Was priority setting included in the Canadian COVID-19 pandemic planning and preparedness? A comparative analysis of COVID-19 pandemic plans from eight provinces and three territories

Abstract

Background

Variation in priorities during pandemic planning among the federal, provincial and territorial jurisdictions are thought to have impacted Canada's ability to effectively control the spread of the COVID-19 virus, and protect the most vulnerable. The potential influence of diverse and divergent political, cultural, and behavioural factors, regarding inclusion of priority setting (PS) in pandemic preparedness planning across the country is not well understood. This study aimed to examine how the Canadian federal, provincial and territorial COVID-19 pandemic preparedness planning documents integrated PS.

Methods

A documentary analysis of the federal, eight provincial, three territorial COVID-19 preparedness and response plans. We assessed the degree to which the documented PS processes fulfilled established quality requirements of effective PS using the Kapiriri & Martin framework.

Results

While the federal plan included most of the parameters of effective PS, the provinces and territories reflected few. The lack of obligation for the provinces and territories to emulate the federal plan is one of the possible reasons for the varying inclusion of these parameters. The parameters included did not vary systematically with the jurisdiction's context.

Conclusion

Provinces could consider using the framework of the federal plan and the WHO guidelines to guide future pandemic planning. Regular evaluation of the instituted PS would provide a mechanism through which lessons can be harnessed and improvement strategies developed. Future studies should describe and evaluate what PS mechanisms were implemented.

1. Introduction

Canada did not escape the major priority setting challenges that were posed by the COVID-19 pandemic. In addition to high transmission and mortality rates, especially among the most underserved and marginalized populations, the pandemic disrupted key health services and diverted scarce resources, resulting in projections of severe disease and negative health outcomes over the next decade [1,2]. There has been criticism of the vast differences in the decisions and policies enacted across jurisdictions in Canada to control and manage COVID-19, with growing concern that this variability impacted Canada's ability to effectively control the spread of the virus, and its ability to protect the most vulnerable [3]. This divergence signals a need to explore and better understand the potential influence of diverse political, cultural, and behavioural factors on including priority setting in pandemic preparedness planning across the country.

Health care priority setting is a process through which health programs, interventions, geographical or political regions or populations are ordered for purposes of allocating scarce resources. Priority setting may be formal and explicit or informal and implicit. It occurs at different levels, including the federal, sub-national (e.g. provincial, regional), health facility and bedside levels. Priorities may be set within or between programs such as, the cardiac care network of Ontario; the provincial cancer care networks; the Canadian Agency for Drugs and Technologies in Health; the western Canada waiting list project; hospital and clinical programmes [4,5,6,7]. While some of the Canadian provinces and territories have experiences with healthcare priority setting and some of these priority setting experiences supported the integration of priority setting in the influenza pandemic plans in provinces such as Ontario [8], it is still unclear if these experiences supported the integration of PS in the COVID-19 pandemic plans and response. Systematic priority setting, if done well, has the potential to improve the quality and fairness of resource allocation decisions and contribute to better population health outcomes [9]. By including priority setting in the planning process, as articulated in preparedness plans, there is a roadmap in place, such that once the response activities are underway, established priorities can be implemented [10].

Examining the extent to which known parameters of effective priority setting were evident in COVID-19 pandemic plans in Canada is relevant, timely and critical for supporting future pandemic planning. To date the literature on COVID-19 and priority setting has commonly focused on vaccines [11,12]. Canada provides a particularly rich context for learning about how priority setting in a federal system of government occurred for a range of health interventions (Box 1, 13).

Box 1.

Overview of Canada's health and public health systems, adapted from [Allin et al., 13].

Canada has a decentralized, universal, publicly funded health system. While there is federal governance for health care, health care is primarily funded and administered by the country's 10 provinces and 3 territories. There are province-specific models of healthcare and insurance plans that determine the benefits available in each jurisdiction. All citizens and permanent residents receive medically necessary hospital and physician services free at the point of use. Excluded services, such as outpatient prescription drugs are paid for out-of-pocket though provinces and territories provide varying coverage of these excluded services for specific groups and about two-thirds of Canadians have private insurance which can also cover excluded services. Public Health is a shared responsibility between municipal, provincial/territorial and federal governments and Indigenous authorities and organizations. There are variations in governance, planning and delivery of public health services between the jurisdictions with accountabilities ranging from the local (i.e., municipal) to regional or provincial levels.

Canada's administration, organization and financing of health and health care services are decentralized. The intra and inter jurisdiction differences in the approaches employed to respond to and manage the COVID-19 pandemic, and the varying experiences with systematic priority setting and other pandemics- provide a useful backdrop for understanding how, within one country, recognition of the importance of priority setting may or may not translate into the same considerations, in specific jurisdictions’ pandemic preparedness plans. Documenting differences in these plans can serve as one explanatory reference for differences in COVID-19 health outcomes across Canadian jurisdictions that may emerge more clearly in time. This evidence can also support planning efforts for future pandemics in Canada and elsewhere, by revealing which healthcare priority setting criteria were absent or not explicitly noted within the country's COVID-19 pandemic planning documents.

The aims of this study were:

• 1To explore the degree to which the federal, provincial and territorial COVID-19 pandemic plans included the parameters of effective priority setting.
• 2To conduct a comparative analysis of the number and range of quality indicators included in these plans.

2. Methods

This paper reports from a Canadian case study which was nested within a global study that assessed the inclusion of priority setting in a sample of national COVID-19 plans.

In addition to reviewing the national (federal) plan, the Canada case study included a review of the publicly available relevant plans from eight provinces and three territories of Canada (see Appendix 1 for list of plans). The decentralized nature of Canadian governance of public health provides insights into how federalism may have impacted COVID-19 planning. Each of the provinces and territories vary along key dimensions, including the political, social demographics, economic status, and COVID-19 epidemiological profiles of morbidity and mortality (Table 1).

Table 1.

Framework for effective priority setting (adapted for the review of the pandemic plans).

Domain	Parameters	Short definition
Contextual Factors	1Conducive Political, Economic, Social, cultural and health system context	Relevant contextual factors that may impact COVID-19 priority setting
Pre-requisites	Political will	Documented or implied politicians’ support for PS within the COVID-19 plans
	Resources	Availability of a budget in the COVID plan, and clear description of resources available or required (including human resources, ICU beds and equipment, PPE, and other resources)
	Legitimate and credible institutions	Documented priority setting institutions, the degree to which they can set priorities, public confidence in the institution
	Incentives for compliance	Explicit description of material and financial incentives to comply with the PS mechanisms in the pandemic plan
The Priority setting process	2Planning for continuity of care across the health systems	Explicit identification of strategies for the continuity of healthcare services during the pandemic
	Stakeholder participation	Description of stakeholders participating in the development and implementation of the COVID plan (and PS activities within the plans)
	Use of clear priority setting process/tool/methods	Documented explicit priority setting process and/or use of priority setting framework
	Use of explicit relevant priority setting criteria	Documented explicit criteria for the priority setting in the COVID plan
	Use of evidence	Explicit mention of the use of evidence to understand the context, the epidemiological situation, or to identify and assess possible interventions to be implemented
	Reflection of public values	Explicit mention that the public is represented, or that public values have been considered for the development or implementation of the plan
	Publicity of priorities and criteria	Documented strategies for communicating PS criteria and decisions, evidence that the plan and criteria for priority-setting have been publicized and documents are openly accessible
	Functional mechanisms for appealing the decision	Description of mechanisms for appealing decisions related to PS within the COVID plan, or evidence that the PS plans has been revised
	Functional mechanisms for enforcement the decision	Description of mechanisms for enforcing decisions related to PS within the COVID plan
	3Efficiency of the priority-setting process	Documented proportion of meeting time spent on priority setting; number of decisions made on time
	3Decreased dissentions	Documented number of complaints from Stakeholder
Implementation	3Allocation of resources according to priorities	Documented degree of alignment of resource allocation and agreed upon priorities
	3Decreased resource wastage / misallocation	3 Reported proportion of budget unused, drug stock-outs
	3Improved internal accountability/reduced corruption	Description of mechanisms for improving the internal accountability or reduce corruption
	3Increased stakeholder understanding, satisfaction and compliance with the Priority setting process	Reported number of SH attending meetings, number of complaints from stakeholder,% stakeholder that can articulate the concepts used in priority setting and appreciate the need for priority setting
	3Strengthening of the PS institution	Documented indicators relating to increased efficiency, use of data, quality of decisions and appropriate resource allocation,% stakeholders with the capacity to set priorities
	3Impact on institutional goals and objectives	% of institutional objectives met that are attributed to the priority setting process
	3Impact on health policy and practice	Changes in health policy to reflect identified priorities, and swiftness of the pandemic response
	3Fair financial contribution	Description of the expected impact of the COVID plan on fair financial contributions
	3Increased public confidence in the health sector	Description of the expected impact of the COVID plan for increasing public confidence in the response to the COVID-19 pandemic
	3Impact on population health	Description of the expected impact of the COVID plan on the population health
	3Impact on reducing inequalities	Description of the expected impact of the COVID plan on reducing inequalities

¹This parameter was not assessed in the national COVID plans, but the information about the political, economic, social, and cultural context was obtained from different sources and provided in this study to identify similarities and differences among countries in the same region.

²This parameter was added to the framework for the specific context of the COVID-19 pandemic.

³These parameters could not be assessed based on the review of COVID-19 plans.

Similar to prior publications [14,15,16], the plans were accessed either through searching the government webpages or by directly requisition from the ministry of health officials. Data extraction was guided by a tool which was derived from the adapted version of the Kapiriri and Martin framework of effective priority setting (Table 2 ). The framework has been validated and used in several settings, to understand and evaluate healthcare priority setting [17,18]. The framework comprises 5 domains and each domain has 3–6 parameters.

Table 2.

Priority setting context.

Province/territories	Four Region Model	Population (2022)	Date of first case	Date of First Community Transmission
Alberta	Western Canada	4442,879	05-Mar-20	15-Mar-20
British Columbia	Western Canada	5214,805	28-Jan-20	05-Mar-20
Manitoba	Western Canada	1383,765	12-Mar-20	01-Apr-20
Saskatchewan	Western Canada	789,225	12-Mar-20	24-Mar-20
New Brunswick	Atlantic Canada	520,553	11-Mar-20	30-Mar-20
Newfoundland and Labrador	Atlantic Canada	45,504	14-Mar-20	28-Mar-20
Nova Scotia	Atlantic Canada	992,055	15-Mar-20	30-Mar-20
Prince Edward Island	Atlantic Canada	39,403	14-Mar-20	08-Apr-20
Ontario	Central Canada	14,826,276	25-Jan-20	05-Mar-20
Québec	Central Canada	164,318	27-Feb-20	24-Mar-20
Northwest Territories	Northern Canada	8604,495	21-Mar-20	08-May-20
Nunavut	Northern Canada	1179,844	06-Nov-20	16-Nov-20
Canada			25-Jan-20	05-Mar-20

The analysis presented here follows the steps that were established for the larger project (described in 14–168). However, in addition to assessing the degree to which the national plan included parameters of effective priority setting, the Canada case study included a sub-national analysis to assess the degree to which each of the provincial and territory plans included the parameters of effective priority setting. Further analysis involved cross province and territory comparisons and also comparisons between the national plan and the provincial and territorial plans.

3. Results

Twelve plans were available in the public domain and included in this study. The federal (national)plan was released prior to the release of most of the provincial and territorial plans. The results are organized according to the parameters of the Kapiriri & Martin framework for evaluating priority setting, namely: context, pre-requisites, process, implementation, and outcomes [20,21] and are summarised in Fig. 1 .

Fig. 1.

Overview of the parameters identified in each plan.

Key: Mentioned in detail; Mentioned but not detailed; Not mentioned.

3.1. Priority setting context

The decentralization of governance and financing for health care services across Canada influences how health care decisions are made in each jurisdiction and thus, entailed different approaches to setting priorities as part of the COVID-19 pandemic response. Consistent with their roles during normal times, the federal government, in addition to funding, was responsible for developing COVID-19 relevant policies, and procuring and distributing stockpiles for relevant supplies such as personal protective equipment. They also provided guidance and recommendations, including guidance about priority setting and resource allocation to inform decision making in the provinces [19,20]. But ultimately, in this decentralized system, the provinces were responsible for determining the jurisdiction-specific strategies for containment. Together with regional public health, health officers and local governments, the Ministries of Health set the COVID-19 policies [2,13].

There are key differences in the population density, size of the immigrant population and number of multigenerational homes between the provinces and territories; factors that were known to drive the rate of the spread of COVID-19, and to have influenced the timing and impact of each of the waves [21]. Lower income communities within each of the provinces were also at increased risk of exposure to COVID-19 due to existing social and structural determinants of health [22]. Ontario stood out as having a population that was most at risk of COVID-19 exposure based on these factors, including the largest immigrant population (approximately 0.5 M) and a higher margin of socioeconomic disadvantage and population density, while the three territories had a population that was least at risk due mostly to smaller populations, low population density and few individuals residing in higher burden areas [22].

Furthermore, the provinces have had varying experiences with prior disease outbreaks. While all provinces were in some way affected by the H1N1 epidemic in 2009, the critical outbreak which was most like COVID-19 was the severe acute respiratory syndrome (SARS) in 2003. The epicenter of the SARS outbreak was Ontario [23], suggesting that Ontario may have been able to leverage prior experience to deal with subsequent health emergencies.

Finally, the provinces have varying degrees of implementation research focused on priority setting, signaling variable experience with incorporating explicit priority setting to support decision making for health. Notably British Columbia, Alberta, Ontario, Quebec and Nova Scotia have had several implementation research projects on priority setting led by Mitton and colleagues in BC [24] and Singer, Martin and colleagues in Ontario [25]. We might expect the resulting expertise in priority setting in each of these jurisdictions to influence the extent to which it is leveraged in times of crisis to support resource allocation decisions.

These contextual factors may have contributed in part to the variable impacts of the pandemic in the provinces and territories [during the initial waves]. For example, in the first wave (2020) Alberta experienced the highest number of COVID-19 cases per capita, while Newfoundland had the lowest number of cases. Quebec experienced the highest number and Prince Edward Island the lowest number of COVID-19 related deaths per capita [26] (Table 3).

Table 3.

Additional COVID-19 and Priority setting contextual factors.

Province	Life expectancy (2019)	Population density per square kilometer	Population in rural areas (%)	Immigrants (%)	First nations (%)	Black population (%)	GDP per capita (2019)	Outbreak experience List the diseases	Priority setting experience	Prior pandemic influenza plan
British Columbia	82.4	5.4	12.7	28.3	4.4	0.05	$60,707	Influenza H1N1	Yes (7–10)	Yes
Alberta	81.6	6.7	15.2	21.2	4.7	0.06	$80,905	Influenza H1N1	Yes (8,9,11,12)	Yes
Saskatchewan	80.3	2.0	31.7	10.5	11.6	0.03	$70,730	Influenza H1N1	Unknown	Yes
Manitoba	80.1	2.5	25.3	18.3	10.6	0.06	$53,897	Influenza H1N1	Unknown	Yes
Ontario	82.4	15.9	13.3	29.1	2.7	0.12	$61.315	SARS 2003 Influenza H1N1	Yes (8,11,13)	Yes
Quebec	82.9	6.5	19.0	13.7	3.4	0.04	$54,149	Influenza H1N1	Yes (8)	Yes
Newfoundland and Labrador	80.0	1.4	40.0	2.4	8.6	0.01	$71,527	Influenza H1N1	Unknown	Yes
New Brunswick	80.7	10.9	49.1	4.6	4.7	0.05	$49,218	Influenza H1N1	Unknown	Yes
Nova Scotia	80.4	18.4	41.1	6.1	5.0	0.23	$47,837	Influenza H1N1	Yes (14)	Yes
Prince Edward Island	81.6	27.2	54.0	6.4	2.6	0.03	$48,039	None	Unknown	Yes
Yukon	79.0	0.1	36.4	12.6	18.0	0.00	$76,114	Influenza H1N1	Unknown	Yes
Northwest Territories	77.4	0.0	34.7	9.0	36.9	0.13	$100,871	Influenza H1N1	Unknown	Yes
Nunavut	77.1	0.0	54.9	2.6	1.9	0.14	$95,535	Influenza H1N1	Unknown	Yes
Canada	82.1	4.2	17.8	21.9	4.1	0.08	$61,466	Influenza H1N1	Yes (7–15)	Yes

Source: https://www12.statcan.gc.ca/census-recensement/index-eng.cfm - Census 2016.

3.2. Pre-requisites

The Kapiriri & Martin framework considers four parameters that assess pre-requisites for effective priority setting: political will, availability of legitimate priority setting institutions, incentives for compliance, and human and financial resources. Each of the plans was reviewed to assess the extent to which these prerequisites were reflected.

3.3. Political will

All the reviewed plans were commissioned by the respective governments, which, according to the evaluation framework, is an indicator of political will and support for the planning process. The federal government's plan reflected strong political leadership as evidenced by the mandates from the prime minister's office, while the provincial plans showed varying degrees of political will- as reflected in the commissioners, mandates and stakeholders involved in the development of the response plans.

3.4. Priority setting institutions

The national plan and four of the provincial/territorial plans (Alberta, British Columbia, Northwest territories and New Brunswick) identified key institutions, including technical and non-technical stakeholders, who comprised the priority setting and decision-making bodies during the pandemic. The institutions identified reflected those that had successful legacies of previous coordination structures which were established to respond to the influenza pandemic or other emergencies.

3.5. Incentives for compliance

Incentives (i.e., positive rewards for compliance or negative consequences, for non- compliance); support the adherence to the set priorities, and hence try to ensure their implementation. None of the reviewed plans explicitly described material and financial incentives (or disincentives) to increase compliance with the priority setting parameters.

3.6. Human and financial resources

The health system context varied and so did pre-existing health resources prior to the pandemic. For example, the jurisdictions had varying ICU capacity; from Newfoundland (2.8/ 100,000 ICU beds) to Alberta (0.4/100,000 ICU beds). The same capacity is observed when considering the number of ICUs with ventilation/ 100,000 population; although in absolute numbers both Ontario and Quebec had 60% of the 286 hospitals in Canada with ICU ventilation capacity (Table 4).

Table 4.

COVID-19 pandemic resources.

	Hospitals and ICU beds capacity				COVID-19
Province	Hospitals with ICUs with ventilation capacity	ICU beds capable of invasive ventilation	Hospitals with ICUs per100,000 population	ICU beds with ventilation capacity per 100,000 population	Rate of Hospitalizations	Average of ICU occupation	Rate cases per100,000 population	Rate deaths per100,000 population
British Columbia	34	304	0.8	6.8	221,235	2369	4242.44	45.43
Alberta	16	292	0.4	0.9	337,808	3271	7603.36	73.62
Saskatchewan	13	108	1.3	10.5	81,510	936	6908.54	79.33
Manitoba	10	93	1.0	9.0	69,113	1341	4994.56	96.91
Ontario	84	1122	0.6	8.6	626,321	10,044	4224.4	67.74
Quebec	87	885	1.1	11.3	458,426	11,596	5327.75	134.77
Newfoundland and Labrador	14	98	2.8	19.3	2076	18	398.81	3.46
New Brunswick	9	103	1.2	13.8	9049	136	1146.57	17.23
Nova Scotia	14	141	1.5	15.0	8481	110	854.89	11.09
Prince Edward Island	2	18	1.4	12.8	403	0	245.26	0
Yukon	3	6	2.7	5.5	1561	14	3631.41	32.57
Northwest Territories					2069	12	4546.85	26.37
Nunavut					676	4	1715.61	10.15
Canada	286	3170	0.9	9.5	1818,741	29,851	4755.36	78.05

1. Fowler, R.A., Abdelmalik, P., Wood, G. et al. Canadian critical care trials group; Canadian ICU capacity group. Critical care capacity in Canada: results of a national cross-sectional study. Crit Care. 2015; 19(1): 133. doi: 10.1186/s13054-015-0852-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426537/

The federal plan and eight (of the eleven) plans from provinces and territories explicitly described the resources that would be required during the pandemic. While the Ontario plan identified several COVID-19 related resources, some of the plans e.g. British Columbia and Nunavut did not specify any resource requirements in their plans. The most frequently identified resources were; healthcare facilities (six plans), human resources and training (five plans), Personal Protective Equipment (PPE) (seven plans), other IPC materials (seven plans), laboratory equipment (five plans), testing kits (four plans), and intensive care unit beds (four plans) (Fig. 2).

Fig. 2.

Resources identified in the plans.

3.7. The priority setting process

The priority setting process domain comprises nine quality parameters, including whether the stipulated process is based on an explicit guiding tool/method/framework, evidence, and criteria. This domain also assesses the degree to which the proposed prioritization process was participatory (involving various stakeholders) and fair (is based on clear rationales, has mechanisms for publicizing, appeals, revisions and enforcement).

3.8. Stakeholder involvement

In relation to stakeholder participation, except for Prince Edward Island and Nunavut, all provinces/territories and the national federal plan described the involvement of- and a need for coordination between public health and healthcare delivery, emergency management and other sectors. Plans also considered the requirements for coordination and communications, and the engagement of different provincial actors. For example, the British Columbia plan identified agencies responsible for disease control and public health. A number of diverse provincial groups with expertise in ethics, clinical care and public health were also identified as key advisors to the development of most plans. The development of the Ontario plan was led by the Ministry of Health and Long Term Care (MOHLTC) which leads the Government of Ontario's response and other individuals/ groups in the MOHLTC such as the Deputy Minister and Ministry Action Group. The Quebec plan identified four stakeholder groups including citizens, informal caregivers, workers and decision makers (from the Ministry of Health). The New Brunswick, Alberta and Northwest Territories plans all identified different government agencies, the ministry of health, technical experts- clinicians, and First Nation partners.

3.9. Explicit prioritization process and criteria

Only the federal plan explicitly considered an approach to prioritization based on a “public health ethical framework” and informed by other logistical, epidemiological and societal considerations. This was also the only plan to explicitly make reference to the Declaration of the Rights of Indigenous Peoples. However, seven provincial/territorial plans did incorporate explicit criteria for priority setting (Alberta, Saskatchewan, New Brunswick, Nova Scotia, Ontario, Northwest territories, and Yukon). For example, New Brunswick identified the following criteria: efficiency, timeliness, transparency, commitment, engagement, representativeness, health equity, flexibility, ethical decision-making, and evidence-informed decision-making. Quebec's plan highlighted principles of protection, solidarity, responsibility, and sound management. Alberta´s plan stated that the goal of pandemic planning was controlling the spread of disease and reducing morbidity and mortality; mitigating societal disruption and ensuring the continuity and recovery of critical services; minimizing adverse economic impact and supporting an efficient and effective use of resources during response and recovery.

3.10. Public values

The federal plan as well as the plans from Quebec and Yukon included some considerations of public values. The federal plan asserted that it was informed by the "Public Health Ethics Framework”, which articulates ethical principles and public values. The Quebec and Yukon plans identified the need to hear from the public but did not discuss whether or how this was done. The Yukon plan recognized that the need for swift response may hamper public involvement. The plan however, explicitly indicated commitment to involve and inform Yukon First Nations governments and all Yukon communities on the direction of the response, with the main goal of fostering public confidence, understanding and support for all public health strategies and decisions.

The British Columbia plan included a general statement about “… integrating shared values into healthcare practices and treatment and funding decisions” but was not specific about whose values, and/ or the role of the public.

3.11. Equity and vulnerable populations’ consideration

This parameter assessed if the plans explicitly included equity as a guiding principle, criterion or operationalized equity identifying the populations that should be prioritised. The federal plan identified all the populations identified as vulnerable in the WHO guidelines. The Alberta plan included all except travellers, while the Ontario plan identified the elderly, immunocompromised and people with co- morbidities, but not the other populations identified by the WHO.

Lastly, we assessed the degree to which the plans prioritised the groups who were identified as priority populations by the human rights commission [27]. The federal plan identified all the populations with the exception of people with low social- economic status, injection drug users and LGBTQ populations. The groups identified as vulnerable in at least two jurisdictions included racialized and ethnic minorities, migrants, refugees, indigenous peoples, persons with disabilities, prisoners, people with lower socioeconomic status, population in rural areas, and homeless population (Fig. 3).

Fig. 3.

Comparison of the populations recommended by the human rights committee and those prioritised in Canada.

Although these populations were explicitly identified, no plan provided details on the ways in which these populations would be prioritised, for example which populations would be prioritized for which interventions.

3.12. Use of evidence

Both the federal and eight provincial/ territories plans (Alberta, British Columbia, Saskatchewan, New Brunswick, Ontario, Quebec, and Northwest territories) were informed by epidemiological data, especially evidence on the progress and severity of the pandemic, available at the time the plan was drafted. Almost all of the reviewed provinces/territories and the federal plans were also informed by prior and current pandemic plans and guidance documents, in particular influenza pandemic plans and emergency and all-hazard plans. All the sampled jurisdictions had comprehensive pandemic influenza plans (see Appendix for the full list). In addition to these guidance documents, the Federal and North West Territories plans made explicit reference to using the WHO pandemic planning guidelines.

3.13. Publicity

Publicity was a key consideration in all the reviewed plans. As expressed in the federal plan; “the trust and confidence of Canadians through timely and transparent communication of evidence-informed public health decisions; communicating appropriate and timely advice (including changes to this advice) to decision-makers, health professionals and the public; taking into consideration the diverse needs of population groups based on vulnerability, ethnicity/culture, ability status, and other socioeconomic and demographic factors; and supporting a coordinated response by working collaboratively with all orders of government and stakeholders”.

Most of the reviewed plans were accessible online and thus were publicly available.

3.14. Mechanisms for appeals, revisions and enforcement

While the plans discussed mechanisms for enforcement, this was in relationship to the public health directives. Enforcement was neither in relationship to priority setting nor to meeting the four conditions of a fair priority setting process (relevance, appeals and revisions). Furthermore, none of the reviewed plans identified explicit mechanisms for appealing and revising the priority setting decisions.

3.15. Plans for continuity of services

Plans for continuity of services were included in the federal plan and five provincial/territorial plans (Alberta, British Columbia, Saskatchewan, Ontario, and Northwest territories). There was emphasis on ensuring that there was least disruption to routine services.

The plans identified populations which were prioritised for continuity of health services during the lock down periods and as part of the strategy to manage surge capacity. The initial focus of the plans was on care for the elderly populations including home and community care, and long-term care. The specific services identified were nursing care, personal care, acute care, supervised or supported living, and palliative care.

Only the Federal and Ontario plans explicitly identified additional population groups for whom services should be prioritised- these included people with pre-existing conditions and children.

3.16. Implementation of the set priorities—impact and outcome

This domain assesses various process and output parameters associated with the implementation of the identified priorities, and the impact of the PS implementation on: the PS institution, organization's policies and practice, health systems’ goals and objectives, population health and equity. These aspects could not be assessed from the planning documents.

3.17. Cross-jurisdiction comparisons

Qualitative comparison between the jurisdictions revealed that while the federal plan included 15/20 parameters of quality priority setting, the province and territory plans reflect far fewer parameters of quality priority setting. The British Columbia plan included the highest number of parameters (11/20), while Alberta, Saskatchewan and Ontario plans included nine parameters. The rest of the plans included eight or fewer parameters.

While there were variations in the number of parameters that were included, some parameters were more common in the sampled plans. Almost all plans explicitly identified stakeholders who were involved in their development. For example, most identified technical stakeholders from a range of sectors. Only the Quebec plan identified citizens as key stakeholders that should be involved in the response plan. Additional parameters common to most of the reviewed plans included approaches to ensure continuity of a sample of services, priority setting criteria, use of evidence and publicity. All these parameters were reflected in the federal government plan.

Some parameters were missing in most of the reviewed plans although they are reflected in the influenza plans which several of the COVID-19 plans referenced. These included: the use of an explicit PS framework or tool, consideration of public values, appeals and enforcement mechanisms. This may be a reflection of how COVID-19 was conceptualized in its initial stages, i.e. as being similar to influenza. It is possible that some provinces also used the influenza plans concurrently with the COVID- 19 plans. Furthermore, since the federal plan included most of the parameters, it is also possible that the provincial plans were developed to compliment the national guidance and used concurrently in implementation.

4. Discussion

This paper has presented findings from a review of the initial COVID-19 pandemic plans from the federal level, eight provinces and three territories in Canada. All plans recognized the importance of including priority setting in their pandemic planning documents, since they all included various parameters of effective priority setting. A key finding is the substantive difference between the federal level plan and the plans from the various jurisdictions regarding the articulation of an explicit approach to priority setting.

There were also differences between the provinces and territories. In centralized contexts, a good national level plan can translate into a good plan at the sub-national level [28]. However, this opportunity was missed in the Canadian context whereby while the federal plan included most of the parameters of effective PS, the lack of obligation of the provinces and territories to emulate that plan resulted in varying inclusions of these quality parameters. This challenge was observed across all COVID-19 response efforts, whereby there was concern that the division of the public health responsibilities between the federal and provincial and territorial jurisdictions might have resulted in “…barriers to achieving effective, consistent, national public health responses…” [29]

The level of decentralization and independence of the provinces and territories may have also impacted the level of consistencies in the approaches used and the ability of the jurisdictions to learn from each other. The varying approaches may have also impacted equitable access and use of resources across jurisdictions [25]. While the pandemic spread across all jurisdictions, some were affected much earlier than others [25,30]. There was ample time for cross jurisdiction sharing of best practices, lessons, including those about priority setting and resources. However, the lack of coordination in the response between jurisdictions, may have contributed to missed opportunities for the jurisdictions to share early lessons and plan effectively. Furthermore, coordination between provinces would have allowed for cross-jurisdiction priority setting- based on agreed upon criteria- and effective resource allocation (e.g. for health human resources that were at times simultaneously in surplus in some settings while depleted in others) as part of a coordinated and pre-emptive strategy; as opposed to what actually occurred where resources were only shared at critical points [31,32].

COVID-19, similar to any public health emergency, highlighted the inequities that exist at the global, national and sub- national levels. Realizing these inequities, the WHO COVID-19 planning guideline stipulated that certain populations should be prioritised for an equitable pandemic response [33]. The Canadian federal plan explicitly considered an approach to prioritization of any limited resource based on an ethics framework and informed by other logistical, epidemiological and societal considerations. This was also the only plan to explicitly make reference to the Declaration of the Rights of Indigenous Peoples, which is critical due to the Canadian history of colonialism and structural marginalization of indigenous people [34]

Only the national plan identified those living in rural areas, and persons with disabilities as vulnerable and prioritised them. Stakeholders across HICs, when faced by the need to limit hospitalization and life-sustaining and saving resources early in the COVID-19, hotly debated the exclusive use of clinical criteria [35]. Where individuals navigate life with chronic disabling illness, or are accustomed to a quality of life defined outside normative biomedical definitions of healthy individuals, the absence of clarity around what will be done to ensure equitable access to care further heightened pre-existing inequities [36].

The lack of explicit focus on groups that are traditionally socially marginalized (e.g. black populations) during the COVID-19 pandemic is indicative that the PS for the pandemic followed a general/whole of population approach- which is consistent with the egalitarian approach which may fail to account for the unique needs of different sub-populations [37]. Such an approach overlooks the equity and social justice literature which argues that groups that have been historically under-serviced/not prioritized should be prioritized as opposed to the more general one size fits all planning model. The weaknesses of this approach were made more apparent in the context of the COVID-19 pandemic where the ‘stakes’ were higher for getting the ‘right’ response to the groups most in need in a timely manner. For one to effectively prioritize and target the vulnerable populations, they need to have been identified early, quantified and engaged in the planning process, - for resource allocation. However initially, the system lacked mechanisms for collecting segregated information [38].

Finally, while stakeholder engagement is evident in all the reviewed plans, there was a consistent lack of reporting on the representation and delays in the effective engagement of equity-deserving populations as contributors to the planning process [39]. This may have impacted the criteria that were defined as relevant for defining priorities and identifying priority populations in the plans. Meaningful engagement of the populations who have been most marginalized across the health systems in Canada – low income, racialized, immigrant, women - was a key oversight in the early planning for the COVID-19 responses, furthering the invisibility of these populations by the health systems across Canada [40]. While this was rectified in subsequent plans, for example through the creation of the Black Scientific Table in Ontario, further research should explore the impact that inattention to equity in priority setting process had on risk of exposure and outcomes for equity deserving populations.

4.1. Limitations

There are two limitations to this study; first, we focused on the initial planning documents and lacked the resources to follow up on the emerging directives throughout the pandemic beyond March 2021. It is possible that aspects of priority setting were integrated with the lessons learnt from each wave. Further inquiry should map how this learning evolved over subsequent waves of the pandemic. Second, we are aware that often policy and practice may vary and even conflict. However, it was beyond the scope of the study to analyze actual practice, post the planning phase. We were unable to independently verify priority setting practice through the plans alone. This should be explored through interviews with the relevant stakeholders who were involved in the planning, the focus of future research.

5. Conclusion

To the best of our knowledge, this is one of the first studies to assess the degree to which initial COVID-19 plans in Canada integrated parameters of effective priority setting; with the findings that provinces and territories did not systematically include all of the evidence-based quality parameters for priority setting.

Since all the provinces and territories in Canada have experienced a disease outbreak, the WHO phases of pandemic planning could have provided a framework for integrating explicit priority setting in the development of the COVID-19 plans in each jurisdiction [9]. Arguably, contexts that have priority setting as a routine part of their policy making may be more likely to integrate it during health emergencies- when it is even more critical. Hence, there is a need for Canadian provinces and territories to integrate priority setting in their routine practice. In so doing, the relevant stakeholders, the acceptable approach, the criteria, the process, and evidence are already institutionalized and could easily pivot in response to emergency situations [41]. Regular evaluation of the instituted priority setting processes would provide a context through which lessons can be harnessed and improvement strategies developed [42]. Based on a document review, this initial analysis provides useful information and a robust framework against which actual priority setting practice can be better embedded into pandemic preparedness planning within Canadian provinces and territories.

Funding

This project was funded by the McMaster university COVID-19 fund.

Ethical approval

Ethical approval for this type of study is not required by our institute

Funding

The study is funded by the PI ’s Institution. The institution played no role in study design; data collection, analysis and interpretation; and report writing.

Declaration of Competing Interest

The authors declare no conflict to declare