Moving Forward from the COVID-19 Pandemic: 10 Opportunities for Strengthening Canada’s Public Health Systems
Section 2: What are the key challenges facing Canada’s public health systems?

Section 2: What are the key challenges facing Canada’s public health systems?

Across dialogue sessions, participants identified several longstanding challenges that must be addressed in order to build robust and equitable public health systems that are equipped to take on the urgent threats facing Canada, the global community, and the planet. These challenges predate the COVID-19 crisis and have long been recognized and debated by the public health community. However, the pandemic put existing gaps and weaknesses into sharp focus and demonstrated the unsustainability of a business-as-usual approach to funding, designing, governing, staffing, and coordinating public health systems in Canada. This section outlines the major issues that dialogue participants identified as requiring immediate attention and action.

Participants consistently identified the persistent challenge of addressing the structural inequities and discrimination that are embedded in and perpetuated by Canada’s public health systems. Across governance, practice, research, training, and data, and from the local to the global levels, there is an urgent need to put equity at the core of public health and an enormous amount of work to be done to build systems that are anti-racist and anti-colonial. The pandemic highlighted this challenge in multiple ways, including the heightened risks faced by communities experiencing conditions of marginalization, governments’ failures to consistently address equity considerations and the circumstances of specific groups in public health recommendations and interventions, and a lack of pre-existing systems to collect race-based data, which led to ad hoc processes that did not always produce high-quality information. Participants emphasized that change is required at the individual and institutional levels. At the individual level, there is a need for critical and ongoing self-examination among those who have been privileged within and played a role in perpetuating the status quo. This reflection must involve a willingness to be uncomfortable and should be linked with ongoing action to ensure that colleagues who are Indigenous, Black and People of Colour (IBPOC) are not asked to do the heavy lifting to effect change. At the institutional level, change must begin with recognizing that existing public health systems have their roots in a colonial and racist society and naming the ways in which these systems have perpetuated colonialism, racism, and other forms of structural violence. This system-wide reckoning must be accompanied by a long-term, well-resourced, and accountable commitment to legislative, policy, and organizational action in partnership with relevant communities – including revisiting how different orders of government address the rights and self-determination of Indigenous peoples within and outside of public health governance.

Dialogue sessions also highlighted that public health is a broad field with many goals, definitions, functions, and specializations. As a result, the importance of the public health sector, its upstream and intersectoral scope, and its role in relation to the broader health and care systems are not always clearly understood and adequately supported. There may not always be agreement about what public health “is” and “does” even within the public health community. One concern voiced by participants is that due to the critical and visible role of public health institutions and practitioners during the COVID-19 pandemic this broad scope of public health may be reduced in the eyes of the public to infectious disease control. Despite this renewed public health focus on health protection due to COVID-19, participants emphasized several areas that will remain core to public health’s mandate in the coming years, including work with partners on the social, structural, and ecological determinants of health and the continuing challenges of promoting mental health and tackling non-communicable diseases. Fulfilling this mandate requires sustained public investment tied to the full spectrum of public health functions and the creation of governance structures that support an intersectoral and whole-of-government policy approach. This will be a critical time for public health strengthening since as participants noted, the public health sector has been chronically underfunded across orders of government and its upstream functions are particularly vulnerable to disinvestment and displacement, with serious consequences for health outcomes in crisis and non-crisis times.

Participants noted that the public health sector’s vulnerability to funding shortfalls is in part linked to a lack of national standards regarding what provincial and territorial systems are expected to deliver. Despite the country-wide implications of, and importance of coordinated action on, existing public health challenges – including infectious diseases such as COVID-19 as well as issues like climate change and health inequities – no nationally agreed-upon basket of essential programs and services or minimum standards for public health delivery exist. This results in a lack of consistency in the scope and functions of public health systems across the country and leaves public health unprotected when budgets are cut and systems are restructured. Clarity regarding the federal government’s role in public health both during and outside of emergencies is also lacking. This fractured approach to public health delivery domestically also extends to Canada’s strategy beyond its borders. Participants described the lack of a coherent link between the country’s domestic and global public health approaches and the absence of a strong voice for the public health sector in Canada’s global health policy.

Despite considerable differences in public health governance and delivery across provincial and territorial systems, dialogue sessions outlined some common institutional design challenges. The COVID-19 pandemic highlighted a need to clarify roles, responsibilities, and authority within governance structures and raised questions about balancing the autonomy and policy influence of public health officials. The lack of clarity in role definition across orders of government weakens accountability and creates challenges to mounting an efficient and coordinated public health response. In addition, the pandemic underlined an ongoing tension between the goals of having public health leaders who are able to access, work with, and advise elected officials in decision-making processes on one hand, and possess the autonomy to advocate externally and maintain credibility as independent experts on the other. For example, although some participants suggested that provincial Chief Medical Officers of Health (CMOHs) would gain autonomy if their role were structured to report to the legislature rather than to Ministry officials, others pointed out that being positioned within executive government can amplify CMOHs’ internal policy influence.

Common challenges also exist within the public health workforce. Participants emphasized that there is a longstanding shortage of surge capacity within public health systems across the country, which impedes the ability to meet expanded human resource needs during crises, reduces opportunities to integrate frontline community knowledge into emergency interventions, and forces community agencies to step in when upstream public health services are disrupted by the system’s shift to crisis response. During the COVID-19 pandemic, inadequate surge capacity was compounded by the lack of effective processes to rapidly connect public health trainees with system needs. It was also complicated by the lack of sufficient and comparable data about the distribution and skills of public health professionals in different parts of the system, including personnel who could perform functions such as testing and contact tracing.

This data challenge extends beyond surge capacity. Dialogue sessions repeatedly made clear that a critical and widespread data gap impairs the ability to measure, evaluate, and compare public health systems, workforces, and needs across Canada. Participants identified a lack of basic data about the number, structure, skills, and racial and Indigenous identities of the public health workforce; major gaps in information about the public health sector’s constituent organizations, resources, programs, funding levels, inputs, and outcomes; inadequate data about social determinants of health and health equity; and insufficient public health systems research to inform institutional design and restructuring. This absence of data and research poses serious challenges to evaluating and coordinating work across provincial, territorial, and municipal public health systems and to scoping future needs. It also precludes adequate tracking of Truth and Reconciliation Commission and employment equity commitments. Dialogue sessions additionally highlighted challenges to cross-jurisdictional coherence in data governance and sharing, including barriers to accessing and linking different sources of public health data due to a lack of common standards or processes related to data ownership, collection, access, and use. In the context of the COVID-19 pandemic, participants noted the lack of interoperable vaccination data across jurisdictions that would have enabled the creation of a national vaccine registry.

Although the need for national coherence in public health system standards and information was a common theme across dialogue sessions, participants also emphasized the public health field’s local roots. Public health delivery is fundamentally community-oriented, but decisions made by other orders of government do not always adequately consider local needs, processes, and knowledge – including the expertise of local Medical Officers of Health (MOHs) and other public health practitioners who engage with communities on the frontlines. Local expertise is particularly important to address different needs within jurisdictions and across geographic settings, such as urban, rural, remote, and Northern environments. A local approach is also essential in data collection. Gaps were identified in the availability of granular data to assess the needs and outcomes of different communities and address inequities among them, including insufficient race-based data and data regarding Indigenous peoples. Participants cautioned that although community-level data on needs and outcomes are necessary to address inequities, it is equally important to tackle stigmatization and discrimination in data collection, interpretation, and use. One example that was raised involved the risk that releasing race-based data on COVID-19 infection and vaccination rates could further marginalize certain communities that had not received adequate support or communication from the public health system.

Dialogue sessions identified that fulfilling public health’s local mandate also requires greater community engagement and public participation in decision-making processes. Without input from relevant communities and individuals with lived experience, public health interventions can be ineffective and harmful in practice – such as hand-washing recommendations that ignore the federal government’s failure to ensure adequate access to water in many Indigenous communities. Similar issues were identified regarding public health research processes. Participants noted that research questions frequently originate outside of the relevant communities, funding deadlines leave inadequate time to build trust and relationships with community partners, and the benefits of funding and research do not typically accrue to community members. Moreover, research that focuses on Indigenous communities too often fails to consider questions of equitable data stewardship, to ensure principled engagement based on authentic relationships, and to reflect Indigenous values, concepts, and ethics. Similar concerns about values, ethics, and community control and ownership were raised regarding research that focuses on Black communities. Much work remains to be done in scrutinizing the ways in which research funding systems and knowledge hierarchies within public health perpetuate colonial worldviews and structural inequities.

Engaging and building trust with communities is also critical to increase the effectiveness of public health messaging. The COVID-19 pandemic highlighted that there is a need to improve the clarity and targeting of public health communications and enhance transparency regarding decision-making processes. This is particularly true in contexts where evidence is limited and changing rapidly, recommendations evolve quickly and differ across jurisdictions, misinformation is amplified on social media platforms, and community members may not trust public health professionals. For example, shifting pandemic recommendations regarding mask-wearing and vaccines highlighted the challenges of communicating rapidly-changing evidence and guidance to the public in an effective and credible way. Pandemic communications also demonstrated that when messaging and recommendations are framed at a population level, specific groups – such as Indigenous peoples and individuals with disabilities – can be overlooked or find recommendations inapplicable to their circumstances. Public health communications strategies also face a challenge in addressing the digital access and literacy divides and adopting alternative messaging modes to ensure that no one is left behind.

Several of the challenges discussed above – including gaps in community engagement, surge capacity, equitable response, and effective messaging – demonstrate that a need exists to align public health training and competencies with current realities and system needs and to create stronger links among the public health research, training, and practice communities. In addition to noting the importance of strengthening competencies in areas such as health analytics, policy and governance literacy, structural and ecological determinants of health, community relationships, management and leadership, and risk communication, participants emphasized the critical lack of training on Indigenous health, anti-racism, and anti-colonialism in public health schools and the gap in public health faculties’ capacity to teach about these issues. Dialogue sessions also highlighted the need for more effective partnerships between the research and practice communities. Specific challenges that were raised included the limited exposure between these communities at the training level, a lack of research on topics of operational relevance, insufficient focus on translating academic research into public health practice, and inadequate opportunities for practitioners to undertake research in an embedded and supported way.

• Previous - Section 1: What did we do, and why?
• Next - Section 3: What opportunities exist?

Date modified:

2022-03-23