A Public Health Mish-M*A*S*H

October 13, 2020 - There are a few things about the organization of public health in the province of Ontario that have complicated the kind of coordinated and organized response a crisis of the scale we are facing with COVID-19 requires.

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Our public health system is made up of three principal components: the Ministry of Health, Public Health Ontario, and our 34 public health units.

The Ministry of Health is responsible for the overall functioning of the health system through the administration, coordination, and funding of health services throughout the province. An important aspect of the Ministry of Health is the newly-minted Ontario Health, which is tasked with the delivery of health care across the province, managing programs like Cancer Care Ontario and eHealth Ontario. Ontario Health took over all non-home and community care responsibilities from the previous LHIN system in late 2019. This means that it’s now their responsibility to plan, coordinate, and provide funding to local healthcare service providers across the province. Dr. David Williams is the Chief Medical Officer of Health with the ministry and is in charge of their public health capacities. Though the ministry itself doesn’t have much in the way of public health capacities.

Public Health Ontario (PHO) is tasked with providing scientific and technical advice to those working across sectors, to help inform policy and practices in the interest of the health of Ontarians. PHO operates as a separate entity from the government and Ministry of Health, but is accountable to the government through the Chair of their Board of Directors. The BoD sets the overall strategic direction of the organization and manages funds, but the CEO, who is not a part of the board, manages the day-to-day operations.

Public Health Units (PHUs), on the other hand, are independent organizations that provide health promotion and disease prevention programming to their jurisdictions. PHUs are established by a group of urban and/or rural municipalities, and can be either completely autonomous or integrated into municipal or regional governments. Interestingly, there’s little in their mandate that establishes a relationship between them and PHO. They’re governed by boards of health, who set strategic direction, but policy direction and day-to-day operations are the responsibility of each health unit’s Medical Officer of Health.

We can see that these are three independent organizations all trying to accomplish broadly the same goal: the health of Ontarians. However, reading through the legislative frameworks of each organization, there is very little accountability or connectivity between agencies. This makes coordinated efforts—the type necessary to overcome a pandemic—difficult to achieve. While PHUs are somewhat accountable to the Ministry for things like finances and board performance, there’s little that makes them accountable in terms of their policy decisions. There’s also nothing that links Ontario Health with PHO or the PHUs. This means that although the decisions of a PHU can impact healthcare service delivery—and vice-versa—they aren’t obligated to consult with service providers or work with them to create new regulations.

A good example of this is that many health units decided to stop immunization programs during the earlier stages of the pandemic, expecting the service to be picked up by healthcare providers. This decision, however, was made without a full understanding of the capacities of providers in towns across Ontario’s central, western and northern region. Some communities were left without access to required immunizations during the pandemic, and in other cases already-stretched hospital and clinic staff were left with another burden to shoulder[i].

This lack of integration and coordination has also made it hard to find the COVID information that you might need. There’s little in the way of a comprehensive one-stop-shop for information, and the information you find from different sources may conflict. For example, on the Algoma Public Health website, you can find information on testing, travel, and face masks, but you have to go to the Ontario Public Health website to find information for those in congregate living settings.

On the Thunder Bay District Health Unit website you can find information on mask-wearing from different agencies: TBDHU, Ontario Public Health, and the provincial government. TBDHU tells you that you should wash your hands a total of four times—before and after you don and remove the mask—while the other two resources only tell you to wash before putting it on and after taking it off. The PHO document indicates that you only need to wear a mask if you have symptoms or are caring for someone with symptoms, while the TBDHU website and government document tell you to don a mask wherever physical distancing is impossible. According to healthcare professionals, conflicting information from different levels was a large issue closer to the start of the pandemic, though it has been getting better[ii].

Clearly, there needs to be improvements to the way we manage our public health system in order to better deal with future public health crises.  British Columbia uses a more integrated approach to healthcare—wherein Regional Health Authorities manage both public health and health service delivery, in addition to directly coordinating with the provincial government. This could be a model worth exploring for Ontario, to help ensure that decisions made in the name of public health are made without letting things fall through the cracks.

 

[i] Personal communication with Wilson Memorial General Hospital physicians
[ii] Personal communication with Wilson Memorial General Hospital physicians
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Mateo Orrantia is a Research Analyst at NPI

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