PACP Committee Report

INTRODUCTION

In 2006, the federal government created the Public Health Agency of Canada (PHAC) to coordinate efforts to identify and respond to public health threats, and to act as a hub for Canada’s health surveillance and disease control programs. The work that PHAC performs is of critical importance: timely health actions can prevent and contain disease outbreaks, reduce the economic costs of infectious diseases, and save the lives of Canadians.

In its May 2008 report, the Office of the Auditor General (OAG) examined whether PHAC, in collaboration with its partners, had obtained, analyzed and disseminated the information needed to respond to threats of infectious disease.^[1]  The OAG also followed up on issues raised by its 1999 and 2002 audits, and examined whether the government had addressed those concerns.^[2]  The Committee notes that work on the OAG audit was substantially completed in October 2007.

The Committee, concerned over the results of the audit and its potential consequences for public health in Canada, met with officials from the OAG and PHAC on 10 March 2009.^[3] From the Office of the Auditor General, the Committee met with Neil Maxwell, Assistant Auditor General; and Louise Dubé, Principal. From the Public Health Agency of Canada the Committee met with David Butler-Jones, Chief Public Health Officer; Gregory Taylor, Director General, Office of Public Health Practice; and Danielle Grondin, Acting Assistant Deputy Minister, Infectious Disease and Emergency Preparedness Branch.

BACKGROUND

PHAC’s mandate is to identify and reduce public health risks and to support national readiness to address public health threats.  Before 2004, PHAC’s functions had been carried out by Health Canada.  The establishment of PHAC followed the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003, and Auditor General reports in 1999 and 2002 that questioned aspects of the federal government’s ability to respond to public health threats.

PHAC surveillance consists of the ongoing, systematic use of routinely collected health data.  PHAC obtains its surveillance data from its partners, which include other federal departments and agencies, provincial territorial and municipal governments, health professionals, hospitals and laboratories.

Canada has international obligations to report serious infectious diseases to the World Health Organization (WHO).  These obligations have become more demanding with the recent strengthening of the International Health Regulations.  Outbreaks such as avian influenza have underscored the need for coordinated responses at the international level to the spread of infectious disease.

ACTION PLAN AND PROGRESS REPORT

The Committee recognizes that PHAC is a new organisation facing substantial challenges, and that it will take time for the organization to grow into its role. Nonetheless, the audit found a number of weaknesses in PHAC systems to detect and monitor existing and emerging infectious diseases in Canada, including gaps in its information and data sharing agreements with the provinces. The audit found that critical arrangements—such as procedures for notifying other parties, and protocols affecting the collection, use, and disclosure of personal information—were still not in place.

In its audit, the OAG recommended, inter alia that PHAC conduct a review of its legislative authorities; take measures to ensure better data sharing with PHAC partners; implement standards for the data it receives from provinces; take measures to better assess data quality; and document user needs in its surveillance systems. As PHAC has agreed with the recommendations, the Committee expects that they will be fully implemented.

In order to demonstrate commitment to the implementation of OAG recommendations, the Committee expects government agencies to prepare an action plan that details what actions will be taken in response to each recommendation, specifies timelines for the completion of the actions, and identifies responsible individuals who will ensure the actions are undertaken in a prompt and effective manner.

In response to the audit, PHAC produced a detailed action plan that outlines how PHAC will implement recommendations over the coming years.^[4] However when the Committee met with officials from PHAC, it was evident that the agency had already fallen behind on some of the timelines set out in the action plan, such as evaluations of surveillance systems, and documentation of user needs.^[5] Moreover, in order to close the accountability loop it is necessary to report on the progress an agency has made on implementing action plans. Hence, the Committee recommends:

RECOMMENDATION 1

That PHAC provide an interim status report to the Public Accounts Committee on its progress in implementing the Office of the Auditor General’s recommendations by 30 September 2009, and that additional status reports be submitted to the Committee annually until the recommendations are fully implemented.

LEGISLATIVE REVIEW

The audit noted that in order to set a strategic direction for infectious disease surveillance, PHAC must establish surveillance objectives and priorities based on public health threats.  The audit found that PHAC had not yet clearly defined its roles and responsibilities, and that updates to its legislation that would provide legal authority to collect and analyze personal information may be necessary.  The Committee recognises that privacy concerns would need to be addressed if legislative changes are necessary. The OAG suggested that a lack of clear and up-to-date legislative authorities, together with recent changes to provincial and territorial privacy legislation, have led some provinces and territories to question PHAC’s authority to collect public health information. In the absence of a decision on new legislation, PHAC has spent two years working on regulations to authorize it to receive public health information under the Public Health Agency of Canada Act.

The OAG recommended that PHAC clarify its roles and responsibilities by working with Health Canada to complete the legislative review and seek additional legislative authority to carry out surveillance, as necessary. In response to the recommendation, Health Canada and PHAC agreed to continue work on the new legislative initiative, although the Action Plan provided to the Committee only commits PHAC and Health Canada to work together on the issue, as well as identify critical steps, and does not provide an explicit timeline for drafting new legislation or regulations.

The Committee shares the OAG’s concern over roles and responsibilities that have yet to be resolved and is troubled that PHAC and Health Canada appear to have no timeline for resolving this critical issue. As many of the recommendations in the audit and in this Report depend on PHAC successfully signing agreements with the provinces, the lack of a clear timeline for conducting the legislative review is a cause for concern. The Committee notes that the issues surrounding the roles and responsibilities for national health surveillance are not new. The OAG first recommended a legislative review in 2002, and the actions taken to address these concerns since that time have been inadequate. Accordingly, the Committee recommends:

RECOMMENDATION 2

That Health Canada and PHAC provide the Public Accounts Committee by 30 September 2009 with a clear timeline for a legislative review that would determine whether additional statutory authorities are necessary.

SURVEILLANCE OF DISEASES THAT PASS FROM ANIMALS TO HUMANS

The Canadian Food Inspection Agency (CFIA) is the federal entity responsible for surveying infectious diseases in animals.  Since 65-80% of newly identified human diseases come from animals, CFIA cooperation is needed in order to contain threats to humans.  The audit found that PHAC and the CFIA have not done a systematic analysis of the risks to human health to justify the selection of the diseases to be monitored.

The audit recommended that, in order to improve their ability to control zoonotic diseases, PHAC and the CFIA should jointly assess the possible risks to human and animal health, clarify how the responsibilities will be divided, and act on joint surveillance objectives and priorities.  PHAC and the CFIA agreed to the recommendation and stated that PHAC, the CFIA and Health Canada were finalizing a memorandum of understanding, and working through the federal-provincial-territorial Public Health Network to address the concerns raised in the audit. The Committee is encouraged by the substantial progress that has already been made by PHAC and the CFIA on this issue and anticipates that the agencies will develop a constructive working relationship in the future.  As this issue appears to have been resolved, the Committee does not have further recommendations at this time.

PHAC SURVEILLANCE ACTIVITIES

To obtain surveillance information, PHAC relies on its partners, the most important of which are health authorities in the provinces and territories.  The OAG selected four infectious diseases for in-depth analysis and concluded that, even though PHAC is struggling with the completeness, timeliness and accuracy of the information provided by its partners, it carries out analyses and disseminates reports that support public health action.  The Committee notes that PHAC is faced with a shortage of public health professionals, and a lack of resources to train people in the field of surveillance. Dedicating more resources to training would improve the ability of PHAC to implement public heath surveillance systems.

The audit noted fundamental weaknesses in PHAC’s surveillance activities.  PHAC relies on the goodwill of the provinces and territories to supply the needed information, and this flow has sometimes been interrupted. In addition the audit found that PHAC has not done enough to assess and document the information needs of users; establish common surveillance standards; implement a data-quality framework; and evaluate its surveillance systems.

The OAG found that comprehensive surveillance standards still need to be finalized in order to ensure that infectious disease occurrences are defined, reported and recorded uniformly across the country.  For example, when Ontario and Quebec send positive HIV test results, they do not indicate the ethnicity or country of origin of the persons testing positive.  Without this information, it is difficult for PHAC to describe fully the HIV situation and target actions appropriately.  The OAG expressed concern that a nationally standardized approach to disease reporting remains years away. 

The audit found that, for emerging infectious diseases, PHAC used internationally recognized systems for monitoring diseases that can be brought into Canada from other countries.  For infectious diseases that have entered Canada, PHAC had a strong laboratory capacity that provided a base for detecting new diseases. According to Dr. Butler-Jones, Canada’s Chief Public Health Officer, Canada was the first country to have a national pandemic plan for the health sector, and has an extensive portable laboratory capacity. However, the audit found that, because of gaps and delays in the data supplied by its partners and weaknesses in its informal data-sharing methods, PHAC may not be able to analyze and report information systematically on public health threats.

The OAG recommended that PHAC establish data-sharing agreements to ensure that it receives timely, complete and accurate surveillance information from all provinces and territories.  The audit recommended that PHAC, in collaboration with its partners, set timelines for putting these agreements in place.  In addition, the audit recommended that PHAC:

PHAC agreed to the OAG’s recommendations, stating that it recognized the importance of sharing data in a timely and accurate fashion.  As well, PHAC stated that, over the last three years, it had worked with provinces and territories to put in place data-sharing agreements and had participated in fora such as the Public Health Network.  In addition, PHAC is in the process of developing a privacy framework for the management of privacy issues, such as record information-sharing and managed information-sharing agreements, with an expected completion date of March 2009.

PHAC is working on data-quality checks and its Surveillance Strategy Framework, which will strengthen and formalize internal procedures, as well as its Evaluation Framework for Surveillance Systems, which will lead to regular evaluations of surveillance systems. Officials from PHAC told the Committee that they had also appointed a senior surveillance advisor, who would be responsible for implementing the surveillance related measures contained in PHAC’s action plan. 

The Committee notes that many of the problems identified in the audit are recurring ones, and that there appears to be a lack of urgency on the part of PHAC in implementing more formal surveillance systems. For example, in its 1999 and 2002 audits, the OAG recommended that Health Canada work with the provinces and territories to establish information-sharing agreements, and it agreed to do so. In 2002, the OAG recommended that Health Canada establish common standards, and it agreed to do so. While the Committee recognizes that PHAC is a relatively new organization, the Committee is seriously concerned that commitments that were made in response to previous audits have yet to be addressed.    

The Committee is concerned about the evidence presented by PHAC officials over  the utility of formal mechanisms of surveillance, such as MOU’s and nationally standardized approaches to disease reporting. In his testimony before the Committee, Dr. Butler-Jones, the Chief Public Health Officer told the Committee that PHAC did not need MOU’s to find information, stating that “it's a matter of degree. We do not have any problem. We have the full cooperation of the provinces. Any information we ask for, we get.”^[6]  Later in his testimony, Dr. Butler-Jones stated that “the most essential thing is to get the information, not the agreement.”^[7]

In the audit, the OAG acknowledges that PHAC does have mechanisms for the collection of relevant information to detect and monitor infectious diseases, but states that “there are risks related to the use of these mechanisms unless they are formalized.” ^[8] The information does not always flow as intended and may not be recorded and reported uniformly across the country. The Committee is deeply troubled by the lack of urgency that PHAC displays on this issue. PHAC cannot continue to rely exclusively on informal networks to fulfill its mandate. The Committee recommends:

RECOMMENDATION 3

That PHAC provide the Public Accounts Committee by 30 September 2009 with a proposed timeline for negotiating information sharing agreements with the provinces and territories, and report progress in making these agreements in its annual status report to the Committee.

WHO STANDARDS

Following outbreaks of diseases such as SARS that were international in scope, the WHO passed new International Health Regulations (the Regulations).  In May 2006, the federal government committed to implement parts of the Regulations.  The audit found that PHAC has made progress on implementing the Regulations, but has not yet taken all of the necessary steps to meet Canada’s commitments.  In the event of a public health emergency, the audit found that PHAC may not be able to obtain the information needed to do an assessment within 48 hours, to notify the WHO within 24 hours, or to keep the WHO informed of subsequent events.  These deficiencies, the audit found, are the result of inadequate information-sharing agreements with the provinces and territories.

The audit recommended that PHAC work with its partners to establish an action plan with clear and realistic deadlines for implementing the memorandum of understanding on the sharing of information during a public health emergency.  PHAC agreed with this recommendation, and said that it will work to complete an action plan by December 2009 which will outline how Canada intends to meet its obligations under the Regulations. PHAC is setting up an Emergency Operations Centre that will operate continuously, and has obtained general support from all of the provinces and territories for implementing the Regulations in Canada.

The OAG found that PHAC has made progress in implementing the WHO Regulations, but has not yet taken all of the necessary steps to meet Canada’s commitments.  While PHAC has developed an intergovernmental memorandum of understanding on sharing information during a public health emergency, the audit found that the memorandum is largely a statement of principle, and is not sufficient to ensure a complete and timely flow of information between the provinces and territories and PHAC. Privacy issues continue to be a concern. Countries are expected to assess their capacity to meet the core surveillance and response capacity requirements by 15 June 2009, and compliance with surveillance aspects of the Regulations will become mandatory in June 2012. It is not clear at this point how PHAC proposes to meet this deadline, especially as it does not have agreements with all provinces and territories.  The Committee recommends:

RECOMMENDATION 4

That PHAC provide  the Public Accounts Committee with its assessment of core surveillance and response capacity requirements by 30 September  2009, along with a timeline detailing  how it intends to meet the WHO Regulations by the mandatory deadline of 2012.

PERFORMANCE REPORTING

The Committee strongly believes that departmental performance reports should give a balanced perspective of an organization’s progress in meeting expected results and should, at the very least, outline key risks the organization faces in achieving those results. This is not the case with PHAC’s performance reports.

The findings of OAG’s audit are serious and indicate that PHAC has made limited progress in addressing several key issues. However, PHAC’s departmental performance reports give no indication of the challenges faced by the agency, nor the risks to public health inherent in deficiencies to surveillance systems. Instead the report simply seems to be a collection of ongoing activities undertaken by PHAC. The Committee recommends:

RECOMMENDATION 5

That PHAC include in its departmental performance reports an outline of the challenges and risks it faces as an organization; and that PHAC provide a balanced appraisal of the results it has achieved in improving its surveillance activities.

CONCLUSION

The 2003 SARS outbreak highlighted the need for the creation of an agency such as PHAC, in order to lessen the potential impact of similar crises. The Committee acknowledges the progress PHAC has made since it was created in 2006, and understands that it takes time for a new agency to find its footing. However many of the issues the OAG identified in the 2008 audit are not new, and there has been limited progress on implementing OAG recommendations over the past decade.

The Committee is concerned that although PHAC has agreed to implement the recommendations contained in the audit, it has not shown sufficient urgency or focus in making the necessary changes. It is the Committee’s belief that fundamental changes are needed to PHAC’s surveillance systems, and that every year that passes without implementing the OAG’s recommendations puts the health of Canadians unnecessarily at risk. The Committee sincerely hopes that PHAC will take prompt action to ensure that a more formal information gathering system is implemented, and that the integrity of Canada’s public health system is upheld.