A Canadian Agency for Public Health: Could it work?
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* Kumanan Wilson

SARS has again exposed some of the fundamental limitations of Canada's public health system, prompting calls for reform.1,2 In response, the National Advisory Committee on SARS and Public Health has provided recommendations for public health renewal.3 A key recommendation is the creation of a Canadian Agency for Public Health, modelled on the US Centers for Disease Control and Prevention. By coordinating public health activities throughout the country and establishing a national public health strategy, the new agency would address some of the major concerns about the public health system. The question is, Will it work?

The SARS committee's proposal is the latest in a series of reports recommending the strengthening of Canada's public health capacity. One of the primary reasons previous reform initiatives have failed is the difficulty of obtaining cooperation among local, provincial/territorial and federal governments. This is due in part to unclear constitutional roles and responsibilities for public health and the potential for disputes to arise over funding and data sharing.4,5 Furthermore, public health agreements have become casualties of the intergovernmental acrimony that has arisen over hospital and medical insurance.

When devising its plan for a new public health agency the SARS committee had to identify mechanisms for overcoming these hurdles. In doing so, it could choose from 4 broad governance options: (a) the current, fragmented state, in which governments work independently (clearly unacceptable); (b) a hierarchical system in which the federal government has a clear leadership role and the power to coerce provinces into cooperating; (c) collaboration by all levels of government to develop a plan for the common good; and (d) a confederal system in which the provinces work together and the federal government is excluded.6

In the spirit of Canadian federalism, the committee designed the Canadian Agency for Public Health in a manner that would foster collaboration between governments. The agency would be at arm's length from government, although answerable to the Minister of Health. It would be federally financed and fund projects through local and provincial/territorial partnerships. The committee viewed this strategy, of several smaller funding agreements between governments, as less contentious than a single, large transfer of money and a key to enhancing collaboration. In addition, the committee recommended other collaborative ventures, including a national public health advisory board and a federal/provincial/territorial network for communicable disease control.

The collaborative approach offers many advantages, including consideration of the interests of all orders of government, minimizing conflict and reducing the likelihood of violating jurisdictional sovereignty. An agency based on a collaborative model would, therefore, go a long way to addressing the core problems of the public health system. However, the model has some important limitations, such as the potential to predispose toward inaction. Collaborative efforts at developing a network for health surveillance in Canada have encountered many obstacles that have stalled full implementation.7,8 The Environmental Management Framework Agreement is another failed collaborative venture.9 The primary difficulty with collaborative approaches is the potential for the decision-making process to lack transparency and for accountability to become blurred. This permits each order of government to blame the other when agreements do not succeed.10

If the collaborative approach is not successful, the federal government will have to adopt a more hierarchical approach to public health reform. The SARS committee has allowed for this option in its proposal. The Canadian Agency for Public Health, in theory, would have the choice of not entering into funding agreements with regions and provinces/territories if it felt that the designed program did not meet national standards. The committee also recommended that the federal government implement back-up legislation if collaborative efforts to develop health protection legislation fail. With both legislation and funding at its disposal, the federal government would have considerable power to coerce agreements from provincial/territorial governments. Not unlike the situation with health care, the federal government might realize that it could contribute an increasingly smaller percentage of funding while continuing to demand high public health standards from the provinces. Legislation could be introduced to prevent this from arising; for example, by requiring that the federal government contribute a certain proportion of public health costs.11 Alternatively, a dispute-resolution mechanism could be developed. The proposed public health advisory board or a national health council could serve in this capacity.

The SARS committee should be congratulated for its comprehensive analysis of the key issues impeding public health reform. The advantages of the overall plan for a Canadian Agency for Public Health clearly outweigh the disadvantages. The plan is an important and correct step to delivering much-needed reform. Now the federal government must demonstrate the political will to translate the committee's vision into reality.

## Footnotes

*   *Competing interests:* None declared.

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