Restructuring public health in Ontario: Implications for heart health promotion

Cardiovascular disease is the principal cause of death and disease in most western nations.' Community-based heart health promotion is viewed as an ef fective means of reducing cardiovascular disease risk. Although public heal th agencies have a central role in the implementation and dissemination of heart health programs,(2) their effectiveness is being challenged by major structural changes to provincial public health systems across Canada. While 9 of Canada's 10 provinces have undergone a devolution of health care deci sion making to the local level over the past decade or so,(3) there has bee n little systematic analysis of the effects of this devolution on public he alth practice and/or the role of a population health perspective in address ing public health challenges.(4) Ontario is the one exception to the appare nt national trend toward regionalization of health care.(3) The public heal th system in Ontario is currently being challenged, however, by major struc tural changes. The first of these involves the 'municipalization' of fundin g responsibilities. In January 1997, the Ontario government announced a cha nge in funding from the previous cost-shared arrangement for beards of heal th to a requirement that boards be 100% municipally funded as of January 1, 1998. At the same time, the province is seeking to retain control through the regulation of public health standards set out in the recently revised " Mandatory Health Programs and Services Guidelines."(5.6) The major guidelin e change (potentially) affecting heart health staff was the reorientation o f the three primary risk factor areas (i.e., nutrition, physical activity a nd tobacco use prevention) from a perspective of 'Healthy Lifestyles' to 'C hronic Disease Prevention'. At the time of this study in 1997, the second a nd penultimate draft had been circulated to each public health unit. As part of the Canadian Heart Health Initiative - Ontario Project (CHHIOP), this study used a qualitative approach to address questions of the implica tions of these major structural changes to Ontario's public health system f or heart health promotion. Detailed descriptions of CHHIOP have been publis hed previously.(7-10) The specific questions addressed in this paper are: 1 ) What are the perceptions of public health staff with respect to the chang es in the mandatory guidelines and the implications of these changes for he art health promotion! and, 2) What is the future of public health in Ontari o in light of the transfer of costs to municipalities! More specifically, w hat are the perceived implications for local heart health promotion and for population health-based strategies?.