The severe acute respiratory syndrome pandemic in 2003 was the catalyst for Canada overhauling its complex federal health system and building an integrated, data-led system for public health – one that doesn’t just patch people up, but keeps them well
In Canada, health care is largely delivered by individual provincial governments, with the federal government responsible for Indigenous peoples, corrections, Canadian Forces, veterans and the Royal Canadian Mounted Police. The governance of health and health care in Canada is complex. But there is nothing healthy about fragmentation in complex systems.
In 1990, as a family doctor, I became involved in the campaign to protect the autonomy of a hospital in downtown Toronto. We believed we were protecting the future of health and health care. We were fighting the merger of our hospital with the largest teaching hospital. We believed that our vision and values would be submerged. Our strengths were multidisciplinary teams, ambulatory care focused on community-based care, addressing the social determinants of health and firmly committed to the patient as a true partner in their care. The goal was the most appropriate care in the most appropriate place, by the most appropriate provider at the most appropriate time. We won that fight and Women’s College Hospital still leads the healthcare revolution.
Since I was elected to Parliament in 1997, I have been involved in conversations about breaking through silos in government departments and the gridlock among all orders of government. From disability issues to childcare to climate change to reducing poverty, fragmentation has hindered progress.
In 2003 after the severe acute respiratory syndrome pandemic, I was appointed Canada’s first minister of state for public health. We set up the Public Health Agency of Canada, appointed the first chief public health officer and set up the Public Health Network for Canada to provide a structure for all 13 provincial and territorial jurisdictions to work together to protect the health of Canadians.
Germs don’t respect borders
It was clear that ‘germs don’t respect borders’. We had to do better. We needed an integrated system for public health. The idea of ‘central command and control’ was anathema to our complex federal system, particularly in the province of Quebec. Four Cs had been put forward as principles for public health: cooperation, collaboration, communication and coordination. The last – coordination – was unacceptable in our federal system, and quickly replaced by ‘clarity of who does what when’. Top-down central command and control would not work.
Learning health systems must be built from the bottom up, respecting local wisdom and local knowledge. Good public policy is the result of decision makers actually picturing the people who are affected by it. A learning health system has to move from fragmentation to integration based on shared, accurate data. Complex adaptive systems measure, adapt and measure again. Local public health authorities working together with community-based organisations need the capacity to measure as they go and to be linked to the scholarly work that can determine the wise and promising practices that are evidence based, trauma informed and culturally competent.
We must remove the unacceptable lag in moving from research to policy, and then from policy to practice, with embedded applied research. Data saves lives. Transparency and accountability in outcomes are required for developing and implementing healthy public policy, so the healthy choices become the easy choices. Putting the public back into public health requires serious intentionality in effective public education, health literacy and civic literacy so that citizens can advocate for real change.
When SARS hit Canada, we had 44 deaths in Toronto compared to zero in British Columbia, where the system was much more integrated. Ontario’s fragmented system killed people. Moving from fragmentation to integration requires that we measure what matters. The public health data, and administrative data from the healthcare system, are insufficient. We need better community-based data. We need to provide support to the already overworked front-line community workers to collect the data and the stories and link that information with the academy so we have the evidence to fund what works and stop funding what does not work.
Mapping health outcomes
If a picture is worth a thousand words, then a map is worth a thousand pictures. Mapping health outcomes with social and environmental determinants can reveal inequities in ways that citizens can understand.
In our fight for evidence-based practice, we also need to tell the stories of unfairness and inequity. The malicious dissemination of misinformation and disinformation is often based on anecdotes. We need stories too, and one unhelpful anecdote needs to be countered by many helpful stories and excellent qualitative research.
The appetite for genuine health and healthcare transformation today makes me optimistic. The Integrated Youth Services model has been adopted by all provinces and territories in Canada with youth-led and youth-centred care for young people aged 12 to 25. Peer support, primary care, psychologists, addiction medicine, social support for housing, education and employment will wrap around each young person. IYS is now an evidence-based success.
Recent federal health investments in provinces and territories have focused on four areas: attachment to family health teams, health human resources, mental health and substance use, and health transformation using modern technology. Each jurisdiction provides action plans with indicators, data, real accountability and transparency to their citizens.
We are all committed to bridging the barriers and obstacles presented by technologies such as diverse and incompatible patient record and referral systems – such harmful fragmentation.
The heartbreaking toxic drug overdose crisis requires integration between public health and public safety and international cooperation on controlling fentanyl precursors and sharing wise and promising practices. All sectors are trying to do their part to end this terrible tragedy. Trade unions hand out Naloxone to members so they can be heroes. Mayors across Canada advocate for supportive housing for the complex cases of people with mental illness and problematic substance use. The largest teaching hospital in Canada – the same hospital whose merger with Women’s College Hospital we fought in 1990 – is investing in 55 prescribable housing units. They all want to be part of the upstream solutions.
For decades we have quoted Tommy Douglas, the father of medicare in Canada, who knew that we would have to “keep people well, not just patch them up when they get sick” if our cherished healthcare system was to be sustainable. We need to learn from the teachings of the medicine wheel: a lifecycle approach to achieving balance mentally, physically, emotionally and spiritually. This integrated approach is clearly superior to the fragmentation of the medical model – the repair shop model I was trained in at medical school.
Health is indeed a political choice. Moving from fragmentation to integration is essential for One Health and Health in All Policies. It is our moral imperative.