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The power of people and systems - An interview with Dr. Rosana Pellizzari

The power of people and systems - An interview with Dr. Rosana Pellizzari

By on November 12, 2013

On December 3rd, we will be hosting an interactive webinar about the people and systems that support equity-oriented approaches in public health practice.  

Help us create the content for this celebrity-interview-style webinar.

  1. Consider the question posed each week by Hannah Moffatt while reading an excerpt interview from Public Health Speaks: Organizational standards as a promising practice to advance health equity
  2. Join us in an online conversation held from November 26th to December 3rd in our Health Equity Clicks: community

Consider this question when reading the below excerpt:

  • What are the elements that support or restrain organizational change in public health systems? 

Public Health Speaks: Implementing Ontario’s Public Health Standards at Peterborough County-City Health Unit. A conversation with Rosana Pellizzari, MD, MSC, CCFP, FRCPC, Medical Officer of Health, Peterborough County-City Health Unit.

Connie Clement, Scientific Director of the National Collaborating Centre for Determinants of Health (NCCDH) had the opportunity to speak with Dr. Rosana Pellizzari, Medical Officer of Health for Peterborough County-City Health Unit (PCCHU) on December 21, 2012 about the Peterborough County-City Health Unit experience of operationalizing and implementing the Ontario Public Health Standards (OPHS) at the local level. Dr. Pellizzari is also Co-Chair of the Performance Management Working Group (PMWG), Public Health Division, Ministry of Health and Long-Term Care. The PMWG supports public health accountability agreements and is currently focused on the development of a measurement strategy for the OPHS.

Connie Clement: Could you tell us about your understanding of the history, development, and purpose of the Ontario Public Health Standards?

Dr. Rosana Pellizzari: The Health Protection and Promotion Act in Ontario states that the Minister may publish guidelines for the provision of mandatory health programs and services and that every board of health shall comply with these published guidelines. Prior to the standards, Ontario had mandatory health programs but they were out of date and needed to be renewed. Consequently, the new Ontario Public Health Standards (OPHS) were developed. The OPHS are much more prescriptive in their description of the minimum scope required for boards of health and can be used to hold boards accountable for the delivery of these programs and services. The standards identify board of health outcomes and the societal goals that all of us, through partnership and collaboration, should be working toward.

Connie Clement: How is health equity included in the new Ontario Public Health Standards?

Dr. Rosana Pellizzari: Health equity is identified in the introduction to the standards. There is an acknowledgement that the health of individuals and communities is impacted and influenced by social and economic determinants, and it states in a very strong sentence that reducing health inequities is fundamental to the work of public health. The introduction and the foundational standard are explicit on health equity, but within the set of standards there is no specific standard addressing health equity or the social determinants of health. For me, that was a disappointment at the time.

Connie Clement: How have you approached implementation of the Ontario Public Health Standards at Peterborough County-City Health Unit?

Dr. Rosana Pellizzari: When the standards were first published, Peterborough public health staff made sure we met with all of our stakeholders and partners. It was important for us that our stakeholders were aware that as a result of the new standards, we would be shifting our work to be more focused, and that there may be impacts as a result of that shift. For example, there may be things that we [PPCHU] would no longer do because of our need to focus on the minimum requirements as laid out in the standards. Internally, we did a couple of key things. The identification of priority populations within our community and the integration of health equity into our planning processes was an early piece of work that we did. We changed our operational planning by developing new tools to identify priority populations. We developed and implemented a reporting mechanism for the board of health, whereby we report on every requirement in the standards on a quarterly basis. At the end of the year, we provided an overview of areas of compliance and non-compliance, some of the challenges we faced, and present options for moving forward. Part of our rationale for such comprehensive reporting was to ensure our board of health became very familiar with the standards and knew what was expected of them. Our Social Determinants Of Health Working Group has used a health equity lens to assess our programs and activities as part of its work with internal staff.

Connie Clement: How have the Ontario Public Health Standards influenced your practice, particularly in the area of health equity?

Dr. Rosana Pellizzari: The Peterborough County-City Health Unit and the board of health were committed to health equity long before I arrived in 2008, and long before the standards were published. The health unit has a long-standing history of working in partnerships to address the social determinants of health and of being leaders on food insecurity issues, specifically. In our case, the standards served to reaffirm the work that we were already doing to address the determinants of health.

We have also been able to use the standards as a bit of a rallying cry to encourage other partners to work with us. We’ve been able to leverage the requirements and the societal goals as a conversation starter to say, ‘we need to work together on this’, so that’s been helpful. The standards have also helped us to “let go” of some work that was not mandated so that we can focus on the Ontario Public Health Standard requirements. For example, our board of health has a long history of providing genetics services as an outreach centre, and we have been able to successfully shift that work over to the local hospital using the standards as our rationale.

Connie Clement: What have some of the barriers been to implementation of the standards at the local level? How have these barriers been overcome?

Dr. Rosana Pellizzari: The tension with the new standards was that it was conceived as a revenue-neutral initiative. We were to redefine our scope of programs and activities within the same envelope of funding. Public health in Ontario has been suffering from some neglect, and it took the E. coli outbreak in Walkerton and SARS (Severe acute respiratory syndrome) to appreciate that public health had become an antiquated system that was not sufficiently funded. As a result of this recognition, we’ve seen a reinvestment and a stronger commitment to the public health system in Ontario; however, we still experience barriers around inadequate resources to support the work we should be doing in the realm of primary prevention. I think the standards articulate that tension in that we certainly know that we could have gone further in some of the standards, but we recognized that increased resources would be needed. There is this ongoing tension between what we should be doing, what we could be doing, and what we’ve been mandated to do.

Connie Clement: How are the standards enabling you to make more upstream choices or more choices that will help to close the gap between the least and the most healthy?

Dr. Rosana Pellizzari: The Health Protection and Promotion Act is written in such a way that public health is responsible for both protecting and promoting health in our communities, and that can translate into a number of actions. Public health is often the “go-to” person for unmet needs in the community, and we often get lobbied to both identify and even fill these gaps. That was certainly the case in the 1990’s when gaps in primary care were often filled by boards of health using nurse practitioners to do critical functions such as Well Baby Care, immunizations, and etc. The standards have helped us focus our efforts. They help guide us in decisions about what we take on as “public health” work and what we need to direct to others to do. They help us clarify our role and contributions in big issues, be it substance misuse, parenting, or even infection control.

Connie Clement: Thinking about your experience as Co-Chair of the Performance Management Working Group, to what extent are the standards supporting health units across Ontario to advance their health equity work?

Dr. Rosana Pellizzari: I have seen increased evidence of boards of health taking positions on health equity. I think an enormous help has been the infusion of capacity to the standards through the provincial funding of two social determinants of health nurses for each health unit. The fact that those nurses were funded provincially and offered to boards of health has encouraged and enabled boards to really make health equity work a possibility. It has provided us with that on the ground capacity that was lacking.

The organizational standards that specifically relate to board strategic plans and the expectation that boards must address health equity as part of their strategic planning process, will encourage boards of health to incorporate health equity as an explicit consideration in these plans. In fact, many boards are currently working to renew their strategic plans. I know our board is. And I know that this time around, health equity will be a strong focus for us. The standards will act as catalysts in what I hope is a shared learning journey.

Connie Clement: The Performance Management Working Group is exploring a measurement strategy in relation to the standards. Can you describe how this strategy is being developed, and
how health equity is being considered in the strategy?

Dr. Rosana Pellizzari: It certainly is a challenge and I think the first way the working group tackled this was through the release of the Initial Report on Public Health in 2009. In this report, we published public health profiles for each of the 36 boards of health, and we grouped them according to peer groupings so that comparisons among similar boards could be made. We published health status indicators that could be used as measurements for health equity. This report made it easy to look at adolescent pregnancy rates, for example, and to note that the rate is lowest in the board of health with the highest per capita income and is highest where per capita incomes are reduced. We supplemented that report of hard indicators with narratives. We wanted to tell the story of what boards of health are actually doing to address health equity. The narratives are equally important as the indicators.

Since then, as we have moved into a new era of accountability agreements with boards, there’s been a great deal of effort in identifying performance indicators for health equity that could be incorporated into these accountability agreements. We may see a time when specific health equity indicators are incorporated into accountability agreements that boards of health will sign with the Ministry of Health.

Connie Clement: What are some of the lessons learned from Peterborough County-City Health Unit’s implementation experience with the Ontario Public Health Standards that might be helpful for other health units and regional health authorities in Canada?

Dr. Rosana Pellizzari: The importance of articulating the need to address health inequities and the social determinants of health in the mandate of public health is a critical lesson learned. We need to be waving health equity as our flag, and if it’s not us, who’s it going to be? The rest of the health care system has clinical care and the care of the ill as their mandated priority. They can certainly be allies, but I do think health equity work needs to be driven by public health, especially because we work so closely across sectors. Health equity must be a principle, and I personally hope that it will be made explicit as its own standard with identified outcomes and requirements. Additionally, health equity work must be supported by scientific and technical supports from our provincial agency, Public Health Ontario.

I think the other lesson that I’ve learned is that the capacity needs to be there. As I said, the infusion of the social determinant of health nurses has really facilitated boards of health to do work in the area of health equity. The value of resource sharing and mentoring that can occur through communities of practice is also a valuable lesson. For example, the video that Sudbury & District Health Unit released called, Let’s start a conversation about health… and not talk about health care at all is being adapted by many boards of health, including the Peterborough County-City Health Unit, to utilize in our communities. It’s great to see how this work can be shared among others.

Connie Clement: Based on your experiences with Peterborough County-City Health Unit and as Co-Chair of the Performance Management Working Group, would you say that organizational standards are an effective strategy to advance health equity in public health settings?

Dr. Rosana Pellizzari: Definitely. Because organizational standards can be mandated, the funder, in the case of Ontario, both provincial and municipal governments, can hold boards of health accountable to those standards. They’re measurable. You can encourage better performance by choosing indicators and setting targets and performance corridors. So yes, I think organizational standards can help our work in health equity. This work could be further improved if organizational standards incorporate explicit requirements, with indicators and targets for health equity.

Connie Clement: Perfect. Is there anything else that you would like to share or add about your experiences with organizational standards?

Dr. Rosana Pellizzari: I am currently chairing the Ontario Public Health Association-Association of Local Public Health Agencies (OPHA-alPHa) joint Health Equity Working Group. Through this working group, we have identified a list of potential health equity indicators. Our next step is to circulate this list among the field for consultation purposes. In the process of creating this list, we discovered how challenging it is to actually measure health equity work. The working group members have come to a consensus that in light of these measurement challenges, indicators should support shared learning right now, rather than accountability. Before we can expect boards of health to be accountable to these indicators, we need to support them in learning more about this work.

The understanding of health equity and the related public health interventions that can influence health equity are complex. It’s not as easy, for example, as increasing physical activity or providing mass immunizations, for example. So rather than a stick, it’s the carrot we need at this time. It’s the encouragement, the support, the learning from peers and creating new knowledge as we go. We’re forging the path here. It’s still early days for us, so it’s really important that we acknowledge that we’re all learning, and that we stay positive rather than punitive. We need to help each other on this journey to achieving health equity in our communities.

Connie Clement: Thanks, that’s a wonderful place to end. Thank you Rosana for sharing your thoughts and experiences, and overall for your leadership in advancing health equity through public health practice. It’s always a pleasure to work with you.

Next week, read the interview with Dr. Benita Cohen. Each of these interviews can be found in the publication Public Health Speaks: Organizational standards as a promising practice to advance health equity.

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CollaborationCompetencies & organizational standards