ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic

 

3. Findings

3.2 Collaboration with provinces and territories

Background

The Public Health Agency of Canada and Health Canada primarily collaborate with their provincial/territorial partners on public health and pandemic preparedness through the Pan-Canadian Public Health Network. The Public Health Network, established in 2005 and made up of academics, scientists, federal public servants, senior officials in provinces and territories, as well and members of non-governmental organizations, aims to address the need for a coordinated approach to public health in Canada. It is a key intergovernmental mechanism for jurisdictions to work together on public health issues, including planning for and responding to pandemics. The Network also provides policy and technical advice to the Conference of Deputy Ministers of Health on public health matters.

Through the Public Health Network, the federal, provincial and territorial governments developed the Canadian Pandemic Influenza Plan for the Health Sector, a broad framework for Canada’s collaborative response to pandemic influenza and guidance for the federal Health Portfolio and other governments.

What worked well?

Federal and provincial/territorial governments demonstrated a high level of collaboration

Public Health Agency of Canada and Health Canada staff, as well as senior officials in the provinces and territories, generally agreed that there was a high level of federal and provincial/territorial collaboration during the H1N1 pandemic.

At the multilateral meeting of federal/provincial/territorial clerks and Cabinet secretaries on January 20 and 21, 2010, jurisdictions agreed that collaboration was strong among their governments. All parties made concerted efforts to work together to minimize the effect of H1N1 on the Canadian population; at the same time, ministers and officials from across the country, both within their governments and in their public communications, demonstrated a solidarity that ensured an effective and transparent response. Daily teleconferences of the Conference of Deputy Ministers of Health, organized primarily through Health Canada and Manitoba (the provincial/territorial co-chair for H1N1 during the first and second waves), ensured senior-level collaboration and appropriate information sharing at the right level among all parties throughout the H1N1 pandemic.

In her report on how Ontario fared during the H1N1 pandemic, Ontario’s Chief Medical Officer of Health described it this way: “Here in Canada, the Federal-Provincial-Territorial response, while not without the kind of challenges you would expect in any undertaking this complex and important, was always driven by an absolute commitment to getting it right on behalf of Canadians.”Footnote 30

Basic mechanisms to support federal/provincial/territorial collaboration were in place

The Pandemic Influenza Committee was established in 2001 under a federal/provincial/territorial working agreement. Members of the Pandemic Influenza Committee included provincial and territorial public health experts, other public health and emergency response experts, an ethicist, and Public Health Agency officials. When the Pan-Canadian Public Health Network Council was established in 2005, the Pandemic Influenza Committee was integrated into this Network as an issue group under the Communicable Disease Control Expert Group.

The Pandemic Influenza Committee mandate was established in 2006 to provide technical and science-based recommendations, liaison capacity and expert opinion to support the health and safety mandates of all orders of government related to the health sector preparation for, and response to, an influenza pandemic. The Pandemic Influenza Committee provided the same services in response to novel influenza viruses with pandemic potential and aimed to ensure federal, provincial/territorial collaboration in the development of the Canadian Pandemic Influenza Plan for the Health Sector.

In December 2007, the Public Health Network Council and the Council of Chief Medical Officers of Health agreed to establish a central coordinating body for pandemic influenza planning to improve the overall management of pandemic-related activities, increase operating efficiency and reduce the strain on federal, provincial and territorial staff resources involved in multiple Public Health Network groups. The Pandemic Preparedness Oversight Committee was established to leverage funds and address federal and provincial/territorial policy issues. This committee became the Pandemic Coordination Committee in June 2009 and the Pandemic Influenza Committee was disbanded.

The Canadian Pandemic Influenza Plan for the Health Sector proved to be an invaluable tool in providing a baseline and structure for the overall H1N1 response. The Plan, however, was a national framework document that had been developed in anticipation of what would be needed to respond to a pandemic situation. While an overarching federal/provincial/territorial structure for managing pandemic influenza had been put in place within the Canadian Pandemic Influenza Plan for the Health Sector, the federal/provincial/territorial governance structure evolved over the course of the pandemic to enable timely decision making on emerging issues. In August 2009, the Conference of Federal/Provincial/Territorial Deputy Ministers of Health approved a time-limited federal/provincial/territorial H1N1 health emergency management response and organization structure with various functional areas co-led by representatives from the provinces, the territories and the federal Health Portfolio.

New structures were created to respond to emerging issues

During the pandemic, federal, provincial and territorial Ministers and Deputy Ministers of Health needed to have more regular contact to share information and make decisions on emerging policy and operational issues related to the H1N1 response as mentioned above. A new time-limited federal/provincial/territorial emergency management structure was established to support Deputy Ministers and their overall management responsibilities during the H1N1 pandemic (see Figure 3.2.1). This governance structure allowed for collaboration in several core response functions including: planning, operations, logistics, communications and health services. A Deputy Minister of Health was assigned for each of these functional groups and was responsible for regular reporting to all federal/provincial/territorial Deputy Ministers of Health on emerging issues. To support this H1N1 governance structure, several new time-limited federal/provincial/territorial task groups were established, including the following:

  • Special Advisory Committee on H1N1: was established in April 2009 to provide a national coordinated response and ensure rapid, evidence-based decisions. This group comprised federal, provincial and territorial members of both the Pan-Canadian Public Health Network Council and the Council of Chief Medical Officers of Health. Reporting to the Deputy Ministers of Health, the Special Advisory Committee provided advice related to technical and operational issues in public health such as clinical care guidelines for pregnant women and antivirals.
  • Logistics Coordination Task Group: examined logistics coordination and support that could benefit from a pan-Canadian approach. The Task Group provided advice on issues such as: the maintenance of essential facilities; surge capacity; mutual aid between jurisdictions; stockpiles for equipment and supplies (e.g. antivirals); procurement; and operational communications and information sharing (e.g. linkages with the emergency voluntary sector).
  • Communications and Media Relations Task Group: used a federal/provincial/territorial communications governance structure to respond to the H1N1 influenza pandemic. Reporting to both the Special Advisory Committee and the federal/provincial/territorial Deputy Ministers of Health, this group facilitated enhanced information sharing and coordinated public responses on emerging issues during the H1N1 pandemic. It also shared social marketing products and communication tools to be used and tailored by all jurisdictions (e.g. public communications on the H1N1 and seasonal influenza vaccines).
  • Human Health Resources Task Group: provided advice to the Deputy Ministers of Health on specific health human resources policy issues during the H1N1 pandemic. For example, this group provided advice on: the use of respiratory protection; the supply of safety officers; facilitating temporary staff transfers; the right to refuse unsafe work; labour legislation provisions; and cross-jurisdictional methods to encourage the vaccination of health care workers.
  • Health Services Task Group: focused on broader health system issues related to clinical and acute care (e.g. intensive care capacity, best practices concerning access and triage) and coordinating broad health services issues during the H1N1 pandemic (e.g. identification of health system surveillance issues).
  • Federal/Provincial/Territorial Liaison Secretariat: provided ongoing support to Deputy Ministers by identifying emerging issues, managing agendas and coordinating activities across the various federal, provincial and territorial H1N1 committees through the use of a federal/provincial/territorial H1N1 workplan.

In addition, certain groups were established to support the Special Advisory Committee:

  • The Pandemic Coordination Committee was formed as an interim committee to manage all pandemic H1N1 national-level priority activities in preparation for the second wave. Discussions between members took place daily for an extended period (primarily by teleconference), allowing for input and information sharing.
  • The following time-limited task groups supported the Pandemic Coordination Committee. The task groups were created where no existing group or expertise could be identified within the existing Public Health Network structure. Composed of technical and scientific experts from across Canada, members were responsible for developing strategic documents, guidance or reports. The composition of the membership of the task groups provided expertise to respond to information and decision-making needs. Some individuals served on more than one task group. This cross-membership between task groups helped facilitate information sharing and collaboration. These task groups covered the following areas:
    • Surveillance, Epidemiology and Laboratory
    • Pandemic Vaccines
    • Public Health Measures
    • Remote and Isolated Communities
    • Zoonoses
    • Infection Control
    • Clinical Care and Antivirals.
  • Pre-existing Public Health Network groups were leveraged for strategic or expert advice in the development of guidance or recommendations. Members were academics, scientists, public servants and members of non-governmental organizations from across Canada. The following existing Public Health Network groups provided guidance during the H1N1 pandemic:
    • Canadian Public Health Laboratories Network (represented on Pandemic Coordination Committee)
    • Communicable Disease Control Expert Group (represented on Pandemic Coordination Committee)
    • Surveillance and Information Expert Group (represented on Pandemic Coordination Committee)
    • Emergency Preparedness and Response Expert Group (represented on Pandemic Coordination Committee)
    • Population Health Promotion Expert Group
    • Chronic Disease and Injury Prevention Expert Group.

Figure 3.2.1 shows the relationship between the groups established for the H1N1 response as they had evolved by December 2009.

Figure 3.2.1 Federal/provincial/territorial H1N1 health emergency management response and organization as of December 21, 2009 (time limited for H1N1 response only)

Text Equivalent - Figure 3.2.1

This organization chart shows the federal, provincial and territorial organization for H1N1 response as it had evolved by December 21, 2009; note that this structure was time-limited and is no longer in effect. The chart shows the Deputy Ministers Committee at the top, being a control, coordination and policy body. Supporting this Committee are the Liaison Secretariat, as well as the Communications/Media Relations Task Group performing H1N1 media relations coordination. Underneath are five functional areas that report to the Deputy Ministers Committee:

1. H1N1 operations and logistics coordination is headed by a Logistics Coordination Group and leads the following sub-groups:

  • Emergency Preparedness and Response Expert Group
  • Council of Health Emergency Management Directors
  • Council of Emergency Social Services Directors
  • Council of Emergency Voluntary Sector Services Directors
  • Pandemic Preparedness Health Operations Committee
  • Pandemic Supplies Procurement Working Group
  • Antiviral Stockpile Management Task Group
  • PHAC — National Office Health Emergency Response Team
  • PHAC — National Emergency Stockpile System
  • PHAC — Canadian Field Epidemiology Program

2. H1N1 planning and coordination is led by a Special Advisory Committee to which the Pandemic Coordination Committee and the Public Health Network Council report.  The Pandemic Coordination Committee itself leads the following sub-groups:

  • Surveillance, Epidemiology and Laboratory Task Group
  • Pandemic Vaccines Task Group
  • Public Health Measures Task Group
  • Remote and Isolated Communities Task Group
  • Zoonoses Task Group
  • Infection Control Task Group
  • Clinical Care and Antivirals Task Group
  • Canadian Immunization Committee
  • Vaccine Supplies Working Group
  • Vaccine Vigilance Working Group
  • Canadian Immunization Registry Network
  • PHAC — FluWatch

The Public Health Network Council, only active as per H1N1 workplans or if otherwise required, leads the following sub groups:

  • Canadian Public Health Laboratories Network [represented on Pandemic Coordination Committee]
  • Communicable Disease Control Expert Group [represented on Pandemic Coordination Committee]
  • Surveillance and Information Expert Group [represented on Pandemic Coordination Committee]
  • Emergency Preparedness and Response Expert Group [represented on Pandemic Coordination Committee]
  • Population Health Promotion Expert Group
  • Chronic Disease and Injury Prevention Expert Group

3. H1N1 health services issues are dealt with by the Health Services Task Group.

4. The Human Health Resources Task Group takes care of H1N1 human resources coordination.

And lastly,

5. an Assistant Deputy Ministers Task Group coordinates H1N1 Finance and  Administration.

Areas for action

While it is generally agreed that federal/provincial/territorial collaboration worked well, concerns were raised by provincial and territorial Deputy Ministers of Health and stakeholders regarding the timeliness of key actions. A few examples are provided below regarding vaccine supply and clinical guidance.

In her report on how Ontario fared during the H1N1 pandemic, Ontario’s Chief Medical Officer of Health stated,

We also were affected, and not always in a positive way, by decisions made elsewhere that had a huge impact on us. For example, the contract between the federal government and [GlaxoSmithKline] required a minimum order to be placed, which resulted in Ontario receiving more than it required. The scientific information to support the use of the products was not available until we actually received the product, meaning that the required professional and public education process needed to occur over a matter of days.Footnote 31

According to the report from the Canadian Medical Association, the College of Family Physicians of Canada and the National Specialty Society for Community Medicine,

Although the Pandemic Influenza Committee and the Special Federal/Provincial/Territorial Advisory Committee on H1N1 Influenza strove for consensus at the national level, individual provinces and territories were under no obligation to implement the guidance agreed to at the federal/provincial/territorial level. Consultative and collaborative processes at the federal/provincial/territorial level created delays in decision making and directly interfered with the capacity of front‐line professionals to respond to the urgent health needs of their patients. This led to a sense of confusion in the media and a loss of trust among the public and health professionals regarding Canada’s capacity to respond to pH1N1.Footnote 32

Lack of timeliness was deemed by some to be directly related to the complexity of the federal/provincial/territorial governance structures and the intensity of their activities. Efficiency and transparency were also concerns. In preparing for any future response, the following governance issues should be considered.

Continue to work with provincial and territorial partners to review and streamline the federal/provincial/territorial governance structure for pandemic influenza

While new committees and task groups were important in dealing with specific H1N1-related issues, the sheer number of meetings and accompanying work added to the complexity of activities associated with the response. One interviewee noted, “Overall I think we really have to look at the need for all of those committees and working groups and what purpose they were serving and how much duplication there was.”

At their January 2010 meeting, federal/provincial/territorial Deputy Ministers of Health agreed that improvements to the governance structure should be continued, with the understanding that any structures would need to be flexible enough to adapt to different types of urgent situations that could affect the health sector and be in place immediately, while respecting jurisdictional responsibilities and authorities.

Clarify and communicate the roles and responsibilities of the various advisory groups within the pandemic governance structure

Responding to H1N1 meant that old structures were reviewed and new committees formed to ensure the appropriate members were at the table for advice or decision making. Establishing new structures in the midst of the pandemic, however, led to further confusion about roles and responsibilities. For example, the introduction of the Pandemic Coordination Committee as a new entity in the governance structure to respond to H1N1 created even further confusion with respect to roles and responsibilities. Existing committee and task groups that were, at the time, fulfilling similar responsibilities, felt undermined when the Pandemic Coordination Committee was formed.

There appeared to be a lack of clarity about roles and responsibilities within and between many task groups and committees, creating confusion and unnecessary effort. For example, there was confusion in the role of the new Pandemic Vaccine Task Group compared with that of the existing National Advisory Committee on Immunization, which had an established mandate, authority and reporting relationship, as well as with the already-established Canadian Immunization Committee. The various actors needed clear direction on the role of a pandemic vaccine expert group in relation to the regulatory body in assessing the manufactured vaccine product. Generally, the creation of the task groups made it unclear how pre-H1N1 committees fit into the overall response to H1N1. Therefore, the expertise residing in the pre-H1N1 or existing structures may not have been used as efficiently as possible.

As part of the federal, provincial and territorial work on pandemic preparedness, a Memorandum of Understanding for Roles and Responsibilities in a Pandemic had been in development prior to H1N1. During the H1N1 pandemic, the federal Minister of Health and most provincial and territorial Ministers of Health agreed in principle to an annex of the Memorandum of Understanding on information sharing, but narrowed its scope to the H1N1 pandemic only. It is worth noting that the Office of the Auditor General has recommended for more than a decade that a formal information-sharing agreement between the federal government and the provinces and territories be developed.

Clarify decision-making processes during a pandemic and communicate them to expert or advisory groups

Communication between decision makers and task groups was often perceived as time consuming and cumbersome. This may have been exacerbated by the solicitation of approvals from various committees.

The decision-making process did not always appear to be transparent for some because communication from decision makers to task groups was not always clear. In addition, repeat and/or additional consultations for decision-making purposes were problematic for timely approvals. This also affected the time allotted to decision makers, who were not provided with documents in adequate time for thorough reviews. The same was true of consultations needed within provinces and territories.

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