are laudable, but where do you think the money should come from in favour of public health? Instead of first suggesting that the public health budget be expanded, aren’t there priorities that public health can set and efficiencies to be gained in what public health departments do?
Sorry – my response is above.
Investing increased funding into “Public Health” (loosely defined as disease prevention, health protection, health promotion and surveillance) as well as focussing on “Determinants of Health” (Income, education, physical and social environments, social services) dollar for dollar is a much more fiscally prudent approach then the current practice of pouring countless funds into the acute health care system. We need more debate about bridging this gap, providing appropriate home based care for our elders, as well as creating healthier environments for our children and youth. We can’t afford to continue the status quo.
Thanks for this comment Michelle, and for highlighting the fact that there is Public Health and the programs and policies that formally come under that title – then there is small-p public health which can refer to the many areas that impact health, which go far beyond what a public health department does. Public Health is just one partner in the range of government departments/organizations/citizens/others whose work can either improve or detract from health.
Thanks to DrPHealth who has written a follow-up piece to this: Public Health Funding Debate – diving deeper – http://drphealth.blogspot.ca/2013/02/public-health-funding-debate-diving.html
J Ross – thanks for your comments. You’ve given some great examples of where public health data systems can be strengthened, the need for a better articulation of what public health funding consists of, and ways to better integrate population health principles into healthcare.
I’m curious – can you say more about the models you’ve mentioned in your last paragraph? The needs-based funding models, the role of marginalization indices, and accountability for population health outcomes – do you have examples of where these are working well or what type of infrastructure/research is needed to successfully implement those models?
Hi Dr. Dutt,
Here are some more details on PH funding models – your others questions require more space than allotted on this blog. As mentioned, most provinces allocate health resources to regional authorities using a “global” funding approach – and often, there is no specific funding methodology related to public health. However…
In ALBERTA – Until recently, Protection-Prevention-Promotion (PPP) utilized a formula for distributing a funding pool covering public health, health protection and community health services (2007/08). PPP was split into three broad age group categories: Age 0-19 (62%), 20-64 (26%), 65+ (12%), and each weighted according to a mean-testing scheme (e.g. regular: 1, subsidy: 2, aboriginal: 5, welfare: 5) to arrive at each region’s share of the three funding sub-pools.
In QUEBEC – global allowances are distributed among regions according to estimated cost during the current year and anticipated expense based on population and the needs indicator (which is based on demographic and socioeconomic factors). The Pampalon and Raymond Deprivation index incorporates: % with no high-school diploma; ratio of employment to population; average income; % who are separated, divorced or widowed; % of single-parent families; and % of people living alone.
In NOVA SCOTIA – PH services are delivered by nine District Health Authorities (DHAs) (at last check, November 2006). The provincial/local budget distribution is approximately 30%/70% and funding is divided equally (one-third) between three components: (1) Base funding: Considers the fixed costs of program delivery, independent of population size, geographic location, or other determinants of health. (2) Population-based funding: Considers the size of the target population served by the program in cases where funding is targeted at a specific population. In most cases, it is calculated using total population. (3) Needs-based funding: Considers the needs of the population served. The weighted factor is applied to the CHB population: (a) 50% is allocated to geography, with population per kilometer of road chosen as the indicator; (b) 25% is allocated to education, with the chosen indicator being percent of population with less than high school education; (c) 10% is allocated to income, with median household income selected as the indicator; (d) 15% is allocated to health, with self-rated health (percent rating health as fair or poor) chosen as the indicator.
These may be out of date now. A new inventory is needed. See http://healthcarefunding.ca for a good overview of activity-based funding vs. global funding. However, we certainly need more research on the value/application of needs-based population health funding models… You may also want to search “HBAM in Ontario” – Ontario’s new healthcare funding model. It stands for “health-based allocation model,” but this is a misnomer from a PH perspective. It’s really just an activity-based funding model that also attempts to predict health spending per SES groups…
I appreciate your responses re. funding models. I might have more to write sometime soon – I’m heading to India tomorrow and am caught up with that tonight and may not be online again for a while. Perhaps we can talk sometime off-blog in the future. Thanks again for your thoughtful posts.
I don’t think more funding for public health is the only answer, although funding definitely needs to be part of the discussion. I think the more fundamental question is one of priorities in health, with a key aspect being prevention and addressing the contributors to poor health from an evidence-based perspective. Our healthcare system is disproportionately focused on illness care rather than prevention. There are ways to deal with the “increasing demand” on hospitals that you mention by seeking ways to avoid needing that hospital care in the first place. There are other models globally that invest proportionately more in prevention/public health than we do in Canada and achieve better health outcomes than we do here.
There could also be more effective allocation of funding in other areas you mentioned, such as education, social services, housing. Just to name a few, investment in early childhood education, ensuring a living wage, and guaranteeing housing to people living in poverty, are just a few of the ways that prevention can result in improved health and more productive citizens in general. Those areas weren’t the focus of the piece I wrote, but every sector, including public health, needs to critically look at what they are trying to achieve and and determine whether their actions are in fact contributing to that goal. No doubt many aspects of public health could work more effectively with the resources available.
In healthcare there is increasing talk of prevention, equity, social determinants of health – a few examples include the Toronto Central LHIN’s Health Equity Action plan (http://www.torontocentrallhin.on.ca/Page.aspx?id=4396), the Canadian Medical Association’s attention to equity, and the Cape Breton District Health Authority’s focus on poverty – and there are many similar initiatives across the country. To ensure these goals are more than just words, there needs to be thought and resources dedicated to these areas, and that may mean a reallocation of funding, with the understanding that the ultimate outcome is better health for more people.
With respect to surveillance, where I did specifically say that public health needs to be better resourced, that is not just my opinion – as I mentioned, numerous external reviews have been done nationally and provincially after events such as SARS and other large infectious disease outbreaks which state that better infrastructure is needed – see links in post. Surveillance goes beyond infectious diseases, but that is one area where significant attention is paid when things go wrong, but attention wanes once the crisis has passed. Which is why numerous recommendations made years ago have yet to be fulfilled, and those cracks in the system will eventually resurface.
I am glad to see that you say that extra funding for public health is not the only answer; however, that is the only answer that you give in your original article. For example:
– the last sentence of your first paragraph sets out the central thesis of the article (“This funding proportion, and the entire method for funding public health, needs to change.”).
– you focus on the “paucity” of funding for surveillance.
– you complain about the imbalance of funding given to acute care instead of public health.
– your last paragraph brings these ideas together by noting that it is hard to argue for more funding at the time of funding cuts, that there could be a reallocation of funding away from other areas to public health, and that short-term public health funding should be maintained if not increased.
Would you please disclose to readers whether your budget is currently being frozen or cut? I am sure readers would like to know whether this article is a piece of advocacy on your part/
I am employed by the Nova Scotia provincial government and work closely with a District Health Authority – I also work as a family physician in several communities. I have no direct control over the DHA public health budget, and so I do not have ownership over a budget that has been cut/frozen/increased.
This piece was not written with a local advocacy goal, but as someone who has worked in, observed, and learned about public health systems across the country. I would write a similar piece if I was still working in Saskatchewan or Ontario or Nunavut or the Northwest Territories. This is a national issue – ie how to develop an overall healthcare system approach and funding models for public health based on rationality and evidence in a way that ultimately improves the health of Canadians.
You may not decide the budget for public health, but you presumably make recommendations on the budget and are impacted by such decisions. While I appreciate you are making an argument about the allocation of funding that extends beyond your local region, my point is simply that you have an interest in the budget decision affecting public health and therefore an interest in promoting an expansion of funding to public health because that is an area in which you work in an executive capacity.
My point is that many people in the health system when they advocate for more funding for particular sectors also have such an interest – readers need to take that into account when assessing a particular argument by an author (whether it be an argument for funding for public health, funding for primary care, funding for community or home care, or nurses arguing for more funding for nurses etc.). I could make this point about a number of other articles published on healthydebate.ca.
You’ve been clear on your feelings about being against increased funding for public health (and other areas in healthcare). Would you have any comments on how to better allocate health-related funding to be more effective – ie to be better at improving the health of Canadians. Do you see prevention as part of that, either within public health or in other parts of the healthcare system? Or are you against the whole idea of greater attention being given to prevention? I’m assuming that given your concern about taxpayers’ dollars, you’d want them to be used in a way that actually achieves better health in a cost-effective way.
I am very tired of people in the health industry of demanding that taxpayers give health providers more money. Is that the only answer?
The fact is that industries everywhere are being asked to do more with less, including in the health service field. Hospitals are dealing with increased demand while having budgets flat-lined or cut; same goes for many other parts of the health field. Same is true in education, housing, social services etc.
The first thing you should be doing in public health is not demanding more money, but looking at your own services, deciding what is a priority/what is not, and managing how to do things more efficiently. That is called leadership, rather than holding your hand out for more money.
Second, there is always a bias from people in the health field asking for money. It is not surprising that people make the case that their field, their speciality needs more money. Your article lacks credibility when you are simply making a case to expand your own bureaucracy.
Please show some leadership by figuring out how to use existing resources better, rather than grasping for more money as the first answer to a problem.
Great article – Indeed, PH in Canada has very limited data systems. An additional example of this is what data and sectors are supported by Ontario’s Health Data Branch. They have robust databases for hospitals and out-patient activities, but nothing for PH. Furthermore, all PH units in Ontario are asked to conduct population health assessments, but trip over each other by running duplicate analyses. The Americans have solved this with tools like: http://www.countyhealthrankings.org – time for Canada to use tools like this.
More broadly re: funding – barriers to PH funding are nicely summarized here: Richardson, A. K. (2012). Investing in public health: barriers and possible solutions. Journal of Public Health, 34(3), 322-327.
As well, the models of funding PH are a mish-mash across Canada, and have received little attention from the field’s heavy-hitters (e.g., Sutherland from UBC @ http://healthcarefunding.ca). Most provinces fund PH via a 1-time lump-sum. It is time to operationalize what we know about the SDOH and investigate need-based funding models, the role of marginalization indices in PH funding, and the implications of holding healthcare providers accountable for population health outcomes (not just outputs). Let’s make hospitals health-producing centers, not just clinical factories that efficiently discharge individuals back into unhealthy environments.