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

3. Findings

3.4 Stakeholder engagement

Background

What may come this fall is something that could test all of us, possibly to a limit we’ve never experienced...Whatever may come, I stress that we’ll best meet the challenges and serve Canadians by cooperating.

―The Honourable Leona Aglukkaq, Minister of Health, August 2009^{Footnote 35}

From the start of the H1N1 outbreak, the federal Minister and Deputy Minister of Health and the Chief Public Health Officer were committed to an inclusive pandemic response. In addition to collaborating with other countries and international organizations, other federal government departments (covered in section 3.9, Operational management) and provincial/territorial governments (covered in section 3.2, Collaboration with provinces and territories), the Health Portfolio engaged:

• national Aboriginal organizations
• health professional associations
• private sector representatives
• emergency response organizations
• organizations representing at-risk populations
• organized labour for the health sector
• academic researchers and institutions.

What worked well?

A stakeholder engagement plan was put in place

There was a clear understanding within the Public Health Agency of Canada and Health Canada that involvement of all stakeholders was crucial to the successful mitigation of the effects of any pandemic. H1N1 stakeholder engagement was guided by two plans. A Public Health Agency H1N1 Strategic Relations Interim Strategy, approved by the Health Portfolio Executive Group in May 2009, outlined a strategic approach to engaging national organizations in the response and establishing mechanisms to share information to respond to emerging issues and concerns. A comprehensive H1N1 Influenza Virus Strategic Relations Plan (Domestic) was approved by the Health Portfolio Executive Group in September 2009. This second plan expanded on the types of mechanisms to be used and the breadth of stakeholder organizations to be engaged. The primary goal of both plans was to build on existing relationships and to engage and communicate in a proactive and timely manner.

A variety of engagement mechanisms were developed by the Public Health Agency of Canada and Health Canada during the H1N1 response, including:

• single-window points of contact (i.e. generic email addresses)
• regular electronic notification of new documentation on the FightFlu.ca website (e.g. approximately 20 email notifications distributed to over 100 stakeholder organizations)
• teleconferences led by Public Health Agency officials every four to six weeks to provide updates, respond to questions, and hear issues and needs
• bilateral and multilateral meetings
• collaborative work (e.g. joint projects to develop guidance)
• task groups.

Engaging key national organizations in the H1N1 response was an opportunity for the Public Health Agency of Canada and Health Canada to communicate directly with stakeholders to provide information on the virus. This engagement also enabled the Health Portfolio to draw more fully on the expertise of major national organizations to inform the development of H1N1-related policy and advice.

Keeping jurisdictional issues in mind, the Public Health Agency of Canada and Health Canada should continue to build on existing stakeholder relationships and mechanisms for engagement established before and during the H1N1 pandemic for pandemic planning and response.

Health professional associations

The Public Health Agency of Canada held regular technical teleconference briefings with national health professional associations to provide information on the virus and respond to issues that organizations raised on behalf of their members and front-line clinicians. This engagement enabled the Public Health Agency of Canada to draw more fully on the expertise of health professionals to inform the development of H1N1-related guidance and advice as the pandemic evolved (discussed in more detail in section 3.3, Guidance). Bilateral and multilateral meetings were held on an as-needed basis to respond to emerging issues.

National Aboriginal organizations

The Public Health Agency of Canada, in collaboration with the First Nations and Inuit Health Branch at Health Canada, held technical teleconference briefings with 11 national Aboriginal organizations (Aboriginal Nurses Association of Canada, Assembly of First Nations, Congress of Aboriginal Peoples, Indigenous Physicians Association of Canada, Inuit Tapiriit Kanatami, Métis National Council, National Aboriginal Health Organization, National Association of Friendship Centres, National Collaborating Centre for Aboriginal Health, Native Women’s Association of Canada, and Pauktuutit Inuit Women of Canada). Other bilateral meetings and specific briefings were held. The objective was to provide key information, answer questions and address concerns to better enable these organizations to support their communities during the H1N1 response.

Private sector

The Public Health Agency of Canada participated in the Conference Board of Canada’s Pandemic Preparedness Workshop held in Ottawa in June 2009. As stated in the workshop report, a pandemic is also an economic and business continuity crisis.^{Footnote 36} As such, it needs engagement with, and leadership from, the business community as well as from pandemic specialists.

Existing mechanisms of engagement were also adapted to support the H1N1 response. The Private Sector Working Group on Avian and Pandemic Influenza Planning (co-chaired by the Public Health Agency of Canada, Public Safety Canada and the Canadian Council of Grocery Distributors) supported information sharing during the H1N1 pandemic through the engagement of 90 private sector organizations from 10 critical infrastructure sectors (energy, information and communication technology, transportation, government, health care, manufacturing, finance, safety, water and food). The Working Group’s mandate is to promote a shared approach to pandemic influenza planning and preparedness through increased awareness and partnerships with private sector organizations and associations.

Collaborative endeavours

Joint efforts between the Health Portfolio and stakeholders were undertaken to address specific aspects of the H1N1 response and the needs of particular communities.

Examples include the following:

• The Public Health Agency of Canada worked in partnership with health professional associations, such as the Canadian Paediatric Society, the Society of Obstetricians and Gynaecologists of Canada, the Canadian Medical Association, the Canadian Public Health Association, the National Specialty Society for Community Medicine and the College of Family Physicians of Canada, to support the development of technical guidance for front-line health care providers (see also section 3.3, Guidance).
• The federal/provincial/territorial H1N1 Remote and Isolated Communities Task Group was co-chaired by Health Canada (First Nations and Inuit Health Branch) and the Chief Medical Officer of Health from Alberta, with participation by national Aboriginal organizations. It produced guidance to address the unique challenges facing remote and isolated communities, many of which are Aboriginal.
• Collaborative work was undertaken between human health partners (Public Health Agency of Canada, Health Canada, provincial/territorial health) and animal health partners (Canadian Food Inspection Agency, provincial agriculture ministries and other experts) to develop a variety of surveillance, guideline and risk management documents to address health issues at the human-animal interface.

The Chief Public Health Officer established a Science Advisory Committee of researchers from the academic community

Members of Canada’s influenza research academic community were engaged through the Chief Public Health Officer’s H1N1 Flu Virus Science Advisory Committee. This Committee was created at the outset of the H1N1 pandemic to provide science and research advice. During the height of the H1N1 pandemic, the Committee held weekly teleconferences, with a total of 24 teleconference meetings held between May 2009 and February 2010.

Specific areas on which advice was sought included:

• public health response
• vaccine development
• development and implementation of rapid point of care diagnostics
• antiviral treatment
• clinical care
• surveillance and epidemiology
• influenza pandemic forecasting and modelling.

Committee members, including Public Health Agency officials, indicated that this forum was valuable and the information shared and discussed was timely.

There was strong collaboration with other countries, as well as international organizations

On the international front, the federal Minister and Deputy Minister of Health, as well as the Chief Public Health Officer, were highly committed to engaging in direct communication with key bilateral and multilateral international partners to address high-priority issues and to promote ongoing collaboration with key international partners. The Public Health Agency of Canada and Health Canada program areas and technical experts already had strong relationships with counterparts internationally, and they continue to sustain them.

Building on lessons learned in the first wave, a Public Health Agency H1N1 flu virus international engagement strategy was developed and approved by senior management in early fall 2009. This strategy identified opportunities to further focus international engagement during the second wave of the pandemic.

Early in the H1N1 pandemic, the leveraging of previously established international relationships and communication protocols proved vital.

• Many bilateral relationships were critical to the Canadian response. For example, Canada collaborated with Australia on unadjuvanted vaccine. To facilitate and improve information sharing, Canada worked closely with Mexico from the onset of the pandemic. Canada also had a liaison network with the United States Department of Health and Human Services prior to and throughout the pandemic.
• Trilateral linkages between the United States, Mexico and Canada had been fostered through the development of the North American Plan for Avian and Pandemic Influenza and were critical to the response in these countries. In the early stages of the response to H1N1, there were daily calls between the United States, Canada and Mexico.
• In keeping with the International Health Regulations, Public Health Agency of Canada and Health Canada officials at all levels continued to work closely with their counterparts at the World Health Organization and the Pan-American Health Organization on the global response to the pandemic. While at times there were challenges with inconsistent communication to the public (given the complexities of working in a multisource environment), the level of cooperation and engagement was consistently high.
• Building on Canada’s ongoing involvement in the Global Health Security Initiative international partnership, including participation in the Global Health Security Action Group, the Canadian H1N1 response was strongly supported by access to rapid communication with, and reaction from, other international partners (particularly France, Germany, Italy, Japan, Mexico, the United Kingdom and the United States). This involvement included two ministerial meetings in 2010, which facilitated information sharing and collaboration during the H1N1 pandemic response.

These international links provided a valuable means of rapid information exchange throughout the response to the H1N1 pandemic. For example, the existence of an international network of national vaccine regulatory authorities to exchange information helped to support the expeditious review, authorization and post-market monitoring of H1N1 vaccines in Canada.

Areas for action

Increase multi-jurisdictional coordination of information for stakeholder groups

Recognizing that within a federation each province/territory makes decisions within their own jurisdiction, coordination of messaging to stakeholder groups can be complex. During the H1N1 pandemic, consistency and timeliness of information to stakeholders was challenging. Stakeholder groups received information from provincial/territorial governments, as well as from the Health Portfolio. The information from these different sources was sometimes inconsistent and, at times, conflicting. In addition, although many stakeholder groups indicated that information they received was helpful, concerns were raised about its timeliness (e.g. online tools such as FightFlu.ca). Moving forward, Health Portfolio communication and engagement strategies should clearly define jurisdictional roles and responsibilities to help support improved consistency and timeliness of information to stakeholder groups.

Enhance capacity to anticipate and respond to issues raised by all stakeholder groups

There was insufficient organizational capacity within the Public Health Agency of Canada, particularly during the first wave, to respond to the significant increase in requirements for information from a variety of stakeholders. This shortfall included the capacity to address both the volume of written correspondence received by the Chief Public Health Officer and others through letters and email, and the need for oral briefings to various groups.

The response was sometimes perceived by stakeholders as reactive and token. Some stakeholders indicated that, “In the first wave, we were uninvolved and felt marginalized. By the second wave, good outreach had resulted in much better communication, but unfortunately it was considered by some members to be ‘too little, too late’.” Issues brought forward by stakeholders need to be meaningfully addressed in a more timely fashion.

With respect to national Aboriginal organizations in particular, stakeholders indicated that information could have been timelier and more culturally appropriate. It was suggested by stakeholders that more preplanning was required, including the need to have information and mechanisms ready to directly and quickly engage and communicate with national Aboriginal organizations.

During the interpandemic period, the Public Health Agency of Canada and Health Canada should review their pandemic strategic relations plans in light of the H1N1 experience. In particular, they should examine the tools, mechanisms and human resources required to ensure they are in a strong position to work proactively with all stakeholders, respond to stakeholder issues and avoid delays.

Support development of guidance documents for health professionals

As stated in section 3.3, Guidance, there was an increased demand for guidance documents for various stakeholders during the H1N1 pandemic, with particularly high demand among health professionals. The Public Health Agency of Canada and external health professional associations addressed this demand on an ad hoc basis and produced various guidance documents and educational tools.

While front-line health care workers indicated that they appreciated the clinical guidance received, they indicated that at times the flow of information to them was neither timely nor met their needs. Stakeholders have indicated that the process for the development and approval of clinical guidance documents:

• took too long
• needed to better incorporate flexibility of evolving and emerging information
• should have involved a broader base of organizations
• did not give enough consideration to the level of the language in the documentation (i.e. it was sometimes too technical, too detailed or unclear).

Although ad hoc structures were created for H1N1, the Public Health Agency of Canada, in collaboration with federal and provincial/territorial partners, should consider establishing a communications and engagement strategy specifically for health professionals, including established processes for the development of guidance and tools.

It has been suggested that the Public Health Agency of Canada should lead a discussion (with its federal, provincial and territorial partners, other levels of government and health professional organizations) on how best to create sources of direct clinical advice for health professionals during a pandemic. As suggested in the United Kingdom’s independent review on influenza pandemic, this role may be more appropriately hosted by one or more of the professional bodies.^{Footnote 37}

Review Health Portfolio management of international relationships

During the H1N1 pandemic, there was a significant increase in the volume of international engagement for Health Portfolio senior management and other staff on both technical science and strategic policy issues. Because of the nature of this event, calls were often convened by other bilateral and multilateral organizations on short notice across different time zones, and without clear knowledge of the expertise required. It was difficult to identify and brief the appropriate Health Portfolio representatives to ensure mutually beneficial discussions.

During the interpandemic period, the Health Portfolio should review its international engagement strategy in light of the H1N1 experience. It should review the designation of senior management representatives and alternates to ensure consistent representation, contributions and efficient use of time. To maintain consistent communication and information sharing across all bilateral and multilateral relationships, it should reconfirm and communicate broadly the role of an international liaison focal point internal to the Health Portfolio during a pandemic. Internal protocols or mechanisms could be put in place to track meetings called through both formal and informal channels.