On April 15, 2019, Toronto’s board of health convened for an urgent meeting. A few days earlier, the government of Ontario had released its budget, which included a plan to restructure public health in Ontario, reducing the number of public health units from 35 to 10, and also to reduce the amount spent on public health by the province by $200 million annually. The budget did not indicate that there would be any changes to the mandated programs and services provided by public health, but stated that the savings would come from “economies of scale,” “back-office functions,” and “better-coordinated action by public health units.”
Robert Kyle, president of the Association of Local Public Health Agencies (alPHa), told the board that $200 million amounts to roughly 26 percent of what the sector receives from the province. Toronto councillor Mike Layton asked Kyle what that reduction would take away from something like chronic disease prevention—one of public health’s core services—in in the region of Durham, where Kyle is the medical officer of health. “Eight or 10 staff,” Kyle estimated. Would that mean less home visits? Layton asked. Less health promotion? “It depends on what programs are currently in place,” said Kyle, explaining that these programs might include public education, enforcement and front-line services.
It’s been said many times that the paradox of public health is that when it’s working, it’s practically invisible. Many people heard about a confirmed case of measles in York Region in mid-April; what didn’t make the news is that staff at the local public health unit spent much of the Easter long weekend on the phone with the more than 250 people they were able to identify and locate who may have been exposed to the infection.
Alerting the public about an infectious disease outbreak is one of public health’s better known functions. But what else is it responsible for? What’s involved in chronic disease prevention, for example? We took a closer look at public health in Ontario—its structure, its functions, and some of the context around the current debate about how it’s funded and delivered.
The structure of Ontario’s public health system
Boards of health govern public health in Ontario. There are three types: autonomous, semi-autonomous, and regional. Autonomous boards are made up of municipal (a majority) and provincial appointees, and strike their own budgets, which they deliver as a “bill” to their sponsoring municipalities. Semi-autonomous boards consist of municipal and citizen appointees. They also strike their own budgets, but ultimately their sponsoring municipalities have final approval of the budget. Regional health boards are not separate from regional governments—their members consist of the regional chair and all the regional councillors, and their budgets are wrapped into the regions’ budgets. In this model, the public health budget “may not get the prominence and priority” that it would in an autonomous model, explains Kyle.
Currently, there are 35 boards of public health in the province. Under each board is a public health unit, which is led by a medical officer of health—a physician who has a graduate degree or specialty certificate in public health—and which is staffed by professionals from many disciplines, including nursing, dental hygiene, and epidemiology.
Boards of health are governed by the Health Promotion and Protection Act as well as tens of other provincial statutes, including Smoke Free Ontario Act and the Child Care and Early Years Act. But to a great extent, the programs and services they are responsible for delivering are dictated by 13 provincial standards. These include “foundational” standards (for monitoring population health data, decreasing health inequities, and implementing effective public health practice and emergency management) as well as programmatic ones (food safety, healthy environments, healthy growth and development, immunization, infectious and communicable diseases prevention and control, safe water, school health, substance use and injury prevention, and chronic disease prevention and well-being). Each standard has deliverable outcomes on which public health units provide detailed performance reports to the province every year.
For several standards, there are corresponding protocols, which attempt to provide uniformity in how programs are delivered across health units. For example, the Tobacco Control protocol specifies that the board of health hire “secret shoppers” under the age of 19 to attempt to buy cigarettes in order to test whether vendors are complying with the provincial statute—it also specifies that each vendor should be tested twice annually. And the province has also provided health boards with guidelines regarding approaches to take when designing and implementing programs, offering theoretical frameworks for considering how to take action—the health equity guideline, for example, offers explanations of concepts such as social determinants of health and a glossary of terms such as colonialism and privilege.
How public health is funded and how the money is spent
For the most part, the cost of public health is split between the province and the municipalities (some money also comes from Health Canada, the Ministry of Children and Youth Services, and community organizations). The province funds 100 percent of some programs (such as dental care for children from low-income families, needle exchange, and several Smoke Free Ontario initiatives) and 75 percent of others.
But this latter split is somewhat misunderstood, says Kyle. What it actually represents is an agreement that the municipalities will contribute at least 25 percent. “It doesn’t mean that the grant you get from the province covers 75 percent of all of your expenses. In several public health units, the municipal contribution exceeds what is required.” He thinks the ratio may be closer to 70–30 or even 60–40.
The province’s plan is to reduce the number of health boards from 35 to 10; the only certain jurisdiction, for the time being, is the city of Toronto. Further, it plans to transition cost-sharing between the province and the larger jurisdictions to a formal ratio of 70–30 or 60–40 over the next few years, and to transition to a cost-sharing ratio of 50–50 with Toronto.
How the health boards currently divvy up their funding varies, and depends on the needs of their constituents. The Toronto board provided the Toronto Star with this breakdown, which indicates the biggest piece of the pie—nearly 40 percent—is directed to “family health.” This doesn’t correspond directly to one of the provincial standards, but likely includes aspects of several, and in particular “Healthy Development,” which addresses pregnancy and parenting and sexuality programs, and “School Health,” which addresses everything from oral health to bullying prevention. A single program may address a number of standards—for example, the budgeting for supporting bike lane policies may fall under “Chronic Disease Prevention,” but it also targets the goals of the newer standard, “Healthy Environments.”
Boards of health are required to complete an annual service plan and translate their local budget into a provincial template, which they submit to the province as a request for funding. In this way, the province receives “pretty granular information” with respect to the boards’ programs and services, says Kyle.
Critiques of the current structure
The conversation around restructuring public health is not new. Under the previous Liberal government, Ontario undertook the Patients First initiative, which aimed, in part, to “provide better coordinated and integrated care.” As part of this initiative, the province struck an expert panel on public health, which was charged with considering the “optimal organizational structure for public health in Ontario” and how best to govern this structure.
The group released a report in June 2017 recommending that the province’s public health boards be consolidated from 36 (at that time) to 14 to both better align with the LHINs (local health integration networks) and also to try and create more of a “critical mass” in each region so as to more readily attract and retain staff. Some of the smaller boards, says Robert Cushman, former MOH at Ottawa’s public health board, have difficulty filling the positions of MOH and epidemiologist, which are both crucial to the functioning of a public health unit. “The small health units are sort of living day-to-day and their capacity is really challenged when there’s a public health crisis,” says Cushman.
Cushman thinks there are too many units currently to provide “robust public health.” On one hand, he says, “there’s too much duplication.” And on the other, if smaller units were amalgamated or absorbed into a bigger one, they would have access to more resources such as epidemiological data or emergency management or public health physicians. Plus, greater regionalization may allow for better integration with the rest of the health care system. And if you want better integration, says Cushman, “maybe you have to bust up the model.”
The relationship between public health and the health care system
Another commonly touted characteristic of public health is that it reduces the load carried by the health care system, keeping people out of hospitals and doctors’ office through prevention of illness and promotion of health. A cost-benefit analysis of immunization programs, for example, has shown that every dollar spent on the MMR vaccine for children saves the greater health care system 16 dollars. And a 2010 Ontario study of how best to tackle tobacco control reported that tobacco use was costing the province $1.6 billion annually in direct health care costs and that for every dollar invested in addressing tobacco use, Ontario saved an estimated three dollars in health care spending. “This estimate may be conservative, since tobacco use is continually linked to more diseases,” the report added.
To tackle tobacco’s ubiquitous reach, public health units employ an array of initiatives. Enforcement officers talk to private vendors about how to display cigarettes in corner stores; health promoters work with high school students on anti-smoking campaigns. An MOH might talk to a hospital CEO about diverting post-surgical patients to a cessation program; a public health nurse might talk to a landlord about data showing tenant retention when buildings are smoke-free. “The strategy is comprehensive,” says Pegeen Walsh, executive director of the Ontario Public Health Association, a non-profit that represents multiple sectors.
And it requires multiple partnerships at the local level, as Kyle points out. This—along with how funding cuts will affect front-line services and the fact that restructuring is expected to begin imminently and be complete within three years—is of great concern to many in the sector. The worry is that regionalization will significantly disrupt years of carefully cultivated collaboration between local health units and any number of partners that address the unique needs of a given community.
Cushman agrees that this type of collaboration is key, but thinks bigger public health units can still have “local knowledge” and “representation that has good roots in the communities” they serve. Kyle is more cautious. “I think it’s a risk,” he says. “And I think it’s a risk that needs to be mitigated.”