January 18, 1999

To:Board of Health

From:Dr. Sheela Basrur, Medical Officer of Health

Subject:Meeting Provincial Standards Across the City for Selected Public Health Programs and Services

Purpose:

To inform the Board of Health of the costs of service options for meeting new provincial standards across the City in three program areas in 1999 and beyond.

Financial Implications:

Recognizing the City's budget constraints, a range of service level options is identified for each program (Table 1). These options correspond to a range of financial impacts (Table 2). No source of funds has been identified. The estimated costs for meeting the new standards in these three program areas cannot be achieved within the current budget without service impacts in other areas. These cost estimates are based on current program configurations. Further analysis and refinement of these estimates is continuing to ensure efficiency and cost-effectiveness in the delivery of these services.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service level options for the Food Safety program and recommend the additional funding required within the 1999 budget approval process:

(a)Provision of an optimal service level for the City of Toronto, at an additional cost of $646,411 in 1999 (including a one-time cost of $61,000), and $1,756,234 in 2000 and subsequent years; or

(b)Provision of the minimum service level mandated by the Province, at an additional cost of $406,630 in 1999 (including a one-time cost of $39,900), and $1,100,189 in 2000 and subsequent years.

(2)the Board of Health select one of the following service options for tuberculosis (TB) control and recommend the additional funding required within the 1999 budget approval process:

(a)Provision of an optimal service level for the City of Toronto, at an additional cost of $726,159 in 1999 (including one-time costs of $100,000) and $1,878,478 in 2000 and subsequent years; or

(b)Provision of the minimum service level mandated by the Province, at an additional cost of $567,572 in 1999 (including one-time costs of $87,000) and $1,441,715 in 2000 and subsequent years.

(3)the Board of Health request Council through the Community & Neighbourhood Services Committee to advocate with the Board of Health and local hospitals for provincial funding to provide appropriate accommodation for people without housing who have active TB in order to reduce disease transmission and promote a stable environment which will assist them to regain their health.

(4)the Board of Health select one of the following service options for needle exchange for the purposes of HIV prevention and recommend the additional funding required within the 1999 budget approval process:

(a)Provision of an optimal service level for the City of Toronto, at an additional cost of $227,878 in 1999 (including one-time costs of $41,000 in 1999) and $560,634 in 2000 and subsequent years plus one-time capital costs of $82,000 in 2000; or

(b)Provision of the minimum service level mandated by the Province, at an additional cost of $180,565 in 1999 (including one-time costs of $41,000) and $418,696 in 2000 and subsequent years.

(5)the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients.

(6)the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999 unless ongoing external funding is obtained to continue the program beyond that date.

Background:

As described in the March 1998 report to the Board of Health entitled "Investing in Public Health", the goals of Toronto Public Health are to make public health programs and services accessible across the city and responsive to diverse needs, to improve the equity of health outcomes and the overall health of the population, and to maximize efficiency in the delivery of public health services. That report also described the potential impact on current services and resources as a result of the new provincial standards outlined in the Mandatory Health Programs and Services Guidelines, which were received from the Province in early 1998.

In August 1998, a preliminary budget forecast was submitted to the Chief Administrative Officer regarding estimated costs to meet these new provincial standards in relation to the following mandatory programs: Food Safety, Tuberculosis Control, and the needle exchange component of the Sexually Transmitted Diseases (including HIV/AIDS) program.

On October 13, 1998 the Board of Health adopted a report entitled "Issues Related to the 1999 Budget Supplementary Report". That report outlined the key directions being proposed by the Medical Officer of Health regarding next year's budget, including these priorities for mandatory program harmonization in relation to the new standards.

Comments:

Legal Framework

The fundamental role of the Toronto Board of Health is to promote and protect the health of the City's population. Health units across the province are regulated by provincial legislation. The Health Protection and Promotion Act, c.H. 7, R.S.O. 1990, the Regulations made pursuant to that Act, and the Mandatory Health Programs and Services Guidelines published by the Minister of Health, prescribe the duties and responsibilities of local health units. The Health Protection and Promotion Act states that every Board of Health shall comply with the mandatory guidelines. Should the Minister of Health determine that a health unit has failed to meet the prescribed standards, the Minister has broad powers to ensure the provision of these mandatory programs, the costs of which may be treated as a debt to the Province of Ontario by the obligated municipality in the health unit concerned. The Province also expects all boards of health to deliver additional programs and services in response to local needs and subject to municipal approval.

Framework for New Standards

In 1997, the Province made a series of "Who Does What" decisions that re-aligned financing responsibilities between the Province and local municipalities, a process commonly referred to as downloading. Public Health had previously been cost-shared between the Province and the former six municipalities in Toronto on a 40:60 ratio, respectively. In addition, the Province paid 100% of the cost of certain programs that reflected provincial priorities. Most of these programs and services were downloaded to the local level effective January 1, 1998. The Province still pays 100% of the cost for a few programs and services, the details of which will be contained in the February report to the Board regarding the proposed 1999 Operating Budget.

The harmonization of public health programs is complicated by the Province's introduction of new program standards in parallel with both downloading and amalgamation. The Mandatory Health Program and Services Guidelines were first promulgated in 1984 and substantially revised in 1989, the version that was in effect in the year preceding amalgamation. These were again revised effective December 1997 (accompanying downloading amendments to the Health Protection and Promotion Act) to ensure that the duties and responsibilities of local boards were clearly spelled out, that the implementation of mandatory programs and services was amenable to monitoring and enforcement by the Ministry, and to ensure that local municipalities paid the expenses incurred by local boards of health in the performance of their duties.

Public Health staff from Toronto and across the province participated in the development of these new standards, although final decisions were subject to the approval of the Minister of Health and Cabinet. The criteria used by the Ministry to develop these standards included:

(a)consideration of the health needs across the province;

(b)the effectiveness of interventions to reduce these needs;

(c)whether it was appropriate for local boards of health to undertake this work; and

(d)whether local boards of health had the capacity to provide or ensure the provision of these programs and services.

Compared with the previous 1989 edition, the new standards are considerably more detailed and prescriptive, leaving little room for discretion in some cases. By contrast, the old guidelines left more opportunity for varying interpretations of the standard. This had resulted in varying levels of program implementation across the former six health units in Toronto. Even without new standards in place, this variation in service level would have had to be addressed by the current Board of Health. Staff are attempting to develop preliminary estimates of the costs for service harmonization had there been no new standards, as compared with the costs of complying with the new standards.

However, it must be noted that the Province gave explicit consideration to the scientific literature and best practices as of 1997, including new and emerging health issues that exist in Toronto and elsewhere. Therefore, the new standards reflect a level of programming that staff could have recommended as the optimal level even if the new standards had not been in place.

Policy Setting Process

Pursuant to direction received from City Council in November, the Chief Administrative Officer is preparing a city-wide report on service level harmonization to the Strategic Policies and Priorities Committee, which will be referred for comments to local Community Councils and then to Standing Committees. This report will include information on the harmonization options contained in this report. It is generally recognized that harmonization will be a multi-year undertaking and that priorities will have to be established for the overall approach and sequencing of programs to be reviewed. Priorities for 1999 will include consideration of service levels for roads, sanitation, libraries and public health. As such, the Board's position on public health service level options should be conveyed to the Chief Administrative Officer as soon as possible. A detailed report on the public health component of the CAO's recommended operating budget will be presented to the Board of Health at its next meeting on February 22, 1999.

The options for service harmonization contained in this report are set out in relation to the City's health needs, evidence-based research, and the Board's legal duty to provide at least the minimum standard of provincially mandated programs. These options describe alternate levels of service which could be provided and which also comply with the prescribed standards under applicable legislation. The Board of Health (and, ultimately, City Council) has to make policy decisions, determined by financial, economic, social and political factors or constraints, as to which option is ultimately selected.

Once these programs have been harmonized, they will be monitored and evaluated to assess the impacts of the service level and funding decisions that have been made and the results will be reported to the Board.

Finally, it must be reiterated that the programs described in this report are the priorities for revision in 1999, not the full scope of public health programs requiring revision or enhancements to bring them into compliance with new provincial standards. As planning and amalgamation work proceeds, service level options for additional programs (e.g. in the Family Health and Lifestyles areas) will be brought forward for consideration in the Year 2000 budget cycle and beyond.

In addition to the programs dealt with in this report, options to harmonize selected local programs are described in companion reports appearing on this agenda including "Harmonization of Dental & Oral Health Services" and "Harmonization of Food Access Grants". Harmonization options for services for the homeless and options to harmonize ETS By-laws will be the subject of separate reports to the Board of Health at its February 22, 1999 meeting. Harmonization of the Animal Control By-law appears elsewhere on this agenda and harmonization options for Animal Services in general will be reported to the Board of Health later in the year for consideration in the 2000 budget cycle.

Description of Harmonization Options:

This report uses report-style appendices to explain the rationale for service harmonization in each area and to present two options for the Board's consideration.

Three of the 14 provincially mandated programs are prioritized for harmonization in 1999:

Food SafetyAppendix A

Tuberculosis ControlAppendix B

Needle Exchange Appendix C

For each program, Option A represents the optimal approach in health terms. This option is based on a combination of information on the City's health needs, evidence-based research, and the Ministry of Health's Mandatory Program and Services Guidelines, 1997. In each case, option A is the one which as Medical Officer of Health I must endorse from a Public Health perspective.

These options are supported because they:

(1)meet legislated requirements;

(2)respond to changing and increasing local needs;

(3)use strategies considered to be "best practice" substantiated by research evidence;

(4)provide coverage that enable achievement of effective prevention in the target or risk groups; and

(5)achieve geographic equity in access to services according to the distribution of need.

Option B represents an alternative approach that is not optimal in health terms but provides some service delivery at lower cost when compared with Option A. For each mandatory program, Option B represents the minimum level of service required by the Ministry of Health. All boards of health in Ontario must provide or ensure the provision of at least this level of service.

Options A and B are also compared with the outcome of a policy decision not to increase program resources. In the case of mandatory programs, the current envelope of funds would be re-distributed to provide a consistent level of service relative to the distribution of health needs across the City, recognizing that this level will fall below the minimum requirement. Redeployment of existing resources to serve the entire City will result in service reductions in one or more regions, with the threshold for service being raised in order to address only those with the highest needs.

Conclusions:

Starting in the fall of 1997, Public Health has consistently indicated that additional resources will be required to harmonize services, to meet health needs in cost effective ways, and to achieve compliance with provincially legislated and regulated requirements. The program options put forward for harmonization in 1999 must be considered in light of available information on health needs, the effectiveness of preventive measures, and the future costs of preventable illness and death. The Board of Health (and, ultimately, City Council) has to make policy decisions, determined by financial, economic, social and political factors or constraints, as to which option is ultimately selected.

Contact Name:

Dr. Sheela Basrur

Medical Officer of Health

Tel:392-7402

Fax:392-0713

Connie Clement, Director

Public Health Planning & Policy

Tel:392-7463

Fax:392-0713

Dr. Sheela V. Basrur

Medical Officer of Health

Table 1

Summary of Service Impact of Program Options