The inevitable health system(s) reform: an opportune time to reflect on systems thinking in public health in Canada.

Aslanyan, Garry ; Benoit, Francois ; Bourgeault, Ivy Lynn 等

Dear Editor,

The Canadian Public Health Association Conference is an unparalleled space in which to reflect on how public health system(s) function in Canada. This past June, we came together for a panel at the conference to critically reflect on whether the recent "public health renaissance" with new investments and greater focus have yielded a coherent health system. Needless to say, we all came to explore this question with our perspectives, biases, interests, expectations and hopes.

As many provinces and territories have recently updated their public health laws or structures and with the 2014 renewal of the First Ministers' Health Accord approaching with inevitable reform discourse, this is an opportune time to reflect on public health through a systems lens. Not only was the panel diverse but also attendees to the session represented similar diversities. A recurring theme was the collective preoccupation with the question of how to optimize governance mechanisms to ensure that public health system(s) are coherent in Canada. We agreed on a number of issues.

First, the Canadian multilevel and multiplayer public health puzzle is a "wicked problem." New ministries and agencies have injected additional complexity in terms of system configuration. This makes already challenging governance mechanisms even more complex both horizontally (between ministries and agencies on a provincial/territorial or national level) and vertically (between national and provincial/territorial/local levels).

Second, public health system(s) that produce and implement healthy public policies will be more effective if non-governmental organizations, community organizations, other sectors of government, academia, and communities themselves play an active role in the process. This helps orient public health to tackle the set of upstream environmental, social, cultural and economic determinants of health. A political and societal system that is focused on 'governance for health' is a prerequisite for effective healthy public policies.

Third, some elected leaders are open to transformation if provided with sound system-oriented advice. That advice should be informed by relevant evidence and rigorous research of both a qualitative and quantitative nature. The policy, systems and governance aspects of public health should increasingly be seen by academia as population health interventions which can and must be studied.

Last, the issue of public health systems thinking is not widely practised in Canada in any forum, except in part at the pan-Canadian Public Health Network Council (PHNC), through the Canadian Coalition for Public Health in the 21st Century or at CIHR's Institute of Population and Public Health (IPPH). The CIHR-IPPH has identified implementation systems in public health, and in other sectors, as a research priority. However, all of these are limited in their interaction with the broader constituency of public health in Canada and lack an overarching mandate.

As CPHA is a national organization with role and mandate for stewardship in public health, we call on CPHA to establish a permanent open forum that will systematically follow public health system aspects in Canada as part of its annual conferences. We stand ready to help CPHA in implementing this as we believe strong leadership and governance mechanisms are required to ensure the coherence of Canadian public health system(s).

Garry Aslanyan, Policy Manager, TDR, World Health Organization (WHO), Geneva, Switzerland

Francois Benoit, Lead, National Collaborating Centre for Healthy Public Policy, Institut national de sante publique du Quebec, Montreal, QC

Ivy Lynn Bourgeault, CIHR/Health Canada Research Chair in Health Human Resources Policy, Professor, Faculty of Health Sciences, University of Ottawa, Ottawa, ON

Nancy Edwards, Scientific Director, CIHR's Institute of Population and Public Health (CIHR-IPPH), Ottawa, ON

Trevor Hancock, Public Health Consultant, Victoria, BC

Arlene King, Chief Medical Officer of Health, Ministry of Health and Long-Term Care, Toronto, ON

Paulina Salamo, Toronto, ON

Carol Timmings, Past President, Ontario Public Health Association and Director, Healthy Living, Toronto Public Health, Toronto, ON