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.