January 15, 1999

To:Board of Health

From:Dr. Sheela V. Basrur, Medical Officer of Health

Subject:Update on Investing in Public Health

Purpose:

To provide an update on the Board of Health's request for an investment strategy for Public Health.

Source of Funds:

Not applicable.

Recommendation:

It is recommended that this report be received for information.

Background:

At its March 24, 1998 meeting, the Board of Health had before it a comprehensive report entitled "Investing in Public Health". Based on that report, the Board of Health adopted a motion to "continue to support needs-based public health funding in order to maintain the health and social infrastructure of the new city." Further, the Board "requested the Medical Officer of Health report back to the Board in the fall of 1998 on a complementary investment strategy for public health in the following budget year."

The "Investing in Public Health" report detailed the Public Health mandate and identified gaps resulting from unmet local needs, inequitable service levels and/or new provincial Mandatory Program Guidelines. The report also provided initial budget estimates to level up certain services. Ten programs were identified for possible extension across the new City at an estimated cost of $16 million. To ensure compliance with the new mandatory health programs and services it was estimated that additional funds of over $20.5 million would be required. Another $5.5 million was estimated for one-time information technology costs over the next three years. Thus, a preliminary estimate of costs associated with extending current programs to a larger population and implementing minimum mandatory services was $42 million. With further review, such costs are now estimated at $35 million. More detailed planning for individual programs is in progress and may lead to further refinement of these estimated costs.

This report provides an update on steps that have been taken and are planned to identify and respond to service needs and gaps, and to amalgamate, harmonize and adjust services and activities.

Comments:

Toronto Public Health is an amalgamating division with downloaded funding for which programming is mandated by provincial legislation. Consequently, the division's amalgamation is taking place within two concurrent pressures: the urgency of the municipal budget constraints and new requirements imposed on Boards of Health to provide very prescribed services. During 1998 Toronto Public Health has engaged in its first phase of amalgamation.

(A)Amalgamation Activity Overview

Key early steps were to identify an agreed-upon mission, vision and guiding principles as a basis to plan and implement a new organizational structure. Level 4 Directors were hired in September 1998, following which the organizational structure within each directorate was designed and level 5 management positions were posted. Managers are expected to be hired into level 5 positions by mid-February, 1999.

Staff conducted a preliminary inventory of existing programs and services, and assessed the extent to which existing services meet the new provincial Mandatory Program and Service Guidelines. Division staff have started to detail gaps and inconsistencies in services, policies and procedures. Initial emphasis has focussed on programs where contradictory practices pose the greatest risk (in terms of health and/or liability for the City) and where the potential to achieve savings in a short time-frame had been identified.

(B)Planning

Planning, with an emphasis on needs, has been an integral part of most amalgamating activities. A companion report (The State of the City's Health: Achieving Public Health Goals in the Millennium) discusses current health needs, status and gains.

The process of creating and analysing city-wide data, usually from data that has never been integrated, is itself time-consuming. Data from numerous sources are being integrated into centralized data bases to be used to inform service planning according to health needs, health outcomes and the distribution of services. Collaboration with other city departments and divisions (eg. Social Development Division, Urban Planning and Development Services) has been undertaken to avoid duplication and unnecessary cost, resulting in improved access to existing information and the development of consistent formats for mapping data. City-wide information about needs and the cultural accessibility and distribution of community-based resources was generated and used to allocate resources for two programs expanded during 1998 (Healthiest Babies Possible and Parents Helping Parents).

When "Investing in Public Health" was presented to the Board of Health in early 1998, it was initially assumed that a comprehensive needs-based planning process would be undertaken prior to preparation of the 1999 budget. However, the time-consuming nature of responding to the combined impacts of amalgamation and the developmental nature of the city-wide data required to undertake program planning required Public Health to defer comprehensive planning until 1999, when the Division's organizational structure and directors and managers will be in place. An eight-month strategic and program-specific planning process is currently being designed. The planning process will include consultation with the Board of Health, staff and community stakeholders. It is anticipated that this needs-based planning process will position the Division to strengthen programs, improve effectiveness, realize efficiencies and reduce service gaps. An information report on this process will be submitted to the Board of Health at a future meeting.

Identification of performance measures is underway for selected activities. These preliminary steps will assist us to identify opportunities for program improvements in coming years, some of which will result in savings.

(C) Program Harmonization, Redesign and Expansions:

In 1998, the vaccine preventable disease program was amalgamated and redesigned. The program is currently working within a transitional structure pending the hiring of level 5 and 6 management.

Three programs -- Healthiest Babies Possible, Parents Helping Parents and Child Nourishment Programs -- were expanded city-wide by Council in 1998. The following list highlights Public Health's successes and progress to date in program harmonization, redesign and/or expansion:

(a)Healthiest Babies Possible dieticians are now working in 50 different community sites to provide high risk pregnant women with one-to-one counselling, food supplements, referrals to public health nurses and other services. Of the 375 women who have entered the program since September 1998, 90% are on welfare, are low income or have no income at all, 61% are food insecure and many live in shelters.

(b)Parents Helping Parents makes intensive home visiting accessible to high risk families referred through the provincial Healthy Babies Healthy Children regardless of where they live, what language they speak or their ethno-cultural group. Recently announced provincial funding is now expected to cover the costs of this expansion over the next three years.

(c)Two hundred and fifteen (215) child nourishment programs now reach 34,000 elementary school children. The municipal funding for child nutrition programs provided equity among existing programs, improved frequency and nutritional content of meals served, and has been successful in leveraging an additional $1.2 million in funding during its first few months of operation.

(d)Communicable diseases control policies and procedures are currently being reviewed and harmonized.

(e)A harmonized Animal Control By-law will soon be completed and a review of these services will soon be underway.

(f)A harmonized ETS by-law is being completed and will be presented to the Board for consideration in early spring.

(g)Recommendations for the harmonization of dental services in Toronto Public Health and Community & Neighbourhood Services will be forthcoming to the January Board of Health meeting.

(h)Two Public Health grants programs (AIDS prevention and drug abuse prevention), previously offered only in the former Toronto, are poised to go city-wide with the next granting cycle. Municipal Grants Review Committee's preliminary recommendations were to retain the same grants budgets into 1999 (with a one-time fiscal adjustment to bring the AIDS prevention grants into accounting alignment with other City grants). A flat-line grants budget means that a service reduction will occur in the former Toronto to accommodate grants allocation in other parts of the City.

Companion reports (Meeting Provincial Standards Across the City for Selected Public Health Programs and Services, January 18, 1999/Harmonization of Dental & Oral Health Services, January 15, 1999/Harmonization of Food Access Grants, January 15, 1999) detail possible program changes, costs and impacts of options for five public health services deemed to be most critical on the basis of: a) burgeoning local poverty and need (dental, food access); b) potential liability for the City and risk to health, resulting from differing service provision across the former health units where new provincial Mandatory Guidelines exist (needle exchange, tuberculosis control, food safety):

Additional program changes, costs and impacts will be brought before the Board of Health for consideration in 1999 as program planning proceeds.

(D) Funding and Budget Issues

To offset municipal spending, Toronto Public Health seeks external revenue in the form of grants to negotiated partnerships. Efforts to increase revenues continued in 1998 with standardization of Environmental Health user fees and research on potential cost recovery mechanisms. Further detail on revenue generation Public Health is provided in Appendix A.

In a report titled "Service Level Harmonization", put before Strategic Policies and Priorities Committee by the Chief Administrative Officer (September 18, 1998), it was recommended that appropriate standing committees review service level variations and that input from the Standing Committees be used by departments for preparation of the 1999 budget estimates. In that report, Public Health harmonization and newly mandated standards were included among programs that could have significant financial impact. The report further recognized that harmonization will be a multi-year undertaking and priorities will have to be established for the sequencing of programs to be reviewed. The companion reports mentioned above, provide this information for Board consideration.

Public Health met all assigned budget savings targets in 1998. Savings worth approximately $1.7 million were achieved in 1998. Annualized savings of $1.6 million resulting from implementing the 1998 budget reduction proposals will be achieved in 1999. Public Health has also reduced its net staffing strength by 24.2 full time equivalents (FTEs). This reduction is a result of reducing 37.2 FTEs in management and staff positions and increasing 13 front-line FTE staff positions for the enhancement of Healthiest Babies Possible and Parents Helping Parents programs in 1998.

It must be noted that, while the 1999 planning process is expected to identify additional savings opportunities, these will not likely be substantial. Almost all former health units had experienced several years of downsizing prior to amalgamation, and were documented by the Ministry of Health to have been underfunded relative to health needs prior to amalgamation and before consideration of new provincial mandatory guidelines. While new revenue generation is being pursued, the results will be modest and incremental over time.

Conclusions:

Comprehensive planning for Public Health programs and services, based on health needs and expected outcomes of interventions, remains a significant challenge for Public Health that will commence once the final management team is in place across the new organization. The Board of Health, along with staff and community stakeholders, will be involved in a planning process that will yield an investment strategy for the year 2000 and beyond. Investment options for 1999 are detailed in a separate reports.

Contact Name:

Connie Clement, Director

Public Health Planning & Policy

Tel:392-7463

Fax:392-0713

email: cclement@toronto.ca

Dr. Sheela V. Basrur

Medical Officer of Health

Attach.

Appendix A

Public Health Cost Offsets and Revenue Generation

To offset municipal spending Public Health seeks revenue and other means to reduce expenditures. While the provincial government is the main non-municipal funder of local public health services, this responsibility -- and the benefits -- are also shared by other sectors: namely, the federal government, business and the non-profit, community sector. This appendix provides an overview of the various mechanisms employed.

(A)Revenue Generation:

(1)Grants received by Toronto Public Health:

Provincial grants to Toronto Public Health exceed $3.3 million in 1998. Provincial funds of $764,000 in 1998, fund 37% of the total cost for child nutrition programs. Higher provincial funding is expected in 1999 for the most recent provincial initiatives (Healthy Babies, Healthy Children; Heart Health). In fact, the preliminary estimate for 1999/00 Healthy Babies, Healthy Children revenue is $9.14 million (up from $4.67 in 1998/99).

One-time provincial funding in 1998 existed for research and education, reproductive health information, AIDS Hotline and Methadone Works and some reimbursement for dental treatment to children of families on social assistance. The future status of this funding is variable. AIDS Hotline funding is in place for 1999. The status of funding for research and education and for two contracted services (Sex Information Education Council of Canada and Planned Parenthood of Ontario's Facts of Life Line) should be determined early in 1999, prior to the end of the current funding which extends to March 31, 1999. Provincial staff have suggested that renewal of the Methadone Works project funding is unlikely.

Health Canada project grants totalling over $175,000 were received in 1998 to develop or evaluate four health promotion programs: Rainbow Fun physical activity for young children; a needle exchange newsletter; the Ambassador Program (an inter-agency project housed within the Drug Abuse Prevention Project); and a provincial food service health promotion program with additional federal and provincial funds for the food service project that will exceed $240,000. The Canadian Public Health Association also paid for the development of a training package on HIV/AIDS partner notification.

External funding such as this enables the Division to develop good quality information for use in Toronto. It also often results in substantial requests for copies of materials, which are generally fulfilled on a cost recovery basis. Examples of successful products are Rainbow Fun and Tooth Whiz, a dental health project, both of which are distributed nationally.

(2)Contracting Public Health services to others:

A pilot project is underway currently whereby a downtown hospital pays for public health nurse home visits to new mothers and newborns discharged from hospital through early discharge arrangements. The pilot is being evaluated and may establish a model that can be emulated.

(3)User fees and charges to others:

In July 1998, Council approved a uniform schedule of environmental user fees which include fees for licenses, requests for file searches and inspections/reinspections, body shipment, mobile food premises approvals, food handler and pool operator training, etc. Under the new schedule, such fees could generate approximately $390,000 per year. User fees and charges are being explored for additional Public Health services, e.g. for educational materials, consultation on services, and the provision of information in response to agency requests.

(B)Corporate Sponsorship

Corporate sponsors assist Toronto Public Health in the following ways.

(a)Corporations contribute funding for programs (e.g. a teen parenting program).

(b)Private firms sponsor the production and distribution of resources (e.g. teacher resource kits for dental programs).

(c)Companies provide materials (e.g. clinic supplies, contraceptives, vouchers/TTC tokens/other incentives for participants in programs such as directly observed therapy).

(d)Corporations directly sponsor campaigns such as safe graduation, senior's influenza immunization promotion, and injury prevention.

Currently Toronto Public Health is exploring additional opportunities to increase sponsorship arrangements.

(C)Expenditure Reduction

(1)Grants received by partnerships and collaborative projects:

Some funders require that grants be flowed to non-profit community organizations (not to a level of government). Therefore, in many partnership situations, grants that we have helped obtain and that contribute to local public health objectives are not reflected in divisional revenues.

In 1998 federal grants (Health Canada, Ministry of Transportation, Human Resources Canada) were received by public health/community partnership programs for local prenatal nutrition, community action programs for children, injury prevention, and cancer prevention. Currently grants from foundations such as Trillium, Children's Aid, Canadian Living fund key partnership programs and neighbourhood initiatives in community care, child health and access to food and housing. Currently, staff are meeting with a local foundation to encourage allocation of the resulting from provincial gambling regulation changes.

(2)Contracting service from non-profit agencies:

In some cases Public Health contracts services from community organizations because of their capacity to effectively serve hard to reach populations who face barriers in accessing mainstream services (immigrant women, people without housing). Short-term grants (in AIDS and drug abuse prevention) are integrated within program policy and used to ensure wide-spread, community-centred service delivery. In many cases this purchased service is not only appropriately community-focussed and accessible, but less expensive than a similar service would be if offered directly by municipal staff. The community agencies that receive grants maximize the value received for each funding dollar by extensively using volunteers, by matching with in kind donations and by leveraging or matching additional grant dollars to the City funding. Thus, spending money to purchase service is often the most cost-effective means of program delivery.

(3)Volunteer and in-kind contributions:

Community partners contribute resources for public health in the following ways:

(a)paying programs costs (e.g. providing food and child care for newcomer prenatal education, funding training for volunteers at programs such as Cooking Healthy Together);

(b)providing staff to assist Public Health delivery (e.g. to assist in the delivery of services such as the methadone program);

(c)guiding the development of services to meet local needs, providing advice and consultation and assisting in evaluation;

(d)fundraising (raising matching funds, writing grant proposals);

(e)delivering services and providing case management (e.g. providing Healthy Babies Healthy Children services beyond the negotiated envelope);

(f)providing outreach, referral and service access, often involving volunteers (e.g. teen peer support volunteers, breast feeding partners and mothers companions)

Volunteers and staff in community agencies who work jointly with Public Health frequently provide complementary services to Public Health, assist clients before and after Public Health's contact, and function as the point of entry for a client to public health services.

It should be noted that in some communities, especially where a small number of agencies have tried to keep pace with increasing local needs, sometimes within a context of diminishing resources, existing partnerships and collaboration opportunities are stretched to the limit. Public Health expenditures for honoraria, shared costs and the like return many-fold through community contributions.