Centralization and integration of public health systems: Perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces.

A strong public health system is critical to the effective management of public health emergencies such the coronavirus disease 2019 (COVID-19) pandemic. A public health system includes public sector organizations mandated to fulfil the essential public health operations of monitoring and response to health hazards and emergencies, disease surveillance and prevention, and health promotion and protection [1,2]. Public health system leaders play a role in directing, advising, implementing, and monitoring national, regional, and local pandemic responses. They include elected officials, government workers involved in health and emergency responses, medical doctors with legislated responsibilities addressing essential public health operations (e.g., medical officers of health), administrators of health services and non-governmental organizations, and scientific specialists (e.g., epidemiologists, microbiologists). Examining how power relations, responsibilities, and resources are distributed and coordinated among public health and other health system leaders and their respective organizations can help explain how systems perform in response to global emergencies. In particular, the extent to which power and responsibilities for public health are centralized versus decentralized and whether and how public health functions are integrated or coordinated with health care services, may impact the effectiveness of pandemic responses.

Centralization and decentralization have been defined as dynamic processes of redistributing powers, responsibilities or resources towards or away from a central government (national or sub-national) [3] or within government, whereby power is redistributed between the head of government and subordinate politicians, civil service members and agency executives [4]. The theoretical arguments for health system decentralization suggest that more local level decision making may allow for health resources and program planning to better reflect needs and preferences of the local population, thereby improving patient/public satisfaction as well as effectiveness [5], [6], [7]. Decentralization may lead to more experimentation and innovation, which could also improve overall health system performance if promising practices or reforms are scaled up. The extent of decentralization is also a key contextual factor influencing the initiation of intersectoral actions to promote health and equity [8,9]. However, more decentralized health systems may also exacerbate geographic inequalities [10], and increase health system costs due to potential duplication of services and functions, and lower economies of scale (e.g., for programs with high fixed costs such as laboratories, and information technology systems). Generally, any positive health system impacts with decentralization will depend on the capacity of the local/regional decision makers, for example, their skill and knowledge in health sector management and their ability to engage with local communities to ensure their needs and priorities inform decisions [5,[11], [12], [13]]. Based on a global review of studies examining the impacts of health system decentralization, decentralized systems appear to benefit from being “close to the ground” whereby leaders have greater access to information on, and experiences with, local community needs which can then translate into more contextually appropriate, efficient, and equitable decisions [3].

During public health emergencies, the potential advantages and disadvantages of decentralization may be different than in normal times. The theoretical benefits of decentralization generally do not apply to public goods with inter-jurisdictional externalities, such as pandemics and public health programs [14,15]. Highly centralized “command and control” style emergency management approaches are thought to be critical for timely decision-making, efficient redistribution of resources to address areas of need, and more effective coordination of the health workforce [16]. However, these approaches do not guarantee that central commanders have sufficient expertise for effective pandemic responses [17]. Within more decentralized systems, regional or sub-regional leadership may be able to compensate for weaknesses of central health system leadership, but may also experience challenges coordinating responses across regions [4,17]. Few studies have examined how public health system performance in a crisis, such as the COVID-19 pandemic, is impacted by centralization and decentralization [3,4,17,18].

The level of integration between public health and acute, or personal, health care systems may also impact pandemic responses. Public health and health care services can be considered administratively integrated when they fall within a common operational leadership structure, share a common mandate, and a shared budget [19]. The delivery of public health programs and services may also be functionally integrated with health care services if they are actively coordinated with one another, they share information systems, and work towards shared performance objectives [19]. The WHO has argued that integrating public health and health care allows for the adoption of a population health perspective in primary care which can lead to improved population health outcomes [20]. Also, during a public health emergency, integration may enable swifter mobilization of resources (e.g., health workforce, personal protective equipment, vaccines) [21,22]. However, the prioritization of resources for allocation to health care services (with a focus on treatment as opposed to prevention) over public health programs and services is a concern with integrating public health and health care sectors, especially in the context of constrained health system resources [23,24]. Whether and how the level and nature of integration between public health and health care services and the extent of centralization of public health systems impact the ability of public health actors to fulfil their roles in a pandemic are thus of critical importance.

Over the past 40 years, most provinces in Canada (except Ontario) have shifted from highly decentralized municipally governed and administered public health systems (e.g., locally-governed Boards of Health) towards more regionalized or centralized structures [25]. “Regionalization” reforms began in the 1990s and both maintained a decentralization of provincial powers but also a consolidation of municipal powers across broader regional geographies and across health service sectors (i.e., reforms reflect elements of both centralization and integration) [25]. Provincial governments have implemented these reforms to varying degrees with sub-provincial regional health authorities generally responsible for administering most public health programs and services. We focus on three provinces in our study with variations in the public health system governance and organizational structure, specifically with varying levels of decentralization and integration between public health and health care. Selecting these cases allowed us to consider whether and how aspects of public health system decentralization and integration impacted pandemic responses from the perspectives of those working in the system. Alberta, Ontario and Québec (see Table 1) are three of the most populous provinces in Canada and each have experienced high COVID-19 incidence and mortality relative to other parts of Canada [26,27].

The Alberta health system underwent successive regionalization reforms starting in the early 1990s [28]. In 2003, 17 regional health authorities were reduced to nine and then in 2008, shortly before the H1N1 influenza pandemic, Alberta centralized its health system [28]. This centralization reform involved the consolidation of nine regional health authorities and the creation of one province-wide arm's-length delegated health authority called Alberta Health Services (AHS) operating with five geographically defined zones [28].

In 2015, the Québec government consolidated 94 Health and Social Service Centres, abolished their regional governance agencies, and integrated 18 Regional Public Health Departments into 22 newly established Integrated Health and Social Service Agencies (Centres intégrés de services de santé et services sociaux [CISSS] and Centres intégrés universitaires de services de santé et services sociaux [CIUSSS]) responsible for the administration and delivery of public health, health care, and social services [29]. This reform was accompanied by regional public health budget reductions and it preserved the regional mandate of Regional Public Health Directors (here forward referred to as regional Medical Officers of Health [MOHs]) which in three regions includes the catchment areas of more than one CISSS/CIUSSS [30], [31], [32].

Ontario is the only province in Canada that maintained its decentralized public health system structure which, from 2007 to 2019, functioned alongside 14 Local Health Integration Networks (LHINs) that were responsible for planning and funding health care services for geographically defined populations [33]. In 2019, LHINs were decommissioned and the province-wide Ontario Health agency along with multi-sectoral Ontario Health Teams (in some regions) were established. The provincial government also began public consultation on plans to consolidate Ontario's 34 local Public Health Units bringing them under ten health regions [34]. These plans were subsequently put on hold due to the COVID-19 pandemic alongside planned reductions in the province's share of funding for local units [35].

In this paper we examine whether and how the characteristics of public health system centralization and integration in Alberta, Ontario, and Québec may have influenced COVID-19 pandemic responses. We are not aware of any study that has examined public health system centralization and integration in Canada in relation to effective public health emergency responses. However, previous experiences with emergencies underscored the tension between the need for centralized administration and coordinated messaging during emergencies with the need for public health leaders to foster strong connection with local communities to maintain trust and design effective, targeted measures [36]. Also, the Severe Acute Respiratory Syndrome (SARS) experience in Ontario revealed the fragmentation between public health and acute/hospital care that was also observed during COVID-19, as well as highlighting major deficiencies in pandemic preparedness and in information systems needed for surveillance [37,38]. Further, during H1N1, there were some challenges noted with the decentralized health systems such as variations in pandemic preparedness and difficulties redeploying health workers across regions [39]. Our objective is to generate insights into potential system-level facilitators and impediments to effective responses that can help inform post-pandemic public health systems reforms.

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