HESA Committee Report

ANALYSIS OF IMPLEMENTATION

PREVENTION, PROMOTION AND PUBLIC HEALTH

Accomplishments

There were three main commitments related to prevention and promotion in the 2004 Accord:

• collaboration and coordination in responding to infectious disease outbreaks and other public health emergencies;
• building on recent investments in immunization, through the National Immunization Strategy; and
• work on a pan-Canadian Public Health Strategy, with efforts to address common risk factors and integrated disease strategies.

Overall, the federal, provincial and territorial governments are meeting their commitments to address these issues.  Specifically:

• In the area of infectious disease outbreaks, governments have supported the creation of the Pan-Canadian Public Health Network as a collaborative body in April 2005, have released the Canadian Pandemic Influenza Plan for the Health Sector in December 2006 and have worked together on Memoranda of Understanding related to mutual aid during an emergency and information sharing for public health emergencies;
• In the area of immunization, P/T governments are working to align their immunization schedules for vaccines recommended under the National Immunization Strategy, while the federal government has provided two waves of funding worth $300 M over three years in Budgets 2004 and 2007 for the P/T implementation of recommended vaccines (i.e. pneumonia, meningitis, chicken pox and whooping cough under the first wave of funding; human papillomavirus under the second); and
• Although development of a pan-Canadian Public Health Strategy was put on hold, the issues identified in this area have been addressed through the F/P/T Pan-Canadian Healthy Living Strategy, which provides the mechanisms for collaboration on chronic diseases and their risk factors, and the federal Healthy Living and Chronic Disease Initiative, which includes a combination of investments to address common risk factors together with disease-specific strategies for major chronic diseases.

Greater detail on each of these areas is provided below.

Infectious disease outbreaks and other public health emergencies

F/P/T governments have successfully collaborated on and improved their pandemic preparedness and response through the Public Health Network, which was created as the mechanism for F/P/T collaborative action on public health.  All jurisdictions actively participate on and are engaged in the Public Health Network Council at the Chief Medical Officer of Health/Assistant Deputy Minister level, and participate in the Public Health Network’s Expert Groups responsible for developing coordinated responses to outbreaks and emergencies. Two Expert Groups, two Task Groups and a number of Issue Groups contribute to this work. The PHAC has demonstrated significant support for the Public Health Network by funding Secretariats to the various components of the Public Health Network and by compensating members for travel.

GoC investments against Infectious Disease Outbreaks and Other Public Health Emergencies include $1B over 5 years for avian and pandemic influenza preparedness ($600M) and contingency purposes ($400M) in Budget 2006.  The $600M was shared between PHAC, Health Canada, the Canadian Institutes for Health Research and the Canadian Food Inspection Agency ($195M to manage avian influenza issues).  Within the health portfolio funding is focussed on seven key areas: prevention and early warning ($40M); vaccines and antivirals ($162M); surge capacity ($29.5M); emergency preparedness ($47M); critical science and regulation ($112.5M); risk communications ($8.4M); and F/P/T collaboration ($22.2M).

This funding will strengthen federal capacity to prepare and respond to pandemic influenza, and each of these activities will directly or indirectly benefit P/Ts, including: enhancing pandemic preparedness and response capacity in First Nations on reserve and Inuit communities; strengthening surveillance across jurisdictions; supporting research on pandemic vaccines to expedite reviews of submissions for new antiviral drugs; and purchasing and positioning across Canada necessary antiviral drugs for the national stockpile.

Collaborative efforts include:

• releasing the Canadian Pandemic Influenza Plan for the Health Sector in December 2006;
• agreeing to increase the national stockpile of antiviral drugs to 55.7 million doses by the end of fiscal year 2007/08.  As of March 2008, the stockpile stood at 53 million doses;
• agreeing on an antiviral early treatment strategy to treat all Canadians who become ill during a pandemic and to contain or prevent an outbreak of pandemic (i.e. use of antivirals in treatment and prophylaxis scenarios);
• developing a draft policy on the use of antivirals for prevention to contain or prevent an outbreak of pandemic;
• agreeing on the need for several MOU to inform joint emergency management efforts in regard to: mutual aid during an emergency (expected to go forward to F/P/T Ministers of Health September 2008); information sharing for public health emergency, including pandemic (expected to go forward to F/P/T Ministers of Health September 2008);ongoing work on an F/P/T governance approach to pandemic planning and decision making to ensure maximum effectiveness and timely decision making by the Council and ultimately by health ministers

The Public Health Network’s main 2007/08 activities included Pandemic and Avian Influenza Preparedness; an MOU on Mutual Aid; an MOU on Information Sharing; and National Health Emergencies Management.  The focus of 2008/2009 will be to continue with these efforts and include work in other areas such as chronic disease management and surveillance and work on indicators of health disparities.

Pandemic and Avian Influenza Preparedness has focussed on six elements: Antivirals for early treatment and prevention; a Canadian Pandemic Influenza Plan; a Pandemic Vaccine Strategy; Real-Time Pandemic Exercise Planning; and Laboratory Response Capacity.

• The Public Health Network’s Task Group on Antivirals for Prophylaxis has developed national policy recommendations on providing prophylactic antivirals during a pandemic influenza.  The recommendations were approved by F/P/T Deputy Ministers of Health in November 2007 and are pending F/P/T Ministers of Health approval.
• In December 2006, F/P/T Ministers of Health approved the Canadian Pandemic Influenza Plan for the Health Sector, which was produced by the Public Health Network’s Pandemic Influenza Committee.  A number of annexes are currently under review and will be released in Summer 2008 (e.g., vaccines, infection control and prevention measures, laboratory services, clinical care).
• The Public Health Network will develop recommendations on a pan-Canadian pandemic vaccine strategy, including considerations for vaccine development and clinical trial design; approaches to immunization; adverse event surveillance and monitoring; and distribution. Final recommendations are expected during Spring 2008.
• The Public Health Network is coordinating the development of a Real Time Planning Exercise, to exercise and validate the capacity and capability of the Canadian health system to prevent, detect and respond to a pandemic in accordance with the Canadian Pandemic Influenza Plan for the Health Sector, and to allow gaps to be identified and addressed.
• Laboratory Response Capacity depends on collaboration and cooperation between laboratories in F/P/T jurisdictions to ensure an integrated and effective approach to epidemiologic investigation and control, particularly during public health events.  Laboratories will be able to respond to testing needs for diagnostic purposes and to support related work, such as the antiviral and vaccination strategies and surveillance.

Two Memoranda of Understanding were developed and approved in principle by F/P/T Ministers of Health in December 2006, with the provision that wording changes be made to address concerns and legal requirements identified by Quebec.  The Memorandum of Understanding on the Sharing of Information During a Public Health Emergency (MOU on Information Sharing) and the Memorandum of Understanding on the Provision of Mutual Aid in Relation to Health Resources during an Emergency Affecting the Health of the Public (MOU on Mutual Aid) have been approved by the Public Health Network Council.

The National Health Emergency Management System is intended to facilitate emergency cross-jurisdictional planning and communication by clearly defining roles and responsibilities and by establishing operational guidelines and protocols to ensure coordinated planning.  The System will also include protocols for requesting and receiving mutual assistance, as identified in the F/P/T MOU on Mutual Aid.

First Nations and Inuit have expressed concerns about engagement in all levels of planning and response capacity, and availability of culturally-adapted communication materials.  Both the PHAC and Health Canada are currently working with the Assembly of First Nations and the Inuit Tapiriit Kanatami to develop culturally appropriate pandemic fact sheets as well as trilateral work plans on pandemic preparedness and response.  In May 2006, the F/P/T Ministers of Health reaffirmed that antivirals from the joint Stockpile, vaccines and essential supplies will be available to First Nations and Aboriginal communities on the same basis as other Canadians  Funding to support training, planning and testing was directly devoted to First Nations and Inuit community pandemic preparedness in Budget 2006 ($6M).

The National Microbiology Laboratory is at the forefront in developing and applying modern public health technologies to diagnostic, vaccines and molecular epidemiology.  The Laboratory is also recognized internationally for its capacity to transfer and deploys its expertise to other countries and through its support to professional interchange.

Canada works with a number of international partners including the WHO and the Pan-American Health Organization in developing coordinated responses to infectious disease outbreaks and other public health emergencies.  A key initiative was the development of the International Health Regulations, which are legally binding regulations adopted by most countries to contain threats from diseases that may rapidly spread from one country to another.

According to a UN survey on avian and pandemic influenza published in December 2007, most developed countries now have pandemic preparedness plans.  As well, an increasing number of low and medium incomes countries are in the process of making pandemic preparedness plans.

A comparative analysis of pandemic plans done in the context of the Global Health Security Initiative (G7+ Mexico) demonstrates a number of similarities among countries, such as a wide spectrum of public health measures, antiviral stockpiles, surveillance, as well as some differences due mainly to contextual contingencies (unpublished).  Canada is one of the few countries to have a pandemic vaccine contract in place with a domestic manufacturer.  A number of G7 (Canada, UK, US, Japan, France) countries are now focussing on the implementation of their respective plans.

Canada is an active contributor to international dialogues about global preparedness via several international bodies: the Global Health Security Initiative; the International Partnership on Avian and Pandemic Influenza; the World Health Organization and the Health Task Force of the Asian Pacific Economic Cooperation.  Between 2005 and 2006, Canada contributed $105M to international Avian and Pandemic Influenza preparedness.

Specific achievements include a North American Plan for Avian and Pandemic Influenza, which was adopted at the Security and Prosperity Partnership Leaders Summit in Quebec in August 2007 and Canada's technical and financial assistance to developing countries and international organizations. In 2007, Canada was listed by the United Nations as one of the top four donors for international avian and pandemic influenza preparedness.

Immunization

The F/P/T governments have met their immunization commitments through the National Immunization Strategy.  Key outcomes are reduction in vaccine preventable diseases, equitable and timely access to recommended vaccines, improved efficiencies of immunization programs, better vaccine safety monitoring and response, and improved security of vaccine supply.  The F/P/T Vaccine Vigilance Working Group was developed to address vaccine safety issues of greatest relevance to F/P/T jurisdictions. 

The GoC provided $300M over three years in Budget 2004 to the P/Ts to support the introduction of and equitable access across Canada to four new recommended childhood vaccines (pneumonia, meningitis, chicken pox and whooping cough for adolescents).  All P/Ts now have publicly funded immunization programs.  More than twice as many children are now protected from these diseases than were in 2003.

In Budget 2007, the GoC announced federal funding of $300M over three years to the P/Ts to support the introduction of Human Papillomavirus (HPV) vaccine programs.  Since then, Ontario, Nova Scotia, Prince Edward Island and Newfoundland and Labrador have announced HPV vaccine programs in fall 2007.  Other P/Ts are expected to launch programs in 2008.

Federal investments have supported Canada Health Infoway’s Pan-Canadian Health Solution for a public health surveillance system that includes the development of an immunization registry module.  Efforts are underway to ensure the module is compliant with existing national standards.  By 2009, all jurisdictions will have access to such a registry.

Two priority federal population groups were identified in the 2007 work plan: First Nations people living off reserve, and immigrants and refugees.  A Task Group is being created with its first priorities being to develop linkages with national and local key organizations and to conduct an environmental scan of F/P/T activities, approaches and material.

Pan-Canadian Public Health Strategy (Chronic Disease Prevention)

Health Goals for Canada were developed through a broad consultation and validation process that involved the F/ P/T governments, public health experts, stakeholders and citizens.  The Public Health Agency of Canada (PHAC) led the development of the Goals through extensive consultations with the P/Ts and over 300 public health experts and stakeholders in twelve P/T roundtables, five thematic events and five regional deliberative dialogues and in consultations with parliamentarians.  Almost 400 individuals, groups, and organizations also provided input via an e‑survey or by holding their own consultations.  The Goals were agreed on by the F/P/T Ministers of Health at their annual meeting in October 2005, and are intended to act as guideposts toward improving Canadians’ health and quality of life and do not reflect a detailed map.

Health promotion, and disease and injury prevention commitments are being met through the implementation of the Pan-Canadian Healthy Living Strategy and the Healthy Living and Chronic Disease initiative.  The Strategy was approved by F/P/T Ministers of Health at their annual conference in October 2005.   The Strategy represents a set of common principles intended to provide a national context, reference point and blueprint for greater alignment and coordination across sectors.

The Healthy Living Issue Group reports on progress in meeting the targets and outcomes contained in the Strategy to the Pan-Canadian Public Health Network Council, through the Population Health Promotion Expert Group.

Through the PHAC, the GoC provides Secretariat support to the Healthy Living Issue Group, which provides a forum to foster collaborative efforts that contribute to improving overall health outcomes and reducing health disparities – the goals of the Pan-Canadian Healthy Living Strategy.  This includes: establishing an Intersectoral Healthy Living Network, a virtual Pan-Canadian network dedicated to healthy living; fostering partnerships; and improving collaboration and information exchange among sectors and across jurisdictions. 

The Healthy Living and Chronic Disease (HLCD) initiative involves collaboration between regional, provincial, territorial, federal and international governments, and stakeholders on HLCD’s three inter-related pillars: health promotion, chronic disease prevention, and detection and management of chronic disease.  Progress has been achieved with Enhanced Surveillance for Chronic Disease initiatives; the Canadian Best Practices Portal for Chronic Disease Prevention, which supports decision makers in practice, policy and research, and in assessing chronic disease risk factors.

To support the HLCD initiative, in February 2007, a fully elaborated GoC Results-Based Management and Accountability Framework was approved by the Treasury Board Secretariat.   P/T involvement in the implementation of the HLCD initiative, mainly through the Pan-Canadian Public Health Network, has facilitated implementation of HLCD initiatives, such as the work of the Population Health Promotion, and Chronic Disease and Injury Prevention, and Control Expert groups.  P/T representatives are also  involved in the implementation of HLCD disease-specific initiatives, such as the development of the Canadian Heart Health Strategy and Action Plan.

The GoC Healthy Living initiative targets all Canadians with an emphasis on children, youth and Aboriginal Canadians.  Actions include the re-establishment of ParticipACTION in 2007/08 with an investment of $1.6M to help Canadians improve their health through regular physical activity. 

GoC progress on HLCD disease-specific strategies includes:

• GoC investments of $4.2M for 2007/08 and $5.2M a year ongoing from 2009/10 to support development of the Canadian Heart Health Strategy and Action Plan, and to fund early federal efforts to address hypertension (a CVD-specific risk factor) and CVD surveillance.
• GoC action on diabetes (e.g. funding community based projects) and has renewed the Canadian Diabetes Strategy at $18M a year, ongoing.
• GoC investments of $13M in 2007/08 and $17M in 2008/09, and ongoing, to support cancer activities, including surveillance; screening and early detection; risk factor analysis and assessment; intramural and extramural research; and public information, community‑based programming and capacity building targeted at Aboriginal, seniors and childhood cancer organizations.  The GoC has provided $800K to National Aboriginal Organizations to enable participation in the Canadian Strategy for Cancer Control.

GoC progress on healthy living activities within HLCD includes:

• The GoC announced an investment of $4.36M in 2007/08 in national healthy living projects through the Physical Activity and Healthy Eating Contribution Fund, the national stream of the Healthy Living Fund.

• The GoC committed $2.66M in 2007/08 to support regional physical activity and healthy eating projects to be developed through bilateral agreements with P/T governments.

• The GoC invested $1.044M in 2007/08 in national projects to support knowledge development on healthy living.

The Framework of the HLCD initiative is consistent with the World Health Organization’s (WHO) Global Strategy on Diet, Physical Activity and Health, which supports a collaborative approach where responsibilities for action to bring about changes in dietary habits and patterns of physical activity rest with many stakeholders from public, private and civil society.

F/P/T discussions have taken place with the Pan-Canadian Public Health Network Council concerning the development of a Pan-Canadian Public Health Strategy and the consensus was to continue to lay a foundation for the Strategy and revisit its development once short term priorities are met.

To address the Healthy Schools commitment, the F/P/T governments have successfully established the Joint Consortium for School Health (JCSH).  This consortium brings together key representatives of F/P/T departments and ministries responsible for health and education.  It builds collaborative capacity and promotes understanding of and support for comprehensive school health initiatives.  Each member jurisdiction now has one or two school health coordinators who report to the department of health or education or both.

The GoC contributes annual funding of $250,000 toward its commitment to the JCSH lead province (currently British Columbia).  The P/Ts contribute $217,000 annually (based on a per capita calculation).  A notable GoC accomplishment is the creation of an internal Federal Coordinating Committee to act as an information exchange forum for the various federal departments/agencies involved in school health.  The Committee has compiled a synthesis of current federal school health activities in a range of departments, including Heritage/Sport Canada, Statistics Canada and Human Resources and Social Development Canada.

Some of the Consortium’s key accomplishments include:

• Networking: established a national network of school health coordinators in every participating P/T and a PHAC representative to support collaboration and information sharing;
• Communications: established a Consortium Internet portal for Canadian school health issues and resources; established a Consortium newsletter about Consortium activities, including news, links to relevant research and information on events and opportunities;
• Promotion and advocacy: organized and hosted a 2006 National Conference on School Health; presentations at various fora on the Consortium and promoting comprehensive school health approaches  (Chronic Disease Prevention Alliance of Canada’s Second National Conference, Integrated Chronic Disease Prevention: Building It Together, 2006;  International Union of Health Promotion and Education Conference, 2007;etc.); and
• Governance: established a regular schedule of teleconferences and meetings among member jurisdictions, including for school health coordinators and for senior representatives.

The Consortium has been recognized as a model of collaboration, with worldwide potential.  The World Bank and the Pan American Health Organization have both expressed interest in the Consortium model, and in working with the Consortium more closely.  The Consortium is also working with the European Network of Health Promoting Schools.

Reporting

There are no reporting commitments, other than the pre-existing requirements for the Pan-Canadian Healthy Living Strategy.  For these, the F/P/T Healthy Living Issue Group reports to the Pan-Canadian Public Health Network Council, through the Population Health Promotion Expert Group, on progress in meeting the targets and outcomes contained in the Strategy.

Future Work

Infectious Disease Outbreaks and Other Public Health Emergencies

Future action on Infectious Disease Outbreaks and Other Public Health Emergencies was addressed in May 2006, when the F/P/T Ministers of Health met, and activities for 2008-09 include:

• The GoC will continue to work with industry and international partners on development, testing and licensing of an effective influenza vaccine.  Canada also participates in the WHO technical working group on vaccine production and regulation.
• The GoC is reviewing its 10 year contract with the domestic vaccine manufacturer to ensure access to new technology and to harness its vaccine production capacity.  The GoC also invests in clinical trials of H5N1 pre-pandemic vaccines.
• Additional investments will be made to ensure First Nations and Inuit needs and concerns are taken into consideration, and a trilateral work plan is being developed to improve pandemic preparedness and response in First Nations and Inuit communities.
• Non-governmental and private sector organizations participation in developing appropriate pandemic preparedness and business continuity plans is needed and beneficial.  Governments and the private sector will work together to ensure continuity of supply of key goods and services.  Cross sectoral workshops will continue to take place and documents, such as Frequently Asked Questions or guidance for the development of business continuity plans, are under development.
• The GoC will achieve the National Antiviral Stockpile target by end of fiscal year 2008-09 by purchasing 2 million pediatric doses of antivirals
• A new version of the Canadian Pandemic Influenza Plan for the Health Sector and related annexes on vaccines, laboratory services, clinical care, infection control and prevention will be released in 2008;
• Annexes on public health measures, surveillance, psychosocial preparedness and planning recommendations for the use of antivirals during a pandemic will also be reviewed for a release in 2009.
• Final recommendations of a pan-Canadian pandemic vaccine strategy will be developed.
• A series of table-top real-time exercises of F/P/T mechanisms for responding to pandemic will take place and each jurisdiction’s effectiveness will be assessed.
• An online certification course for early detection, management and reporting of emerging infectious disease, including influenza will be launched in 2008.

Immunization

The GoC is committed to build on recent success in expanding immunization programs and improving access, and is continuing to work with the P/Ts through the National Immunization Strategy to strengthen immunization infrastructure and programs.  New vaccines will have a major impact on immunization programs and the epidemiology of vaccine-preventable diseases in the coming years.

Pan-Canadian Public Health Strategy (Chronic Disease Prevention)

The Health Goals may provide a tool to guide jurisdictions’ further action on the determinants of health and may help to strengthen the management of horizontal issues with experts.

Health Promotion, and Disease and Injury Prevention plans for 2007/08 will involve activities related to governance, coordination and continued implementation of the HLCD initiative, including through monitoring and evaluation.

The PHAC will work through the Public Health Network to continue to identify emerging public health priorities and will gauge readiness to move forward on the Pan-Canadian Public Health Strategy via the Public Health Network Council.

Future work on Healthy Schools includes facilitating a more coherent system for reporting on the health and social development of children and youth in school settings; publishing reports on emerging issues and trends on nutrition/healthy eating, physical activity, social behaviours, sexual health and others; implementing an evaluation framework; and collaborating with international agencies, including the WHO, the Pan American Health Organization, the World Bank and the European Union Healthy Schools Collaborating Centre.