Healthcare Quarterly

Healthcare Quarterly 9(4) September 2006 : 21-22.doi:10.12927/hcq.2006.18397

ICES Report: Performance Reporting and Public Health: Bridging the Gap

Doug Manuel


Scientists at the Institute for Clinical Evaluative Sciences (ICES) recently created the "smoking regulatory index" (SRI) to compare how well municipal by-laws protect people against the harmful health effects of second-hand smoke. We used publicly available information on current municipal by-laws in Canada, along with evidence that restrictions on smoking reduce adverse health effects from second-hand smoke, to measure the effectiveness of these public health policies. The results showed a wide range in the degree to which municipal by-laws protect their citizens - from almost no protection in many municipalities on the East Coast to complete protection on the West Coast. Typically, the municipalities that had the fewest by-laws had the highest smoking and heart disease rates - following the same East to West Coast gradient.

Creating the SRI highlighted the issue of how little information actually exists that adequately describes public health services for smoking prevention or cessation in Canada. Despite the obvious significance of smoking as a health risk, the only national public information on smoking by-laws that we were able to find dated back to 2001, and many municipalities were not represented. We were able to find some details on tobacco pricing and taxes, but nothing that described other smoking prevention or cessation programs. Some of this information is available from local public health departments/regions, but no information could be found that compared regions across Canada.

In fact, there are widespread gaps across the board in available information about public health services and performance in Canada. There is almost no national information that describes which public health services are provided. And there is even less available to allow an evaluation of whether the levels of these public health services are sufficient enough or of high enough quality to be effective.

Performance Reporting in the Canadian Healthcare System

Health system performance reporting is now part of the Canadian landscape. The first reports were for hospital care, but now there are reports for many healthcare sectors. "Report cards" of healthcare performance are seen as helpful accountability instruments for facilitating improvements in service quality and effectiveness. Report cards also play an important role in advocacy and performance research, including evaluation of healthcare programs and managerial practices. More than anything else, performance reports describe the type and level of services that are provided. In the past few years, they have also included reports on the quality or performance of services, including patient/client perspectives.

Performance Reporting in Public Health

Historically, public health was the leader in reporting about the health of the community. For over 100 years, public health has been the primary source of information on health status and health behaviour. However, public health has now fallen behind other sectors with respect to providing public information about services and performance. For example, in 2003, the National Advisory Committee on Severe Acute Respiratory Syndrome (SARS) and Public Health had difficulty reporting even the spending level of public health in Canada. The Canadian Institute for Health Information can now report per capita spending, but collectively in Canada there is little additional information.  

The actual amount of available public health performance information is difficult to determine. A quick assessment could include determining what information is known or reasonably available to key audiences, such as the media, general public and elected leaders, in terms of priority public health programs or health risks. As it stands now, the general public would likely have difficulty finding information about many key public health programs (see Table 1).

Table 1. Availability of national standards and status of available public health service information for key public health issues in Canada
Public Health Issue Status of Reporting
Is our drinking water safe? • We are not aware of regular or publicly available information that describes drinking water safety across Canada, despite notable water-borne infectious outbreaks and subsequent public enquiry.
• Data systems to report on drinking water standards and other regular water reporting information have not yet been developed (except in Alberta).
Are children vaccinated against vaccine- preventable diseases? • Reports of immunization coverage rates are sporadic and generally not comparable between provinces.
• Immunization registries and other data systems are incomplete for most provinces.

Proposal: A National Annual Report on Public Health Services

We propose that Canada should have a national annual report on public health services. A first report should provide answers to common questions for key programs, such as:  

  • How often is my drinking water being tested?   Is it safe? 
  • Are children being immunized?  
  • Are restaurants being inspected? Are they safe?  
  • Are schools a healthy environment for children?  

A public health performance report should elucidate differences in the level of public health services across Canada - in addition to the large differences already observed in levels of public health funding and in smoking by-laws.  

Public health is different from other healthcare services, thus performance reports will necessarily be different. However, some lessons learned from previous healthcare performance assessments are applicable. We previously proposed a framework for public health performance reporting based on the Balanced Scorecard approach that is already widely used in healthcare (Figure 1). Our public health adaptation was based on a review of existing public health reporting and on information we acquired through consultation with various public health practitioners and experts. These consultations emphasized the need to improve data relating to service delivery and to create an independent public health reporting system with dedicated funding. Following the first annual report, we would expect that a process would be created, whereby reporting could be developed and improved over future years.

Figure 1. Proposed quadrants in a balanced scorecard for public health
Health Determinants and Health Status
(Clinical Utilization and Outcomes)*
Community Views
(Patient Satisfaction)*
Finance and Resource Allocation
(Financial Performance and Condition)*
Policy and Organization Structure
(System Integration and Change)*
*Hospital sector framework


Public health services in Canada could benefit greatly from regular "checkups," through appropriately designed performance reporting, which would measure how well policies are working and identify areas for improvement. The result will be a stronger, more effective and more efficient national public health system that will better serve the healthcare needs of Canadians.

About the Author(s)

Doug Manuel, MD, MSc, FRCPC, is a Scientist at the Institute for Clinical Evaluative Sciences. He is also a Career Scientist with the Ontario Ministry of Health and Long-Term Care, an Associate Professor in the Department of Public Health Sciences, University of Toronto and a primary care physician in rural areas of Ontario. For more information contact Doug Manuel at


Federal-Provincial-Territorial Committee on Drinking Water. 37th Meeting. 2005. Ottawa, Canada.  

First Canadian National Immunization Conference - Immunization in the '90s: Challenges & Solutions. 1994. Quebec City, Quebec.

Inamdar, N., R.S. Kaplan and M. Bower. 2002. "Applying the Balanced Scorecard in Healthcare Provider Organizations." Journal of Healthcare Management 47: 179-95.

Manuel, D.G. and V. Goel. 2002. Population Health Indicators for Measuring Health System Performance. Hospital Report 2001. Toronto, Ontario Hospital Association.

National Advisory Committee on SARS and Public Health 2003. 2004. Learning from SARS. Renewal of Public Health in Canada. Ottawa: Health Canada. Report No.: H21-220/2003E.  

National Standards for Immunization Coverage Assessment: Recommendations from the Canadian Immunization Registry Network. 2005. Canada Communicable Disease Report 31(9). Public Health Agency of Canada.  

Rosenfield, D., D.G. Manuel and D.A. Alter. 2006. "The Smoking Regulatory Index: A New Way to Measure Public Health Performance." Canadian Medical Association Journal 174(10): 1403-04.

Woodward, G., D.G. Manuel and V. Goel. 2004. Developing a Balanced Scorecard for Public Health. ICES Investigative Report. Toronto: Institute for Clinical Evaluative Sciences.  


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