Section 2: Evaluation of the surveillance function at the Public Health Agency of Canada – Background and context

2. Background and context

2.1 The Public Health Agency’s surveillance activities

According to the Public Health Agency’s 2012-13 Program Alignment Architecture^{Footnote 29}, public health surveillance is located under Program Activity 1.2 Surveillance and Population Health Assessment and is organized under three ‘Sub-Sub-Activities’:

• Surveillance of Risk Factors and Determinants of Health (1.2.1.1) involves national surveillance in the areas of maternal, infant and child health and injury, child maltreatment and developmental disorders and congenital anomalies as well as support to Health Canada by assessing risks associated with consumer products. The Centre for Chronic Disease Prevention is responsible for this Sub-Sub-Activity.
• Surveillance of Chronic Disease (1.2.1.2) involves national surveillance of chronic diseases and their risk factors. The Centre for Chronic Disease Prevention is responsible for this Sub-Sub-Activity.
• Surveillance of Infectious Disease (1.2.1.3) focuses on the prevention and control of infections in Canada by detecting, identifying, monitoring and reporting risk factors, disease exposure and trends associated with vaccine-preventable and infectious diseases. This Sub-Sub-Activity also comprises the sharing of routinely collected data with Canadian and international public health experts to facilitate prevention by informing system-wide and coordinated approaches to evidence-based program and policy development. Responsibility for this Sub-Sub-Activity is shared among the Centre for Communicable Diseases and Infection Control, the Centre for Foodborne, Environmental and Zoonotic Infectious Diseases, the Centre for Immunization and Respiratory Infectious Disease, the National Microbiology Laboratory and the Laboratory for Foodborne Zoonosis.

2.2 The Public Health Agency’s 2007 Surveillance Strategic Plan

In 2007, the Chief Public Health Officer launched a multi-disciplinary working group to review the status of surveillance activities within the Public Health Agency. The objective was to guide the organization from a wide variety of disparate surveillance systems towards a more coherent approach to surveillance that maximized the full potential of surveillance as a strategic resource. The 2007 Surveillance Strategic Plan^{Footnote 30} was the result of the working group’s deliberations.

The plan describes the surveillance vision:

• “National policies and programs to improve the health of Canadians are guided by high quality, timely and on-going population information that is collaboratively produced by the federal, provincial, territorial, and local levels.”
  
  and mission:
• “to provide leadership and collaborate with our federal, provincial, territorial, and local partners on an integrated and sustainable pan-Canadian approach to surveillance information for use in public health decisions.”

To assess performance, the evaluation examined the Public Health Agency’s progress in achieving the goals of the 2007 Surveillance Strategic Plan^{Footnote 31}. The plan identified the following five goals to facilitate achieving the vision, mission and expected outcomes of the surveillance function:

• Governance and organization: create, implement and maintain a responsive governance structure for surveillance within the Public Health Agency, accountable to the Chief Public Health Officer and with cross-organizational representation, which ensures alignment with Public Health Agency priorities
• Integrated surveillance: develop, implement, and maintain an efficient network of surveillance systems, accessible to Public Health Agency partners and stakeholders where applicable, which strategically links people, processes and technologies, and that is purposeful and used for public health action
• Knowledge management: establish and maintain a constant transfer of information and knowledge for public health decision making
• Partnerships and collaboration: effectively manage and maintain internal and external partnerships and engage them in collaborative surveillance activities that support public health action
• Performance measurement, quality assurance and evaluation: develop, implement and maintain performance measurement, quality assurance and evaluation activities that are timely, relevant and used to improve surveillance within the Public Health Agency and ensure that it is constantly aligned with Public Health Agency priorities.

The original plan was intended as a medium-term strategy from 2007 to 2012. At the time of this evaluation, work on a renewal to the 2007 Surveillance Strategic Plan^{Footnote 32} was already underway. Wherever possible, the evaluation has taken into account this dynamic and evaluation findings have contributed to the development of the new surveillance strategic plan.

2.3 Resource allocation

The Public Health Agency’s Program Alignment Architecture was modified for 2010-11 to include the Public Health Surveillance Sub-Activity and its related Sub-Sub-Activities. Before 2010-11, the allocation of resources for surveillance was captured under each program.

In 2010-11, the Public Health Agency recorded $66.3 million against the Public Health Surveillance Sub-Activity. This represents approximately 11 per cent of the Public Health Agency’s total expenditures in that year. As the Public Health Agency’s definition of surveillance continues to evolve, the amounts recorded against the Public Health Surveillance Sub-Activity in 2010-11 should be considered an estimate.

As shown in Table 4, these expenditures were spread across the surveillance of risk factors and determinants of health (14 per cent), surveillance of chronic disease (24 per cent) and surveillance of infectious disease (62 per cent). Figure 4 provides a break-out of how the $66.3 million was expended.

2.4 The environment for public health surveillance

The environment in which public health surveillance operates is complex. The following points highlight some of the sources of complexity and significant changes that present challenges, as well as new opportunities, not only for the Public Health Agency but for surveillance generally:

• Privacy considerations: The effect of privacy legislation on public health surveillance is that policy makers must balance the communities’ right to shared data that could provide information about a public health threat with the right of individuals to privacy (e.g. infectious diseases such as HIV/AIDS).
• Globalization: As noted in the May 2008 Report of the Auditor General of Canada, “infectious diseases do not respect national borders and are emerging more quickly than ever before. Global food supply chains, new food technologies and cost pressures have resulted in worldwide sourcing of food products and ingredients. Many countries lack the regulatory frameworks to ensure the safety of their products.”^{Footnote 33}
  
  As an example of the Public Health Agency’s response to the increased risks associated with travel, the Public Health Agency’s Office of Border Health Services uses both domestic and international surveillance data as an early warning system for impending public health emergencies, and to assist in determining appropriate measures to protect public health. The Office of Border Health Services also conducts various types of surveillance, such as travel health reports on international travellers, and uses the data it collects to inform public health policy and strategies and to identify trends among international travellers who are ill.
• Shift in focus: In the last 15 years, public health surveillance has expanded its focus from protecting communities from communicable diseases to include tracking the occurrence of many non-communicable conditions like injuries, chronic conditions, mental illness and environmental exposures to health risks.
• Expanded data sources: Public health surveillance is taking advantage of newly available data, including unstructured clinical data (for example, handwritten or transcribed narrative notes that are scanned into a system), Internet data, media content and environmental and climate change data. This data provides new opportunities to enhance health knowledge using a more detailed characterization of events of interest with respect to time, place and person. The challenge for the Public Health Agency is to determine how best to tap into these opportunities. The Public Health Agency’s Global Public Health Intelligence Network (known as GPHIN) system, managed by the Centre for Emergency Preparedness and Response, is an example of a new source of data. GPHIN is a 24/7 multilingual early-warning and situational awareness system for potential public health threats.
• International Health Regulations: Public health surveillance is being reshaped by the 2005 changes to the International Health Regulations^{Footnote 34} and the rapid development of new global networks for disease surveillance and bioterrorism. The International Health Regulations are a binding international legal instrument that requires member states to report to the World Health Organization, in a timely way, any cases within their borders of specific diseases, as well as any accidental or deliberate threat that qualify as a public health emergency of international concern.
• New information technology: Advances in technology and informatics have changed the methods of surveillance, offering opportunities to strengthen surveillance capacity in the areas of disease detection, epidemiological analysis and communications. However, with these advances in technology come heightened expectations for timely and improved health information.

2.5 Governance and accountability of surveillance

2.5.1 Public Health Agency surveillance governance structure

An internal governance structure for the surveillance function (refer to Appendix C) was created in 2007 and was in effect during the period covered by this evaluation. Three groups supported the governance role of the Senior Surveillance Advisor (now referred to as the Chief Health Surveillance Officer).

Note that the Public Health Agency transitioned to a new surveillance governance structure in 2012 (refer to Appendix D) that aligns with the new Public Health Agency governance committee structure and with the Pan-Canadian Public Health Network governance structure.

Surveillance Management Committee

The Surveillance Management Committee is a director general-level committee. It provides oversight for surveillance at the Public Health Agency and serves as a forum for senior management deliberation and decision making about surveillance-based activities within the Public Health Agency.^{Footnote 35} This committee is co-chaired by the Chief Health Surveillance Officer and the Director General of the Centre for Chronic Disease Prevention. The Committee responds to and makes recommendations to the Chief Public Health Officer and to the Public Health Agency’s Executive Committee.

Surveillance Integration Team

The Surveillance Integration Team is a director- and manager-level committee. It oversees the coordination of actions necessary to implement the components of the Surveillance Strategic Plan^{Footnote 36}, facilitates decision making, coordinates horizontal surveillance issues and initiatives and sustains the governance model. The Surveillance Integration Team is supported by time-limited working groups that are responsible for specific initiatives.

The Surveillance Coordination Unit

The Surveillance Coordination Unit was established in 2009 to manage horizontal project coordination, strategic analysis and development, and support to the Chief Health Surveillance Officer. The Surveillance Coordination Unit also reports on surveillance initiatives and investments, and coordinates prioritization and risk management activities with the surveillance governance bodies.

Accountability for individual surveillance systems and surveillance programs resides with the directors general of the responsible program areas. Budgetary authority and the ongoing monitoring and financial administration of the individual surveillance systems and surveillance programs reside with branches and individual program areas.

2.5.2 Pan-Canadian Public Health Network governance structure

At the federal, provincial and territorial levels, public health officials work together through the Pan-Canadian Public Health Network and its committees to strengthen public health measures, including surveillance. While surveillance issues cut across the various Pan-Canadian Public Health Network committees, surveillance infrastructure issues are dealt with by the Public Health Infrastructure Steering Committee. This steering committee is supported by two task groups.

The National Surveillance Infrastructure Task Group

The purpose of this task group is to examine and prioritize identified gaps in the foundational elements of national public health surveillance based on the current state of federal, provincial and territorial surveillance in Canada. The task group also supports the work of the Multi-lateral Information Sharing Agreement Task Group by helping develop a template and the technical schedules for information sharing.

The Multi-lateral Information Sharing Task Group

The purpose of this task group is to develop a multi-lateral information-sharing agreement to enable the exchange of public health information and its subsequent use and disclosure by the parties for surveillance of, and response to, infectious diseases and public health events, including urgent public health events. The objectives of the agreement are to:

• formalize an arrangement for the timely and consistent exchange of public health information among federal, provincial and territorial governments
• clarify the terms and conditions for the collection, use and disclosure of public health information
• set out the rights and obligations of the federal government, provinces and territories in relation to the collection, use and disclosure of such information
• facilitate compliance with international obligations relating to health, including those under the International Health Regulations^{Footnote 37}.

Under the agreement, the Government of Canada, provinces and territories will work together to:

• ensure consistency in information by applying common standards and practices
• verify accuracy and completeness of public health information
• take reasonable steps towards timely disclosure of public health information.

Appendix E provides further details about the Pan-Canadian Public Health Network governance structure for public health surveillance.

2.6 Partners and beneficiaries

Effective surveillance relies on the development of active and interconnected networks and relationships at many levels. The many sectors involved in public health surveillance participate in collecting, aggregating, analyzing and sharing data. In addition to the provinces and territories, the Public Health Agency works with the following sectors:

• Government of Canada departments and agencies, and national laboratories
• non-governmental organizations and service providers
• Canadian Institute for Health Information
• academic community
• national and international surveillance networks and partnerships
• international public health community.

The direct beneficiaries are the users of the information produced by the Public Health Agency’s surveillance activities. The Public Health Agency’s programs, as well as the national and international public health community, use surveillance evidence to inform their disease prevention and health promotion programs and policies. Ultimately, Canadians benefit from public health policy and program decisions informed by surveillance evidence that is timely and of high quality.