Introduction

Public health systems and services research (PHSSR) refers to the systematic study of “the impact of the organization, staffing, financing, and management of public health systems on access to, delivery, cost, quality and outcomes of population-based services and interventions” (Acheson, 1988, p. 284). This field is underdeveloped in Canada, due in large part to a lack of infrastructure for the routine collection of nationally comparable evidence on public health system and service operation across the country. By way of contrast, the field of PHSSR is far better developed in the United States where, since 1989, there have been important efforts to develop and administer regular surveys that provide a national profile of local public health departments (National Association of County and City Health Officials, 2017).

One of the primary reasons that the routine collection of nationally comparable data on local public health activities has not emerged in Canada is that public health in Canada is highly decentralized and orchestrated very differently from one region of the country to the next. In effect, public health practice in Canada consists of 14 different and largely siloed public health systems, one for each province, territory, and the Public Health Agency of Canada operating at the federal level, and each one is characterized by different levels of local regionalization and organization. Advancing PHSSR requires us to be able to identify apples-to-apples comparisons between similar local public health units from one jurisdiction to the next. However, at present, there is no established approach for identifying comparable local public health units across jurisdictions due to their diverse and frequently changing organizational structures.

We submit that the elementary unit of PHSSR in Canada should be what we elect to call the “local public health unit” (LPHU), which is analogous to the “local health departments” that have emerged as the elementary units of PHSSR in the USA (NACCHO, 2020) and similar arrangements which exist in more or less centralized forms throughout Europe (Jakubowski et al., 2018). In this commentary, we propose a definition for LPHU which can be applied uniformly throughout Canada to identify common units and support interregional comparative research on public health systems and services. Although not our focus, we anticipate that it could also be applied to diverse regions internationally, providing additional opportunities for comparison and learning.

Proposed definition

An ideal definition for LPHU for research should be specific enough that it can identify a meaningful unit of analysis and generic enough that it can be applied consistently across diverse contexts. With this in mind, we propose that for Canadian research an LPHU should be defined as:

The lowest unit of independent (or delegated) responsibility for a defined population, having direct responsibility for the administration of public health programs and services, and led (or co-led) by a qualified Medical Health Officer/Medical Officer of Health.

According to this definition, an LPHU is a health unit that meets three overlapping criteria. In the following sections, we discuss in turn each of these three criteria and our reasoning for selecting them. A health unit that fails to meet any one of the three criteria should not be considered an LPHU for research purposes.

1. “The lowest unit of independent (or delegated) responsibility for a defined population”

We can think of a “public health unit” as an institution that is responsible for the administration of public health programs and services and led (or co-led) by a qualified Medical Health Officer/Medical Officer of Health (MHO/MOH). A public health unit is considered local when it is the “lowest unit of independent (or delegated) responsibility for a defined population.” Historically, it was more common in Canada for the responsibility of LPHU to be independent of wider health or public health authorities (Rutty & Sullivan, 2010); however, in recent years, amalgamations have resulted in LPHU becoming embedded within wider health systems in most provinces. For example, while the responsibility of Toronto Public Health derives from the City of Toronto and it does not answer to any wider health authority, the responsibility of the Edmonton Zone in Alberta follows most of the country and is delegated by the provincial health authority, Alberta Health Services. If there is no unit of independent (or delegated) responsibility below the provincial or territorial level, then a local health unit may cover an entire province or territory. This is the case, for example, in Prince Edward Island.

Additionally, “a defined population” often pertains to a population within a defined geography. In our definition, they do not have to be. For example, the defined local population of the First Nations Health Authority (FNHA) in British Columbia is delineated by First Nations status. In this instance, its responsibility covers a defined population for which there is no lower level of delegated responsibility.

2. “Having direct responsibility for the administration of public health programs and services”

An LPHU has direct responsibility for administering health programs and services which fall within recognized categories of “core” or “essential” public health functions. In recent years, representative public health bodies across Canada have made efforts to define the scope of the field, including by defining “core” and “essential” public health functions (CPHA, 2017; Government of British Columbia, 2017; Government of Ontario, 2018). In Canada, six categories of essential public health functions are generally most widely recognized, having been identified and distinguished in Learning from SARS: Renewal of Public Health in Canada—also referred to as “The Naylor Report” (Naylor et al., 2003). These categories are (1) health protection, (2) health surveillance, (3) disease and injury prevention, (4) population health assessment, (5) health promotion, and, sometimes, (6) disaster response. A unit can be considered an LPHU as long as it has direct responsibility to administer programs and services providing any one of these core functions. In some regions of the country, some of these functions are distributed separately between local and regional units, which we describe elsewhere (Plante et al., 2022)

Additionally, to say that the unit has direct responsibility for the administration of public health programs and services means that they have the ability to decide on program and service priorities and budget accordingly for their defined population. In recent years, we have begun to see an erosion of the role of LPHU in some regions, such that their administrative and budgetary responsibilities are being stripped from them and they are increasingly only being called upon to act as implementers or “technical consultants” (Cassola et al., 2022). Oftentimes, even these relatively modest advisory roles are not being clearly defined.

3. “Led (or co-led) by a qualified Medical Health Officer/Medical Officer of Health”

LPHU are not the only units that may have local responsibility for a defined population and administer public health programs and services. Crucially, the last characteristic that has to be met for a local unit to qualify as an LPHU is that it has to be led by a “qualified Medical Health Officer/Medical Officer of Health.” A qualified MHO/MOH is typically defined at the provincial or territorial level by a combination of provincial legislation (e.g. a provincial public health act, but oftentimes regulations under the act) and provincial medical regulatory or licensing authorities. Most commonly, a qualified MHO/MOH is defined as a medical doctor with an FRCPC or equivalent specialization in Public Health and Preventive Medicine. In less common instances, a qualified MHO/MOH could be a medical doctor with another public health specialization (such as a Master’s in Public Health). These qualified public health professionals may lead their LPHU by themselves or as part of formalized collaborative partnerships with others, oftentimes non-medical administrative leadership.

Sometimes organizations that are not LPHU administer public health services and programs to local populations. These organizations could be other health service providers or they could be non-public sector community organizations that have stepped in to fill a need. For example, community health centres (CHC) work to provide a more integrated approach to primary care, which means that they also often provide some services that fall within public health’s core functions, such as health promotion. This also means that they will routinely employ public health professionals as part of their teams, but this alone does not make them LPHU.

Conclusion

Public health systems and services research in Canada needs an agreed-upon unit of analysis in order to facilitate comparisons between diverse settings and ensure the advancement of the field. The purpose of this commentary is not to supplant existing public health naming conventions or unit arrangements. Rather, it is to provide a common language so that diverse existing arrangements can be related and compared and so that their experiences can more effectively inform one another in a research context. This includes also being able to identify common units within the same jurisdiction over time in such a way that transcends system reorganization. In this commentary, we propose that this unit should be the local public health unit (LPHU) and provide a generic definition. Table 1 provides a complete list of all the LPHU in each province and territory in 2021 based on this definition. This list was compiled from official websites and documentation and through consultation with local MHO/MOH.

Table 1 Non-First Nation regional and local public health units (LPHU) by province and territories in accordance with our proposed definition
Full size table

We have discussed at greater length some of the limitations and challenges posed by our definition (Plante et al., 2022). A unit of public health professionals that is not empowered to act on public health should not be considered a public health unit for research purposes. Likewise, a unit that is empowered to act on public health but is not headed by a qualified practitioner should also not be considered one. These conditions could be a barrier to the adoption of our definition in some regions and settings but we believe that the clarity it brings offsets this risk. For instance, it allows for comparison between LPHU and different forms of non-LPHU and their impacts on health.

There still remain important differences between LPHU as we define them. However, rather than rendering these units incomparable, these differences represent variations that can be used to generate new hypotheses and advance our understanding of LPHU and their impacts. For example, in some regions of the country, LPHU are embedded within ministries of health. Working with our common unit allows us to see how these units are similar to those in regions that decouple their local public health operations from government while also leading us to consider the impacts of this difference.