The United States and Canada have long compared the relative performance of their medical care systems in order to identify pathways for improvement, but the public health systems of these two countries receive much less attention by scholars and pundits. Having spent the past few days meeting with some of the best public health minds and hands in Canada, I conclude that there is much to be learned about ways of improving the organization, financing and delivery of public health strategies in the U.S. through comparative research with Canadian models.
Canada’s system of universal health care financing and delivery formed incrementally during the 1940s through the 1980s, but its public health institutions developed quite independently following a much longer time path. The result – at least until relatively recently – was public health institutions that operated relatively autonomously from health care delivery institutions with separate funding streams, much like the U.S. experience. Over time, Canada’s provinces and territories have implemented various forms of regionalized health care delivery in an effort to pool resources and expertise for the purposes of improving quality, constraining costs, and reducing inequities in delivery. Over the past decade or so, many (but not all) provinces have transferred public health responsibilities and funding from municipal and provincial agencies to these regional health care delivery institutions, called regional health authorities. Provincial Ministries of Health have retained overall responsibilities for stewardship of their integrated regional health systems using the levers of funding, policy, monitoring and accountability. The provinces also administer some core public health functions centrally such as selected surveillance, epidemiology, and laboratory capabilities – much like many state public health agencies in the U.S.
Structurally, Canada’s integrated regional health authorities look and feel like advanced versions of the accountable care organization (ACO) models that are now taking shape in the U.S., at least in the more comprehensive and ambitious ACO models that endeavor to incorporate public health responsibilities into “totally accountable care” strategies. As such, Canada seems to offer Americans a unique opportunity to gaze into the future and anticipate some of the benefits and challenges associated with bridging public health and medical care delivery systems to improve population health.
Why am I so enthusiastic about the knowledge to be gained from US-Canadian comparative research on public health systems and services? In full disclosure, most of my knowledge derives from several days of intensive exchange with colleagues in the west coast province of British Columbia. BC has a diverse population of about 4.3 million, spread across a geographic area larger than Texas. Five regional health authorities operate in the province of BC, two of which serve the heavily urbanized population of greater Vancouver, with other authorities serving vast areas of sparsely populated rural and remote communities. In my couple of days in this province, I was able to gather intelligence on Canadian public health systems research and share insight from our U.S. based studies through a number of different venues, including:
§ Giving seminars for the BC Centre for Disease Control and the multi-institutional BC Population Health Network based in urban Vancouver, where some of the province’s best public health scientists and practitioners convene (slides here and here);
§ Speaking at the 141st meeting of the Health Officer’s Council of British Columbia held in suburban New Westminster and meeting with this fiercely independent group of public health physician leaders, many of whom function within the regional health authorities (slides here);
§ Jumping a seaplane over to the island city of Victoria to meet and lecture with the awe-inspiring intellectual leaders of public health systems research at the University of Victoria and their colleagues at collaborating institutions like the University of British Columbia, University of Toronto, and University of Saskatchewan (slides here);
§ Boarding the mothership at the Province of British Columbia Ministry of Health to meet with their Population and Public Health Division and speak as part of the Ministry’s research and policy rounds (slides here and here).
My conclusion from this whirlwind: the evidence, experiences, and ideas of this diverse Canadian providence are extremely relevant to our American experimentation with public health system transformation. Moreover, the other Canadian provinces beyond BC offer yet additional models of public health organization, financing, and delivery that are ripe for comparative analysis. Health systems researchers would be foolish not to harvest the rich opportunities for comparative public health delivery research spanning the American-Canadian border.
Fortunately, Canada already has a strong foundation of applied public health services and systems research (PHSSR) led by ongoing studies of researchers based at the University of Victoria. This group embarked on a large program of research known as the Core Public Health Functions Research Initiative in 2006, with the goal of elucidating the implementation and impact of BC’s multi-pronged strategies to improve the effectiveness of core public health functions across the province. This effort led to an even larger and geographically more expansive research program funded by the Canadian Institutes of Health Research (CIHR) beginning in 2009 and known as the Renewal of Public Health Services in BC and Ontario, which supports comparative research on the implementation and impact of core public health strategies across these two diverse provinces. The academic ringleaders of Canada’s PHSSR enterprise include Professor Marjorie McDonald, RN, PhD, who holds a chair in public health education and population intervention research at the School of Nursing, and Dr. Trevor Hancock, MB, MHSc, who is a professor and senior scholar in the School of Public Health and Social Policy and one of the founders of the international Healthy Cities/Healthy Communities movement.
These Canadian PHSSR researchers approach their work with the versatility and realism that only mixed-method investigations can achieve. And much like our U.S. based public health PBRNs, these scholars are firmly entrenched in the principles and practices of collaborative, practice-based research. Every study is led by a team of “knowledge users” firmly embedded in the real world of public health practice and policy, along with relevant academic researchers. Not coincidentally, this research group has produced some of its best work to date on studies of “Knowledge to Action” strategies that support the use of evidence in public health program development and implementation processes. Another defining feature of this team’s research it its strategic selection of specific public health practice domains to study as “exemplars” for how public health delivery systems function as a whole – a concept that is analogous to the long-standing use of tracer conditions in health services research. To date UVic’s exemplars have included healthy living strategies, food safety, unintentional injury prevention, and emergency preparedness.
To be sure, BC’s rich public health research environment is only partially attributable to its research universities like UVic and UBC. A large, diverse, and talented pool of scholars exists within the BC Ministry of Health and within regional health authorities like Frasier Health, many of whom have formal linkages and appointments with the surrounding universities. Epidemiologists, economists, sociologists, engineers, policy and legal scholars, biomedical scientists, and many other disciplines are represented among these “pracademics” who produce and publish top-shelf research alongside their operational and managerial responsibilities within the health system. Conducting applied research studies within the Ministry of Health and its regional health authorities appears to be far from a novel concept within the province of BC. A new Guiding Framework for Public Health in BC was released by the Ministry last year, which has begun to provide new focus for applied research and evaluation within the province.
My few days of immersion in BC public health research and reality left me with a few intriguing impressions that seem worthy of further exploration through comparative PHSSR and public health economics research, including the following:
§ Bringing public health and medical care delivery under a common organizational structure and global budget may not automatically and instantaneously result in integrated health systems that adopt a population health perspective and prioritize upstream, long-term strategies for disease prevention and health promotion. Challenges persist in balancing the resource needs and performance expectations of medical care and public health even in integrated regional structures. Our American ACOs need to learn from relevant Canadian models and experiences.
§ Governance and decision-making structures for public health vary in their composition and functioning across Canada as they do in the U.S. These structures appear highly influential in shaping public health strategy and implementation, and as such represent worthy mechanisms to study and understand.
§ Canada’s health system leaders and public health researchers are making enviable progress in integrating a health equity lens into their science, policy and practice. BC’s new First Nation’s Health Authority is one manifestation of this perspective that is worthy of special attention from researchers and policy analysts, particularly given its explicit emphasis on wellness and culture and its unique governance and decision-making structures. The U.S. PHSSR enterprise has not been particularly deliberate nor successful in incorporating the perspectives and experiences of Native American populations into its research, so this is an area that could benefit from Canadian leadership and expertise.
§ Canadian policy leaders and researchers continue to struggle with the underlying theory, methods and mechanics of defining and measuring core public health functions, their costs, and their health and economic value. These are challenges that American scholars and practitioners clearly share. For forward momentum, there appears to be some enthusiasm behind the idea of adapting some of our U.S. PHSSR methods and measures for deployment in the Canadian context, including our National Longitudinal Survey of Public Health Systems, our MPROVE measures of public health implementation, and our DACS cost estimation methods. Doing so would open up some extremely powerful opportunities for international comparative research.
I encourage fellow travelers in PHSSR and public health economics to look northward for inspiration and insight that can advance your own programs of research. Watch this blog for future posts on our progress in mobilizing Canadian-American comparative research on public health delivery systems.