Policy responses for Canada - HSRM

Canada


Policy responses for Canada

5. Governance

5.1 Governance

The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.

Most restrictions on education, working, and large gatherings are put in place at the provincial and territorial (PT) level and most PTs have published, and begun to execute, their own exit strategies. For example, the Government of Alberta has laid out their exit plan in three stages; the first stage began on May 14, 2020 to reopen some business and recreation sites (camp sites, golf courses) and to permit gatherings of up to 15 people (Government of Alberta, 2020b); notably, the province’s two largest cities did not enter Stage 1 until June 1 (Government of Alberta, 2020b). In contrast, the Government of Ontario released a three-stage framework for reopening the province, without specific dates at which each stage will be triggered, the kinds of restrictions to be lifted, and the types of businesses to be opened (Ontario, 2020g). Ontario has taken a staged regional approach in response to the local epidemiology of COVID-19 in public health units; for example, the province moved to stage 1 of reopening on May 19 and most regions in the province moved to Stage 2 in early June (Ontario, 2020g). All regions in the province had moved on to Stage 2 as of July 8, 2020 (Ontario, 2020k).

On June 11, 2020, the federal government announced it was accelerating the usual payment to PTs through the federal Gas Tax Fund, in response to increased infrastructure needs due to COVID-19 (Infrastructure Canada, 2018). This funding is usually provided twice a year to PTs but, in light of the COVID-19 pandemic, it was decided that both payments would be provided as one single payment in June this year (ibid). Communities will still be free to choose the projects that will be supported by this funding (Infrastructure Canada, 2018). The amount of funding that each PT has received is intended to be used during the 2020-21 fiscal year. Payments vary by population size and range from CA$16.5 million (Infrastructure Canada, 2020) to CA$816 million .

Also on June 11, the federal government announced two new funds to help Indigenous-led and -owned small businesses and microbusinesses that have suffered a loss of income due to COVID-19 (Indigenous Services Canada, 2020b). The first was a CA$133 million fund specific to Indigenous businesses, of which CA$117 million is dedicated to community-owned First Nations, Inuit and Metis businesses (Indigenous Services Canada, 2020b). A second CA$16 million fund was also made available for businesses operating in the Indigenous tourism sector (Indigenous Services Canada, 2020b).

On June 12, 2020, the federal government announced additional measures to help the territories by increasing the borrowing limit of the Yukon from CA$400 million to CA$800 million (Department of Finance, 2020d), the Northwest Territories from CA$1.3 million to CA$1.8 million (Department of Finance, 2020c), and Nunavut from CA$650 million to CA$750 million (Department of Finance, 2020b). The borrowing limits of the Yukon and the Northwest Territories were increased at the request of their respective territorial governments (Department of Finance, 2020d, 2020c).

On July 27, 2020, the Government of Canada passed Bill C-20, An Act respecting further COVID-19 measures, to ensure that the Canada Emergency Wage Subsidy is extended until December 19, 2020 and becomes progressively accessible to employers who have experienced less than a 30% revenue loss, the previous threshold for this subsidy (Department of Finance, 2020e) (see section 6.5 for more details).

On July 16, 2020, the Prime Minister and Deputy Prime Minister announced the Safe Restart Agreement, with a CA$19 billion investment from the federal government, to be used over six to eight months to restart the economy while protecting the health of Canadians. This Agreement focuses on seven key priorities: (1) testing, contact tracing, and data management; (2) health care capacity, including mental health and substance use; (3) protecting vulnerable populations, including seniors in long-term care facilities; (4)securing personal protective equipment; (5) child care for returning workers; (6) support for municipalities including for public transit; and (7) sick leave (Intergovernmental Affairs, 2020). As part of the Safe Restart Agreement, provinces and territories were asked to submit letters to the Federal government detailing how funds would best be allocated within provinces within their jurisdictions. These letters were submitted and reviewed, and it was announced on September 16 2020 that this federal funding will be transferred to provinces and territories (Prime Minister of Canada, 2020b). All Provincial letters detailing plans for their Safe Restart funding can be found here.

On September 29, 2020, the Government of Canada signed an agreement with Abbott Rapid Diagnostics to purchase up to 7.9 million ID NOW rapid point-of-care tests, to be deployed across PTs once Health Canada authorization is obtained (Canada, 2020cc).

On October 9, 2020, Canada’s Minister of Health announced an investment of more than CA$10.2 million in mental health and substance use research. This supports 55 research teams across the country in tackling the mental health and substance use crisis that worsened as a result of the pandemic. Findings from these research teams were immediately used to inform policy and practice across the country (CIHR, 2020).

On November 10, 2020, an additional agreement for COVID-19 antigen rapid tests was signed with Becton, Dickinson and Company to purchase 7.6 million rapid tests and over 2000 analyzers to ramp up COVID-19 testing across the country (Canada, 2020cu). In addition, on November 24, the Government of Canada signed an agreement with Eli Lilly for an order of 26,000 doses of COVID-19 monoclonal antibody therapy, to be used between December 2020 and February 2021 to treat individuals infected with COVID-19 (Canada, 2020cv). This therapy, Bamlanivimab, was approved for distribution with English-only labels on December 18, 2020 (Health Canada, 2020q).

On December 14, 2020, a contribution of CA$230 million was announced to procure COVID-19 treatments for developing countries; this enables UNICEF to procure up to 3 million courses of antibody therapeutics as soon as clinical trials and regulatory approvals have been completed (Global Affairs Canada, 2020e).

Specific PT measures are reported by the North American Observatory on Health Systems and Policies on their dedicated COVID-19 page (https://ihpme.utoronto.ca/research/research-centres-initiatives/nao/covid19/).

See full reference list under ‘Key links and articles: Full list of references’.

Prior to the COVID-19 pandemic, the Government of Canada had a pandemic response plan in place called the federal/provincial/territorial (FPT) Public Health Response Plan for Biological Events (PHAC, 2018). It is maintained by the Centre for Emergency Preparedness and Response, a division of the Public Health Agency of Canada (PHAC), and is revised every three years (PHAC, 2018). It was last revised in October of 2017 (ibid). This plan is to be activated when a biological hazard is identified that may need coordination between FPT governments. The first step is a situational assessment that classifies the response needed on a scale of 1 to 4. The rest of the plan is set into motion if a Level 3 or 4 response (“Escalated” and “Emergency”, respectively) is determined to be needed, as was the case for the COVID-19 pandemic on January 15, 2020 (PHAC, 2020c).

In addition, there exists a Canadian Pandemic Influenza Preparedness (CPIP) plan, detailing guidance for the health sector (Canada, 2006). This Plan was largely influenced and improved by the 2009 SARS pandemic, and last updated in August 2018. It aims to minimize serious illness and deaths first, and then to minimize societal disruption among Canadians. It details the relevant components of managing a potential influenza pandemic, including surveillance, laboratory services, public health measures vaccination and antiviral distribution, occupational health and health care services, and guidelines for clinical care and research (Canada, 2006).

The goals of this plan are outbreak control, outbreak prevention, risk mitigation, exposure control, and providing support and aid to the population (PHAC, 2018). The plan provides a detailed list of objectives for each goal. The plan outlines that relevant FPT stakeholders should meet to discuss actions that sufficiently address these goals (PHAC, 2018). A special advisory committee for establishing this plan is made up of three branches: (1) technical (representing laboratories, public health branches from each province, research teams, etc.); (2) communications (e.g. for information dissemination to the public); and (3) logistics (e.g. for procurement of equipment and health care delivery) (ibid). The advisory committee is responsible for implementing the plan and, following the threat, a response review and de-escalation process should occur (PHAC, 2018). This de-escalation is to be informed by situational and risk assessments and when the risk of infection for Canadians is considered “low”, the Special Advisory Committee on the Novel Coronavirus (SAC) will develop a de-escalation plan in consultation with the provinces and territories. The plan makes a distinction between de-escalation, e.g. bringing the risk category down from Level 3 or 4 and continuing to manage the public health threat, and recovery, i.e., the aim to restore normal activities once the threat has passed (ibid). Recovery activities are outside the scope of the FPT Plan.

The SAC was established at the end of January 2020, as per the “Public Health Response Plan” (PHAC, 2020c). A Level 3 threat, according to the Public Health Response Plan, was announced by Dr Theresa Tam on February 27, 2020 (Young, 2020). A Cabinet Committee on the federal response to the coronavirus disease was also established on March 5, 2020 to provide pan-Canadian leadership (PHAC, 2020c). This Cabinet Committee is currently co-chaired by the Deputy Prime Minister and the President of the Treasury Board and exists to address health, economic, and social impacts of COVID-19 (PHAC, 2020c).

Bill C-13, the COVID-19 Emergency Response Act, passed on March 25, 2020, which provides CA$107 billion in extra financing for COVID-related measures, defers CA$55 billion in federal taxes until early September, and allows both the federal Minister of Finance and Minister of Health to approve any borrowing or spending until September 30, 2020 (Parliament, 2020). In addition, the Quarantine Act, originally assented to in 2005, came into force on April 14, 2020 to allow federal, provincial and territorial law enforcement agencies more power in issuing tickets to individuals who do not comply with mandatory quarantine measures (Department of Justice, 2020b). The Quarantine Act provides regulations on the quarantining of travellers, disposal of human remains, information collection and gives the Health Minister and their officers the power to quarantine specific areas of the country (Legislative Services, 2020).

On March 18, 2020, the federal Minister of Health approved an interim order opening a COVID-19-specific application process for medical devices, including ventilators and test kits, to speed up the review and approval process by Health Canada (Canada, 2020f). For instance, many manufacturers have expressed willingness to produce disinfectants (ibid). The specific application process has resulted in numerous approved suppliers manufacturing technical-grade ethanol for use in hand sanitizers; on April 18, 2020, the federal government released a set of conditions to produce this ethanol (Health Canada, 2020d). The federal government has also made fast-tracked research grants available through the Rapid Response Research Grants of the National Science Foundation (Canada, 2020f). On March 31st, 2020, Canada announced a new partnership with 3,000 Canadian industries to bolster diagnostic testing and the purchase of ventilators and PPE, with a CA$2 billion investment (Canada, 2020g). On May 12, 2020, the National Research Council of Canada (NRC) partnered with the University of Saskatchewan’s Vaccine and Infectious Disease Organization – International Vaccine Centre (VIDO-InterVac) for the development of a  COVID-19 vaccine (NRC, 2020b). Similarly, also on May 12, the NRC partnered with CanSino Biologics Inc. to help advance the bioprocessing of a vaccine that is currently in clinical trials in China (NRC, 2020a). On the same date, Health Canada authorized the first serological test for COVID-19 for use in Canada, which allows for the detection of COVID-19 antibodies (Health Canada, 2020g). On June 9, 2020, the Government of Canada launched a new online hub to aid organizations buying and selling PPE (Public Safety Canada, 2020). This hub contains information for all provinces and territories and facilitates PPE purchasing by providing a supplier list (Public Safety Canada, 2020).

On May 27, 2020, Health Canada, the Canadian Institutes of Health Research (CIHR) and Canadian Association of Research Ethics Boards (CAREB) released a joint statement regarding the urgent need to conduct clinical trials to evaluate the safety and efficacy of a drug, vaccine or medical device to be used for managing COVID-19 (Health Canada, 2020k). They announced a new initiative to have monthly engagement sessions on clinical trial oversight, led by Health Canada, so that policy makers, regulators, funders and oversight bodies can share information on clinical trials across Canada to make the process more efficient (Health Canada, 2020k). This was closely followed by two guidance documents published the same day to support the interim order Respecting Clinical Trials for Medical Devices and Drugs Relating to COVID-19 (Health Canada, 2020h). This interim order outlines the procedure to be followed for clinical trials during the pandemic (Health Canada, 2020j). It introduced an alternate pathway intending to facilitate clinical trials for potential COVID-19 drugs and medical devices and, further, allowed for flexibility for broader types of clinical trials (ibid). It reduces administrative requirements, allows for alternate means of obtaining patient consent, broadens the criteria of a qualified health professional who can carry out the investigator duties and expands the range of applicants who are able to apply for a clinical trial authorization (Health Canada, 2020j). Also, as of May 27, Health Canada had approved, to date, 37 clinical trials for COVID-19 therapies and vaccines (Health Canada, 2020i).

Surveillance begins with municipal/provincial/territorial laboratories; in the case of municipal or hospital laboratories, positive cases are reported to provincial authorities (PHAC, 2020g). For example:
• In Ontario, the provincial laboratory is Public Health Ontario Laboratories, a division of Public Health Ontario, the office of public health for the province that is responsible for coordinating Ontario’s public health response and reporting (PHAC, 2020g). Specifically, testing of suspected cases is carried out in accordance with the Canadian Public Health Laboratory Network guidelines, Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI) (PHAC, 2020g). Importantly, all cases sent for testing are considered positive for the purposes of delivering self-quarantine advice until determined otherwise (ibid). In some cases, provincial laboratories are required to conduct a second, confirmatory test before reporting the positive case to the Public Health Agency of Canada (PHAC) (PHAC, 2020g).
• In Quebec, the Ministère de la Santé et des Services Sociaux (MSSS), Quebec’s ministry of health, states that a second test by its provincial laboratory is not required (Laboratoire de Santé Publique du Québec) before reporting to PHAC (MSSS, 2020b). This decision was made March 9, 2020 (MSSS, 2020b).

Surveillance for the pandemic at the federal level is conducted by PHAC, which provides an online form for use by PTs to report cases (PHAC, 2020g) (see Section 1). As COVID-19 is a nationally notifiable disease, all confirmed cases identified in Canada are to be reported to PHAC, by the designated PT authority, within 24 hours through this form (ibid). Reporting is voluntary and is performed according to mutual agreements with PTs; each PT has its own legal requirements for reporting specific “notifiable” or “reportable” diseases of public health importance, such as COVID-19. Canada has a voluntary obligation, under the International Health Regulations, to inform the World Health Organization (WHO) of events of international public health concern; new cases of COVID-19 are typically reported by PHAC to the WHO within 24 hours of PHAC receiving the above form (ibid). Copies are also sent to the United States and Mexico within 24 hours of national notification, under Article 6 of the International Health Regulations National Focal Point (IHR NFP) (PHAC, 2020g).

Communication about the virus, precautionary measures, and country-wide epidemiological data is coordinated by and through the Government of Canada website, with each PT communicating similar information on their local websites (National Collaborating Center for Infectious Disease, 2015; PHAC, 2020c). On April 2, 2020, Canada launched a COVID-19 mobile app (for iOS and Android) with the latest COVID-19 information and a symptom checker (Turnbull, 2020). On April 30, the Government of Canada announced the release of a new email service, “Get Updates on COVID-19”, and the ArriveCAN mobile app (Health Canada, 2020e). More details of these can be found in Section 6.2.

Further governance structures and legislation exists at the PT and municipal levels. For example, in Ontario, the pandemic response plan is the Emergency Management and Civil Protection Act; once triggered, this act allows the province to close any public or private establishment, restrict travel, and procure necessary goods and services (Ontario, 2020a). It was triggered on March 17, 2020 when the province declared a state of emergency (Ontario, 2020a). In British Columbia (BC), the overarching pandemic governance plan is the “BC Pandemic Provincial Coordination Plan”, last updated March 5, 2020 (British Columbia, 2020a). The plan includes isolation as required, rapid diffusion of health information, and mobilization of a rapid response team (ibid). The actions described in the  plan can be enacted through two acts, the Emergency Response Act (British Columbia, 1994) and the Public Health Act (British Columbia, 2008).

The federal government is primarily responsible for the administration of health services for First Nations Peoples living on-reserve. There are some exceptions: for example, the BC First Nations Health Authority (FNHA) is responsible for coordinating health specific requests from Indigenous communities and the governments of the Yukon, Northwest Territories, and Nunavut are responsible for the delivery of community and public health services within their jurisdictions. The Government of Quebec is responsible for the delivery of primary and public health for residents of Nunavik, the homeland of Inuit within the province of Quebec. Within Nunatsiavut, the homeland of the Labrador Inuit, the Government of Newfoundland and Labrador is responsible for the delivery of primary health care and the Government of Nunatsiavut is responsible for the delivery of public health services within the area (Canada, 2020e).

On May 27, 2020, Health Canada, the Canadian Institutes of Health Research (CIHR) and Canadian Association of Research Ethics Boards (CAREB) released a joint statement regarding the urgent need to conduct clinical trials to evaluate the safety and efficacy of a drug, vaccine or medical device to be used for managing COVID-19 (Health Canada, 2020k). They announced a new initiative to have monthly engagement sessions on clinical trial oversight, led by Health Canada, so that policy makers, regulators, funders and oversight bodies can share information on clinical trials across Canada to make the process more efficient (Health Canada, 2020k). This was closely followed by two guidance documents published the same day to support the interim order Respecting Clinical Trials for Medical Devices and Drugs Relating to COVID-19 (Health Canada, 2020h). This interim order outlines the procedure to be followed for clinical trials during the pandemic (Health Canada, 2020j). It introduced an alternate pathway intending to facilitate clinical trials for potential COVID-19 drugs and medical devices and, further, allowed for flexibility for broader types of clinical trials (ibid). It reduces administrative requirements, allows for alternate means of obtaining patient consent, broadens the criteria of a qualified health professional who can carry out the investigator duties and expands the range of applicants who are able to apply for a clinical trial authorization (Health Canada, 2020j). As of May 27, 2020, Health Canada approved 37 clinical trials for COVID-19 therapies and vaccines (Health Canada, 2020i).

Specific PT measures are reported by the North American Observatory on Health Systems and Policies on their dedicated COVID-19 page (https://ihpme.utoronto.ca/research/research-centres-initiatives/nao/covid19/).

See full reference list under ‘Key links and articles: Full list of references’.