The changes proposed by Minister Dubé, aimed at improving the efficiency of the Ministère de la Santé et des Services sociaux (MSSS) and the network, give us the opportunity, as former national directors of public health, to come back to the notion of autonomy associated with this function.
We are emerging from a pandemic that has provided daily opportunities to see and question the closeness between our elected officials and the national director of public health. The perception of the lack of independence is also associated with his other role as assistant deputy minister, which consists in deploying the department’s preventive decisions and programs. These two complementary roles can be separated as in other Canadian governments, but Quebec has chosen to unite them, because the column of advantages exceeds, in our opinion, that of disadvantages when certain conditions are met.
Before examining them, let us specify that autonomy is a relative concept marked out firstly by public confidence, secondly by taking into account the evolution of our knowledge, and thirdly by the interrelationship of a multitude of sociopolitical factors and economic also called determinants of health. A single example is enough to illustrate this interrelation when we observe that the average life expectancy of the inhabitants of all the countries of the world is linked first to their level of wealth, but even more to the redistribution of this wealth. between classes. It should be remembered that players in the health sector in Quebec have the opportunity to rely on the skills of the National Institute of Public Health to support them scientifically. In short, the autonomy of an expert does not mean that he can do what he wants when he wants. Control, code of ethics, regulations are all constraints well known to many professionals.
Leadership in public health is therefore a matter of collaboration between all sectors of society. It is also for this reason that the MSSS, an elected member of the government’s cabinet, is the ultimate public health authority. Ultimately, he is the one who makes the strategic decisions, whether we are in a health emergency or not. The national director then does not act as a decision-maker, but rather as an adviser to the minister, and it is subsequently as assistant deputy minister that the national director deploys and coordinates actions with the other sectors and departments at the national and regional scale with regional public health directors. It is this continuity in action and active participation at all stages that explains so many advantages of merging roles.
The perception of independence between the adviser and the decision-maker is therefore based on a good understanding of the roles and above all on transparency in this process. It should be noted in this respect that while the regional directors and the National Institute of Public Health mentioned above find their mandate to inform the population written into a law, the national director lives with the ambiguity of this legislative vacuum. Other governments have clearly identified the need to protect this power to communicate directly and transparently with the public and the legislature. However, the national director does not have this power. He must be authorized by the Minister for this purpose.
In the same vein, Quebec is proud of section 54 of its Public Health Act, which has been in force for almost 21 years, which has institutionalized a process for assessing the health impact of laws and regulations of the various ministries before their adoption. Unfortunately, this colossal work led by the national director, in collaboration with each of the ministries concerned, is invisible. The publication of the opinions associated with such analyzes would constitute a major point to illustrate its independence. Communication with “his patient” (ie the entire population as far as he/she is concerned) is therefore the most important guarantee of autonomy. Also associated with independence are preservation of public health budgets and resources, and protection against unjust dismissal, which inevitably brings us to the terms of employment.
Notice to readers, the following is biased! The “political” process of appointing the national director that applied to both of us did not cause any obvious misfortunes… but since independence is a matter of perception, improvements are possible. It is obviously necessary to maintain the requirement to select among doctors who have completed their initial training by obtaining a specialty in preventive medicine and public health, but a paper does not guarantee everything. A committee of experts could propose to the minister a limited number of interesting and interested candidates. The choice of the minister should then be supported by a qualified majority vote (2/3) of the National Assembly, For example. The additional steps would increase confidence in the quality and representativeness of the position.
Our suggestions, which are inspired by our combined 70 years of work in public health, including 15 as national director and assistant deputy minister, could easily be integrated into the improvements that Mr. Dubé will make to Bill 15 currently at the study in parliamentary committee.