September 30, 1999
To:Board of Health
From:Dr. Sheela V. Basrur, Medical Officer of Health
Subject:Chief Administrative Officer Review of Public Health Programs and Services, City of Toronto
Purpose:
This report is to inform the Board of Health of the context and Terms of Reference for the Review of Public Health
Programs and Services (see Appendix A).
Source of Funds:
There are no financial implications for the 1999 budget year. However, the results of this review may have implications for
the 2000 budget cycle and subsequent budget years.
Recommendations:
It is recommended that the Board of Health receive this report for information.
Council Reference/Background/History:
City Council at its meeting of April 26 and 27, 1999 directed that a review be undertaken of "all Public Health programs in
terms of defining the extent of mandatory/ discretionary programs". Their direction was based on the April 20, 1999
recommendations of the (former) Strategic Policy and Priorities Committee and the April 16 Budget Committee. This
review of Public Health was one of many projects in the Corporation identified to be undertaken by the Chief
Administrative Officer (CAO).
Within the Public Health Division, there are currently six external reviews in process; four pertaining to Dental Services,
one to Animal Services and this review. The responsibility for these reviews rests singly or in some combination of the
Auditor, the Chief Administrative Officer (CAO), the Commissioner of Community and Neighbourhood Services, and the
Medical Officer of Health (MOH). The CAO, in consultation with the MOH, has responsibility for this review.
The CAO and the MOH have had several meetings and discussions to delineate the scope of this review. At this point, the
review is described in two phases (see Appendix A). The first phase will define the extent of mandatory and
non-mandatory/discretionary program and service delivery by Toronto Public Health in consultation with the Medical
Officer of Health. The anticipated time frame is from October 1999 to February 2000.
The second phase, if required, will take place from March to May 2000. This phase would entail a comprehensive review
of mandatory and non-mandatory/discretionary public health programs and services; in consultation with the MOH.
Comments:
Public Health programs have been impacted by the combined affects of amalgamation, downloading, and new mandatory
provincial public health standards that are more detailed and prescriptive than previously. This review was initially
requested in early 1999 when public health programs and services were essentially to be totally funded by the municipality
after being downloaded by the Province. However, in March 1999, the provincial government announced its intention to
cost-share public health services 50 - 50 with local municipalities. In April 1999, City Council approved the 1999 Public
Health budget.
The issue of provincially mandated versus locally mandated by City Council is complex and incorporates pivotal policy,
financial and governance issues for the Board of Health, City Council and the provincial Ministry of Health. Legally, under
the Health Protection and Promotion Act, Part II, Section 5, local Boards of Health must provide or ensure the provision of
a minimum level of public health programs and services in specified areas. The Minister of Health establishes the
Mandatory Health Programs and Services Guidelines. It is expected that Boards of Health will deliver additional programs
and services in response to local needs, as outlined in Section 9 of the Health Protection and Promotion Act.
For each of the mandatory programs the Ministry of Health has established monitoring and assessment indicators for the
1998 Mandatory Program Indicator Questionnaire. Each Board of Health reports compliance to the Ministry of Health
Conclusions:
Toronto Public Health will continue to work in close collaboration with the CAO throughout the review process.
Contact Name:
Connie Clement, Director
Public Health Planning & Policy
Tel: 392-7463
Fax: 392-0713
Betty Burcher, Manager Health Planning
Toronto Public Health
Tel: 392-7450
Fax: 392-7418
Dr. Sheela V. Basrur
Medical Officer of Health
Attach.
Appendix 1
TERMS OF REFERENCE
REVIEW OF PUBLIC HEALTH PROGRAMS AND SERVICES
CITY OF TORONTO
Project Description:
The City of Toronto Council has directed that the programs and services of the Toronto Public Health Unit be reviewed in
various levels of detail. The purpose of this review is to differentiate mandatory and non-mandatory programs, inform the
priority-setting process of the Board of Health and Council, and identify service delivery and related issues based on these
findings.
Source of Directives:
City Council at its meeting of April 26 and 27, 1999 directed the undertaking of a Public Health program and service
review. Their approval was based on the April 20, 1999 recommendations of the (former) Strategic Policy and Priorities
Committee, having considered the recommendations of the April 17, 1999, Budget Committee.
Specifically, the Chief Administrative Officer (CAO) was directed to:
- Define the extent of mandatory and non-mandatory/discretionary program and service delivery by Public Health, in
consultation with the Medical Officer of Health;
- Undertake a comprehensive review of public health programs and services, including both mandatory and
non-mandatory/discretionary activities in consultation with the Medical Officer of Health; and
- Report to Council on the findings and recommendations of the review through the Board of Health to ensure
compliance with the Health Protection and Promotion Act, RSO 1990, Chapter H.7.
Project Approach:
Distinct project phases are being delineated to address the directives and fulfill the intent of Council. This is necessary in
light of the transitional state at the Province and in the Toronto Public Health Unit (TPH), in implementing new mandatory
requirements, operating and compliance parameters. Review phases allow a planned and logical integration of the required
study tasks with the current initiatives of TPH as it addresses Provincial and City mandates while continuing to merge six
formerly independent health units into a single management and service delivery structure.
Project Phases, Timing and Staff Responsibilities:
Phase 1:
To define the extent of mandatory and non-mandatory/discretionary program and service delivery by TPH in consultation
with the Medical Officer of Health (MOH).
Timeframe:October 1999 to February 2000.
Project Lead:Laurie McQueen, Senior Corporate Management and Policy Consultant, Strategic and Corporate Policy
Division, Office of the CAO.
Project Liaison:Betty Burcher, Manager of Health Planning, Toronto Public Health, Community and Neighbourhood
Services Department.
Steering Committee:Dr. Sheela Basrur, Medical Officer of Health; Shirley Hoy, Commissioner of Community and
Neighbourhood Services; Rosanna Scotti, Director of Strategic and Corporate Policy; and Mike Garrett, CAO, as required.
Reporting Process:Status up-date reporting will occur as required to the Chairs of the BOH, Policy and Finance
Committee and Community Services Committee.
Reporting on study findings will be jointly by the CAO and the MOH through the Board of Health to the Policy and
Finance Committee and Council, in early 2000.
Phase 2:
If required, based on Phase 1 results, to undertake a comprehensive review of mandatory and non-mandatory/discretionary
public health programs and services in consultation with the MOH.
Timeframe:March 2000 to May 2000.
Project Leads:Laurie McQueen, Office of the CAO; Betty Burcher, Toronto Public Health; and a representative from
the Audit Department.
Project Team:May be expanded to include external consulting assistance if required.
Steering Committee:Sheela Basrur, MOH; Shirley Hoy, Commissioner of Community and Neighbourhood Services;
Rosanna Scotti, Director of Strategic and Corporate Policy; and Mike Garrett, CAO, as required.
Reporting Process:Status up-date reporting would be as required to the Chairs of the BOH, Policy and Finance
Committee and the Community Services Committee.
Reporting on study findings would be jointly by the CAO and the MOH through the Board of Health to the Policy and
Finance Committee and Council, in mid 2000.
The Traditional Role of Government in Public Health:
Historically, local boards of health were the earliest public structures created by the Government of Lower Canada. This
was precipitated by an outbreak of cholera in the 1830's and the recognition of the importance of sanitation in reducing
diseases and their transmission. In this context, health was no longer perceived as an individual responsibility, but one of
common public concern. In 1833, the Legislature of Upper Canada passed an Act allowing local municipalities "to
establish Boards of Health to guard against the introduction of malignant, contagious and infectious disease in the
province."
By 1882, the Ontario government passed the Public Health Act establishing the Ontario Board of Health and two years
later, the Act was amended to make it compulsory for local municipal Councils to form permanent local boards and to hire
medical officers of health. The delegation of public health responsibility to the local level 115 years ago has continued to
the present day.
The Changing Role of Government in Public Health:
Over the years, the Province has gradually increased its role in program direction and funding decisions. In 1997, as part of
Ontario's Services Improvement Act, public health legislation was also amended. Specifically, the Health Protection and
Promotion Act, RSO, 1990, was revised to include up-dated Mandatory Health Programs and Services Guidelines replacing
the 1989 Mandatory Core Guidelines. The Province also announced that municipalities would assume full funding
responsibility for public health services effective January 1, 1998 with the exception of certain programs identified as
province-wide priorities. The total impact on the City of provincial downloading in 1998 was approximately $40 million in
public health costs, compared to the receipt of $5.2 million in ongoing provincial funding and $2.7 million in one-time
funding.
Prior to 1998, general public health programs in Ontario were cost-shared 75%-25% by the Province and most
municipalities respectively, while the Province fully funded aspects of certain programs such as AIDS education,
enforcement of the Tobacco Control Act, sexual health, children's dental treatment and certain biological activities
(vaccines, antibiotics). In the six municipalities comprising the former Municipality of Metropolitan Toronto, and now
forming the City of Toronto, cost sharing for general programs prior to 1998, was 40% by the Province and 60% by the
municipalities.
The purpose of the Mandatory Health Programs and Services Guidelines, the MHPSG, is to establish minimum
requirements for public health programs considered fundamental for all communities. The programs and services are
targeted at the traditional areas of public health namely, the prevention of disease, the promotion of health and the
protection of health.
In March 1999, the Minister of Health announced that the Province was reinstating its funding to municipalities for
MHPSG activities. The funding formula is consistent across Ontario at 50% each from the Province and municipalities.
The province also announced additional funding to augment specific public health programs and services deemed priorities
by the Ministry of Health, and continued 100% funding for several programs such as the Healthy Babies/Healthy Children
program and the Pre-school Speech and Language program.
Toronto Public Health:
Role:
Public health activities are primarily focused on disease prevention, health protection and health promotion for the
population as a whole. In addition, public health has traditionally ensured access to health services for sub-groups of the
population such as persons of low-income, people in need, and people for whom no other agency services are available.
All programs and services provided take into account the underlying determinants of health (for example, education level,
workforce participation, social equity, social supports, and safety of the environment), factors to enhance health, and
modifiable risk factors. Acting in partnership with the community and other agencies is central to TPH as it identifies and
develops programs and methods of service delivery to respond to public health needs.
Legislation and Reporting Relationships:
Within the new City of Toronto, the Toronto Public Health Unit is an amalgamating area still in the process of bringing
together six formerly separate municipal health units. The TPH is headed by a Medical Officer of Health (MOH) and is
organizationally aligned with the Community and Neighbourhood Services Department. The MOH has a dual reporting
relationship. She reports to Council through the Department Commissioner in addition to reporting to the Board of Health
(BOH) as required in the provincial Health Protection and Promotion Act.
The Council is the employer of record and sets employment policy and funding levels in accordance with City-wide
budgetary processes. However, City Council is legally obligated (under the Act) to pay the expenses of the BOH and the
MOH with respect to the cost of mandatory programs and any additional programs to address local needs as recommended
by the Board and approved by Council (i.e. non-mandatory programs). The BOH reports directly to the City Council and is
comprised of 13 members, of whom six are City of Toronto Councillors, six are citizen members, and one is a trustee with
the Toronto District School Board.
Staff Complement and Organization Structure:
The total staffing of TPH in 1999 is approximately, 1,350 full-time equivalents (FTE's). The organization structure is a
mix of Directors having central management responsibilities for two major programs and, Regional Directors having both
decentralized delivery responsibilities across their regions for all programs, as well as responsibility for coordinating a
number of the sub-programs and services pertaining to centralized programs.
In the most simple terms, TPH can be described as having five central program functions; Family Health and Healthy
Lifestyles with 721.6 FTE's; Communicable Diseases with 245.3 FTE's; Healthy Environments with 214.7 FTE's; Public
Health Planning and Policy with 95.2 FTE's; and Support Services with 73.0 FTE's. TPH has a manager to front-line
worker ratio of about 1:12 and a ratio of senior management to all other staff of about 1:145.
Funding and Budget:
The amalgamation of the City coincided on January 1, 1998, with the effective date of the provincial MHPSG and
municipal responsibilities for 100% public health funding for general programs. Due to provincial reinstatement of funding
of MHPSG at 50% in 1999, the net operating budget is approximately $29.9 million less than that in 1998. In addition, the
1999 level of Provincial support, about $41.2 million, permitted TPH to address some City-wide harmonization priorities
in three MHPSG areas, namely, the Tuberculosis Control, Needle Exchange, and Food Safety programs.
Staffing costs comprise nearly 90% of the $111.8 million gross budget of TPH. The net budget of TPH was approximately
$53.5 million in 1999. The province provides 100% funding for approximately 5 managers, 1 supervisor and 31 front-line
staff positions.
TPH has met its 1998 and 1999 fiscal targets. It has also achieved its FTE amalgamation target by reducing the number of
staff by 37.5 in 1998 and by 27.5 in 1999, the majority of which (70%) were senior management positions.
Overview of Public Health Review Issues:
One of the major issues facing TPH, is the ongoing need to address differences within the organization that were created by
amalgamating former municipal public health units. These differences include variances in the definition and interpretation
of programs, the level and type of services, philosophies of intervention, and service delivery methods.
A second issue is the degree of appropriateness of the provincial MHPSG for a large urban area like Toronto with its many
high-risk population sub-groups. The guidelines prescribe mandated programs and services for all public health units in the
province and are being reviewed across Ontario in terms of activities, intervention strategies, and resource requirements.
A third issue is the number of concurrent conflicting political and economic demands being experienced by TPH. As in
other City operations, TPH is under pressure from Council to continue to find savings and to further reduce its
expenditures. Simultaneously, however, public health is unable to rely on cost-sharing consistency from the province, its
traditional funding partner. The Province first downloaded 100% of public health funding to municipalities in 1998, and
then resumed a funding role by assuming 50% of the costs of mandatory public health programs in 1999. Furthermore, the
MHPSG are very specific in their requirements for program activities. Preliminary assessment indicates that the guidelines
will necessitate a significant increase in staff and budget to fully implement.
Fourth, there are other matters related to the use of the MHPSG for which details are not yet available. For example,
methods for determining compliance with the guidelines are under consideration across Ontario. Also under consideration
is whether the release of 50% Provincial funding for mandatory activities, will be on a global or program-specific basis.
The decisions in this regard will have significant implications for the credibility and sustainability of public health in the
City. Both of these matters also serve to bring the role of the Board of Health into focus. Specifically, the Board has
responsibility under section 72 of the Health Protection and Promotion Act, to ensure that the amount paid for public
health is sufficient for the provision of the functions prescribed under the Act. The guidelines are part of the specified
functions and the Board is required to determine the resources necessary to attain compliance, as well as to ask for the
necessary funding from the City.
A fifth challenge for Toronto Public Health is to determine what type of service vision is appropriate for the City. This
includes identifying an appropriate balance in the City between a 'targeted population' vision that identifies the groups
most in need for intervention and assistance, and a 'population health' vision that is most concerned with reaching the
greatest number of people. Accordingly, this necessitates assessing what type and level of service will achieve both
compliance with MHPSG and best serve local community needs. It also involves managing workload according to
identifying priorities among provincially established mandatory programs and non-mandatory (locally established)
programs. In addition, TPH must assess its resource allocations and priorities among direct front-line service delivery in
relation to community development and advocacy activities.
Objectives of the Review:
Adjustments on the part of the City to increasing service requirements in light of fewer resources have been varied, ranging
from using a provincial loan to avoid an impending budget crisis, to decisions by Council to undertake several reviews of
public health programs. In addition to this comprehensive review of public health programs and services, there are also
reviews underway for the specialized TPH programs of Animal Services and Dental Services.
The operational and strategic planning exercise underway by TPH will inform and assist this review. The results of
collaborative MHPSG assessments by TPH, other public health units, municipal associations and university public health
representatives, will also be considered when available.
A phased approach to the review is recommended according to the following objectives:
Phase 1 Objectives:
(1)To review and document the evolution of the role of the City in public health service provision through an analysis of:
(a)pivotal policy decisions;
(b)purpose, context and benefit of policy decisions;
(c)process and responsibility for resource allocations;
(d)benchmarks of financial and other support levels;
(e)philosophical underpinnings of program development; and
(f)extent of non-mandatory, locally established programs and services.
(2)To identify the program responsibilities and objectives of Toronto Public Health in terms of:
- mandate, legislation, and Corporate objectives;
- functions performed;
- operations;
- budgetary and in-kind or partnership resources utilized; and
- role and relationship with other jurisdictions and associations including local municipalities, the Province of
Ontario, the Federal Government, school boards, community-based agencies, institutions for care, and the private
sector.
(3)To assess the capacity of Toronto Public Health to respond appropriately to changes in health needs through an
examination of:
(a)accomplishments to-date;
(b)relative priorities between mandatory and non-mandatory programs, program delivery methods, policy and service
coordination and innovation;
(c)procedures and standards providing management and operational control;
(d)program efficiency and effectiveness; and
(e)planning processes, administrative systems and reporting relationships.
(4)To identify the major policy, funding and operational issues that require prioritization and resolution.
(5)To confirm further review requirements based on Phase 1 findings and the outcomes of other related program and
service review initiatives underway at the City, the Province and by other public health and municipal associations.
If there is a Phase 2 Study, it may include the following Objectives:
(1)To articulate a framework to obtain the highest impact in service delivery by examining:
(a)the four key Provincial principles: need, impact, appropriateness and capacity;
(b)the availability of measures to assess the need, utility, impact and relative priority of Public Health programs and
services;
(c)options inherent in Board of Health legislation to "ensure" the availability of service (in addition to the requirement to
directly provide certain services); and
(d)options to raise external revenue, including corporate sponsorships and user fees.
(2)To identify TPH improvements to-date, as well as those needed to support BOH activities at a high-level through:
(a)reviewing current work, background reports, City and Provincial Ministry of Health legislation and current policy and
evaluative initiatives;
(b)ensuring clarity in the terminology, scope and definition of TPH programs in relation to provincial mandatory program
guidelines;
(c)assessing the inter-relationships between mandatory programs and community development and advocacy strategies
involving external organizations; and
(d)examining program management options like intervention-based groupings (e.g., all school-based programs;
stand-alone programs like TB; and same sub-population programs).
(3)To confirm with TPH staff and BOH members, the assumptions, rationale and priorities for non-mandatory programs
in order to identify:
(a)detailed needs assessment studies;
(b)service and agency/community partnership inventory listings;
(c)service utilization demand statistics;
(d)areas of apparent duplication, growth, or decrease; and
(e)associated staffing levels.
(4)To identify the major factors contributing to workload and work methods including:
(a)volume and nature of requests (including BOH, Council and provincial demands);
(b)volume and nature of consultations and site-visits;
(c)current utilization and output of staff resources;
(d)incidence of overtime and analysis of productivity;
(e)internal procedures for tracking and prioritization, case disposition and management, bring forward and follow-up
support systems, and clarity of program/output targets, as they may affect demand.
(5)To assess Phase 2 findings against those from internal and other TPH reviews, province-wide and municipal sector
association studies, and provincial MHPSG developments.
The Purpose of Program Review:
It should be noted that the program review process seeks to improve public, statutory, and procedural accountability in the
City of Toronto. Matters of relevance from this perspective include for example, examining whether programs are
operating according to their mandate, whether the residents of the City are receiving efficient and effective service, and
whether new initiatives and practices are required to meet demands in the current environment.
The program review is not, however, intended to be a comprehensive policy document. It will not, for example,
recommend specific public health service or organizational design, new policies or programs, or other initiatives that
require full consultation with the public health sector, the community, the Board of Health, and the City Council.
