Section 3: Evaluation of the International Health Grants Program (2008–09 to 2012–13) – Findings — relevance

3. Findings — relevance

3.1.Continued need

Evidence from both the document review and interviews all strongly supported the need for the Program as the over-arching program structure for the funding of all international initiatives within the Health Portfolio. When the program authorities were renewed in 2008 and modified in 2012, the Program delivery model was confirmed as the best approach in the given circumstances to fund international health activities.

Ultimately, there is a need for countries, including Canada, to interact on an international scale to help shape global health priorities. By participating and collaborating in the global health arena, the Health Portfolio not only promotes Canadian values and a broad range of Canadian interests, but also protects the health of Canadians. Canadians have benefited from a collaborative and unified approach/response to previous health crises (e.g., SARS in 2003, H5N1 in the mid-2000s and H1N1 in 2009). These health crises were surmounted by collaborating with international partners provided through membership in various international organizations.

3.1.1.Continued need for membership in the Pan American Health Organization

Canada’s membership in PAHO has benefitted Canadians and has contributed to the work of the Organization. Evidence from the document and literature review, as well as a strong consensus amongst all internal and external respondents, indicated that there was a continued need for Canada to be a member of PAHO in order to continue to play an important role in influencing global health decisions.

Canada needs to be engaged internationally in setting international standards, building capacity, and influencing global public health policies and priorities. Globalization has a direct impact on the health and security of Canadians. In this globalized world, international collaboration on global health issues is necessary as public health risks increasingly transcend borders. Risks that originate in other countries can significantly influence the health of Canadians.^{Endnote 30} There is a need, therefore, for countries to consider new ways to interact on an international scale to help address global health issues. Issues such as pandemic influenza preparedness, HIV/AIDS strategies and global health security highlight the need for Canada to continue to place priority on engagement with key external health partners such as the World Health Organization and PAHO, two organizations bringing together international partners to address global health issues.

Canada benefits from its membership in PAHO
Canada derives significant benefits from its membership in PAHO. For example:

• In its leadership role in the region for monitoring and responding to requests for assistance in the event of natural disasters, PAHO has an effective disease surveillance system at the country level which is used extensively to provide an early warning system for Canadian tourists and business interests in Latin America and the Caribbean. This infrastructure is essential to ensure Canada is better prepared to respond to emerging and re-emerging infectious diseases.
• PAHO plays a crucial role in the Americas in the price negotiation and procurement of essential medicines such as vaccines. In 2006, approximately US$1.3 million of Canadian supplies was procured.
• As a major source of cross-national data on health status, determinants of health, and health care systems in the hemisphere, PAHO’s reports and micro-data files are a source of comparative information. Canada’s inclusion in PAHO’s country reports provides a valuable source for comparison of health-related factors with other countries of the western hemisphere. PAHO also provides important health information, best practices and guidelines that enable Canada to prepare and respond to health threats and supports evidence based decision-making.
• Canada’s membership supports the Government of Canada’s Americas Strategy which seeks to strengthen Canada’s multilateral and bilateral relationships in the hemisphere within the health sector.
• Participation by Canadian health experts in PAHO-sponsored activities throughout the hemisphere also strengthens Canada’s bilateral linkages with key countries in Latin America and the Caribbean such as Brazil, Chile, Mexico and the Caribbean.
• Membership provides links to the work of the nearly 200 PAHO/World Health Organization collaborating centres in 15 countries in the Americas, including 26 across Canada. Collaborating centres may be departments, laboratories or divisions within an academic or research institution, hospital or government. They cooperate with a specified PAHO/World Health Organization Technical Area, according to mutually agreed upon terms of reference.

PAHO/WHO Collaborating Centres contribute to the achievement of Public Health Agency and Government of Canada priorities The collaborating centres undertake important health research and project implementation throughout the Americas region which benefits both Canada and PAHO. This collaborative approach, regional networks and the exchange of experiences and lessons learned pertaining to policies, programming and best practices greatly benefit Canadian research units and health organizations. Other benefits for Canada include increased visibility and recognition of Canadian organizations and institutes nationally and within the region; greater global application and impact of Canada’s activities; new synergies and peer-to-peer opportunities; opportunities to mobilize additional and sometimes important resources from funding partners and better alignment with World Health Organization programs. The collaborating centres also help Canadian researchers connect with the other research, policy and practice teams connected to the World Health Organization to solve problems together, and provide a vehicle for sharing their research results with players on the global stage as well as national Ministries of Health around the world.

For example, a case study of the Collaborating Centre on Noncommunicable Disease Policy at the Public Health Agency of Canada indicated that the Collaborating Centre and its multisectoral policy focus of its 2012-2016 work plan contributed to achievement of key Public Health Agency and Government of Canada priorities, including:

• Action on the Declaration on Prevention and Promotion, adopted by federal, provincial and territorial Ministers of Health (2010)^{Endnote 31}
• Action in response to Curbing Obesity: An F/P/T Framework to Promote Healthy Weights^{Endnote 32}
• Implementation of the United Nations Political Declaration on the prevention and control of noncommunicable diseases (2011).
• As a member of the PAHO/World Health Organization Executive Committee, Canada benefits from working with other Members to: ensure that the Organization’s structure, accountability measures and results-based management practices continue to be updated and strengthened; align PAHO’s regional strategies with that of the World Health Organization; ensure that the recommendations of the United Nations Commission on Accountability with respect to maternal and child health in the Americas are implemented; advance regulatory capacity in setting standards, laws, and policies for safe medicines, including pharmaceutical products, vaccines and other biological; support building eHealth capacity to deliver quality services in remote and indigenous communities; and advocate regional approaches to address public health emergency preparedness and response.
• Canada’s membership provides the opportunity to assist other member states with the implementation of the International Health Regulations, allowing Canada to contribute to health security in the region which in turn, is important for sustaining regional economic stabilit

Recent reviews have concluded that there is a continued need for membership in PAHO

Other recent evaluations and studies have also concluded that there is a continued need for Canada’s membership in PAHO. The Evaluation of the Americas Strategy Final Report^{Endnote 33} and the Evaluation of CIDA’s Regional Inter-American Program^{Endnote 34}, both conducted within the last five years, demonstrated that it was in Canada’s interest to be a member of PAHO.

A recent review of Canada’s international memberships, including PAHO, emphasized that Canada’s membership in PAHO aligns well with the objectives of the Government of Canada’s Strategy for the Americas.^{Endnote 35} The Organization’s focus on communicable disease prevention and control in the region addresses public health security as described in the Strategy. The review confirmed that on-going interaction with the Organization and its 35 Member Governments served to advance Canada’s influence and interests in the Americas with respect to good governance, implementation of standard regulations, and capacity building. The review concluded that there were no substantive policy reasons for Canada to withdraw from PAHO as this membership serves Canada well in advancing and protecting its diverse interests in the Region.^{Endnote 36}

Non-membership in PAHO would have significant implications

Further, the Department of Foreign Affairs and International Trade of Canada’s review of international memberships, as well as interviews, identified a number of potential implications if Canada were to withdraw its membership in PAHO. Among them would be a negative impact on Canada’s membership in the World Health Organization. It might impact Canada’s implementation of its treaty obligations to cooperate with other countries in implementing the World Health Organization — Framework Convention on Tobacco Control, and the International Health Regulations in the hemisphere. Canada would no longer have access to PAHO’s networks that are essential for the protection of Canadians. Withdrawal could also result in significant loss of influence for Canada on the health agenda for the Americas as there would be limited interaction with other Member Governments within the multilateral forum.

The document review and interviews indicate that the implications for Canada of non-membership in PAHO, a strategic multilateral partner, would:

• limit Canada’s chances of being elected as a member of the Executive Board of the World Health Organization.
• lead to a loss of linkages with regional surveillance networks and emergency response centres, leading to a reduced capacity to respond to emerging health threats and to respond to international commitments to international legal frameworks such as the World Health Organization — Framework Convention for Tobacco Control and the International Health Regulations
• require greater effort required to engage countries of the hemisphere directly on health issues of mutual importance and to participate in a “level playing field” on issues of importance to the Americas
• reduce Canada’s ability to achieve the objectives of its Americas Strategy to influence and contribute to the promotion of Canada’s principles of democratic governance, security and economic prosperity in the hemisphere.

Similarly, Canada’s withdrawal of its membership would have significant implications on PAHO. As the second largest contributor in terms of membership fees, withdrawal would significantly impact on PAHO’s operations.

3.1.2.Continued need for the project component of the International Health Grants Program

The evidence pointed to the continued need for the project component of the Program. The findings of both the Summative Evaluation of the Program (2008)^{Endnote 37} and the Mid-Point Review (2010)^{Endnote 38} concluded that there was a continued need for the project component. The majority of interview respondents also agreed that there was a need for the project component, citing benefits for Canada. Interview respondents mentioned the following reasons to continue the project component of the Program. The project component:

• provided flexibility to fund smaller one-time projects that address priorities and emerging health issues
• enabled the Health Portfolio to leverage additional funding from other sources
• provided a mechanism for Canada and its experts to access platforms and groups researching emerging health issues.

A few respondents had mixed responses regarding the continued need for the project component and raised the issue of competing priorities in a fiscally limited environment. However, many interviewees cited that the project component was the only mechanism that the Health Portfolio had to respond to emerging global health issues.

Interview respondents also identified a need to continue to support individual smaller projects with domestic or international partners. Respondents indicated that in each year, there are more projects qualified for funding than the Program project funding component can fund. A file review conducted for this evaluation also supports this; in 2009-2010, there were 44 applications and only 21 (47%) were funded. To quote one of the interviewees “the needs always go far beyond what we can support. I think the challenge with this program is the limited resources”.

The document review also indicated that there is a continued need to support Canada’s membership in IARC. A recent Foreign Affairs and International Trade Canada review (2009-2010)^{Endnote 39} of Canada’s engagement with some multilateral organizations confirmed the continued need for Canada to be a member of IARC. The fact that the membership in this multilateral organization was maintained following the review reflected the importance of this organization for Canada.

Statistics from the Canadian Cancer Society indicate that cancer is a common disease among Canadians and, therefore, there is a continued need to be involved in addressing this issue. It was estimated that 2 out of 5 Canadians is expected to develop cancer during their lifetime, and 1 out of every 4 Canadians is expected to die from cancer.^{Endnote 40} Canadians benefit from the work of this intergovernmental organization, which is focussed on cancer research. Canada’s membership in IARC created an important interface with an international health organization and connected Canada to the latest best practices from other countries to help Canadians prevent, detect and manage cancer.

Canada’s membership was voluntary and a reflection of the continued importance of the disease to the health and wellbeing of Canadians. The document review found that Canada benefits from its membership in IARC by making use of the latest cancer research produced by IARC and by linking with worldwide international research endeavours through the international cancer research programme of IARC. For example, the review by the Department of Foreign Affairs and International Trade indicated that the scientific information provided by IARC is an important source of information to guide Government of Canada regulators in the approval of products or substances and to ensure, to the extent possible, that Canadians do not come into contact with carcinogenic substances.^{Endnote 41}

The amount provided to IARC was relatively small (S1.11 million in 2012-2013) compared to the total federal investment in cancer research ($212.3 million in 2006-2007). Canada’s membership in IARC eliminates unnecessary duplication of research and reduces the overall costs of etiologic research in Canada and worldwide.

The document review also supports a continued need for an on-going relationship with the Health Committee of the Organization for Economic Cooperation and Development. Health Canada benefited from its relationship with the Organization by using the Organization for Economic Cooperation and Development reports, internationally renowned for their credibility and high quality, to assess Canada’s health care system achievements and to learn from and share best practices in health policy development. The Health Portfolio disseminates the Organization’s publications to working groups and networks within Canada.

3.2.Alignment with Government of Canada and departmental priorities

The 2009-2010 ^{Endnote 42}and 2010-2011^{Endnote 43}Reports on Plans and Priorities for Health Canada reported on an International Health Affairs component, which aligned with Health Canada’s strategic outcome of an “accessible and sustainable health system responsive to the health needs of Canadians”. The 2009-2010 Health Canada Report on Plans and Priorities noted that the International Affairs program activity, under which the Program fell, provided strategic policy advice on health care issues to the Minister of Health, senior management and the Health Portfolio.^{Endnote 44} Consequently, this Program was expected to generate knowledge that would be brought back to Canada to inform domestic programs and policies. The 2010-2011 Report on Plans and Priorities acknowledged that Health Canada collaborates with international health partners to promote the priorities and values of Canadians and to promote and protect the health of Canadians.^{Endnote 45}

The activities of the Program were also found to align with Government of Canada priorities. Government of Canada announcements in its 2009 Budget^{Endnote 46} stated that to support Canadians’ health priorities and a strengthened health care system, it would take steps to better deliver on its core federal role in health and pursue innovative domestic and international partnerships. In the 2010 Speech from the Throne^{Endnote 47}, the Government of Canada committed itself to responding to international health needs (i.e., maternal and child health) and promoting Canadian values of global peace, security, leadership in health and financial market regulation.

The Program funding and activities also aligned with and helped to strengthen Health Portfolio priorities to meet Canada’s commitments in the area of global health. Evidence of alignment with Health Portfolio priorities was found in the following sources:

• International Health Strategy 2008-2011^{Endnote 48} endorsed by the Minister of Health in 2008. Through the Program’s engagement with PAHO, Canada worked toward joint solutions to hemispheric challenges. Membership in IARC supported the generation of research evidence on the causes of cancer, particularly the causal link between cancer and the environment. These activities align with the following goals of the International Health Strategy:
  • improve and protect the health of Canadians
  • enhance global health security
  • support global health efforts.
• International Engagement Priorities 2010-2012^{Endnote 49}endorsed by Health Canada’s senior management in March 2010. The Framework for Cooperation called for heightened and focused cooperation between PAHO and Canadian government agencies and nongovernmental organizations in priority areas, including governance, health system strengthening, emerging and re-emerging diseases, chronic non-communicable diseases, health of indigenous peoples, gender and human rights, and research for evidence-based decision making. Further, the focus of activities outlined in the Canada — Pan American Health Organization Biennial Workplan Budget (2012-2013) include mental health, maternal mortality and morbidly, gender equality, strengthened national regulatory authorities for pharmaceuticals, medical devices and food safety. The activities supported through the Framework and the Bienniel Workplan Budget contribute to the achievement of the five strategic priorities articulated in the International Engagement Priorities 2012-2013:
  • preventing, preparing and responding to global health threats
  • food, health and consumer product safety
  • health and the environment
  • health systems and capacity
  • health promotion and disease prevention.

Global Health Framework for the Public Health Agency of Canada’s International Activities 2012-2017^{Endnote 50}. Similarly, Program activities aligned with the guiding principles and objectives of the Global Health Framework. The guiding principles state that global health activities are to:

• fall within the Public Health Agency of Canada’s mandate and align with Agency/Government of Canada strategic objectives and priorities
• focus on issues where there is a high likelihood of impact on the health of Canadians
• address existing and emerging global health threats
• increase the Agency’s response capacity
• foster partnerships and facilitate collaboration to achieve common goals
• demonstrate value for money and longer term sustainability.

The activities and priorities articulated in the Canada-PAHO Framework for Cooperation and the Canada-PAHO Biennial Workplan Budget also align with the objectives of the Global Health Framework, which are to:

• improve risk identification, risk assessment and management of existing and emerging public health threats
• strengthen domestic and global security efforts
• build domestic and international health capacity.

Although the objectives and activities of the two components of the Program were aligned with the goals of the international health strategy, with the strategic priorities described in the international engagement priorities, and the guiding principles and objectives of the Global Health Framework for the Public Health Agency of Canada’s International Activities, the Program is not mentioned in these documents. However, elements of the Program, such as membership in PAHO and IARC, are referenced.

Canada’s engagement with PAHO contributed to the achievement of the goals of the Government of Canada's Americas Strategy^{Endnote 51}, a Government of Canada priority. In March 2012, the Foreign Affairs and Defense Committee approved the renewal of the Strategy (2012-2017) and Foreign Affairs and International Trade Canada was tasked with the development of an implementation plan for the Strategy.

The Strategy has three goals:

• increase economic opportunity
• strengthen security and institutions with a focus on Mexico, Central America, and the Caribbean
• build a stable foundation for Canada's engagement.^{Endnote 52}

The Americas Strategy seeks to work cooperatively and constructively to advance common values and interests and to build stronger multilateral and bilateral relations in the hemisphere and within the health sector.^{Endnote 53} As part of the Inter-American system, PAHO contributes to broader hemispheric initiatives pertaining to health and development within the context of the Summit of the Americas process²² , a key priority of Canadian engagement in the Americas.

PAHO provides technical cooperation in epidemic alert and response, disaster preparedness, health services organization and financing, immunization, nutrition, environmental health, mental health, road safety, health legislation, access to medicines and technologies, regulatory capacity, and other areas.^{Endnote 54} Participation of Canadian health experts in PAHO-sponsored activities throughout the hemisphere has strengthened Canada’s bilateral linkages with Latin American and Caribbean countries such as Brazil, Chile, Mexico and the Caribbean.

PAHO’s focus is complementary to Health Canada’s health goals and priorities as described in its International Health Strategy 2008-2011^{Endnote 55} and its International Engagement Priorities 2010-2012.^{Endnote 56} The Pan American Health Organization’s focus on communicable disease prevention and control in the region as outlined in its 2008-2012 Strategic Plan^{Endnote 57} addressed Canada’s international objectives related to public health security and also aligned well with Canada’s Strategy for the Americas.^{Endnote 58}

The Health Portfolio’s active engagement in the Americas Region has also furthered Canada’s broad international health objectives as articulated in the International Health Strategy 2008-2011^{Endnote 59} to contribute to the achievement of the following results:

• Improving and protecting the health of Canadians through comparative policy analysis and strengthening collaboration on common challenges in regulatory standard setting, public health and health care delivery
• Enhancing global health security through strengthening regional emergency preparedness and response to emerging infectious diseases, and creating new knowledge and strategies to mitigate health risks and improve health outcomes
• Supporting global health efforts to share best practices and lessons learned in strengthening health systems and in building capacity.

PAHO is also a key institutional partner for the Canadian International Development Agency in pursuing its strategic health objectives for the Americas, especially in strengthening health systems, improving delivery of primary health care services, and preventing and controlling communicable disease.^{Endnote 60} The Canadian International Development Agency’s regional inter-American program evaluation confirmed that PAHO’s priorities align with Canada’s Official Development Assistance priorities and objectives.^{Endnote 61}

In September 2011, the Minister of International Cooperation announced new funding to PAHO to help strengthen basic primary health care systems and service delivery in Latin America and the Caribbean, as part of Canada's Muskoka Initiative^{Endnote 62} to improve the health of mothers and children.

The evidence also indicated that project component activities align with the Health Portfolio’s strategic priorities and outcomes. Both the 2010 Mid-Point Review^{Endnote 63} and the Summative Evaluation of 2008^{Endnote 64} confirmed that the projects funded meet the government priorities and those of the Health Portfolio. Evidence from the project selection process revealed that all projects funded were subject to a rigorous review to ensure that they aligned well with the health portfolio’s priorities and objectives.

3.3.Alignment with federal roles and responsibilities

The Health Portfolio’s authority to engage in international activities is mandated by legislation. The Department of Health Act,^{Endnote 65} allows the Minister of Health to do or fund work outside Canada provided it relates to promoting and preserving the health of the people of Canada. Also, the Preamble to the Public Health Agency of Canada Act^{Endnote 66} expresses the desire of the Government of Canada to foster co-operation and collaboration with foreign governments and international organizations, as well as other interested persons or organizations.

The Government of Canada also has treaty obligations under the World Health Organization’s International Health Regulations,^{Endnote 67} a binding international legal instrument. Implementation of the Regulations is the responsibility of the Public Health Agency of Canada. The Center for Emergency Preparedness and Response is the national focal point and is responsible for gathering and reporting significant public health events to the World Health Organization, through the regional offices of PAHO.

The appropriateness of the federal role in international activities was further supported by the fact that membership in international organizations, such as the World Health Organization and PAHO, are comprised of States and these States are represented by government officials. Membership cannot be delegated to a third-party organization or another level of government.^{Endnote 68} The funding from the Program to cover Canada’s memberships in these multilateral organizations gives Canada the opportunity to be represented at PAHO and, by extension, World Health Organization subsidiary bodies in cases where representation is facilitated through World Health Organization regional offices.

The document review and interviewees also noted that non-membership in PAHO may limit Canada’s chance of being elected as a member of the Executive Board of the World Health Organization and thus appointing a Canadian to the Executive Board. The Executive Board is composed of 34 persons who are technically qualified in the field of health, each designated by a Member State which has been elected to serve by the World Health Assembly. Member States are elected for three-year terms.^{Endnote 69} The task of the Executive Board is to “give effect to the decisions and policies of the Health Assembly, to advise it and generally to facilitate its work.” Membership on the Executive Board, therefore, gives members an opportunity to influence the governance, strategic direction, decisions and policies of the World Health Assembly. Furthermore, membership on key World Health Organization Committees, such as the Programme, Budget and Administration Committee, are drawn from Executive Board members.

Health Canada/Public Health Agency has the lead role in representing Canada on international health forums on the world stage.^{Endnote 70} There was a broad consensus among interviewees that Health Canada was the most appropriate federal organization to lead Canada’s relations with the PAHO. However, the issue of whether the assessed contribution should be paid by Health Canada was raised. Some respondents questioned if it would not be more appropriate that the actual membership fee be covered by the budget of the Department of Foreign Affairs and International Trade, as is the case for the majority of multilateral memberships. For example, Canada’s membership fee for the World Health Organization is paid by the Department of Foreign Affairs and International Trade, but the lead role remains with the Health Portfolio. However, the historical context of this membership in the PAHO must be taken into account when reflecting on alternative delivery models as the payment for this membership was transferred to Health Canada from the Department of Foreign Affairs and International Trade in 1991.