The Municipal Role in Public Health

Abstract

Public health is a rich and broad concept. It includes the direct provision of programs and services, but also encompasses expansive notions of a healthy society. In this sense, a wide range of government functions intersect with public health. In fact, 90 percent of municipal operational expenditures in Ontario contribute directly or indirectly to the social determinants of health. The formal public health system cuts across federal, provincial, regional, and municipal jurisdictions. The COVID-19 pandemic serves as a case in point: the federal government was responsible for certain quarantine requirements and the Public Health Agency of Canada, which served as the face of the national response; provincial governments set in place province-wide mandates; and local governments played a key role in implementing, or even going beyond, the measures required by higher levels of government. As public health is both a complex concept and a shared responsibility, coordination and cooperation between levels of government take on special importance. Municipalities Katherine Fierlbeck and Gaynor Watson-Creed set out the broad scope of municipal engagement in public health, noting that the urban context can have a direct impact on the health of individuals. They stress the important role of municipalities in tailoring public health interventions to the local context. Similarly, Lawrence Loh highlights how municipalities sometimes act as first movers, setting precedents later adopted at the provincial level, and sometimes play the opposite role, adjusting provincial policies to fit the local context. He cites the examples of the Smoke-Free Ontario Act, which the province introduced only after many cities had already banned smoking in public spaces, and the COVID-19 pandemic response, where municipalities adapted provincial decisions to fit local needs. Lindsay McLaren and Jason Cabaj put forward a vision of public health in which municipal governments have a more clearly defined role, and which, in turn, supports a broader well-being agenda as a path to population health and health equity. Provincial governments Fierlbeck and Watson-Creed note that while the role of the formal public health system is enshrined in provincial legislation, some provincially led reorganizations have undermined the system’s effectiveness. Provinces must collaborate and share data with municipalities to achieve better outcomes. Loh recognizes the provincial government’s role in putting in place overall frameworks which local authorities can adapt, or exceed, as necessary. In this context, Loh emphasizes the need for the provinces to adequately and equitably resource local public health units. McLaren and Cabaj call for legislative changes at the provincial level to facilitate coordination with municipalities. However, they also point out that a well-being approach to public health applies to provincial governments as well as municipal governments, since it hinges on a broader, coherent societal vision of health rather than the actions of a single level of government. Federal government Fierlbeck and Watson-Creed argue that failure to coordinate across levels of government, including at the federal level, characterized the handling of the SARS outbreak in 2003. But improved coordination does not necessarily mean centralization: information and data-sharing at the national level should strengthen local governance of public health. McLaren and Cabaj also emphasize the federal government’s role in coordination, as well as in funding and establishing accountability mechanisms. To this end, they explore the possibility of a national Public Health Act. Such legislation would enhance public understanding that formal public health involves all levels of government. Intergovernmental cooperation Cooperation between levels of government underpins the recommendations in all three papers. For example, Fierlbeck and Watson-Creed describe how a national framework for health data collection could bolster public health surveillance. Loh concludes that Ontario’s balance between local and provincial policy-making can lead to complicated dialogue but achieve good results. McLaren and Cabaj frame intergovernmental cooperation in two contexts: first, as the cornerstone of incremental efforts to strengthen the formal public health system, and second, as a means to implement a bolder well-being agenda, which will require action on the part of all levels of government.