Centralization and integration of public health systems: Perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces

Robert William Smith; Tamika Jarvis; Harman Singh Sandhu; Andrew D Pinto; Meghan O'Neill; Erica Di Ruggiero; Jasmine Pawa; Laura Rosella; Sara Allin

doi:10.1016/j.healthpol.2022.11.011

Centralization and integration of public health systems: Perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces

Health Policy. 2023 Jan:127:19-28. doi: 10.1016/j.healthpol.2022.11.011. Epub 2022 Nov 23.

Authors

Robert William Smith¹, Tamika Jarvis², Harman Singh Sandhu³, Andrew D Pinto⁴, Meghan O'Neill⁵, Erica Di Ruggiero⁶, Jasmine Pawa⁷, Laura Rosella⁸, Sara Allin⁹

Affiliations

¹ Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, Ontario M5T 3M7, Canada. Electronic address: robw.smith@mail.utoronto.ca.
² Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. Electronic address: jarvistl@mcmaster.ca.
³ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada. Electronic address: hs.sandhu@mail.utoronto.ca.
⁴ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada; Upstream Lab, MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, 30 Bond St, Toronto, ON M5B 1W8, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada. Electronic address: andrew.pinto@utoronto.ca.
⁵ Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada. Electronic address: meghan.oneill@utoronto.ca.
⁶ Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, Ontario M5T 3M7, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada. Electronic address: e.diruggiero@utoronto.ca.
⁷ Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada. Electronic address: jasmine.pawa@mail.utoronto.ca.
⁸ Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, Ontario M5T 3M7, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada; Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada; Institute for Better Health, Trillium Health Partners, 100 Queensway West, Clinical and Administrative Building, Mississauga, ON L5B 1B8, Canada. Electronic address: laura.rosella@utoronto.ca.
⁹ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada; North American Observatory on Health Systems and Policies, Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M7, Canada. Electronic address: sara.allin@utoronto.ca.

Abstract

The extent to which power, resources, and responsibilities for public health are centralized or decentralized within a jurisdiction and how public health functions are integrated or coordinated with health care services may shape pandemic responses. However, little is known about the impacts of centralization and integration on public health system responses to the COVID-19 pandemic. We examine how public health leaders perceive centralization and integration facilitated and impeded effective COVID-19 responses in three Canadian provinces. We conducted a comparative case study involving semi-structured interviews with 58 public health system leaders in three Canadian provinces with varying degrees of centralization and integration. Greater public health system centralization and integration was seen by public health leaders to facilitate more rapidly initiated and well-coordinated provincial COVID-19 responses. Decentralization may have enabled locally tailored responses in the context of limited provincial leadership. Opacity in provincial decision-making processes, jurisdictional ambiguity impacting Indigenous communities, and ineffectual public health investments were impediments across jurisdictions and thus appear to be less impacted by centralization and integration. Our study generates novel insights about potential structural facilitators and impediments of effective COVID-19 pandemic responses during the second year of the pandemic. Findings highlight key areas for future research to inform system design that support leaders to manage large-scale public health emergencies.

Keywords: COVID-19; Canada; Decentralization; Governance; Organizational structure; Public health systems.

Publication types

Review

MeSH terms

COVID-19*
Canada / epidemiology
Government Programs
Humans
Pandemics
Public Health