On October 3, 2018, and February 20, 2019, the Standing Committee on Public Accounts held public hearings on the audit of Public Health: Chronic Disease Prevention (Section 3.10 of the Auditor General’s 2017 Annual Report) as administered by the Ministry of Health and Long-Term Care.

The Committee endorses the Auditor’s findings and recommendations, and presents its own findings, views, and recommendations in this report. The Committee requests that the Ministry provide the Clerk of the Committee with written responses to the recommendations within 120 calendar days of the tabling of this report with the Speaker of the Legislative Assembly, unless otherwise specified.

Acknowledgements

The Committee extends its appreciation to officials from the Ministry of Health and Long-Term Care, Public Health Ontario, and the Medical Officers of Health from the Chatham-Kent Public Health Unit, the Durham Region Health Department, the Thunder Bay District Health Unit, and Toronto Public Health. The Committee also acknowledges the assistance provided during the hearings and report-writing deliberations by the Office of the Auditor General, the Clerk of the Committee, and staff in the Legislative Research Service.

Background

Public health focuses on promoting healthy lifestyle behaviour and preventing the spread of illnesses and diseases, including chronic diseases. Chronic diseases are those that persist for a long time and usually cannot be prevented by vaccines or cured by medication. Major chronic diseases include cardiovascular and respiratory diseases as well as diabetes and cancer. The prevalence (the proportion of a population with any of these four chronic diseases at a given time) has increased in Ontario between 2003 and 2013.

While people living with chronic diseases may have a poorer quality of life than the general population, chronic diseases are also a significant cost burden to Ontario’s health system. According to the Institute for Clinical Evaluative Sciences (a not-for-profit organization that researches Ontario’s health-related data) four modifiable risk factors that contribute significantly to chronic diseases—physical inactivity, smoking, unhealthy eating, and excessive alcohol consumption—cost Ontario’s health care system nearly $90 billion (22% of health care costs) between 2004 and 2013.

Through limiting such risk factors, most chronic diseases may be prevented or their onset delayed. Ontario has focused its public health efforts on reducing smoking, and between 2003 and 2014, the smoking rate for Ontarians aged 12 and over decreased by just under five percentage points, from 22.3% to 17.4%. According to Cancer Care Ontario, the decrease in the incidence of small cell lung cancer (a type of cancer primarily attributable to smoking) may be the result of this decline in tobacco use.

Legislation

The Health Protection and Promotion Act governs the delivery of public health programs and services. The Act provides for “the organization and delivery of public health programs and services, the prevention of the spread of disease and the promotion and protection of the health of the people of Ontario.” Other legislation related to public health includes the Immunization of School Pupils Act and the Smoke-Free Ontario Act, 2017. Public Health Ontario was established by the Ontario Agency for Health Protection and Promotion Act, 2007.

Funding

In 2016/17, the Ministry of Health and Long-Term Care spent $1.2 billion on public health and health promotion programs. Public health units received $702 million (58%) and Public Health Ontario $163 million (14%) of provincial public health funding. Overall, Ontario spent about $192 million (16% of total public health spending) on preventing chronic diseases.

Public Health System

The Ministry of Health and Long-Term Care co-funds (with municipalities)
35 public health units (36 at the time of the audit) across the province to directly provide public health services. Public health units also receive funding from other sources including the Ministry of Children, Community and Social Services; Health Canada, and community organizations.

Each public health unit provides services and resources to meet local needs, serving populations that range in profile and size from about 34,000 people in Timiskaming to nearly three million people in Toronto. Each public health unit has a Public Health Funding and Accountability Agreement with the Ministry of Health and Long-Term Care which sets out the terms and conditions governing its funding. These accountability agreements have no expiry date and are updated annually to include new requirements and performance targets.

Ontario’s public health units are each governed by a local Board of Health which is administered and led by a Medical Officer of Health who reports to the Board on public health and other matters. However, because the Act does not mandate a standard governance model for all Boards of Health, governance models vary considerably across the province. All Boards of Health are municipally controlled to some degree, ranging from autonomous Boards with municipally-appointed members to Boards that are part of the municipal or regional government structure.

Under the Health Protection and Promotion Act (Act), each Board of Health is responsible for meeting provincial guidelines called the Ontario Public Health Standards (Standards) which set out the minimum requirements that the public health units must adhere to in delivering programs and services. The Act provides the authority to implement the Standards, and outlines the roles and responsibilities between the public health units and the Ministry of Health and Long-Term Care. Originally developed in 2008, new Standards came into effect on January 1, 2018 (after the audit report was published).

The Standards document includes the Public Health Accountability Framework which specifies reporting and monitoring requirements for Boards of Health to demonstrate accountability to the Ministry in four domains: delivery of programs and services; fiduciary requirements; good governance and management practices; and public health practice.

The Healthy Populations Policy and Program Unit of the Ministry of Health and Long-Term Care is responsible for developing provincial public health initiatives and strategies as well as monitoring public health programs delivered by public health units.

The Province’s Chief Medical Officer of Health reports directly to the Deputy Minister of Health and Long-Term Care. The Chief Medical Officer’s responsibilities include

providing clinical and public health practice leadership and advice to the public-health sector;
identifying and assessing risk and opportunities for improving public health in Ontario;
communicating directly with the public regarding public health matters such as the risk of the Zika virus to Ontarians; and
reporting annually to the Legislature on the state of provincial public health.

Public Health Ontario provides technical advice and support activities, such as population health assessment, public health research, epidemiology, and program planning and evaluation to protect and improve the health of Ontarians. Public Health Ontario conducts surveillance and outbreak investigations, and generates public health science and research expertise in communicable diseases, environmental health, and chronic diseases and injuries. It also operates the province’s eleven public health laboratories which offer services including clinical and environmental testing, bioterrorism testing, and evaluation of new laboratory technologies and methodologies.

Epidemiology is the scientific study of the frequency and pattern of health events in a population and the application of this study to the control of health problems. It is considered the foundation of public health. Epidemiology is also used to identify relevant social and environmental determinants of health, which are the causes and other factors that influence the occurrence of disease and other health-related events. Social determinants of health, for example, might include poverty, homelessness, poor housing, unemployment, violence, access to healthy food, and other factors.

2017 Audit Objective and Scope

The audit objective was to assess whether the Ministry of Health and Long-Term Care (Ministry), Boards of Health, and Public Health Ontario have effective systems and processes in place to:

oversee, coordinate and deliver chronic disease prevention programs and services in an equitable and cost-effective manner; and
measure and report on the effectiveness of these programs and services in reducing the cost burden on the health care system and improving population health outcomes.

The audit focused on public health activities since 2014, and considered relevant data and events over the decade preceding the audit (which was conducted from November 2016 to May 2017). The audit was conducted primarily at the Population and Public Health Division of the Ministry, at Public Health Ontario, and at four public health units: Chatham-Kent, Durham, Thunder Bay, and Toronto. The audit team also met with representatives from a number of other public health and health organizations, reviewed complaints made to the Ombudsman’s office, and surveyed relevant staff from all 36 public health units (reduced to 35 since the completion of the audit).

Main Points of Audit

Ontario lacks an overarching policy framework on chronic disease prevention to guide provincial program planning, development, and continuous evaluation.

· Ontario does not have a comprehensive approach for assessing the anticipated impact on public health of legislation and policies as they are being developed.

· The Ministry does not fully measure public health units’ performance in chronic disease prevention, and has not set any measurable goals to improve overall population health.

The Auditor pointed to the following models of public health planning in other jurisdictions:

· British Columbia’s Guiding Framework for Public Health (2017) creates a long-term vision for the public health system (underpinned by modernized legislation); formalizes a collaborative process to identify future public health priorities; reinforces core public health functions as the foundation for public health services; supports a population health approach and the public health role in health equity; and connects to and supports self-care, primary care, and clinical prevention.

· The Health in All Policies approach (adopted by Quebec and other jurisdictions outside Canada) makes policymakers accountable for taking into consideration how government decisions affect population health. Quebec’s Public Health Act requires policymakers to assess the effect of proposed policies on public health as part of the policymaking process.

Issues Raised in the Audit and Before the Committee

Significant issues were raised in the audit and before the Committee.

The Committee considers the following issues to be of particular importance.

It was noted that Public Health Ontario was established a decade ago in the wake of SARS, and is predominantly focused on keeping Ontarians safe from communicable diseases such as SARS, Ebola, and Zika. Of the 950 staff at Public Health Ontario, more than 600 are front-line lab workers who do the tests for HIV, tuberculosis, hepatitis, and over 300 separate disease entities.

The Committee heard that new, modernized Ontario Public Health Standards were issued on January 1, 2018 (after the audit took place), and revised on July 1, 2018. The Ministry is monitoring the implementation of these new Standards, and boards of health are required to provide detailed reporting to the Ministry on the content and impact of the requirements under the Public Health Accountability Framework.

The Committee asked how public health officials address the social determinants of health. It was explained that the Health Equity Standard is one of the four foundational standards within the Public Health Standards and sets out board of health requirements directly related to the social determinants of health. It applies to all public health programs and services, with the overarching goal of decreasing health inequities experienced by priority populations.

Questions were raised about the public health response to the legalization of cannabis, and what is being done to alert the public to the health effects of cannabis consumption, whether in the form of smoking, vaping, or edibles. The Ministry explained that it is working collaboratively with the federal government on public education about the responsible use of cannabis; that cannabis usage is an evolving situation, and the priority is to protect young people. It was noted that the status of cannabis as an illicit drug has hindered research on the long-term consequences of its use. However, public health units have been able to collect data on cannabis use via the Ontario Student Drug and Health Survey (conducted by the Centre for Addiction and Mental Health every two years), as well as from hospitalization and emergency room data.

Medical officers of health noted that their comprehensive approach to tobacco control is not just about cessation but also about prevention that targets youth and young adults, and enforcement of the Smoke-Free Ontario Act, 2017. A Public Health Ontario representative pointed to this Act as an example of how legislation can bolster public health goals. The Committee heard that while great progress has been made in reducing smoking province-wide, smoking rates are much higher in northern and Indigenous communities.

It was noted that along with the legalization of cannabis, it also became legal to advertise vaping products, including e-cigarettes. Both the Committee and Public Health Ontario expressed concerns about widespread e-cigarette advertising that targets young people and the potential health impact of growing e-cigarette use by young people. The Ministry has been in contact with Health Canada about this issue, which it regards as a priority.

The Committee asked about the overall effectiveness of public health interventions. Public health officials explained that it is very difficult to measure what has been prevented through successful public health efforts to change attitudes and behaviour. Because public health initiatives tend to emphasize health promotion, advocacy, and prevention, the effects of interventions are not felt immediately but rather over the long-term. However, it is possible to measure the extent of risk factor reduction in areas such as the numbers of people who smoke tobacco, or who get regular exercise.

Some of the returns on public health investments have been calculated as follows: each dollar invested in mental health and addictions saves $30 in lost productivity and social costs; $1 in immunizing children saves $16 in health care costs; a dollar invested in water fluoridation saves $38 in dental care; a dollar invested in tobacco prevention saves $20 in future health care; and a dollar invested in early childhood development saves about $9 in future spending on health, social and justice services.

The Committee asked whether there are opportunities through public health to help reduce ‘hallway medicine’ (the term for patients waiting on gurneys in hospital hallways resulting from a shortage of hospital beds) as well as to help reduce overall costs to the health system. The Ministry agreed that effective public health strategies and interventions help to keep people with chronic disease well, and help Ontarians to manage their care in the community and not in a hospital setting.

Public health officials noted that anything that prevents or even delays the onset of chronic disease has the potential to save huge amounts of money in the health care system. A Ministry official noted that the four common risk factors of smoking, physical inactivity, unhealthy eating, and excessive alcohol consumption contributed nearly $90 billion to health care costs between 2004 and 2013.

Figure 1: 2018 Annual Service Plans and Budget Submissions:
Total Public Health Unit Budget by Program*

Ontario Public Health Standards	Total Budget by Standard (at 100%)	% of Total Budget
Infectious and Communicable Diseases Prevention and Control	$171,446,531	21.74%
School Health	$133,086,890	16.87%
Healthy Growth and Development	$105,249,939	13.34%
Chronic Disease Prevention and Well-Being	$85,018,923	10.78%
Foundational Standards (including Emergency Management)	$74,418,241	9.43%
Substance Use and Injury Prevention	$72,406,508	9.18%
Food Safety	$53,190,929	6.74%
Immunization	$48,416,921	6.14%
Safe Water	$22,847,438	2.90%
Healthy Environments	$22,684,916	2.88%
TOTAL	$788,767,236	100.00%

*As submitted by boards of health (includes both provincial and municipal portions).

Source: Ministry of Health and Long-Term Care, 2019.

Addressing Chronic Disease Risk Factors

The Auditor found that there is no current provincial strategy on preventing chronic disease and no provincial reporting on overall population health status. As well, the Province does not have a comprehensive approach to assess the public health impact of legislation and policy development. While comprehensive policy was developed and dedicated funding provided for tobacco control, the same was not done for physical activity, healthy eating, and lower alcohol consumption.

The Ministry explained that it is midway through conducting a comprehensive review of all its chronic disease prevention and other public health programs to identify gaps in programming related to key risk factors for chronic disease, to ensure that measurable outcomes are in place and that there is an efficient use of funds for public health programs. The Office of the Chief Medical Officer of Health is leading this review (which is projected to be completed by March 2020).

The Ministry informed the Committee that it is developing a comprehensive provincial approach to promote health, prevent disease, and help all Ontarians lead long, healthy lives. This strategy, with phased implementation that began in 2018/19, uses an integrated approach that recognizes the impact of social determinants of health. Monitoring, evaluation, and continuous quality improvement are key components of the proposed strategy.

The Committee asked about the Auditor’s recommendation that the Province’s Chief Medical Officer of Health should assess and report on the overall state of public health in Ontario. The Ministry explained that the implementation of an enhanced surveillance system will require investment from the Province.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Chief Medical Officer of Health should conduct assessments of, and publicly report on, the overall state of public health in Ontario in the Chief Medical Officer of Health’s annual report.
The Ministry of Health and Long-Term Care should implement a provincial strategy to guide activities on chronic disease prevention that includes measurable goals for population health; provides timelines for achieving these goals; and also delineates responsibilities for achieving these goals.
The Ministry of Health and Long-Term Care should develop comprehensive policies focusing on the key risk factors of chronic diseases such as physical inactivity, unhealthy eating, and alcohol consumption, in addition to tobacco use.

Provincial Coordination of Program Planning and Delivery

The Auditor concluded that the Ministry

does not have the needed processes and systems in place to ensure that public health units plan and deliver chronic disease prevention programs and services in a cost-effective manner;
has not sufficiently supported coordination among the provincial ministries or public health units to help public health units plan and deliver programs more efficiently;
has not ensured that Public Health Ontario provides the necessary and sufficient support to the public health units with scientific and technical advice in the areas of population health assessment, epidemiology, and program planning and evaluation; and
does not guide public health units on a methodology to evaluate, measure, and report on whether their chronic disease prevention and health promotion programs have been effective.

The Auditor also found that because the Ministry does not require public health units to use any established program evaluation methodology, each unit takes its own approach to conducting evaluations of its own programs. And not all public health units evaluated the results of their programs.

Ministry representatives told the Committee that they agreed with the Auditor’s recommendation that a more comprehensive and coordinated provincial approach to public health is needed. They explained that the new Public Health Standards focus on improving outcomes, accountability, evaluation and transparency. The Chronic Disease Prevention and Well-Being Standard requires public health units to develop and implement local programs of public health interventions that address chronic disease risk factors. These local programs will be developed to address specific priorities based on an assessment of local needs.

Recognizing the importance of measuring the local impact of their interventions, public health officials use a number of evaluative tools to do so. For example, modelling can show how many diabetes cases might be expected over the following decade versus how many actually occurred after public health interventions. A chronic disease prevention risk tool is currently being developed. However, public health officials agreed that Public Health Ontario is better positioned to undertake this type of analysis than the local public health units.

Public health officials explained that risk factors for chronic disease cannot be understood in isolation from social and environmental determinants of health. While public health units may engage in advocacy to combat some of the factors that impinge on public health, such as pollution (an important contributor to chronic respiratory disease and cardiovascular disease), these are outside the control of any single public health unit.

The Committee asked for the Ministry’s view of the Health in All Policies, whole-of-government approach. The Ministry agreed such an approach is worth considering, noting that it has been recommended by the World Health Organization. The Ministry is working to improve coordination and collaboration across the government to make sure that other policies support public health goals.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Ministry of Health and Long-Term Care should ensure that Public Health Ontario provides scientific, technical, and other support to assist local public health units with population health assessment, epidemiology, and program planning and evaluation.
The Ministry of Health and Long-Term Care should actively support coordination among provincial ministries and local public health units to ensure that public health units plan and deliver programs more efficiently.
The Ministry of Health and Long-Term Care should collaborate with other ministries to develop a comprehensive Health in All Policies, whole-of-government approach to assessing the public health impact of legislation and policy development.

Planning and Delivery of Programs for Children and Youth

The Auditor found that coordination was needed at the provincial level to aid program planning and development of public health units’ delivery of programs to children and youth.

The Committee noted the importance of early prevention and public health education for young people. The Committee raised questions about the extent of public health work being done in schools, and whether public health units have conducted equity assessments in order to determine which schools they work with. The Ministry noted that the new Public Health Standards include a School Health Standard that requires boards of health to, among other things, develop and implement a program of public health interventions to improve the health of school-aged children and youth. This includes the need to identify priority populations in schools, as well as school communities at risk for increased health inequities and negative health outcomes. The new Standards also require boards of health to report to the Ministry annually on how health equity strategies and approaches have been embedded into school health programs and services. In addition, the Health Equity Guideline requires consideration of health equity.

The Ministry was asked about the Auditor’s finding that, due to the lack of coordination at the provincial level between the Ministry of Health and Long-Term Care and the Ministry of Education, public health units spend resources to build relationships with schools, and are not engaged in nearly a third of Ontario schools. The Ministry noted that the Ministry of Health and Long-Term Care and the Ministry of Education have established a directors’ forum in order to better collaborate on public health work in schools.

Public Health Ontario added that educating children and youth on the risk factors for chronic disease prevention is a critical component of public health work. Lessons were learned from the successful public health efforts to reduce cigarette smoking among young people. Officials noted that some of these efforts, such as preventing cigarette advertising that targeted young people, required legislation.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Ministry of Health and Long-Term Care should work with Public Health Ontario, the Ministry of Education, and the Ministry of Children, Community and Social Services to coordinate public health units’ planning, development, and delivery of programs to children and youth.
The Ministry of Health and Long-Term Care should work with Public Health Ontario and the Ministry of Education to ensure that public health units conduct health equity audits to identify and engage with priority populations in schools as well as with school communities at risk for increased health inequities and negative health outcomes.
The Ministry of Health and Long-Term Care should work with Public Health Ontario and the Ministry of Education to educate children and young people on the health impacts of both e-cigarettes and cannabis consumption.
The Ministry of Health and Long-Term Care should work with Public Health Ontario to prevent the advertising and sale of vaping products to young people under the age of 19.

Collection and Analysis of Epidemiological Data

The Auditor found that the Ministry has not established specific standards on how much epidemiological work the public health units have to undertake for chronic disease prevention, or assessed whether certain analyses could be better conducted centrally. The smaller local public health units lacked the resources and capacity to do the substantive data collection and analysis needed to guide their work, and not all public health units have access to local epidemiological data. Significant duplication of effort results from having each public health unit conduct its own research and data analysis. There are limited formal systems in place to coordinate their activities and share best practices.

The Auditor found that epidemiological data on certain demographic groups, such as Indigenous populations, is not readily available to public health units. The Committee asked whether any of the Province’s public health chronic disease prevention work is currently done on-reserve in First Nations communities, and whether public health units have participated in Indigenous cultural competency training. It was explained that, as part of their year-end annual report to the Ministry, boards of health will be required to report on how many of their staff have completed Indigenous cultural competency training. In addition, under the new Public Health Standards, public health units are required to dialogue and work with Indigenous communities to ensure that any messages and services are appropriate to the communities’ traditions.

It was explained that local public health units use surveillance and epidemiological research to understand the needs of local populations, and identify priority neighborhoods and communities, including First Nations communities, which have low income levels and a disproportionate burden of chronic disease. Programs are then tailored to meet these specific local needs.

The Committee asked about whether more data collection and analysis could be done centrally by Public Health Ontario and provided to the local public health units. Public Health Ontario noted that since the Auditor’s report, the agency has begun providing online “Snapshots” of data on health-related behaviours, organized by public health unit area. This enables local public health units to tailor their responses to focus on the areas of greatest local need.

The Ministry is working with Public Health Ontario to develop a provincially-defined and centrally-provided set of epidemiological data and population health indicators. This is meant to assist public health units with conducting local analyses that can inform program planning, evaluation, and population health assessment.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Ministry of Health and Long-Term Care should work with Public Health Ontario and public health units to

a) evaluate the feasibility of centralizing epidemiological expertise that can perform analysis or provide support to all public health units;

b) establish benchmarks for the extent of epidemiological analyses of chronic diseases needed and monitor whether these benchmarks are met;

c) collaborate with Indigenous community leaders to obtain epidemiological data that would serve to inform program development that would benefit Indigenous communities in Ontario; and

d) identify other areas in which relevant data is not consistently available to all public health units, such as data on children and youth, and develop and implement a process to collect such data.

Program Evaluation

The Committee asked how local public health units evaluate their own program outcomes. Public health units explained that they focus on measuring the impact of a particular intervention. The design of the evaluation depends on the nature of the intervention, the data sources available, and addressing any factors beyond the intervention that may have an impact on outcomes.

The public health units explained that under the new Standards each unit is required to prepare an annual budget submission with a plan of public health intervention that outlines specific activities, and identifies community partners, the budget, and target outcomes. A work program is also developed for population health assessment and surveillance, program evaluation, research, and knowledge exchange.

Beyond the new Standards, local public health units are responsible for identifying major issues that are impeding optimal health status and creating disparities in their local populations, looking for effective interventions, and implementing them.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Ministry of Health and Long-Term Care should require public health units to develop measurable program objectives for their chronic disease prevention programs and services, and establish time frames for achieving these objectives.
The Ministry of Health and Long-Term Care should

a) set standards for evidence-based program evaluation methodology;

b) require all public health units to conduct evaluations of their programs; and

c) support capacity-building for local public health units to conduct program evaluations.

Measuring and Reporting Performance of Public Health Units

The Auditor found that current performance indicators do not fully measure public health units’ performance in preventing chronic diseases and promoting health. The lack of public reporting on public health units’ chronic disease prevention performance means that the Ministry has limited insights into public health units’ use of resources.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Ministry of Health and Long-Term Care should establish performance indicators and targets, linked to the new Ontario Public Health Standards, for public health units.
The Ministry of Health and Long-Term Care should publicly report on the performance of public health units, including annual results and targets of their performance indicators.
The Ministry of Health and Long-Term Care should monitor the resources invested by public health units in chronic disease prevention programs against the program outcomes.

Rollout of Needs-based Funding Model

The Auditor noted that the current level of provincial funding to the public health units has been primarily driven by historical decisions and is not based on any distribution formula, resulting in wide variations in per capita funding for public health spending across the province. In 2013, the Funding Review Working Group convened by the Ministry recommended a new model for identifying an appropriate level of funding for each public health unit.

In 2015, the Ministry began to apply a public health unit funding model meant to ensure that public health funding is distributed based on need, and to reduce funding inequities among public health units. The Ministry estimated that it could take another 10 years to ensure that funding is more equitably allocated to all public health units under this model.

The June 2017 final report of the Expert Panel on Public Health recommended that the public health units be reorganized into 14 regional public health entities. If the Ministry were to adopt this recommendation, the funding model recommended in 2013 might then become obsolete and a new funding model would have to be established.

The Auditor reported that provincial funding for public health units is not approved until the last quarter in the year, which makes it challenging for medical officers of health and chief executive officers at public health units to plan programs and services without knowing how much funding will be received.

The Committee heard that the Ministry has made progress in finalizing annual funding for public health units as early in the fiscal year as possible, and is exploring funding approaches for public health units that would ensure a more equitable delivery of public health programs and services. In addition, the new Public Health Standards require a new approach to funding, which the Ministry will consider during a comprehensive review of all transfer payment recipients.

Committee Recommendation

The Standing Committee on Public Accounts recommends that:

The Ministry of Health and Long-Term Care should expedite its efforts to ensure equitable funding for public health units.

Consolidated List of Committee Recommendations

The Standing Committee on Public Accounts recommends that:

The Chief Medical Officer of Health should conduct assessments of, and publicly report on, the overall state of public health in Ontario in the Chief Medical Officer of Health’s annual report.
The Ministry of Health and Long-Term Care should implement a provincial strategy to guide activities on chronic disease prevention that includes measurable goals for population health; provides timelines for achieving these goals; and also delineates responsibilities for achieving these goals.
The Ministry of Health and Long-Term Care should develop comprehensive policies focusing on the key risk factors of chronic diseases such as physical inactivity, unhealthy eating, and alcohol consumption, in addition to tobacco use.
The Ministry of Health and Long-Term Care should ensure that Public Health Ontario provides scientific, technical, and other support to assist local public health units with population health assessment, epidemiology, and program planning and evaluation.
The Ministry of Health and Long-Term Care should actively support coordination among provincial ministries and local public health units to ensure that public health units plan and deliver programs more efficiently.
The Ministry of Health and Long-Term Care should collaborate with other ministries to develop a comprehensive Health in All Policies, whole-of-government approach to assessing the public health impact of legislation and policy development.

7. The Ministry of Health and Long-Term Care should work with Public Health Ontario, the Ministry of Education, and the Ministry of Children, Community and Social Services to coordinate public health units’ planning, development, and delivery of programs to children and youth.

8. The Ministry of Health and Long-Term Care should work with Public Health Ontario and the Ministry of Education to ensure that public health units conduct health equity audits to identify and engage with priority populations in schools as well as with school communities at risk for increased health inequities and negative health outcomes.

9. The Ministry of Health and Long-Term Care should work with Public Health Ontario and the Ministry of Education to educate children and young people on the health impacts of both e-cigarettes and cannabis consumption.

10. The Ministry of Health and Long-Term Care should work with Public Health Ontario to prevent the advertising and sale of vaping products to young people under the age of 19.

The Ministry of Health and Long-Term Care should work with Public Health Ontario and public health units to

a) evaluate the feasibility of centralizing epidemiological expertise that can perform analysis or provide support to all public health units;

b) establish benchmarks for the extent of epidemiological analyses of chronic diseases needed and monitor whether these benchmarks are met;

c) collaborate with Indigenous community leaders to obtain epidemiological data that would serve to inform program development that would benefit Indigenous communities in Ontario; and

The Ministry of Health and Long-Term Care should require public health units to develop measurable program objectives for their chronic disease prevention programs and services, and establish time frames for achieving these objectives.
The Ministry of Health and Long-Term Care should

a) set standards for evidence-based program evaluation methodology;

b) require all public health units to conduct evaluations of their programs; and

c) support capacity-building for local public health units to conduct program evaluations.

The Ministry of Health and Long-Term Care should establish performance indicators and targets, linked to the new Ontario Public Health Standards, for public health units.
The Ministry of Health and Long-Term Care should publicly report on the performance of public health units, including annual results and targets of their performance indicators.
The Ministry of Health and Long-Term Care should monitor the resources invested by public health units in chronic disease prevention programs against the program outcomes.
The Ministry of Health and Long-Term Care should expedite its efforts to ensure equitable funding for public health units.