Section 1: Evaluation of the International Health Grants Program (2008–09 to 2012–13) – Introduction

1. Introduction

The evaluation of the Program was undertaken to meet the requirements of the Financial Administration Act^{Endnote 1}, Treasury Board of Canada Secretariat’s Policy on Transfer Payments^{Endnote 2} and its Policy on Evaluation^{Endnote 3}.

The evaluation covers the period between 2008-2009 and 2012-2013. The evaluation was conducted between November 2012 and April 2013. The objective of the evaluation was to provide strategic advice to senior management on the relevance and performance of the Health Portfolio’s Program and to contribute to decisions on the future direction of the Program in the newly combined Office of International Affairs for the Health Portfolio. The evaluation was also intended to inform program renewals, including the assessed contribution^{Footnote 5} to the Pan American Health Organization (PAHO), which are in the process of being renewed.

1.1.Background and context

Since July 2012, the International Health Grants Program (which will be referred to as the “Program”) has been situated in the Office of International Affairs for the Health Portfolio, located in the Public Health Agency of Canada. However, during much of the period covered by the evaluation, the responsibility for the Program resided with Health Canada. Much of the focus of this report, therefore, is on activities undertaken by Health Canada. Activities undertaken by the Office of International Affairs for the Health Portfolio are addressed for the period July 2012 to March 2013.

The Program is responsible for the administration of funding to facilitate Canada’s membership in PAHO and for a project component that involves financial support and assistance to cover:

• Canada’s assessed contribution to IARC
• a grant to fund the World Health Organization — Framework Convention on Tobacco Control
• grants to international and national organizations and initiatives that support current federal priorities and emerging global health issues, commitments and obligations. The projects or initiatives selected for grants are solicited through a call for proposal process, and change annually.

The Program was the main mechanism within Health Canada for funding memberships in international organizations and/or facilitating the Department’s participation in international health initiatives whose mandates are consistent with the Department’s policy objectives and priorities.

By supporting the Health Portfolio’s participation in a variety of international activities and fora, the Program serves as a mechanism to strengthen and maintain relationships with key bilateral and multilateral partners and is a vehicle for identifying and developing responses to key global health policy issues. The Program is intended to strengthen intersectoral collaboration, promote increased awareness and understanding of current and emerging global health issues of priority to Canada, promote Canadian values of equity and assist the Health Portfolio in advancing Canada’s domestic health interests in order to maintain and improve the health of Canadians, to respond to Canada’s international health commitments and obligations and to advance Canada’s foreign policy objectives.

As illustrated in Figure 1, the Program is organized as two components:

• the PAHO component that covers the assessed contribution for Canada’s membership
• a project component that covers Canada’s assessed contribution to IARC and grants to cover other international commitments such as the World Health Organization — Framework Convention on Tobacco Control^{Footnote 6}, as well as other individual health initiatives and projects.

Figure 1: Organization of the International Health Grants Program (2008-2013)

The Program currently falls under the Public Health Infrastructure Program (1.1) and the Public Health Information and Networks Sub Program (1.1.2) of the Public Health Agency of Canada’s Program Alignment Architecture. It contributes to the Public Health Agency of Canada’s strategic outcome “protecting Canadians and empowering them to improve their health” and ultimately to the Government of Canada strategic outcome of Healthy Canadians.

1.2.Program objectives, activities and outcomes

The evaluation team was unable to find overarching objectives or outcomes for the Program. As each component of the Program had a different focus, objectives and expected outcomes were different and were defined in their respective program authorities.^{Footnote 7}

1.2.1.Component objectives and outcomes

According to program authorities, the objectives of Canada’s engagement with PAHO were to:

• advance Canada’s global health priorities through strategic approaches
• promote the common values of PAHO and Canada of equity through: universal access of quality, not-for-profit, health care services; equity for marginalized populations, including indigenous populations by promoting the population health/determinants of health approach
• ensure effective management of Canada’s policy and financial contributions to PAHO, including the effectiveness of Canada’s portion of PAHO’s program budget
• increase Canada’s participation and influence on PAHO’s related policies, programs and projects within the Americas i.e. sharing Canadian knowledge, experiences (models and best practices) with other countries in the Americas
• enhance Canadian awareness and knowledge of PAHO.^{Endnote 4}

Canada’s participation in PAHO furthers the Health Portfolio’s broad global health objectives and promotes the following outcomes aimed at:

• protecting the health of Canadians by enhancing regional health security multilaterally and bilaterally
• advancing Canada’s influence and interests in the region
• contributing to the reduction of health disparities leading to greater economic stability to align with Canada’s foreign policy objectives for the Americas. ^{Endnote 5}

In addition to the objectives specified in the program authorities, more explicit objectives, linked to Canada’s expectations, are agreed upon during the development of budgets and strategic documents. For instance, specific objectives are articulated in the Framework for Cooperation between the Pan American Health Organization and the Department of Health of Canada^{Endnote 6}, signed by Canada and PAHO in 2010 (see Appendix 2) and in biennial work plan budgets^{Footnote 8} between Canada and PAHO (see Appendix 3).

The objectives for the project component of the Program, as specified in the program authorities^{Endnote 7}, were to:

• identify, assess and promote approaches, models, and best practices that respond to Canada’s global health priorities, and international commitments and obligations
• increase knowledge on current and emerging global health issues to inform policy and program development and contribute to improving health outcomes within and outside Canada
• increase collaboration and strengthen relationships with key partners and stakeholders on current and emerging global health issues of importance to the Health Portfolio
• strengthen Canada’s leadership on global health issues and ensure that Canada’s priorities are reflected on the international health agenda
• enhance global health capacity/participation in areas directly related to the Health Portfolio and/or Government of Canada priorities.^{Endnote 8}

The expected immediate outcomes as identified in the logic model^{Endnote 9} (see Appendix 1) were:

• increased awareness of current and emerging priority global health issues and approaches, models and best practices
• increased knowledge and understanding of current and emerging priority global health issues and approaches, models and best practices
• improved collaboration on international responses to emerging and current priority global health issues
• decreased domestic and international barriers to the development and implementation of global health responses for current and emerging issues
• adoption/use of knowledge and information.

The expected intermediate outcomes as identified in the logic model were:

• strengthened/reinforced government policies, programs, strategies and policy options;
• improved international capacity/participation in addressing priority global health issues.

Health Canada, in consultation with the Canadian Institutes of Health Research, developed the following objectives for working with IARC:

• utilize IARC’s research findings in assessment of new or existing substances and products and in identifying potential carcinogens and their impact on the health of Canadians
• influence the current and future research agenda of IARC
• ensure effective utilization of resources provided by Canada and other participating states
• participate fully on Governing Council sessions
• ensure Canadian representation on the Science Council
• enhance Canadian awareness of IARC and the utilization of its research products.^{Endnote 10}

In the long-term, the Program was expected to contribute to improved health outcomes for Canadians.^{Endnote 11}

1.2.2.Component activities and delivery instruments

PAHO component^{Footnote 9}
PAHO is the specialized health agency of the Organization of the American States in the Inter-American System and serves as the World Health Organization’s Regional Office for the Americas. Member States include all 35 countries of the Americas, and Puerto Rico, Aruba, Curacao and Saint-Maarten as Associate members.^{Endnote 12} The mission of PAHO is “to lead strategic collaborative efforts among Member States and other partners to promote equity in health, to combat disease, and to improve the quality of, and lengthen the lives of peoples of the Americas.”^{Endnote 13}

Since July 2012, the focal point for Canada’s relationship with PAHO has been the Public Health Agency of Canada. However, for most of the period covered by the evaluation (specifically, April 2008 to July 2012), Health Canada was the focal point and had the overall substantive lead for the Government of Canada in its relations with PAHO, including preparing for, and coordinating the Government of Canada’s positions on policy, programming, and administrative issues. In addition to Health Canada, several other federal departments and agencie^{Footnote 10} worked with PAHO.

The Program’s assessed contribution to PAHO enabled Canada to meet its financial obligations to the Organization and, by extension, to the Organization of American States and the United Nations. This membership gave Canada voting rights, and enabled Canada to further the federal government’s health and foreign policy goals both within the Americas region and more broadly. Health Canada’s responsibilities as the lead department included:

• attending and leading the Government of Canada delegations to PAHO’s three governing body meetings (the Directing Council, Executive Committee and the Subcommittee on Program, Budget and Administration)
• providing strategic direction on key health policy, planning, governance and administration issues
• providing in-kind contributions to PAHO. These primarily involved providing health experts and technical support for PAHO projects including participation on committees, working groups and meetings. There is currently no formal mechanism in place to capture all activities related to PAHO; however, a scan performed in early 2013 indicated that key areas of in-kind contribution include efforts to support preparedness, surveillance and response, and capacity building and cooperation in non-communicable diseases and infectious disease control.
• supporting country offices of PAHO to strengthen their capacity with respect to communicable disease surveillance, and regional capacity to prevent, detect and respond to current and emerging public health threats, in line with their international responsibility under the International Health Regulations^{Endnote 14}. For example, in 2012 the Public Health Agency mobilized six epidemiologists to Caribbean countries in response to requests for assistance by PAHO and the Caribbean Epidemiology Centre. Another example is the Public Health Agency’s support to the Caribbean Community Member States in the establishment of the Caribbean Public Health Agency.^{Endnote 15}
• managing six^{Footnote 11} PAHO/World Health Organization Collaborating Centres.^{Footnote 12} Collaborating Centres are institutions which contribute to PAHO by conducting work in areas that support, or align with, PAHO’s Strategic Plan.^{Endnote 16} However, as these collaborating centres were not funded through the Program, they were not included in this evaluation.

Health Canada’s relationship with PAHO is described in the Framework for Cooperation between the Pan American Health Organization and the Department of Health of Canada, signed in May 2010. The purpose of this Framework is to “heighten a whole-of-government approach to Canada’s relations with PAHO, and to promote joint actions aimed at strengthening Canada’s and the Organization’s capacity to contribute to the global and regional response to health and development issues of common concern.”^{Endnote 17}

For additional information on PAHO, including the Collaborating Centres, refer to the PAHO website.^{Footnote 13}

Project component
The following describes the commitments, obligations and individual projects under the project component of the Program.

(a) International Agency for Research on CancerFootnote 14 IARC is an independently funded subsidiary of the World Health Organization. Its work generates evidence for cancer prevention around the globe. IARC plans, promotes, and develops research in all phases of the causation, treatment, and prevention of cancer; collects and disseminates information on the epidemiology of cancer, on cancer research, and on the causation and prevention of cancer; and trains researchers.

Through its membership in IARC, Canada supports the generation of evidence on the causes of human cancer, the mechanisms of carcinogenesis, and the development of scientific strategies for cancer prevention and control. Health Canada, and now the Office of International Affairs for the Health Portfolio, coordinated Canada’s engagement with IARC. Canadian government officials actively participated in the deliberations of the Governing Council of IARC to ensure oversight for how resources were spent, what type of research was conducted and how information was disseminated. Canada also held a seat on IARC’s Scientific Council — a body whose primary role is to ensure the scientific integrity of the activities of IARC, provide impartial scientific advice to the Director and to the Governing Council and provide direction on the scientific program of the Agency. The Canadian delegation attending meetings of the Scientific Council always included a scientific representative from the Canadian Institutes of Health Research.

(b) Organization for Economic Cooperation and Development Health Committee
Canada has had an ongoing relationship with the Organization for Economic Cooperation and Development Health Committee since 2005. The mandate of the Health Committee is to provide leadership in the area of health data and statistics as well as providing analyses on the financial sustainability, efficiency and quality of health and long-term care systems in member countries. The Organization also examines other health related issues such as the implications of chemicals on health, evaluates the application of biotechnology to health care, and reviews the health systems of non-members.

(c) Global Health Research Initiative
The mission of the International Development Research Centre’s Global Health Research Initiative is to fund research on global health problems, strengthen capacity to perform research and to use research findings to deal with global challenges.^{Endnote 18} The initiative was viewed as an integrated approach to global health research. Health Canada has not contributed funding to this partnership since March 2012, when the Memorandum of Understanding expired, due to its limited direct benefits to the health mandate. However, Health Canada has offered technical and policy advice through the Global Health Research Initiative Strategic Planning Committee.

As stated in the 2001 Memorandum of Understanding and the 2008 amendment, the initiative was a partnership of the following Canadian government agencies:

• Health Canada, with its knowledge base and recognized leadership
• International Development Research Centre, with its experience with research in developing country settings
• Canadian Institutes of Health Research, with its strong tradition of excellence in research through the peer review process
• Canadian International Development Agency, with its considerable development experience and its emphasis on evidence based health development
• Public Health Agency of Canada with its role in helping build an effective public health system in Canada and responsibility for surveillance, monitoring, researching, investigating and reporting on diseases, injuries, other preventable health risks and their determinants, and the general state of public health in Canada and internationally.^{Endnote 19}

(d) Grants to international organizations and initiatives
The project component of the International Health Grant Program provides financial assistance and support in the form of individual grants for projects that support the following:

• current federal global health priorities and international commitments and obligations. Current issues of priority include food and product safety, health and the environment, and health system and capacity.
• emerging global health issues that will change over time as new global health challenges and opportunities are identified.

Eligible recipients for grants are international and Canadian not-for-profit organizations and institutions (e.g., bilateral and multilateral international organizations and institutions with established relationships with Canada, federal crown corporations, non-governmental organizations and academic institutions). Projects were selected based on their alignment with established Government of Canada and departmental funding priorities for international health engagement/activities.

1.3.Program governance

Currently, the responsibility for the Program resides in the Office of International Affairs for the Health Portfolio, part of the Public Health Agency of Canada. However, from 2008-2009 to 2011-2012, accountability and supervision of the Program resided in the following two areas of Health Canada:

• April to November 2008, the responsibility for the Program resided with the Strategic Policy Branch of Health Canada.
• In December 2008 the program was transferred to the Regions and Programs Branch. For the period between December 2008 and July 2012, the responsibility for the Program was shared between Regions and Programs Branch and the Strategic Policy Branch.

Regions and Programs Branch paid the membership fees on behalf of Canada and had responsibility for managing the projects. The Strategic Policy Branch provided policy advice and analysis of international issues affecting health, including the identification of priorities for program-based projects. The Branch was also responsible for providing guidance to the Minister regarding Health Canada’s participation in international organizations and initiatives.^{Endnote 20}

Effective July 1, 2012, in support of Budget 2012, the Program was transferred to the Office of International Affairs for the Health Portfolio^{Footnote 15}, located in the Public Health Agency of Canada. This occurred simultaneously with the transfer of Health Canada's international affairs function to the Public Health Agency to create a shared service for the international affairs function that would serve the Health Portfolio. This new entity, the Office of International Affairs for the Health Portfolio, provides policy advice, integration, and coordination of international affairs for the Health Portfolio to advance Canada’s domestic health policy objectives and priorities internationally, and to ensure that Canada’s interest and values are reflected in the global health agenda.

1.4.Resources

1.4.1.Health Portfolio

The Program was split into the following two envelopes of funding:

• Funding to cover the payment of Canada’s membership in PAHO (assessed contribution)
• Funding of the project component of the Program.

Membership in PAHO had priority for Program funds. The next priority were the commitments to international organizations (IARC, and to the World Health Organization — Framework Convention on Tobacco Control). Finally, any remaining funds were granted to individual national and international projects that supported federal priorities and emerging global health issues.

Table 1 shows the actual spending between 2008-2009 and 2012-2013 for the two components of the Program.

Most of the Program budget is used to pay for Canada’s membership in PAHO. Taking 2011-2012 as an example, and as Figure 2 illustrates, the assessed contribution to PAHO represented 83 per cent of the Program budget.

Over the past five years, payments to support Canada’s memberships in multilateral organizations (PAHO and IARC) have accounted for approximately 95 per cent of the total budget of the Program. The remaining 5 per cent was used to fund international commitments and projects. The membership fees were paid in foreign currency (US dollar and Euro) so fluctuations in the exchange rate also impacted on the amount subsequently available to individual projects.

Figure 2: International Health Grants Program 2011-2012 budget analysis

Funding of the Pan American Health Organization component
The assessed contribution is determined by PAHO in accordance with a formula approved by Member States. Table 1 shows that Canada’s assessed contribution totaled $62,288,382 over the five year period of the evaluation.^{Footnote 19} The average annual assessed contribution over this period was $12,457,676. During the period of the evaluation, Health Canada as the lead department for Canada’s engagement with PAHO, assumed payment of Canada’s assessed contribution through existing reference levels.

Canada’s fee for membership in PAHO contributed to the Organization’s on-going operational and administrative expenses and main activities. These included, for example, the salaries and benefits of professional and general staff, support for the Organization’s programming, maintenance of the premises, costs associated with convening meetings of the governing bodies attended by member states, printing and supplies and travel.

Funding of the project component
Table 1 shows the breakdown of the funding of the Program project component between 2008-2009 and 2012-2013. During that period, 46 projects were funded totalling $9,636,195.

Canada’s assessed contribution for membership in IARC is paid as a grant. The total cost for Canada’s membership over the past five years was $5,757,629. Funding of the Organization for Economic Cooperation and Development’s Health Committee and the Global Health Research Initiative for the five year period totalled $1,375,000 (USD).

In terms of individual projects, expenditures per project ranged from $20,000 to $150,000. Projects identified in the 2008-09 call for proposals were only funded in 2009-2010 as the solicitation and approval stage concluded late in the fiscal year. In 2012-2013 there were no calls for proposals as the Program was transitioning from Health Canada to the Public Health Agency of Canada. Table 2, shows that over the period of the evaluation, the most commonly funded individual projects were with multilateral organizations (41.3 per cent). Multilaterals include PAHO, the World Health Organization, the International AIDS Society, and the Organisation for Economic Co-operation and Development. The second most commonly funded groups were non-governmental organizations which accounted for 39.1 per cent of the initiatives. Some examples of Non-governmental Organizations include Health Bridge Canada, the Canadian Treatment Action Control, and the Canadian Public Health Association. A list of funded projects is provided in Appendix 2.

1.4.2.Total Resources for the Pan American Health Organization (including those from other Federal departments, agencies and crown corporations)

PAHO’s program budget^{Footnote 20} is funded on a two year basis. For 2012 and 2013, the program budget was $626.7M (USD). This included $194.4M (USD) (31 per cent) in assessed contributions from Member States, and $339.6M (USD) (54 per cent) from other sources, including voluntary contributions.^{Endnote 21} Sources of voluntary contributions include Member States, philanthropic organizations, and industry. These funds are predominantly earmarked for specific purposes/projects within PAHO’s program of work.

The Health Portfolio’s assessed contribution to PAHO was complemented by funding and other support from Government of Canada departments, agencies, and crown corporations who work regularly with PAHO:

• The Canadian International Development Agency
• Canadian Institutes of Health Research
• The Department of Foreign Affairs and International Trade
• The International Development Research Centre
• Canadian Food Inspection Agency.

For example, in 2010 and 2011, Canada was the third largest contributor, among Member States, of voluntary contributions to PAHO. Canada’s voluntary contributions amounted to $35.08M (USD) in 2010 and 2011 ($17.19M (USD) and $17.89M (USD), respectively). Of that total, the Canadian International Development Agency made the most sizable voluntary contributions, totaling $33.6M (USD) ^{Endnote 22}. The Canadian International Development Agency contributions were directed to PAHO’s development assistance programs. These programs were primarily related to strengthening health systems and health information systems, infectious diseases, maternal and childhood health, emergency response to crises such as H1N1 influenza and natural disasters such as the earthquake followed by the cholera outbreak in Haiti.^{Endnote 23} In comparison, in this same period, the Health Portfolio’s voluntary contributions to PAHO totalled $917,617 (USD)^{Footnote 21}.

The development assistance partnership between the Canadian International Development Agency and PAHO is complemented by ongoing policy dialogue, which has allowed the Canadian International Development Agency to influence policy responses to key health and governance issues, while benefitting from health-related analysis provided by PAHO.

Similarly, the Department of Foreign Affairs and International Trade is increasingly looking at the foreign policy aspects of global and regional health issues, and the Permanent Mission of Canada to the Organization of American States in Washington plays an important liaison role, gathering and transmitting relevant information and analysis back to Ottawa.