Appendix B: Evaluation of the National Emergency Stockpile System (NESS) – Technical annex

Appendix B: Technical annex

Part 1: Methodology

Approach and Design

This ex-post evaluation was conducted by Evaluation Services, a group that is internal to the Public Health Agency but that is not involved in the program area responsible for administration of the Public Health Agency's National Emergency Stockpile System activities.

The overall approach to this evaluation integrated two conceptual evaluation models − goals-based and process-based.

A goals-based model allowed the evaluators to explore whether the program was meeting its predetermined goals and objectives as set out in the original program mandate. Given changes in the Canadian emergency preparedness context over the past 60 years, the initial purpose of the evaluation was to look at (a) program relevance and whether or not program goals should be changed, as well as (b) how program goals should be established in the future.
The other purpose of the evaluation was to fully understand how the National Emergency Stockpile System program is actually working today; therefore a process-based model was also appropriate. While this long-standing program had evolved since it was first established in the 1950s, it appeared that clients had had concerns/complaints about the need to modernize the program, and there appeared to be a number of inefficiencies in delivering program services.

The short time frame to conduct the evaluation was based on target dates stipulated in the management response to the 2010 Audit of Emergency Preparedness and Response. To respond in a timely fashion, a non-experimental cross-sectional design was used to take a retrospective look at this long established program. Since little baseline information was available, this design allowed evaluators to analyze information at one point in time from multiple sources. It explored performance, as well as the alignment and "value-added" of the Public Health Agency's National Emergency Stockpile System activities with the Public Health Agency's roles and priorities.

The impetus for this evaluation included:

a request from senior management for a thorough review of program relevance and performance of program activities
a request from the Audit Committee in response to the Public Health Agency's 2010 Audit of Emergency Preparedness and Response that suggested an in depth review of the relevance and performance of this program was needed at this time.

The decision to use multiple lines of evidence to address relevance and performance, and the retrospective nature of the evaluation design, was influenced by a number of evaluation risk factors, including:

a paucity of current performance measurement data available for this program
the very long history of this program (almost 60 years) and little evaluative analysis undertaken over the life of the program
a lack of a clearly articulated logic model or program theory for this long standing program, and a considerable shift in the context of emergency preparedness and response since the establishment of the program.

In addition to the perspectives of a broad cross section of program management and staff, major stakeholders' perspectives were considered. In particular, the evaluators sought out the perspectives of recipients of the services provided through the National Emergency Stockpile System program, including provincial/territorial counterparts and other government departments. Information was also gathered from other organizations that provide related services domestically (such as the Canadian Red Cross) and internationally (in other countries). External and internal issue experts in the field of emergency preparedness and response were interviewed.

Methods

The evaluation used multiple lines of evidence, including literature and document reviews. It was important to triangulate these data sources with surveys, focus groups and interviews with relevant stakeholders. Five case studies were compiled detailing the approaches and activities of two domestic (Appendix F) and three international (Appendix G) organizations involved in delivering emergency stockpile services.

1. Literature review

A streamlined literature review was conducted to explore the nature of emergency stockpiling in Canada and internationally. It addressed evaluation issues related to relevance (evaluation questions #1, #2 and #3). The purpose of this review was to obtain information regarding the need for the program, including whether it represents a legitimate and necessary role for the Government of Canada as well as best practices which may represent potential improvements to program design and delivery.

In total, 110 documents were reviewed. These documents included all of the available literature suggested by program staff, including grey literature, as well as documents identified through Internet searches, and bibliographic key word searches. Bibliographic key word searches for recent (last 10 years) academic publications in English and French on this topic, in particular literature on the need for and the management of emergency stockpiles, were completed. The following databases were searched: Scopus (which contains the content of Medline & Embase), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Global Health.

2. Document review

The evaluation team undertook a review of available National Emergency Stockpile System documentation. Many documents were identified by program management and staff. This review was used to address particular evaluation issues related to relevance (evaluation question #1, #2, #3, #4 and #5) and performance (evaluation questions #6, #7 and #8). In total, 93 documents were reviewed by the evaluation team.

The types of documents reviewed included the following:

previous audits and reviews of the National Emergency Stockpile System program
records of decision from various internal committee meetings
correspondence and communication related to the National Emergency Stockpile System program
program records on the deployment of National Emergency Stockpile System supplies.

3. Survey and focus groups with provincial/territorial representatives

The purpose of the survey and focus groups was to learn about partners' perspectives on:

their roles in the program
progress made towards achievement of the expected NESS outcomes
opportunities for improvement.

An email survey solicited written survey responses through two Councils of the Public Health Network: the Council of Health Emergency Management Directors and the Council of Emergency Social Services Directors. From December 22, 2010 to January 14, 2011 surveys were sent out in English and French. Each Council is comprised of one representative from each province and territory – 13 representatives in total. One survey was sent to each representative of the two Councils therefore a total of 26 individual representatives were sent a survey to complete. A total of 14 survey recipients completed the survey out of a sample of 26, for a response rate of approximately 54%. Most surveys (93%) were completed in English; the balance in French. All respondents (100%) submitted the survey by return email. Of a total of 13 jurisdictions, 9 jurisdictions were represented.

To validate the feedback provided in the email survey and explore issues further, two separate bilingual focus groups were conducted with provincial/territorial representatives through the Council of Health Emergency Management Directors (CHEMD) and the Council of Emergency Social Services Directors (CESSD). A summary of the email survey feedback was provided to participants in advance of the focus groups. A total of 21 individuals participated in the focus groups; some individuals participated in more than one group. Of a total of 13 jurisdictions, 11 jurisdictions were represented (85% of jurisdictions were represented between the two focus groups).

By province/territory, participation in the focus groups was as follows:

Province / territory	Number of participants
Newfoundland	2
Nova Scotia	2
Prince Edward Island	2
New Brunswick	1
Quebec	3
Ontario	3
Manitoba	1
Saskatchewan	2
Alberta	1
British Columbia	3
Yukon	1
Northwest Territories	0
Nunavut	0
TOTAL	21

The focus groups were conducted by teleconference on January 24 and 25, 2011 and were one hour in duration. The focus groups were facilitated by two Evaluation Services evaluators in Ottawa.

4. Interviews with key senior managers and staff from the Public Health Agency, emergency stockpile contacts with other federal government departments, external experts in the field of emergency preparedness and response, and specialists from selected other countries

The purpose of the interviews was to obtain a further description of how various elements of the program have been implemented as well as receive input on program relevance and performance.

The interviews were conducted using structured interview guides. Interview guides were developed in discussion with internal and external experts in the field of emergency preparedness and response.

Key informants were identified by program management and staff and Internet searches (for other key international contacts only). The sampling approach was purposive. Evaluation Services notified key informants of the evaluation and requested their participation. From November 8, 2010 to January 24, 2011, 22 one-hour interviews were conducted with 38 interviewees. Several interviews involved more than one key informant.

The breakdown of interviewees by type of key informant was as follows:

Interview sub-group	Number of interviewees
Public Health Agency senior managers and staff	26
Emergency stockpile contacts with other federal government departments	2
External experts in the field of emergency preparedness and response	7
Specialists from selected other countries	3
TOTAL	38

5. Survey with selected other government departments

The purpose of this survey was to obtain comparable data on the programs delivered by other federal government departments as well as identify best practices that could represent potential improvements to program design and delivery.

An email survey solicited written responses from a selection of federal government departments from January 21 and 31, 2011. This purposeful sample was with all federal departments with a known role in emergency preparedness and response or a known stockpile of emergency supplies. Representatives were identified by the National Emergency Stockpile System program area. One survey was sent to a representative from each department. A total of seven survey recipients completed the survey out of a sample of 12, for a response rate of approximately 58%. All the surveys (100%) were completed in English. All respondents (100%) submitted the survey by return email.

6. Case studies of international and domestic organizations

Case studies were conducted to highlight the approaches to emergency stockpiling undertaken by two domestic organizations and three other countries. The purposeful sampling strategy was used to focus on potential duplication of domestic emergency services provided and international best practices.

The domestic case studies included:

Department of National Defence
Canadian Red Cross.

The international case studies included:

United States: Centers for Disease Control and Prevention – Strategic National Stockpile
Australia: National Medical Stockpile
Norway: Norwegian Emergency Preparedness Stockpile System (NOREPS).

A review of available Internet information and documentation provided by each organization, as well as one interview, were conducted for each case study. The interview guide was developed in discussion with external experts in emergency preparedness and response. A total of five interviews were conducted with 10 interviewees.

Evaluation tools, such as interview or focus group guides, are available upon request.

**Data source matrix**
Issue	Question	Line of Evidence	Data Source
Relevance issue #1: Continued need for program	1. What needs does the NESS intend to address? 2. Do these needs still exist?	Literature review	published literature on emergency preparedness (Canada and International) and on utility of emergency stockpiles of social service and medical supplies
		Document review	key internal documents including: Records of Decision from original Cabinet decisions to establish the program; previous audits and reviews of the NESS program; records of decision from various internal committee meetings; correspondence and communication related to the NESS program; program records on the deployment of NESS supplies
		Survey and focus groups	written survey responses and focus group feedback from provincial/territorial representatives through the Council of Health Emergency Management Directors (CHEMD) and the Council of Emergency Social Services Directors (CESSD); written survey responses from selected other government department representatives
		Key informant interviews	interviews with key senior managers and staff from the Public Health Agency, selected other government departments and non-governmental organizations, and external experts in the field of emergency preparedness and response; interviews with specialists in a selection of other countries (Australia, Norway and the United States)
Relevance issue #2: Alignment with government priorities	3. Is the NESS program consistent with the current Government of Canada and Public Health Agency mandate and strategic priorities?	Literature review	published literature on emergency preparedness and emergency stockpiles of social service and medical supplies
		Document review	key internal documents including: previous audits and reviews of the NESS program; records of decision from various internal committee meetings; correspondence and communication related to the NESS program; program records on the deployment of NESS supplies
Relevance issue #3: Alignment with federal roles and responsibilities	4. Should the federal government be delivering the services provided by NESS, either in its entirety or for each type of asset? 5. Which types of assets remain relevant for the Public Health Agency?	Document review	key internal documents including: previous audits and reviews of the NESS program; records of decision from various internal committee meetings; correspondence and communication related to the NESS program; program records on the deployment of NESS supplies
		Survey and focus groups	written survey responses and focus group feedback from provincial/territorial representatives through the Council of Health Emergency Management Directors (CHEMD) and the Council of Emergency Social Services Directors (CESSD); written survey responses from selected other government department representatives
		Key informant interviews	interviews with key senior managers and staff from the Public Health Agency, selected other government departments and non-governmental organizations, and external experts in the field of emergency preparedness and response; interviews with specialists in a selection of other countries (Australia, Norway and the United States)
		Case studies	two domestic case studies explored potential duplication of domestic emergency services provided and three international case studies explored international best practices
Performance issue #4: Achievement of expected outcomes	6. Have needs changed over time? 7. Has the program design changed to accommodate these needs? 8. Are there further changes that should be implemented?	Document review	key internal documents including: previous audits and reviews of the NESS program; records of decision from various internal committee meetings; correspondence and communication related to the NESS program; program records on the deployment of NESS supplies
		Survey and focus groups	written survey responses and focus group feedback from provincial/territorial representatives through the Council of Health Emergency Management Directors (CHEMD) and the Council of Emergency Social Services Directors (CESSD); written survey responses from selected other government department representatives
		Key informant interviews	interviews with key senior managers and staff from the Public Health Agency, selected other government departments and non-governmental organizations, and external experts in the field of emergency preparedness and response
Performance issue #5: Demonstration of efficiency and economy	9. Is there overlap/duplication or complementarity in service delivery?	Survey and focus groups	written survey responses and focus group feedback from provincial/territorial representatives through the Council of Health Emergency Management Directors (CHEMD) and the Council of Emergency Social Services Directors (CESSD); written survey responses from selected other government department representatives
		Key informant interviews	interviews with key senior managers and staff from the Public Health Agency, selected other government departments and non-governmental organizations, and external experts in the field of emergency preparedness and response
		Case studies	two domestic case studies explored potential duplication of domestic emergency services provided and three international case studies explored international best practices

Part 2: Results and discussion

Findings and evidence matrix

**QUESTION #1: What needs does the NESS intend to address? Do these needs still exist?**
Findings	Evidence
While relatively few catastrophic events have taken place on Canadian soil in recent memory, this country is not impervious to these threats. These challenges require well-thought-out emergency response plans, including timely access to essential provisions.	The federal, provincial and territorial (FPT) Ministers Responsible for Emergency Management joined efforts to produce the Emergency Management Framework for Canada (2011). It states that "...the accumulating risks associated with factors such as increased urbanization, critical infrastructure dependencies and interdependencies, terrorism, climate change, environmental change, animal and human diseases, and the heightened movement of people and goods around the world, have increased the potential for various types of catastrophes."[Link to footnote 20] Key informants indicated that there is a history of natural and man-made disasters, including pandemic events, in urban and remote communities in Canada. Terrorist threats on western nations are likely to persist. Domestic and international public health events can change rapidly. These events, if and when they do happen, can have enormous and detrimental consequences for Canadians. According to records kept by the Agency, the NESS program has been deployed 128 times in the past 25 years (1985 to 2010) to respond to a domestic event as a result of a hazard. Just over four in ten deployments (43%) have been in response to meteorological or hydrological events, i.e. floods, ice storms. Over the last 25 years, just under half the number of supplies deployed to respond to domestic events have been social service supplies (46%). Medical supplies (44%) have been deployed slightly less often. Pharmaceuticals (6%) or units/kits, such as the trauma or the casualty collecting unit (4%), have been deployed far less often. While there is no specified mandate to provide supplies from the stockpile to assist in international public health events, over the past 25 years, the stockpile has been deployed internationally at least 22 times. Whereas domestically we saw a greater need for social service supplies in response to natural disasters, internationally there was a greater need for health supplies in response to conflicts or geological events – tsunamis, hurricanes, earthquakes. Key informants indicated that the potential public health threats faced by other countries are not unlike the threats Canada can be expected to face. The Public Health Agency can anticipate future requests for the international deployment of NESS supplies. Some of them may be at the request of the Government of Canada, others at the request of the World Health Organization, the Pan-American Health Organization or a national government.
The NESS program has adopted an "all-hazards" approach, meaning that decisions about the composition and management of this national reserve of provisions are to be based on up-to-date risk assessments.	Over the past 25 years NESS supplies have been deployed domestically to respond to a wide variety of events. The principal activity of the NESS program has been to have sufficient quantities of medical and social service supplies, strategically located across Canada, in a state of readiness for immediate response to a natural or human-caused disaster.

**QUESTION #2: Is the NESS program consistent with the current Government of Canada and Public Health Agency mandate and strategic priorities?**
Findings	Evidence
The Government of Canada's commitment to the safety of Canadians in the face of human and natural threats has been reiterated in a variety of communications, instruments and agreements.	In the 2010 Speech from the Throne, the Governor General highlighted again that "Our peaceful, prosperous and pluralistic society is one of the safest places in the world to live. Yet Canada faces real, significant and shifting threats. ...Protecting the health and safety of Canadians and their families is a priority of our Government."^{[Link to footnote 21]}
PHAC planning documents have consistency cited the National Emergency Stockpile System as strategically important.	The NESS program is mentioned specifically in both the Public Health Agency's Strategic Plan 2007-2012 and more recently in the Public Health Agency of Canada 2010-11 Report on Plans and Priorities: Strategic Plan 2007-2012: "Enhancements will be made to the National Emergency Stockpile System, ensuring that sufficient supplies of appropriate and modern products and materials are available in the event of a public health emergency." 2010-11 Report on Plans and Priorities: "...operate the National Emergency Stockpile System and..., as required, to respond to infectious disease emergencies and bioterrorism incidents in Canada or around the world."

**QUESTION #3: Should the federal government be delivering the services provided by NESS?**
Findings	Evidence
There is documentation that confirms the broader federal role in emergency preparedness and response in Canada.	The Emergency Management Act (2007) states, "The Minister [of Public Safety Canada] is responsible for exercising leadership relating to emergency management in Canada by coordinating, among government institutions and in cooperation with the provinces and other entities, emergency management activities." Through the Federal Emergency Response Plan (2009), the Government of Canada mobilizes and coordinates resources and capabilities from the following organizations: federal departmental headquarters and federal regional departments, Crown corporations and agencies, provincial and territorial emergency management organizations, industry and the private sector, and non-governmental organizations.^{[Link to footnote 22]}
The Public Health Agency of Canada was established to support, and currently undertakes, public health emergency preparedness and response activities domestically and internationally, including the dissemination of emergency supplies.	The Public Health Agency was established in 2004 in direct response to concerns about the capacity of Canada's public health system to anticipate and respond effectively to public health threats. Its mandate is to protect and promote the health and safety for all Canadians through leadership, partnership, innovation and action. The Agency works closely with provinces and territories to keep Canadians healthy by focusing on effective efforts such as preventing chronic diseases like cancer and heart diseases, preventing injuries, and responding to public health emergencies. The Public Health Agency has a federal leadership role and has identified the management of public health emergencies as one it its key priorities. To address this responsibility, the Public Health Agency undertakes specific activities, including: manage international aspects of public health emergency preparedness and response, including liaising with the World Health Organization and acting as the focal point for coordinating implementation of the International Health Regulations (2005) provide regional coordination of federal public health emergency activities, support provinces and territories when requested, or to respond to complex emergencies on a national scale, by: providing access to materials from the federally controlled stockpile to assist provinces and territories with surge capacity, and facilitating the procurement of additional emergency supplies to complement provincial and territorial stockpiles.
Canada is required at the national level to have the capacity to provide support for logistical assistance. There is some documentation that specifies the federal role in the provision of emergency supplies in response to a domestic disaster.	There is a mandate from the World Health Organization to the Government of Canada to provide national level support in the case of a domestic public health event. As a signatory to the World Health Organization-led International Health Regulations (2005), Canada is required at the national level to have the capacity to provide support for logistical assistance (e.g. equipment, supplies and transport) for its citizens in case of a domestic public health event.^{[Link to footnote 23]} The NESS antivirals are mentioned specifically in the Canadian Pandemic Influenza Plan for the Health Sector (2006): "In addition to the National Antiviral Stockpile, the National Emergency Stockpiling System (NESS) also contains oseltamivir, which could be used during domestic avian influenza outbreaks or for P/T support during the Pandemic Alert or Pandemic Period."^{[Link to footnote 24]}
The Minister of Health (responsibilities include Public Health Agency of Canada) is mandated to provide a federal emergency support function for public health. There is little documentation that describes a specific Public Health Agency of Canada role in the provision of emergency supplies in response to a domestic public health event.	The Emergency Management Act (2007) requires all Ministers accountable to Parliament for a government institution to identify the risks that are within or related to his or her area of responsibility, including those related to critical infrastructure, and to do the following in accordance with the policies, programs and other measures established by the Minister: prepare emergency management plans in respect of those risks maintain, test and implement those plans conduct exercises and training in relation to those plans.^{[Link to footnote 25]} Annex A of the Federal Emergency Response Plan (2009) outlines the federal emergency support functions. The Minister of Health is listed as the Minister with primary responsibility for public health and essential human services. Canada's Minister of Health (responsibilities include the Public Health Agency) is primarily responsible for developing and maintaining the federal health portfolio emergency plans for national public health threats or events, such as major disease outbreaks, natural or man-made disasters, or major chemical, biological or radio-nuclear events.
There is some documentation that specifies the federal role in the provision of emergency supplies in response to an international disaster. No mandate or specific authority for PHAC has been stipulated for responding to public health events that take place outside Canada.	The domestic Emergency Management Act (2007) indicates that the responsibility of the Minister of Public Safety Canada includes "...participating, in accordance with Canada's foreign relations policies, in international emergency management activities." Furthermore, "In consultation with the Minister of Foreign Affairs, the Minister may develop joint emergency management plans with the relevant United States' authorities and, in accordance with those plans, coordinate Canada's response to emergencies in the United States and provide assistance in response to those emergencies."[Link to footnote 26] There are also numerous cross-border agreements between Mexico, Canada and the United States, as well as between various American states and Canadian provinces for the reciprocal exchange of information and/or support during a public health event or emergency (see Appendix C, international sections on trilateral relations and bilateral relations). While there is no specified mandate to provide supplies from the stockpile to assist in international public health events, over the past 25 years, the stockpile has been deployed internationally at least 22 times. For a number of past deployments, key informants indicated that official Cabinet authorities have had to be sought to support each of these deployments. Section 61 of the Financial Administration Act and Orders in Council have been used, whereby "...the Governor in Council on recommendation of Treasury Board may authorize or make regulations for the transfer, lease or loan of public property other than federal property."[Link to footnote 27] These approval processes can be time consuming in situations where timely responses are critical. Moving forward, if an international role was determined for NESS, ongoing policy and financial authority would be required.
The implications for an international role are not understood nor formally acknowledged by all partners and stakeholders. The NESS program would need to be able to meet both domestic and international needs.	Key informants indicated that the primary purpose of the NESS program is to provide surge capacity for the provinces and territories. If an international role was considered for the stockpile, this role should be ancillary, with domestic response continuing to be the primary role of NESS. The first priority for the NESS program should be to formalize its domestic mandate and update its domestic inventory and operations. Some stakeholders identified a need to look at the Public Health Agency's international emergency response programs as a whole, along with the infrastructure that needs to be put in place. For example, the Public Health Agency could consider the implications of the deployment of human resources and physical supplies together. Given the current risks of asset obsolescence in stockpile management, a number of NESS stakeholders observed that potential benefits of continuing international deployments include opportunities to rotate stock and refine response protocols and supplies.
The need for formal relationships and a clear definition of roles and responsibilities would need to be considered as part of the exploration of a more formal international mandate. A formal international role would require collaboration with other stakeholders in advance to ensure planning for an international role reflects the wealth of information from those most practiced in this field.	Key informants with the program indicated that requests for assistance are typically coordinated through the Canadian International Development Agency or the Department of Foreign Affairs and International Trade, as these federal organizations have the lead on international responses. Currently the NESS management team and staff maintain informal relationships with these key partners, as well as the international arm of the Canadian Red Cross. In particular, the international role for NESS could be linked with the existing international assistance roles of both the Canadian International Development Agency and the Department of Foreign Affairs and International Trade. Key informants indicated that number of the current supplies in the NESS stockpile are outdated and are being reviewed/revamped. Some of the provisions in the current stockpile are not in a state of readiness to be deployed internationally at this time. In some instances, the NESS program may not be able to respond optimally to an international request. Key informants also indicate that if the NESS program has a formalized international role, then it could have the planning and processes in place to support that role. Criteria governing the NESS role could be established (i.e. what could be provided and under what circumstances should supplies be sent abroad).

QUESTION #4: Which types of assets remain relevant for the Public Health Agency? Have needs changed over time? Has the program design changed to accommodate these needs? Are there further changes that should be implemented?
Findings	Evidence
There are potential efficiencies to be gained by partnering with organizations that already have well-established infrastructures, e.g. non-governmental organizations, other government departments and other administrations.	The Norwegian Emergency Preparedness System (NOREPS) promotes a collaborative approach among a group of humanitarian organizations in Norway. In Australia, the Australian Red Cross Society (ARCS) is a major partner in responding to events. The Department of Health and Ageing provides funding to ARCS to support a broad range of health-related humanitarian work and community activities, including disaster preparedness, first aid, disaster response and refugee services, and the society's work in the Asia-Pacific region. There are opportunities to partner with organizations for other purposes. For example, in 2009, the Centers for Disease Control and Prevention and the American Association of Respiratory Care partnered to offer a webcast training module for doctors and first responders on how to best use the LTV 1200 ventilator in an emergency.
Other countries concentrate on stockpiling pharmaceuticals and medical supplies but not for a social service response. Other organizations within these jurisdictions provide this type of service.	As highlighted in each of the international case studies, Appendix G, the provision of social service supplies is not typically the purview of a federal Department of Health. This response may be led by: non-governmental organizations (e.g. the Australian Red Cross Society, funded by the Australian government, states and territories for both domestic and international emergencies) another government department (e.g. the United States' Federal Emergency Management Agency under the Department of Homeland Security) a public/private partnership (e.g. Innovation Norway's consortia of public/private partners for the Norwegian Emergency Preparedness Stockpile System).
In other countries, stockpile systems are constantly evolving and updated in response to regular review.	The Centers for Disease Control and Prevention in the United States indicated that they regularly review their threats and risks and, on that basis, add medicine and medical supplies (e.g. antivirals, respirators, masks and gloves) to the Strategic National Stockpile to help fight against pandemic flu. Australia is currently conducting a strategic review of issues such as procurement, stock rotation, logistics and transportation.
Pandemic preparedness is a key and clearly defined role of the Public Health Agency.	As outlined in the Canadian Pandemic Influenza Plan for the Health Sector (2006), the Public Health Agency is the lead federal agency responsible for addressing pandemic influenza preparedness and response. Key activities include the following: conducting scientific research to better identify, understand and track the virus obtaining surveillance (or tracking) information from its federal, provincial, territorial and local partners, as well as non-governmental organizations (influenza surveillance helps to determine: when, where and which influenza viruses are circulating; their intensity, spread and impact; and if specific population groups are at higher risk for illness) providing information and advice to the general public and particular groups, such as vulnerable populations, as well as issuing guidance for health professionals and other stakeholders providing regional coordination of federal health emergency activities managing international aspects of pandemic preparedness and response, including liaising with the World Health Organization and acting as the focal point for coordinating the implementation of the International Health Regulations developing and supporting the process required to update and maintain the Canadian Pandemic Influenza Plan for the Health Sector, in cooperation with health portfolio and provincial/territorial representatives ordering sufficient vaccine for the Canadian population, in collaboration with the provinces and territories stockpiling pharmaceuticals, equipment and supplies to assist the provinces and territories with surge capacity.^{[Link to footnote 28]} Since the SARS outbreak, the NESS program has been increasing its supply of pandemic response materials. As part of this expansion, NESS stockpiled these materials prior to and during the 2009-10 H1H1 outbreak. Pandemic supplies include: antiviral agents, antibiotics specific to pandemic response, syringes, ventilators and related oxygen supply equipment, personal protective equipment (masks, face shields, gloves), and other supplies such as gowns, disposable sheets, pillows, needles, syringes, body bags, etc.
The Public Health Agency has been responsive to requirements for pre-deployment of emergency medical supplies for mass gatherings.	The NESS program has supported provinces and territories during times of emergency and also during planned such as papal visits (1984, 1987, 2002), World Youth Day (2002), the Winter Olympic and Paralympic Games in British Columbia (2010), the G8/G20 Summits in Ontario (2010), World Youth Day (2011) in Nova Scotia, and other nationally hosted events in Canada. There are now higher security requirements for these types of mass gathering events. The Public Health Agency has been proactive in the past 10 years, offering preparations and pre-deployments for these types of planned events, with a more flexible, scalable and interoperable modular concept of emergency medical service delivery (mini-clinics) should local emergency health services become overwhelmed. Deploying these mini-clinics also provides an opportunity to field test this asset and make refinements.
The NESS program acquires and holds medical countermeasures, but its mandate is less clear in the distribution of these centrally held, highly specialized pharmaceuticals.	Key informants indicated that many of the medical countermeasures for potential bioterrorist attacks do not exist in the hospital system or in the pharmacy system in Canada. Because they are expensive, difficult to acquire (few manufacturers, licensing restrictions, many not approved for sale in Canada), and their life cycle is very distinctive, the Public Health Agency started to acquire and store them in the NESS. As the lead for the Federal Nuclear Emergency Plan (2002), the health portfolio is accountable for action to address CBRN risks. This role encompasses planning, preparedness activities, and response structures, processes and linkages for a coordinated federal, provincial and territorial response to nuclear emergencies affecting Canada or Canadians at home or abroad. The Health Portfolio Chemical Emergency Response Plan (2010) outlines the role of the health portfolio for chemical emergencies. The Portfolio provides scientific and public health support to assist response efforts. The support is primarily intended for the provinces and territories. It can also extend to other federal departments and international counterparts when required. One of the Public Health Agency's roles within the health portfolio is the acquisition, storage and distribution of highly specialized pharmaceuticals in response to CBRN risks. Key informants indicated that given the rapidly devastating nature of CBRN events, it would be challenging to get these medical countermeasures out to the various jurisdictions in time to be of assistance. The Norwegian Emergency Preparedness System has found that the nearer stocks are to a crisis site, the more effective they are in saving lives and preventing suffering; however, representatives stress that this must be balanced against the cost of maintaining stocks at a lot of different locations and the longer turnover period. In Australia, every state and territory has its own stockpile, including an inventory of antiviral agents. Australia's planning and response to pandemics relies on partnerships between the Department of Health and Ageing and its state and territory counterparts. The Centers for Disease Control and Prevention in the United States has established CHEMPACK, a voluntary participation project with states, for the "forward placement" of sustainable repositories of nerve agent antidotes. Thirty-nine states already have containers and seven others are in the process of obtaining them. Key informants indicated that updating the program has meant the acquisition of provisions that are more expensive and harder to acquire and store (not widely available, strict licensing restrictions) or that require a long lead time for procurement. Pharmaceuticals typically have a shelf life – legal limit on length of storage time before it is considered unsuitable for use. Shelf life can create challenges for stockpiling as these supplies may expire before they are needed and may require replacement.
Efforts will need to be undertaken to support rural, remote and/or northern communities jurisdictions in developing needs assessments for emergency preparedness and response, identifying unique and specific needs, and further clarifying areas in which the Public Health Agency can provide assistance to address requirements.	Key informants and documents reviewed indicated that rural, remote and/or northern communities face numerous gaps and challenges in emergency management because of their unique circumstances.^{[Link to footnote 29]}
The requirements for emergency supplies have changed considerably over the last 60 years, and in the last 10 years in particular.	As defined almost 60 years ago, the mandate of the NESS program was to provide surge capacity to provinces and territories: NESS social service and medical supplies were only to be deployed when provincial and territorial resources had been exhausted. The intent of the NESS program was to bolster the response of provincial, territorial or local governments in the event of a medical emergency. Prior to the "9-11" terrorist attacks in the United States (2001) and the more recent SARS (2003-04) and H1N1 influenza (2009) pandemic events, the primary role of the NESS program had been to respond to a broad base of man-made and natural disasters. The more recent events have accelerated efforts to address more contemporary and specific public health threats. Key informants indicated that higher security risks for mass gatherings have led to a federal role in pre-positioning medical supplies for these events in case local medical supplies are overwhelmed. Key informants indicated that when responding to many of these new public health threats, especially those that require very rapid responses, such as the release of a chemical agent, the NESS program may be required to take on the role of a primary supplier at the request of the provinces and territories rather than a resource of last resort once provincial and territorial supplies have been exhausted.
Other than NESS, there are alternatives to consider for the provision of social service supplies in Canada.	While there continues to be a need during public health events for a social service response, the capacity of the provinces and territories, and non-governmental organizations (such as the Canadian Red Cross and a variety of other response agencies), to assist with the provision of these supplies at the local level has increased. This situation was highlighted in both interviews with key informants and domestic case studies. Other countries, as well as some provinces and territories in Canada, are already working with other organizations for social services support during an emergency: non-governmental organizations (e.g. the Australian Red Cross Society, funded by the Australian government, states and territories for both domestic and international emergencies) another government department (e.g. the United States' Federal Emergency Management Agency under the Department of Homeland Security) a public/private partnership (e.g. Innovation Norway's consortia of public/private partners for the Norwegian Emergency Preparedness Stockpile System).
It is estimated by the program that a significant proportion of the supplies and equipment in the current NESS stockpile is out of date and/or is not in accordance with current medical standards or practices.	Key informants indicated that many of the cots in stock are considered to be difficult for seniors and people with disabilities to use because they are too low to the ground. Some of the blankets supplied by the NESS program are wool-based and considered by some users to not be desirable. Medical technology has advanced significantly since many of the medical components of the 200-bed hospitals and CCUs (critical care units) were acquired in the 1960s. This equipment is unsafe to use by modern medical standards or uses technology that is no longer relevant to current medical practice. Provincial and territorial representatives are aware of this issue and feedback indicated that this situation has to some extent eroded confidence in the overall value of the entire complement of NESS supplies. Provinces and territories are responsible for providing the space for storing these supplies; some jurisdictions expressed frustration that they are paying to store products that can never be used. Key informants indicated that disposal will be time consuming and expensive, but is necessary to update the stockpile. The Centre for Emergency Preparedness and Response has begun disposal; however, the process is complicated. In addition to disposal of supplies at the Ottawa warehouse, the process may involve shipping all or many of the products back to the Ottawa warehouse from the pre-positioned sites in provinces and territories and sorting in accordance with the Treasury Board of Canada Directive on the Disposal of Surplus Material (2006). There are a number of different disposal avenues for each product, depending upon its resale value and material composition (i.e. recycle, resale, or disposal).

**QUESTION #5: Is there overlap/duplication or complementarity in service delivery?**
Findings	Evidence
Roles and responsibilities concerning the NESS are not clearly understood by provinces/territories and other government departments. Part of the value added for the federal role is to draw on existing expertise through partnering, collaboration and communication.	Key informants indicated that the sharing of knowledge and expertise across jurisdictions is critical to the success of emergency preparedness in Canada; this is no less true for the coordination and management of surge supplies. It is about knowing what other jurisdictions are doing, both domestically and internationally, including the introduction of cutting-edge products and protocols, and being synthesizers, transmitters and users of that information. They suggested that these efforts will allow the Public Health Agency to propose good models and practices, provide opportunities for information sharing, and ensure the most appropriate and efficient systems and knowledge are in place.
The broader management of stockpiles of medical supplies in Canada would benefit from an enhanced focus on evidence-based decision making, a consultative approach and a plan that is reflective of stakeholder needs.	Several federal departments manage stockpiles of emergency medical supplies and/or pharmaceuticals to meet their own operational needs, including: the Department of National Defence, Canadian Food Inspection Agency, Department of Foreign Affairs and International Trade, and Health Canada. The current management of these federal stockpiles is largely focused on departmental requirements. Key informants suggested that there is a great deal of variability across Canada in knowledge about, and capacity for, surge response. In building a community of experts across jurisdictions, the Public Health Agency demonstrates its leadership role in bringing together different partners and expertise to build tools to support dialogue, share resources and facilitate evidence-based decision making in a public health context. For example, expert groups could be established or enhanced for medical equipment and for pandemic, food-borne, CBRN risks, etc. To ensure the NESS inventory meets current standards, and is operationally relevant to end users, the continued engagement of experts from across Canada is critical to focused decision making.
The NESS program is as relevant as its ability to meet the real needs of its primary users, that is, to support provinces and territories in their emergency responses. There could be better communication about the supplies that are available in the stockpile.	Key informants from both the program and the provinces and territories suggested that there has not always been consistent provincial and territorial involvement in decisions on acquisitions, positioning and deployment of materials for the NESS program. They indicated that there needs to be consultation with and information shared by a broad base of provincial and territorial experts to ensure that cross-jurisdictional and individual provincial and territorial considerations are well understood by the Public Health Agency. It was clear that enhanced information about stock held in other jurisdictions could facilitate the exploration of options on partnered federal/provincial/territorial stockpile initiatives, such as planning, procurement, stock rotation, quality control, distribution, facility management and life-cycle issues. Along the same lines, the Memoranda of Understanding (MOU) with provinces and territories established in the 1960s and 1970s (there is no MOU with Nunavut) are outdated and do not match today's complex operational and business environment. The Public Health Agency has engaged a task group with provincial/territorial representatives to discuss this matter. Task group members have confirmed that these agreements need to be renegotiated with each of the provinces and territories. Updated agreements need to outline current expectations, as well as accountability and security for NESS supplies. Representatives from the provinces and territories stated that, in some jurisdictions, little information was available to them regarding processes and products. Some were not aware of which supplies are available to them. One option for achieving this goal is to develop an electronic database, accessible to provinces and territories, which will provide a clearer understanding of NESS supplies and the Public Health Agency's role in the provision of these supplies. This electronic database could also serve as a tool to provide a consistent avenue of communication among federal, provincial and territorial counterparts. In the United States, the Centers for Disease Control and Prevention (CDC) has an electronic database (an extranet site), which allows states to view specific items held in the stockpile. A similar system could be considered for the NESS program, whereby users/clients (provinces and territories) could search the database either by event (e.g. a chemical accident) or by product (e.g. ventilators).

**Conclusions to recommendations matrix**
	Findings	Conclusions	Recommendations
R E L E V A N C E	While relatively few catastrophic events have taken place on Canadian soil in recent memory, this country is not impervious to these threats. These challenges require well-thought-out emergency response plans, including timely access to essential provisions.	Relevance The NESS program is relevant (although the current asset mix should be reviewed in line with federal public health priorities). It is consistent with the current Government of Canada and Public Health Agency strategic priorities. There is a Government of Canada role to coordinate emergency management activities across jurisdictions, where appropriate. While there appears to be a Government of Canada role in international health emergency response, specifically in the deployment of emergency supplies, the specific role of the Public Health Agency is not clear. Any consideration of a formal international role would require interdepartmental consultations and formal authorities to do so.	#1 Retain some but not all of the current NESS asset mix. Focus on an appropriate public health role when planning for and determining the future strategic mix of assets rather than on a more general social services role in responding to events.
	The NESS program has adopted an "all-hazards" approach, meaning that decisions about the composition and management of this national reserve of provisions are to be based on up-to-date risk assessments.
	The Government of Canada's commitment to the safety of Canadians in the face of human and natural threats has been reiterated in a variety of communications, instruments and agreements.
	PHAC planning documents have consistency cited the National Emergency Stockpile System as strategically important.
	There is documentation that confirms the broader federal role in emergency preparedness and response in Canada.
	The Public Health Agency of Canada was established to support, and currently undertakes, public health emergency preparedness and response activities domestically and internationally, including the dissemination of emergency supplies.
	Canada is required at the national level to have the capacity to provide support for logistical assistance. There is some documentation that specifies the federal role in the provision of emergency supplies in response to a domestic disaster.
	The Minister of Health (responsibilities include Public Health Agency of Canada) is mandated to provide a federal emergency support function for public health. There is little documentation that describes a specific Public Health Agency of Canada role in the provision of emergency supplies in response to a domestic public health event.
	There is some documentation that specifies the federal role in the provision of emergency supplies in response to an international disaster. No mandate or specific authority for PHAC has been stipulated for responding to public health events that take place outside Canada.		#4 Include specific consideration of the NESS in the Agency's broader discussions of its international role.
	The implications for an international role will need to be well understood and formally acknowledged by all partners and stakeholders. The NESS program would need to be able to meet both domestic and international needs.
	The need for formal relationships and a clear definition of roles and responsibilities would need to be considered as part of the exploration of a more formal international mandate. A formal international role would require collaboration with other stakeholders in advance to ensure planning for an international role reflects the wealth of information from those most practiced in this field.
P E R F O R M A N C E	There are potential efficiencies to be gained by partnering with organizations that already have well-established infrastructures, e.g. non-governmental organizations, other government departments and other administrations.	Performance While a thorough assessment of performance was limited due to a lack of performance data, there were indications that NESS was deployed in a timely fashion. However, overall improvements could be made to the NESS program. There is a need to provide surge capacity to provinces and territories. However, the mandate outlined 60 years ago is outdated and not reflective of current realities. A more up-to-date NESS program requires focused decision making that emphasizes the acquisition and distribution of more strategic supplies, based on risk assessments that reflect modern risks and the Public Health Agency's role in emergency response. In line with developments in capacity, and the reality of current public health threats, the NESS program needs to focus on its niche role in current emergency response requirements when determining what supplies should be in the stockpile. An Agency commitment to clearing the NESS warehouses of outdated supplies will help to rebuild confidence among provinces and territories in the overall program. The broader management of stockpiles of medical supplies in Canada would benefit from an enhanced focus on evidence-based decision making, a consultative approach and a plan that is reflective of stakeholder needs.	#1 Retain some but not all of the current NESS asset mix. Focus on an appropriate public health role when planning for and determining the future strategic mix of assets rather than on a more general social services role in responding to events. #1 a) Continue to ensure the following stock is available for provincial/territorial surge: pandemic preparedness supplies; medical and pharmaceutical supplies for planned mass gatherings of national significance and unplanned natural or manmade disasters; and chemical, biological and radio-nuclear (CBRN) countermeasures. b) Consider eliminating social service supplies from the NESS asset mix while ensuring their continued availability. For stock being acquired and retained, attention must be paid to its life-cycle management (see Appendix A).
	Other countries concentrate on stockpiling pharmaceuticals and medical supplies but not for a social service response. Other organizations within these jurisdictions provide this type of service.
	In other countries, stockpile systems are constantly evolving and updated in response to regular review.
	Pandemic preparedness is a key and clearly defined role of the Public Health Agency.
	The Public Health Agency has been responsive to requirements for pre-deployment of emergency medical supplies for mass gatherings.
	The NESS program acquires and holds medical countermeasures, but its mandate is less clear in the distribution of these centrally held, highly specialized pharmaceuticals.
	Efforts will need to be undertaken to support rural, remote and/or northern communities jurisdictions in developing needs assessments for emergency preparedness and response, identifying unique and specific needs, and further clarifying areas in which the Public Health Agency can provide assistance to address requirements.
	The requirements for emergency supplies have changed considerably over the last 60 years, and in the last 10 years in particular.
	Other than NESS, there are alternatives to consider for the provision of social service supplies in Canada.
	It is estimated by the program and end users that a significant proportion of the supplies and equipment in the current NESS stockpile is out of date and/or is not in accordance with current medical standards or practices.		#2 Develop, resource and implement a disposal strategy to allow for the disposal of: a) equipment and supplies that are outdated, no longer meet current medical standards, or are of poor quality (i.e. emergency hospitals, casualty collecting units, etc.) b) individual social services items (i.e. cots and blankets) and social services units (i.e. mobile feeding units, reception centre kits, etc.) (contingent on the outcome of recommendation 1b).
	Roles and responsibilities concerning the NESS are not clearly understood by provinces/territories and other government departments. Part of the value added for the federal role is to draw on existing expertise through partnering, collaboration and communication.		#3 Develop, implement and monitor a strategy to help communicate the Public Health Agency's role in stockpiling supplies for public health responses, considering the following target groups: Other federal government departments and agencies Provinces/territories, including specialized areas: End users (health practitioners) Materiel management specialists Logistical teams.
	The broader management of stockpiles of medical supplies in Canada would benefit from an enhanced focus on evidence-based decision making, a consultative approach and a plan that is reflective of stakeholder needs.
	The NESS program is as relevant as its ability to meet the real needs of its primary users, that is, to support provinces and territories in their emergency responses. There could be better communication about the supplies that are available in the stockpile.

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Date modified:: 2012-08-28

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