LAUSR

Canadian scholars report that funding health services is “among the most complex” aspects of health policy. They also report that the past 50 years of health system funding experience in Canada can be summarized as “tinkering at the margins”, with little evidence that funding model changes have better aligned resources with need or impact. If this is true, then selecting a funding model for public health (PH) in Canada is akin to tinkering in the dark given the limited evidence on this topic. While there is no shortage of opinion on how to fund PH, there is little to no published Canadian evidence that rigorously examines, evaluates or compares the efficacy of PH funding models. As noted elsewhere, we even lack reliable estimates of how much Canada spends on PH at each level in different jurisdictions. Published estimates range from 1.5% to 5.6% of total health spending in different jurisdictions. The Canadian Institute for Health Information reports that PH funding has increased, and PH leaders report it is decreasing. Both may be true. No one knows. We raise these issues in light of the recent report from the Ontario Minister’s Expert Panel on PH, and the commentaries in this journal that have described the structural and financial challenges facing PH systems across Canada. We echo the concerns reported in these commentaries and in particular, we wholeheartedly agree on the need for increased PH funding. We are unsure whether a national inquiry, as suggested by Guyon et al. is warranted (particularly given the lack of meaningful outcomes so far from the current National Inquiry into Missing and Murdered Indigenous Women and Girls). However, if a review is undertaken, we advocate that critical questions regarding how PH is funded be at the forefront. PH funding shortages undermine all aspects of PH service delivery. One need only look back through the landmark reports on Canadian PH systems renewal to find that nearly all funding model recommendations are based on opinion, and lack an evidence basis. This includes recommendations of the Ontario Minister’s Expert Panel. This cannot continue. These critical knowledge gaps not only create risk of bad decision-making, they leave PH leaders ill-equipped to advocate effectively. We agree with others that the evidence on why PH should be funded is clear. We suggest that there is also a solid, growing evidence base on what PH interventions should be funded. The most critical evidence gaps, in our opinion, relate to how PH system financing in Canada should occur. Specifically, these are four of the most critical questions: 1. How much funding should national, provincial/territorial, and local PH systems receive? 2. How should PH services be funded? Specifically: a. What are the most effective funding formulas/models? b. Where would these resources come from? 3. How can PH access/receive this funding? 4. How well does the PH workforce manage its resources?