Redesigning local environmental health programs.

Introduction

Alberta, the second-most westerly province of Canada, has a population of about 2.5 million. Traditionally, local environmental health programs (EHPs) in Alberta have resided in twenty-seven local public health units and have been delivered by a relatively small network of certified public health inspectors (PHIs)/environmental health officers (EHOs) - about 140 in all. These local EHPs have been funded and assisted by Alberta Health, the provincial department of health. The local EHPs have tended to work in relative isolation from other health programs and agencies. Activities have focused largely on routine inspections and responses to complaints about microbiological hazards. Local EHPs in Alberta, however (like their counterparts elsewhere in North America and in Europe), are increasingly operating in an environment that is undergoing fundamental social, political, and scientific change. Some of the major challenges facing these programs are:

* increasing recognition of chemical and physical hazards resulting from technology and industrialization;

For most of these hazards, the actual risk to human health is unknown. At the same time, local EHPs cannot afford to neglect the control of communicable diseases related to microbiological hazards.

* global environmental threats to long-term human survival, including overpopulation, species extinction, global warming, stratospheric ozone depletion, wastes, desertification, deforestation, and planetary overload;

These require resolution at national and international levels, but local environmental health staff, as front-line workers, will increasingly be asked to address the local health implications associated with these global issues.

* strong public concern about the effects of environmental pollution on human health;

The health system simply cannot ignore the public's ever-growing expressions of concern about the impact of environmental factors on its collective health and well-being. On the other hand, public health programs cannot afford to establish priorities for action based upon a grossly inaccurate understanding of health risks.

* high levels of uncertainty and perceptions of vulnerability experienced by local EHPs and all other health services in Alberta in light of major governmental and health system restructuring;

In particular, the governance of public health activities in Alberta is now being undertaken by 17 Regional Health Authority Boards whose members generally have more experience with hospital and medical services than with environmental health programs.

* appearance of and public awareness about chemical hazards resulting in an increased number of agencies dealing with, and players interested in, environmental health.

This increased interest has often resulted in fragmentation and duplication of services.

The National Environmental Health Association in the U.S.A. (1), the Audit Commission in Great Britain (2), and the authors of a previous study commissioned by Alberta Health (3) have all recommended changes in the delivery of local environmental health services. In March 1992, Alberta Health initiated a study to lay the foundation to strengthen and improve the ability of local public health units to protect the health of their communities from physical, chemical, or biological environmental contaminants and hazards. This study was undertaken by a multidisciplinary team from the Department of Public Health Sciences at the University of Alberta under the direction of a working committee consisting of environmental health unit program directors/managers and staff from Alberta Health Environmental Health Services Branch (4).

The purpose of this paper is to outline the process followed in the study, describe the model that was developed for the delivery of local environmental health services, and discuss issues of importance to the implementation of the proposed model.

The Study Approach

The initial emphasis of the study was on assessing existing environmental health services delivered through local health authorities. This was achieved by soliciting input from both internal and external stake-holders through surveys of and discussions with local health authority staff, focus group sessions with representatives of the general public, and discussions with senior officials of government departments whose staff relate to local EHPs. In addition to provincial stake-holders, contacts were made with environmental health experts in Canada and in other countries (U.S.A., England, Scotland, and the WHO Regional Office for Europe in Copenhagen) to allow comparison of service delivery models and obtain feedback on aspects of the model as it was developed. Targeted literature reviews were also undertaken.

The methods and results of the survey of local authority staff are described elsewhere (5,6). Briefly, confidential questionnaires were sent to chief executive officers (CEOs), EHP directors, and EHOs for all 27 local health authorities in Alberta. The objective of the survey was to obtain a profile of existing environmental health programs and current and emerging issues faced by these programs. Response rates were 100% (27 of 27), 100% (27/27), and 89% (89 of 100) for CEOs, EHP directors, and EHOs respectively. Staff attitude and the inadequate number of program staff were rated as the largest strengths and weaknesses of the programs, respectively, by all three groups of respondents. Food safety occupied more field time than any other issue. The issues presenting the greatest current challenges were waste management (as seen by managers and EHOs) and program resources (as seen by CEOs). Waste management, environmental protection (e.g., ambient air quality), the built environment (e.g., aging housing stocks), and training/expertise were seen as significant future challenges. The level of program planning and evaluation varied widely across programs. Improvements suggested by respondents included more staff, increased educational opportunities for existing staff, improved information systems, improved legislation, and greater support from Alberta Health. Site visits were made to six local health authorities to follow up on specific issues identified in the survey. Two issues of particular note that emerged from these site-visits were lack of program resources and the need to allow EHOs to use professional judgment in dealing with situations.

The methods and results of the focus group sessions are also reported elsewhere (7). Briefly, focus group sessions were held in four local authority areas in Alberta (a large city, a medium sized city, and two rural areas). At each site, separate focus group sessions were held for groups of health professionals and members of the general public. These groups were asked to address their concerns about the effect of the environment on their health and that of their community, and what they thought could be done about these issues in particular at the local level. The mean number of participants for these sessions was 6.5 (range 4 to 8). A large number of environmental health issues of concern were identified by the groups. A number of concerns were also expressed about the current delivery of environmental health services. These included inadequate communication with the public and fragmentation of services.

The information obtained throughout the early stages of the project was incorporated into the development of a reference model for local EHPs. The structure, components, and content of the model were developed collaboratively between the University of Alberta Study Team and the Project Working Committee. This was accomplished through regular joint meetings.

Once critical elements of the model began to take shape, input was solicited from local health authority board members, chief executive officers, and environmental health program managers and staff through regional meetings held in Edmonton and Calgary. In addition, comments on the model were solicited from national and international environmental health contacts established during the project.

After endorsement for the model was obtained at the regional meetings, task groups were established to make recommendations for implementing the model. They were comprised of members from the Study Team, Working Committee, and other managers/staff from Alberta Health Environmental Health Services Branch and local health units.

Results of Initial Assessment

Our initial assessment of the strengths and weaknesses of local EHPs and the opportunities for improvement were based on the results of the surveys, site visits, focus group sessions, and discussions with various stake-holders. We identified a number of issues which impeded local EHPs in Alberta in dealing with challenges faced by contemporary EHPs.

Obstacles Facing Local Environmental Health Programs in Alberta

Outdated Legislative Framework

In Alberta, the Public Health Act is paramount over all other pieces of legislation with the exception of the Alberta Bill of Rights. It is powerful and flexible, and allows for rapid resolution of local issues locally. However, many environmental health regulations under this Act were perceived as outdated and inflexible. Current regulations bias program priorities towards issues covered by regulation at the expense of issues of higher health risk. Revision of these regulations is a slow process.

Inadequate Funding

In 1993/94 the annualized funding for local EHPs in Alberta was $7.6 million (Cdn) or approximately $3.00 (Cdn) per Albertan. At the site visits, concern was expressed that there had not been a significant increase in funding of local EHPs in Alberta over the past two decades despite the increases in service demands, complexity of issues, and increases in population. Insufficient numbers of staff, inadequate access to expert resources, and inadequate information system capacity were identified program weaknesses related to insufficient funding. Without sufficient funding, programs are frustrated in their attempts to address new environmental health issues while at the same time being obliged to address traditional areas of concern.

Deficiencies in Program Management

The limited extent to which some programs undertake proactive planning and evaluation of their services hinders them from coping with increasing program demands. Deficiencies identified as part of the survey were a lack of an outcomes orientation to program planning and evaluation, and a lack of written procedural protocols.

Barriers to Professional Training and Development

Historically, EHOs have been trained as generalists. This is still considered to be appropriate, however, specialist expertise in a variety of disciplines is needed by programs to deal with the increasing scope and complexity of issues. Lack of funding and support to attend courses and seminars, geographical constraints, and insufficient access to computers were identified as barriers to ongoing professional development.

In addition to these problems, a number of existing program strengths were identified that ought to be retained.

Strengths of Local Environmental Health Programs in Alberta

Placement in Health Sector

Public opinion surveys indicate that the public has great concern about the impact of environmental hazards on human health (8,9). Therefore, the current placement of local EHPs within the health sector was seen as a strength. In addition, placement within the health sector avoids the conflict of interest considerations that arise when an agency is both responsible for industrial or agricultural development and the protection of human health.

Regulatory Authority 

The regulatory authority to enforce public health legislation, should other interventions prove inadequate, is of fundamental importance in restricting the presence or effects of environmental health hazards.

Local Placement

Basing environmental health services at the local level provides a structure conducive to the effective and efficient resolution of local environmental health issues within the local jurisdiction.

Trained Staff

The presence of a cadre of well-trained generalist public health inspectors in local EHPs is a definite asset considering the broad scope of the environmental health mandate. Despite the barriers to professional development described previously, 56% of managers and staff were found in the survey to have or to be studying for Bachelor or Master degrees. The recent acquisition of specialized risk assessment, epidemiology, and toxicology expertise in Alberta Health strengthens the capacity of local EHPs to deal with more complex situations.

Past Successes

The effectiveness of EHPs has been measured historically by success in dealing with communicable disease. It is important that, in the bid to address the current concern with chemical and physical hazards, the traditional food and water safety components of EHPs be maintained.

Based on the initial assessment, a number of adjustments or re-alignments in the delivery of local EHPs were indicated.

Re-alignment of Local Environmental Health Programs in Alberta

Reactive to Proactive Management

EHPs need to become more proactive in managing environmental health issues rather than reacting to problem situations. Prioritization of issues for proactive management is essential to ensure optimal use of limited program resources.

A Broader Range of Interventions

While maintaining their capacity to enforce environmental health legislation, environmental health staff will need to become increasingly adept at applying intervention strategies that are alternatives to enforcement, such as health promotion, applying market incentives, and collaborative problem-solving. Process to Outcome Evaluation

As resources for health services become more scarce, all programs will be judged on the effectiveness of their activities on improving health status. This presents particular challenges for environmental health services due to long disease latency periods and difficulties with linking specific causes and outcomes of environmentally-related diseases. Only 4 of 16 programs submitting program planning and evaluation documentation as part of the survey demonstrated an outcomes orientation.

Rule-Driven Approach to Mission-Driven Approach

Because EHPs will be required to deal with a high level of uncertainty in solving complex issues, staff will need to apply considerable professional judgment to the situations they will be facing. Therefore, programs and staff will need to rely less on pre-determined regulations and actions.

Independence to Interdependence 

As program staff deal with the multitude of players involved in the environmental health arena, they will need to work in closer collaboration with the many interest groups that share concerns and responsibility for action.

The above considerations guided the development of the reference model and were the basis of recommendations to facilitate implementation of the model. The reference model and implementation recommendations are described in the following sections.

The Reference Model

The model was designed to address the important contemporary issues outlined previously: the increasing importance of chemical and physical hazards; local action regarding global issues; public concern; accountability; and linkages with other relevant agencies. It builds on the perceived strengths of the current local programs in Alberta and incorporates the re-alignments suggested in our preparatory review. Rather than developing a model that focused on detailing how best to deal with current problems, we proposed a flexible approach that could be applied to deal with local issues and could be adapted to new situations as they arose. This approach is consistent with directions advocated for EHPs (1,2,3) and has the following conceptual underpinnings:

* a health outcomes orientation;

* prioritization of services based on health risk;

* a proactive approach to program management;

* a mission- rather than rule-driven approach to service delivery.

The reference model is made up of the five elements listed in Figure 1.

Environmental Health Vision for Alberta

The vision statement outlines the beliefs that local EHPs hold about the rights and responsibilities of Albertans with respect to environmental health. It was adapted from Environment and Health: The European Charter and Commentary (10). Although the adoption by all individuals and organizations/agencies of their respective rights and responsibilities lies beyond the control of local EHPs, the vision statement is intended to express the beliefs, perspectives, or assumptions from which local environmental health staff approach their responsibilities. The vision statement can be used as a starting point for discussion of environmental health issues with the public and other concerned agencies.

The vision statement places the health of each Albertan at the forefront, including his/her rights to receive health protection from environmental hazards that are beyond his/her control, have access to information, and participate in decisions regarding environmental health issues. The vision statement also makes it clear that the responsibility for environmental health does not lie with government and non-government institutions alone. All Albertans have the responsibility to protect themselves and others from environmental hazards.

Mission Statement

The mission statement specifies that the purpose for which local EHPs exist is to protect and improve the health of human populations by limiting their exposure to biological, chemical, and physical hazards in their present or future environments.

The mission statement restricts the mandate of local programs to environmental issues that affect or may affect human health. Thus, within the broad spectrum of programs and services related to environment and health issues, the focus and unique contribution of a local environmental health program is in dealing with the health effects of environmental hazards found in or experienced by local communities.

Scope Statement

The scope statement specifies the focus of local EHPs. It defines a broad playing field for these programs, as it is recognized that the potential for adverse human health effects stems from hazardous agents found in different media. The possible sources and sites of these hazardous agents are numerous.

EHPs complement the roles and responsibilities of a wide range of departments, organizations, and individuals who are concerned with issues of health and the environment. Within this network of interdependent relationships, local EHPs have a major responsibility for ensuring that community-level interventions are undertaken to limit existing and potential hazards in the local environment, and for educating and communicating risks to individuals and the public who reside within their jurisdictions. In addition to dealing with localized hazards, it is expected that local programs will be concerned about broader ecosystem health issues which have the potential to adversely affect human health. This role is primarily a supportive one, as global health issues are most effectively addressed at national and international levels. Community-based activities which implement the philosophy of "thinking globally, acting locally" are endorsed. Local EHPs can also contribute to the overall enhancement of quality of life of the members of the communities within their jurisdictions through their participation in and support of broader public health and related initiatives (e.g., healthy communities).

Environmental Health Program Principles and Values Statement

The statement of principles and values reflects the principles which are valued by the EHP. These will guide the actions and behaviours of EHP staff in the delivery of their services.

The texts of the environmental health vision, mission, scope, and environmental health program principles and values statements can be obtained from the authors (11).

Program Design

The vision, mission, scope, and principles and values statements provide the context in which environmental health programs provide services. The program design involves specifying what health-status-related and public satisfaction objectives the program strives to achieve (outcomes); what activities, roles, functions, and strategies will be employed by the program in order to achieve the chosen outcomes (processes); and what inputs are required to perform chosen process activities (structures).

The order of presentation (outcomes - processes - structures) is significant. Health service programs have historically been developed in the reverse order. Available resources and mandates have dictated activities. Only recently have programs been asked to look beyond their activities to state explicitly what outcomes they are intending to achieve by these activities. In this model we do not prescribe outcomes, processes, or structures for local EHPs. Instead, we suggest a process for prioritizing local environmental health issues which takes into account evidence about the health risks of particular hazards, public concern, and the frequency and sites of the hazards in local settings. Using the generic types of outcomes, processes, and structural elements shown in Table 1 we have also developed a comprehensive inventory of structured outcome objectives (and process and structure indicators) for use by local EHPs in dealing with their priorities. These objectives and indicators were developed for common environmental health issues associated with eight media through which hazards are transmitted: indoor air, ambient air, drinking water, recreational water, soil, food, the built environment, and animal/insect vectors.

The development of these objectives is discussed more comprehensively (12) and they are listed in total (13) in other publications. It is expected that each local EHP will undertake a strategic planning process to identify the outcomes, processes, and structures appropriate for the particular circumstances and priorities of their region. The inventory of objectives and indicators developed in this project can be used by local EHPs to select processes and structures best suited to addressing their local priorities. Relevant objectives from the inventory can also be used for program evaluation. Differing objectives across local programs will reflect variances in local health authority size, industrial makeup, geographical considerations, and the extent of involvement of other agencies or programs in the activities listed.

Implementation Considerations

Based on the work of task groups, the study team made a number of recommendations to facilitate the implementation by local EHPs of the directions proposed in the model.

Legislative Framework

It was considered critical that the parts of the Public Health Act that allow local authorities to respond to health hazards in a direct and effective manner be retained. Also, certain key regulations should be retained. It was recommended, however, that most regulations should be rescinded and replaced with standards. It was anticipated that standards would be developed in consultation with the stake-holders involved. These standards should reflect current evidence about health risk and should be applied by EHOs/PHIs using a risk analysis approach.

Funding

It was evident to the study team that an imbalance existed between the expectations placed on environmental health programs and the funding levels provided for the provision of services. Three strategies may be employed to address this imbalance: decrease services, change the way services are delivered, and/or increase funding. In addition to changing the way services are delivered, the study team recommended that funding for local EHPs in Alberta should be increased to enable programs to maintain traditional services, address priority needs, and respond to public demands with respect to chemical and physical hazards.

Technical and Specialized Support Services 

Access to laboratories, information systems, and specialized expertise (e.g., toxicology, epidemiology) is crucial for the effective and efficient operation of local EHPs. It was recommended that task forces be established to investigate how best to provide laboratory and information system support in order to meet the varied needs of local programs. Recommendations were also made regarding the complementary roles of the provincial health and other agencies in ensuring the effective delivery of local environmental health services.

Management

Strong leadership will be required from Regional Health Authority (RHA) Boards, senior health system managers, and EHP managers to implement the proposed model. Each RHA Board must clearly understand its unique role and responsibilities in applying the Public Health Act. Senior health system managers will need to understand that EHPs operate under a different paradigm than that of providers of personal care services directed to individual patients. EHP managers in turn will need to develop program management skills in change management, data utilization, leadership, and program planning and evaluation.

Professional Training and Development

We anticipate that the core staff of future EHPs will continue to be EHOs/PHIs. However, there will be an increasing reliance on professionals with specialized expertise in areas such as epidemiology and toxicology, and on support personnel who undertake routine tasks under the supervision of EHOs/PHIs. Provincial and local EHPs, the Canadian Institute of Public Health Inspectors (CIPHI), and post-secondary institutions should work collaboratively to ensure an adequate supply of EHOs/PHIs with requisite skills. It is also recommended that CIPHI be encouraged to develop guidelines for the appropriate use and supervision of support personnel.

Discussion

We believe that adoption of the proposed model and implementation of the recommendations will significantly enhance the capacity of local EHPs to meet current and emerging challenges.

The environmental health vision statement is a potential starting point for discussion among a wide group of stake-holders including the public, environmental interest groups, and other agencies about the values Albertans hold about environmental health issues. This clarification of values is important with regard to making decisions about both the funding levels and the priority issues for programs. Clear mission and scope statements help define the mandate of local EHPs visa vis those of other agencies. Within the wide spectrum of environmental concerns, these statements lay claim to a primary role for local EHPs in addressing local environmental hazards that may affect human health. The principles and values statement serves as a guide to the program staff regarding the way they should perform their activities, and also as a guide to the public regarding what expectations they should have.

The proposed project design provides a template for local EHPs to design their programs to address local environmental health issues of concern. It encourages a proactive approach to dealing with environmental health problems rather than waiting for problems to occur. Recognizing the need for fiscal restraint, the prioritization of services based on health risk is strongly recommended. The outcomes orientation is consistent with the need for program accountability. A mission- rather than a rule-driven approach is facilitated by the adoption of risk assessment and risk management approaches. Staff are encouraged to choose appropriate responses based on the level of potential risk and scientific certainty rather than to rely predominantly on enforcement.

The model takes into account the present challenges facing contemporary local EHPs in North America and Europe that were listed in the introduction. It provides an approach to prioritizing different microbiological, chemical, and physical hazards, and for designing appropriate interventions to deal with these. The importance of global environmental threats to long-term human survival is recognized. EHPs are encouraged to support national and international activities to address these threats. The environmental health vision and the principles and values statements make clear that an EHP is accountable to the public it serves. Expertise in risk communication is crucial for EHPs to ensure that interventions address both health risks and the concerns associated with them. Having a clear understanding of their roles and modes of operation should place EHPs in a better position to obtain support from those in governance and higher managerial positions. Finally, the interdependence of various agencies dealing with and players interested in environmental health is recognized in the environmental health vision statement. Recommendations for negotiating the roles of different agencies based on program expertise rather than turf have been outlined.

The degree to which EHPs in Alberta will reorient their activities in the direction proposed by the model will be determined by the willingness of program managers and staff to embrace change. We have been encouraged by changes already occurring in some programs and by the enthusiasm and dedication shown by many of the program managers and staff. In addition, those in governing or higher-level management positions need to recognize the value of these programs. Without this recognition and the accompanying infrastructure and moral support, programs will be hard-pressed to meet contemporary and future challenges.

Acknowledgements

Many people were involved in the project on which this paper is based. These include members of the Project Steering Committee; members of the Project Working Committee; Alberta Health Environmental Health Program staff; Alberta Health Unit Board Members, Chief Executive Officers, and Environmental Health Program managers and staff. In particular, we would like to thank other members of the Study Team: Clarke Hazlett; Lory Laing; Cathy Drixler; the members of the Working Committee: George Flynn, Rob Elliot, Susan Harley, Alex MacKenzie, Kevin McLeod, Jim Meagher, John O'Laney, and Trevor Walker; Kenneth Stewart (Environmental Health [Scotland] Unit); and Xavier Bonnefoy and Ian Macarthur (WHO Regional Office for Europe). The project was funded by Alberta Health. Opinions expressed in this article are those of the authors and are not necessarily those of Alberta Health or others who were acknowledged.

REFERENCES

1. National Environmental Health Association (1993), "The Future of Environmental Health: Parts one and two," Journal of Environmental Health, 55(4):28-32; 55(5):42-45.

2. Audit Commission for Local Authorities and the National Health Service in England and Wales (1990), Towards a Healthier Environment: Managing environmental health services, London, England: HMSO Publications Centre.

3. Resource Management Consultants (1991), Strategic Options for Environmental Health in Alberta, Final Report, Resource Management Consultants, Edmonton, Alberta.

4. Saunders, L.D., M.I. Wanke, T.L. Guidotti, S.F. Hrudey, J.M. Pelton, C.B. Hazlett, L.M. Laing (1994), Strategic Directions for Regional Environmental Health Programs in Alberta: A guide to the future, University of Alberta, Edmonton, Alberta.

5. University of Alberta (1993), Environmental Health Services in Alberta Health Units, Survey of Health Unit Chief Executive Officers, Environmental Health Managers and Public Health Inspectors, University of Alberta, Edmonton, Alberta.

6. Wanke, M.I., and L.D. Saunders (submitted for publication), "Survey of Local Environmental Health Programs in Alberta," Can. J. Public Hlth.

7. University of Alberta (1993), Final Report, Results of Focus Group Discussions of Environmental Health Concerns and Issues in Alberta Communities, University of Alberta, Edmonton, Alberta.

8. International Environmental Monitor (1991-93), "The Environmental Monitor Report," cited in Canada's Health Promotion Survey 1990: Technical report, ed. T. Stephens & D. Graham, Ottawa: Minister of Supply and Services Canada, 1993, Catalogue No. H39-263/2-1990E, p.81.

9. Edmonton Board of Health (1991), "Survey Shows Leading Edmonton Health Issues," Press Release, Edmonton, Alberta.

10. World Health Organization Regional Office for Europe, Copenhagen (1989), Environment and Health: The European Charter and Commentary, First European Conference on Environment and Health, World Health Organization Regional Publications (European Series No. 35), Frankfurt, Germany.

11. University of Alberta (1994), Reference Model for Environmental Programs in Alberta Regional Health Authorities, University of Alberta, Edmonton, Alberta, pp.9-12.

12. Saunders, L.D., M.J. Wanke, T.L. Guidotti, and S.E. Hrudey (1996), "Measurable Objectives for Local Environmental Health Programs," Journal of Environmental Health, 58(6):6-12.

13. University of Alberta (1994), Reference Model for Environmental Health Programs in Alberta Regional Health Authorities, University of Alberta, Edmonton, Alberta, pp.13-135.

Corresponding Author: L.D. Saunders, M.B.B.Ch., Ph.D., Department of Public Health Sciences, 13-103 Clinical Sciences Building, University of Alberta, Edmonton, Alberta T6G 2G3, Canada.

RELATED ARTICLE: FIGURE 1

Reference Model Elements

Environmental Health Vision for Alberta

* Beliefs Held About Environmental Health Rights and Responsibilities

Mission Statement

* Purpose of Environmental Health Program

Scope Statement

* Focus of Environmental Health Program

Environmental Health Program Principles and Values

* Guide for Actions of Environmental Health Program Staff

Environmental Health Design

* Outcomes, Processes, and Structures of Environmental Health Programs and Sub-Programs

RELATED ARTICLE: Table 1

Program Design

OUTCOME (Goals/Objectives)

* Health Status

* Risk Reduction

* Controlling the Environment

* Knowledge of Operators

* Public Understanding of Risk

* Healthy Public Policy

* Environmental Health Incidents

* Disease Reports

* Contamination/Exposure Incidents

* Public Satisfaction

PROCESS (Roles/Functions/Strategies)

* Management

* Problem Assessment

* Planning

* Implementation

* Evaluation

* Service Delivery

* Risk Identification and Assessment

* Planning

* Risk Management

* Evaluation

STRUCTURE (Inputs Required)

* Legislative Framework and Policies

* Standards/Guidelines

* Staffing

* Knowledge and Skills

* Equipment and Materials

* Linkages and Relationship

* Information Sources

* Computerized Databases

* Provincial Expertise

* National and International Contacts