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Building public health Ontario: experience in developing a new public health agency.

Following the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, a number of reviews were commissioned on the state of public health in Canada (1) and in Ontario. (2,3) Significant changes at the national level as a result of their recommendations include the creation of the Public Health Agency of Canada, the National Collaborating Centres for Public Health, and the Pan-Canadian Public Health Network.

In Ontario, which was hardest hit by SARS (as well as other significant events such as the E. coli outbreak in the town of Walkerton), Operation Health Protection outlined a plan for renewal of the system. (4) This plan identified strategic priorities to enhance capacity in public health for leadership, health emergency preparedness and response, infectious disease prevention and control, and health human resources. A key recommendation was the creation of a dedicated organization to provide scientific and technical advice in the areas of health protection and promotion.

The creation of this type of new organization was consistent with the establishment of public health agencies in British Columbia (the British Columbia Centre for Disease Control) and Quebec (Institut national de sante publique du Quebec). To develop a plan for creating such an organization, the Agency Implementation Task Force (AITF) was struck. (5) In parallel, work was commenced on reviewing the Ontario Public Health Laboratories (OPHL), which were within the Ministry of Health and Long-Term Care (MOHLTC), with a view to combining that function with the new agency.

This paper briefly outlines the development and first three years of operations for this new organization and provides some observations regarding the lessons learned in building a new public health agency.

The organization

The AITF's final report (5) provided a detailed blueprint for the governance, structure and functions of the new agency. It also included a two-year start-up plan and priorities for the first three years of operation. In June 2007, the Ontario Agency for Health Protection and Promotion Act received royal assent. This act provided the statutory basis for the governance of the organization and outlined its legal objects (Figure 1).

A start-up board was struck and held its first meeting in September 2007. The board retained a transition team to support the creation of the organizational infrastructure and to prepare for the transfer of the public health laboratories.

My appointment as President and Chief Executive Officer was announced in March 2008, the fifth anniversary of SARS. Initially, I worked closely with the Board and transition team to recruit staff, secure space and develop the corporate infrastructure. A Memorandum of Understanding with the Minister of Health and LongTerm Care was negotiated. Significant preparations were made for the transfer of the OPHL, which was to be concluded by the end of calendar year 2008. An initial three-year strategic plan to guide the development of the organization was produced.

The vision, mission and mandate (Figure 2) as developed by the AITF were adopted by the Board. The strategic plan provided for the three broad goals of providing information, knowledge and support to public health partners. The organizational functions that have been developed are: Infectious Diseases Prevention and Control; Health Promotion, Chronic Disease and Injury Prevention; Environmental and Occupational Health; Public Health Laboratories; Surveillance and Epidemiology; Emergency Management Support; and Knowledge Services (research services, libraries and education).
Figure 1. Ontario Agency for Health Protection and Promotion Act

The purpose of this Act is to enhance the protection and promotion
of the health of Ontarians and to contribute to efforts to reduce
health inequities through the establishment of an agency to provide
scientific and technical advice and support to those working across
sectors to protect and improve the health of Ontarians and to carry
out and support activities such as population health assessment,
public health research, surveillance, epidemiology, planning and
evaluation.

The objects of the Corporation are,

(a) to provide scientific and technical advice and support to the
health care system and the Government of Ontario in order to
protect and promote the health of Ontarians and reduce health
inequities;

(b) to develop, disseminate and advance public health knowledge,
best practices, and research in the areas of population health
assessment, infectious diseases, health promotion, chronic
diseases, injury prevention, and environmental health;

(c) to inform and contribute to policy development processes across
sectors of the health care system and within the Government of
Ontario through advice and impact analysis of public health issues;

(d) to develop, collect, use, analyse and disclose data, including
population health, surveillance and epidemiological data, across
sectors, including human health, environmental, animal,
agricultural, education, community and social services and housing
sectors, in a manner that informs and enhances healthy public
policy and public health planning, evaluation and action;

(e) to undertake, promote and co-ordinate public health research in
cooperation with academic and research experts as well as the
community;

(f) to provide education and professional development for public
health professionals, scientists, researchers, and policymakers
across sectors;

(g) to establish, operate and maintain laboratory centres and to
provide laboratory services;

(h) to serve as a model for bridging the areas of infection control
and occupational health and safety;

(i) to undertake research related to evaluating the modes of
transmission of febrile respiratory illnesses and the risk to
health workers;

(j) as directed by the Chief Medical Officer of Health, to provide
scientific and technical advice and operational support to any
person or entity in an emergency or outbreak situation that has
health implications; and

(k) any additional objects the Lieutenant Governor in Council may
prescribe.


The organization has grown through new hires as well as divestment of government programs. In addition to the transfer of the public health laboratories, significant transfers have included the Regional Infection Control Networks (RICNs), the Provincial Infectious Diseases Advisory Committee (PIDAC), the provincial share of the Public Health Research, Education and Development (PHRED) program, and MOHLTC functions related to infectious and communicable disease surveillance and scientific and technical advice.

During 2011, the organization rebranded from its legal name, Ontario Agency for Health Protection and Promotion, to Public Health Ontario (PHO). PHO has an operating budget of approximately $150 million, with close to 1,000 employees at 28 sites across Ontario.

PHO provides scientific and technical advice and support to public health practitioners and the health care system. Its services include the provision of surveillance services and products, laboratory testing, knowledge synthesis, research and professional development. Trainees from a broad range of academic programs participate in placements and projects. Much of its work is conducted through partnerships.

PHO works very closely with the Chief Medical Officer of Health and staff of the Public Health Division in MOHLTC. PHO provides scientific and technical advice and support while the CMOH and the MOHLTC retain statutory authority for public health functions at the provincial level, including setting standards, measuring performance, and allocating provincial funding for local public health.

[FIGURE 2 OMITTED]

DISCUSSION

In a short period of time, PHO has grown to be an integral part of the public health system in Ontario and is starting to make contributions nationally and internationally. There has been tremendous support from government and partners throughout the province and the country. However, there have obviously been challenges as well.

As a new organization, PHO has had to work with many partners to clarify roles and responsibilities and to develop appropriate processes to become inserted into existing workflows. Public health services are delivered through a complex set of local, provincial and national organizations that cross many sectors. Inserting a new organization into such a system requires the building of many new partnerships, evolution of existing work practices and creation of new ones.

The development of PHO has benefitted tremendously from the excellent work of the AITF. However, we have also had to be flexible in our work and responsive to emerging and changing priorities. In the first year of our operation, there were several significant outbreaks of diseases such as listeriosis, E. coli, and the first wave of pandemic H1N1. While PHO was not fully operational, many activities were undertaken to support the province's response to H1N1, including provision of laboratory services and surveillance, supporting the scientific response team, and development of guidance documents and communication products for health care providers. PHO staff engaged in a number of significant research projects to inform decision-making in real time and to support better preparedness in the future. As is always the case for public health, balancing the need to be responsive to emerging events with that of maintaining a focus on long-term strategic priorities is a challenge.

An area that has been particularly challenging is one of data access. Limitations in sharing data across organizations, real or perceived, were a significant factor during SARS. Subsequent AuditorGeneral reports (6) have identified that there continue to be gaps in availability of surveillance data. Even though Ontario privacy legislation was amended to enable PHO to access data for its legislated objects, considerable effort has had to be devoted to developing, negotiating and executing dozens of different data-sharing agreements.

Skilled public health workers are the cornerstone of public health organizations. The post-SARS reviews identified challenges in recruiting and retaining public health staff and many initiatives have been launched to support renewal of public health. In building PHO, we have benefitted tremendously in bringing together staff from different organizations through direct recruitment of new staff as well as through divestments. However, this has led to significant effort being required in the areas of change management and building a cohesive organizational structure. Because of the timing of the various divestments, this has also meant that we operate in a very complex labour relations environment. Furthermore, PHO has faced all of the challenges of the shortages of skilled workers in the relevant professional and scientific areas.

PHO came into operations as the global economy faced its greatest challenges in close to a century. These challenges continue, and Ontario in particular faces very difficult circumstances. Ontario has also undertaken a review of relationships with its Crown Agencies. (7) Factors such as these have led to major efforts being required to meet accountability and reporting requirements. PHO has developed a very lean and efficient operation and recognizes the importance of transparency and maintaining public trust.

The largest challenge has been meeting and managing expectations. The reviews and committees that led to the creation of PHO were broadly consultative. As a result, the processes engaged many different sectors which each developed visions of what the new organization could do. PHO has to make sure continually that it reaches the right balance in a number of areas: between research and service; building specialized central capacity and local/regional supports; and between its health protection and health promotion mandates.

Despite these challenges, much has been accomplished. In 2012, the Board of PHO will commission an independent international peer review of the organization. Based on that review and input from our stakeholders, a new five-year strategic plan will be developed that will chart directions for the continued development and evolution of the agency. As our early growth has focused on communicable and infectious diseases, major areas for further development include growing our capacity in health promotion and environmental health and ensuring that our work supports our partners in addressing the broad social determinants of health.

Received: March 2, 2012

Accepted: May 21, 2012

REFERENCES

(1.) National Advisory Committee on SARS and Public Health. Learning from SARS: Renewal of Public Health in Canada. Ottawa, ON: Health Canada, 2003.

(2.) Expert Panel on SARS and Infectious Disease Control. For the Public's Health: A Plan for Action. Toronto, ON: Ministry of Health and Long-Term Care, 2004.

(3.) Campbell A. SARS Commission Final Report: Spring of Fear. Toronto: Ministry of Health and Long-Term Care, 2006.

(4.) Operation Health Protection: An Action Plan to Prevent Threats to Our Health and to Promote a Healthy Ontario. Toronto: Ministry of Health and Long Term Care, 2004.

(5.) Agency Implementation Task Force. From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion. Toronto: Ministry of Health and Long-Term Care, 2006.

(6.) Auditor General of Canada. 2008 May Report; Chapter 5: Surveillance of Infectious Diseases. Ottawa, 2008.

(7.) Burak R. Report of the Special Advisor on Government Agencies. Toronto: Ministry of Government Services, 2010.

Vivek Goel, MD, MSc, FRCPC

Author Affiliations

President and CEO, Public Health Ontario; Professor, Dalla Lana School of Public Health, and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON

Correspondence: Dr. Vivek Goel, Public Health Ontario, 480 University Avenue, Suite 300, Toronto, ON M5G 1V2, Tel: 647-260-7111, E-mail: president@oahpp.ca

Acknowledgement: Public Health Ontario is supported by the Ontario Ministry of Health and Long-Term Care. The opinions and conclusions reported in this paper are those of the author. No endorsement by the Ministry or Public Health Ontario is intended or should be inferred.

Conflict of Interest: None to declare.
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Article Details
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Title Annotation:COMMENTARY; Ontario, Canada
Author:Goel, Vivek
Publication:Canadian Journal of Public Health
Article Type:Report
Geographic Code:1CANA
Date:Jul 1, 2012
Words:2147
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