The Medical Officer of Health and the First Nations and Inuit Health Branch Transfer Initiative

This document was prepared by C. Mustard, 1996, and revised by D. Shedden with advice from Regional Communicable Disease Officers and other First Nations and Inuit Health Branch (FNIHB) medical officers. January, 1997 / Ref.: cmmoh.3

Under the First Nations and Inuit Health Branch (FNIHB) Transfer initiative and other activities undertaken to facilitate the transfer of control of First Nations health services to First Nations, communities are able to assume control of "community-based" health services. In order to ensure that programs are in place for health protection, the following programs have been designated "mandatory":

• Communicable Disease Control;
• Environmental Health; and
• Emergency Response.

Special arrangements are also required in many communities to ensure that there is access to treatment services. This is particularly so in communities where nurses practise in an expanded role (i.e. providing limited treatment).

For the purposes of the environmental health, communicable disease control and emergency response programs, each community must ensure that services are available from an environmental health officer (EHO) and a medical officer of health (MOH). This pertains particularly to the above listed public health programs and does not address issues related to so called "professional supervision" of nurses practising in an expanded role, issues related to access to treatment services provided by physicians nor to the role of physicians in the Non-insured Health Benefits program [Where a physician maintains clinical knowledge and skills, the supervision of the clinical practice of nurses working in an expanded role - that is, as "nurse practitioners" - may be undertaken. Such arrangements would have to be made on an individual basis].

Medical officers of health play key roles in the administration of provincial Public Health Acts, in which their responsibilities are usually elaborated in detail.

Role of the Medical Officer of Health

In Canada, all communities are under the jurisdiction of an MOH. The roles of medical officers of health vary from jurisdiction to jurisdiction but always include responsibilities related to public health and safety. Authority to enforce provincial legislation must be given to physicians by the relevant provincial Ministers of Health.

The functions of the MOH generally include the following:

1. responsibility for communicable disease control;
2. working with other stakeholders to assess environmental health concerns and to intervene as necessary;
3. providing leadership in emergency situations where there is a potentially negative impact on public health;
4. overseeing health surveillance activities;
5. undertaking in-depth epidemiological studies where necessary;
6. acting as consultant on health promotion and disease prevention;
7. developing, recommending and implementing public policies in support of improved health;
8. managing programs, including planning, implementation and evaluation;
9. education of other health care providers.

Mandatory Roles under FNIHB Transfer Initiative

The complete role and responsibilities of an MOH working with a transferred community will vary from one place to another depending on legislation and prevailing standards and practices. Many of the functions outlined above may be included upon mutual agreement between the physician and the community representatives. However, the community must allocate the appropriate resources and ensure that the MOH is willing and able to provide the following services related to public health and safety:

1. Immunization

1.1 Schedule

• formulating routine immunization schedules for children and adults;
• making decisions pertaining to the use of vaccines in exceptional circumstances (e.g. outbreaks or epidemics);
• where legislated immunization requirements are in place for school entry and day care entry, providing advice to staff on the adequacy of the immunization status of children;
• recommending immunization schedules for workers in various community occupational settings;
• recommending immunization schedules for individuals with other special concerns (e.g. immuno-compromised patients, travellers etc.).

1.2 Supervision of Program Delivery

The MOH will ensure that appropriate guidelines are in place for the following:

• vaccine acquisition, transport, storage and handling;
• the acquisition of informed consent;
• pre-immunization counselling;
• immunization procedures;
• record keeping;
• emergency procedures (in the event of adverse reactions to vaccine administration).
• The MOH may also ensure that processes are in place for education and certification of nurses and for quality assurance. In Quebec, immunization is a delegated medical act. In that instance, the MOH may be required to formally delegate the function. In most jurisdictions, however, these matters are the responsibility of public health nursing. In some places, immunization is recognised as an advanced nursing skill requiring the demonstration of competence by nurses before they can undertake immunization procedures.

1.3 Surveillance

The MOH will:

• ensure that record keeping allows for regular reviews of immunization coverage. Community coverage will be reviewed at least annually with appropriate action as needed;
• be notified in a timely fashion of all significant adverse events. The MOH will ensure that these are followed up as necessary, including the linkage of information to the provincial/territorial and national surveillance systems.

2. Communicable Disease Control (other than immunization)

2.1 Surveillance

The MOH will:

• ensure that procedures are in place for the timely reporting of all reportable diseases and outbreaks;
• review communicable disease reports in a timely, on-going fashion and on a quarterly basis;
• annually write a communicable disease summary for submission to the health agency and to FNIHB;
• promptly notify FNIHB of any communicable disease outbreaks where an emergency response may be required.

2.2 Laboratory

The MOH will:

• make recommendations on appropriate laboratory specimens to be submitted for diagnosis and follow-up of communicable diseases;
• ensure that appropriate procedures are in place for collection, storage and handling of samples used in the diagnosis of communicable diseases;
• provide advice on the interpretation of laboratory reports.

Advice on diagnosis and treatment will normally be given to local family physicians and to nurses providing limited treatment services.

2.3 Screening

The MOH will make recommendations on screening for communicable diseases, including:

• screening for STDs (Sexually Transmitted Disease);
• screening in occupational health settings (e.g. for tuberculosis);
• screening in schools, day care centres, National Native Alcohol and Drug Abuse Program (NNADAP) treatment centres etc.;
• screening for tuberculosis. (This will be done in consultation with provincial TB Directors where the latter are on contract to provide TB services).

2.4 Case finding / Diagnosis

The MOH will:

• provide advice on case finding activities;
• provide advice on the diagnosis of communicable diseases;
• propose case definitions for surveillance purposes;
• encourage the use of appropriate diagnostic procedures related to the case definitions.

2.5 Case Management / Follow-up

For patients with a reportable disease, the MOH will advise on the following matters and make certain that procedures are in place to ensure that:

• appropriate treatment has been instituted;
• patient education / counselling has taken place;
• an appropriate interview has taken place to determine the source of infection;
• where appropriate, an interview has taken place to identify and undertake preventive therapy and/or testing of possible contacts;
• where necessary, mechanisms are in place to ensure that therapy is completed.

The MOH will ensure that appropriate action is taken in situations where a person with a communicable disease may, by his/her actions, be placing others at risk.

2.6 Contact Tracing

The MOH will make recommendations on the identification, counselling, testing and follow-up of contacts of patients with communicable diseases. The MOH will ensure that community health nurses are trained in the appropriate procedures before undertaking contact tracing.

2.7 Source of Infection

Where indicated, the MOH will ensure that appropriate follow-up has been undertaken to reduce the risk of communicable disease in the future. This will involve extensive liaison with EHOs, community health representatives (CHRs), community health nurses, physicians and others.

2.8 Outbreak management

The MOH will assume the lead in outbreak situations. The role will include the following:

• determining when an outbreak has occurred;
• undertaking appropriate investigation of the outbreak;
• ensuring that all key stakeholders are involved and kept aware of developments;
• taking appropriate measures to control outbreaks.

3. Environmental Health

The MOH will work with other personnel - particularly EHOs - to give assistance by:

• providing advice on the possible health effects of environmental factors;
• investigating health concerns to determine potential associations with environmental factors.

4. Public Health Legislation

All public health legislation (and a variety of related legislation) includes provisions related to communicable disease control and environmental health. Medical officers of health designated by the legislation have specific duties and authority related to these. In some jurisdictions this authority may be delegated to an MOH employed by a community. In others, the community-employed MOH will have to collaborate closely with the provincially-authorised MOH in certain situations if the law is to be applied.

5. Emergency Response

The community's emergency response plan must be reviewed and approved by the MOH. The MOH will play a key role in the following situations:

• emergencies involving communicable diseases or having the potential for giving rise to outbreaks;
• environmental situations where there is an imminent risk to health;
• situations involving the rapid relocation of residents of communities.

Availability

A qualified medical officer of health should be available by phone at all times and should be able to visit the community if urgent situations arise. Since many communities will be hiring medical officers of health on a part-time basis, the following points may be considered:

• payment of a retainer fee to ensure availability;
• possession of cellular phones;
• on-call arrangements with:
  • other medical officers of health working with First Nations communities;
  • provincial / municipal medical officers of health;
  • FNIHB medical officers.

Professional Requirements - description of training

The medical officer of health must satisfy the following professional requirements:

1. A degree in medicine recognised by the provincial medical licensing body;
   AND
2. a licence to practise medicine in the province in which the community is located. This is the case for medical officers employed or retained by or under contract to First Nations. [If employed by FNIHB, however, licensure in any province or territory is sufficient provided that the work is restricted to the federal jurisdiction];
   AND
3. liability protection;
   AND
4. either: a) a fellowship of the Royal College of Physicians of Canada in community medicine - FRCP(C); OR b) a recognised masters degree in public health; OR c) 10 years experience which was primarily in public health; OR d) a formal arrangement for supervision by a physician who fulfills criteria a), b) or c);
   AND
5. a demonstrated, basic understanding of public health principles.

Most family physicians do not have the specialised training to enable them to undertake the responsibilities of an MOH. Special arrangements for supervision would have to be made if this were the only available option.

Cost

The daily fee for a qualified MOH is in the range $450 - $750 (1996). Annual salaries, with benefits, vary from $90 000 to $130 000 (again, 1996). Retainer fees should depend on responsibilities. Operating costs (accommodation, telephone, travel, liability protection, membership fees, continuing education etc.) must also be taken into account.

Options

Regional Transfer Officers can identify the level of resources available for transfer. This is usually a per capita proportion of the zone or regional resources devoted to the medical officer. Most communities will not have the funds available nor the need to employ a full-time MOH. Communities must be able to demonstrate, however, that the services which are provided by medical officers of health are available to the community.

The following options may be considered:

1. Employment of a full-time MOH. This is likely to be possible only by health agencies of tribal councils or other large groupings of communities.
2. Pooling of resources with other communities to hire or contract with an MOH on a full- or part-time basis.
3. Daily fee or part-time employment with arrangements made for full-time coverage or continuous availability.
4. Contract with a provincial/municipal MOH.
5. Continued use of FNIHB medical officers (funds not transferred).
6. Purchase of MOH services from FNIHB. In this case, funds are transferred to the community which then purchases services based on a memorandum of understanding.
7. Contract with a university Community Medicine Department.