Federal/Provincial/Territorial Memorandum of Understanding (MOU) on the Provision of Mutual Aid in Relation to Health Resources During an Emergency Affecting the Health of the Public
- 1. DEFINITIONS
- 2. PURPOSE
- 3. SCOPE
- 4. INTRA-JURISDICTIONAL CO-ORDINATION AND IMPLEMENTATION
- 5. HEALTH CARE PERSONNEL
- 6. REQUESTS FOR AND PROVISION OF MUTUAL AID
- 7. REIMBURSEMENT
- 8. ROLE OF THE PAN CANADIAN PUBLIC HEALTH NETWORK COUNCIL
- 9. GENERAL
- Annex A - Proposed criteria to determine a Public Health Emergency of national or international concern
- Annex B - Principles for Mutual Aid Adopted by the Federal/Provincial/Territorial Deputy Ministers of Health
- Annex C - Checklist of Intra-Jurisdictional Coordination and Implementation
- Annex D - Requests for and Provision of Mutual Aid
- The jurisdictions which are signatories to this MOU (the “Jurisdictions”) wish to enter into an understanding regarding mutual assistance in relation to Health Resources during and Emergency.
- For Québec, the MOU relates to only the mutual aid assistance during an urgency of public health, as defined by the World Health Assembly on May 23 2005 and presented in Appendix A.
- The Federal / Provincial / Territorial Deputy Ministers of Health adopted five principles for purposes of addressing and responding to jurisdictional collaboration and assistance in an Emergency, which principles are attached as Annex B to this MOU (the “Principles”)
- To give effect to the Principles, the Federal / Provincial / Territorial Deputy Ministers of Health have tasked the Pan-Canadian Public Health Network to work with the Jurisdictions to develop an MOU on mutual aid designed to facilitate the sharing of human and material resources in a coordinated and cooperative manner across Canada.
- It is recognized that emergencies are managed within the broader emergency management system in each jurisdiction, , and that this MOU is complementary, and in some cases supplementary, to other MOU’s and agreements which may be established pursuant to other mandates.
- The purpose of this MOU is to establish a framework for Jurisdictions to provide and receive human and material Health Resources having regard to the unique and complex health care delivery structures and health professional regulatory environment in each Jurisdiction.
- This MOU describes the general intentions of the Jurisdictions. It does not create or describe legally binding obligations and does not limit or derogate from the exercise of any statutory power or legislative authority of each Jurisdiction.
Emergency means an urgent and critical situation, of a temporary nature, regardless of its cause1, that seriously endangers or threatens the health of the public that in the opinion of the Receiving Jurisdiction, is of such proportions or nature that it exceeds or may exceed the capacity or authority of the Receiving Jurisdiction to deal with;
Expenses include the direct costs of Resources (such as direct costs related to delivery and use of medical and surgical supplies, drugs and costs related to travel and accommodation of personnel), and the indirect costs (any cost not specifically or directly associated with the provision of Resources). For example, Expenses may include, but not be limited to, the salary and benefits of Health Care Personnel for the period of deployment, and the costs incurred in transporting Health Care Personnel to and from the area where they are assigned as well as any out of pocket costs incurred by the Sending Jurisdiction as a result of rendering Mutual Aid.
Health Care Material and Supplies includes any physical asset that could be used to prevent illness (e.g. vaccines or prescription drugs such as anti-viral drugs) or to care for or treat persons who may be ill or injured as a result of an Emergency;
Health Care Personnel means any natural person, whether or not in the employ of a Sending Jurisdiction, who provides health care services including, but not limited to, dentists, emergency medical personnel, emergency medical technicians, drivers of emergency vehicles used for public health purposes, nurses, nurse practitioners, physicians, physician assistants, pharmacists and any other staff needed to respond to an Emergency;
Health Resources mean Health Care Material and Supplies and Health Care Personnel provided by a Sending Jurisdiction to a Receiving Jurisdiction to be used during an Emergency;
Jurisdiction means a government which is a signatory to this MOU.
Mutual Aid means the provision of Health Resources in the event of an Emergency, [including providing for the movement, housing and care of Health Care Personnel transferred out of or across the territories of a Jurisdiction];
Receiving Jurisdiction means the P/T government on whose territory the emergency occurs, or the federal government if the emergency occurs on land and properties under federal responsibility, that requests and is in receipt of any form of Mutual Aid from a Sending Jurisdiction;
Sending Jurisdiction means the jurisdiction which receives a request to provide to a Receiving Jurisdiction Mutual Aid during an Emergency;
1 including a natural disaster (e.g., flood, earthquake, tornado, infectious disease outbreak etc.) or human-caused disaster, either accidental or malicious (e.g., acts of biological, chemical, radio-nuclear or explosive terrorism), epidemic/pandemic disease outbreak, or a novel/highly fatal infectious agent or biological toxin
The purpose of this MOU is to establish a framework for Mutual Aid amongst Canadian Jurisdictions in accordance with the Principles set out in Annex B, and in accordance with the following Understandings, namely:
- Each Jurisdiction has full power and authority to enact legislation within its sphere of constitutional competence and this MOU does not aim to commit a Jurisdiction to the exercise of its legislative function.
- Each Jurisdiction has unique and complex health care delivery systems and structures, including unique and varied employment and health professional arrangements.
- The regulatory control over most health care professionals in each Jurisdiction is administered by self-regulating bodies pursuant to applicable legislation, regulation and bylaws.
- The Jurisdictions acknowledge that they have limited authority to commit Health Care Materials and Supplies or to commit or require Health Care Personnel to participate in responding to an Emergency by way of this MOU.
- Each Jurisdiction may, if considered advisable, enter into further bilateral or multilateral MOU’s or agreements with other Jurisdictions for the purpose of describing in greater detail the Mutual Aid arrangements as between or among them.
- This MOU is an expression of intent by the Jurisdictions to explore, review and undertake the measures set out in this MOU, having regard to the Principles and Understandings, with a view to making appropriate administrative, policy and legislative changes considered advisable by each Jurisdiction to give effect to the intentions expressed in this MOU.
3.1 This MOU applies to an Emergency, as determined by the Jurisdiction in which the Emergency occurs, and to the provision of Mutual Aid from a Sending Jurisdiction to a Receiving Jurisdiction.
4.1 It is the intent of the Jurisdictions to each facilitate the implementation of this MOU within their own Jurisdictions by working internally to develop or provide the protocols identified in Annex C.
5.1 With respect to the provision of Health Care Personnel pursuant to a request for Mutual Aid, it is the intent of the Jurisdictions to develop mechanisms to ensure that:
- Health Care Personnel will be able to practice lawfully in the Receiving Jurisdiction within their recognized scope of practice and;
- Health Care Personnel will not be unreasonably disadvantaged in any way, either directly or indirectly, with respect to matters relating to salary or compensation, health care benefits, disability protection and benefits, death benefits, liability and immunity protections, worker's compensation benefits and coverage, while providing health care services in the Receiving Jurisdiction.
The specific mechanisms to be used in relation to the above intentions will be determined by each Jurisdiction which may include, without limitation, compensation and/or indemnification in lieu of coverage by the Receiving Jurisdiction.
5.2 Nothing in this MOU restricts the authority or ability of a Receiving Jurisdiction to expand or limit the scope of practice of an assigned Health Care Personnel for which the individual is licensed in the Sending Jurisdiction provided: 1) where the scope of practice is expanded, the Receiving Jurisdiction arranges for the requisite training, to that individual, and 2) the principles set out in clause 5.1 are met.
5.3 It is the intent of the Jurisdictions to consult with the bodies responsible for the regulation of Health Care Personnel in their jurisdiction and with other relevant groups to determine how to handle complaints that arise in relation to health care services provided by Health Care Personnel while on assignment in the Receiving Jurisdiction..
5.4 The period of assignment of a Health Care Personnel begins when the Health Care Personnel leaves the Jurisdiction of the Sending Jurisdiction and ends upon return to that Jurisdiction, and includes any period during which a Health Care Personnel receives training from the Receiving Jurisdiction.
5.5 During a period of assignment, a Health Care Personnel will be under the command and control of the person assigned by the Receiving Jurisdiction.
6.1 It is the intent of the Jurisdictions to adopt and act in accordance with the principles and protocols identified in Annex D when either requesting or responding to requests for Mutual Aid.
7.1 It is the intent of the Jurisdictions that, upon receipt of a detailed written request from the Sending Jurisdiction, the Receiving Jurisdiction will reimburse the Sending Jurisdiction for all reasonable Expenses incurred in or as a consequence of the provision of Mutual Aid to the Receiving Jurisdiction. For greater certainty, the Receiving Jurisdiction will be responsible for all Expenses incurred as a result of the receipt of Mutual Aid notwithstanding the fact that the:
- Expenses were incurred by another person, board, authority or agency within the Sending Jurisdiction, and
- Sending Jurisdiction has not directly incurred any expense or suffered any cost, loss or damage.
7.2 The Jurisdictions may enter into MOU’s or other agreements respecting the reimbursement of Expenses arising from the provision of Mutual Aid.
8.1 As the senior and central governance body of the Pan-Canadian Public Health Network, the Pan-Canadian Public Health Network Council (the “Council”) will support the implementation of this MOU in achieving the principles set out in Annex B.
8.2 The Council will report such findings to the Conference of Deputy Ministers of Health.
9.1 Additional Agreements - Nothing in this MOU precludes any Jurisdiction from entering into other agreements relating to the provision of Mutual Aid in respect of Emergencies, nor does this MOU affect any other agreements already in force.
9.2 Harmonization with Other Agreements - The Jurisdictions intend to harmonize, where appropriate, with this MOU any other applicable agreements relating to Mutual Aid for Emergencies entered after the coming into effect of this MOU.
9.3 Effective upon execution - This MOU is effective upon being signed by any two Jurisdictions, and is effective in respect of any other Jurisdiction upon its signing by that Jurisdiction.
9.4 New Parties - A Province or a Territory may become a signatory to this MOU at any time.
9.5 Withdrawal - Any Jurisdiction may withdraw from this MOU by providing written notice to all other Jurisdictions. The withdrawal is effective 30 days after written notice is provided.
9.6 Amendment - This MOU may only be modified by the mutual consent of all Jurisdictions. To be effective, all proposed amendments must be in writing and must be accepted in writing by all Jurisdictions within 90 (ninety) days of the initial proposal. If accepted, the amendments will come into force on a date agreed upon by all Jurisdictions.
9.7 Mediation - It is intended that any disputes arising from this MOU will be resolved using mediation. The process to be used for mediation will be determined by agreement of the Jurisdictions to the dispute.
9.8 Review – This MOU will be reviewed by the Public Health Network Council every two years and the PHN Council will recommend any revisions to the Conference of F/P/T Deputy Ministers of Health.
Proposed criteria to determine a Public Health Emergency of national or international concern
NOTE: the test to determine whether a “Public Health Emergency” exists is derived and adapted from Annex 2 of the IHRs as adopted by the 58th World Health Assembly on May 23, 2005.
Public Health Emergency:
An extraordinary, unexpected, or unusual health event…
Q. 1) Is the health event extraordinary, or unusual?
The following are examples of extraordinary or unusual events:
- The event is caused by an unknown agent or the source, vehicle, route of transmission is unusual or unknown.
- Evolution of cases more severe than expected (including morbidity or case-fatality) or with unusual symptoms.
- Occurrence of the event itself is unusual for the area, season, or population.
Q. 2) Is the health event unexpected from a public health perspective?
The following is an example of an unexpected events:
- Event caused by a Disease/agent that had already been eradicated from the jurisdiction or not previously reported.
If the answer to either Q1) or Q2) is yes, then the health event should be considered extraordinary, unexpected, or unusual.
... determined to i) constitute a Public Health Risk to other jurisdictions and/or internationally through the spread of Disease
Q. 3) Is there a significant risk of spread to other jurisdictions and/or internationally?
Q. 4) Is there evidence of an epidemiological link in other jurisdictions?
Q. 5) Is there any factor that should alert health authorities to the potential for cross border movement of the agent, vehicle, or host.
The following are examples that may predispose to jurisdictional and/or international spread:
- Where there is evidence of local spread, an index case (or other linked cases) with a history within the previous month of:
- inter-jurisdictional and/or international travel (or time equivalent to the incubation period if the pathogen is known)
- participation in an inter-jurisdictional and/or international gathering (pilgrimage, sports event, conference, etc.)
- Close contact with an inter-jurisdictional and/or international traveller or a highly mobile population.
- Event caused by an environmental contamination that has the potential to spread across inter-jurisdictional and/or international borders.
If the answer to either Q3), Q4) or Q5) is yes, then the health event is determined to constitute a public health risk to other jurisdictions and/or internationally through the spread of Disease
... ii) have a serious adverse impact on the health of the population
Q. 6) Is the number of cases and/or number of deaths for this type of health event large for the given place, time, or population?
Q. 7) Has the event the potential to have an adverse impact on public health?
The following are examples of circumstances that contribute to an adverse impact on public health:
- Event caused by a pathogen with high potential to cause epidemic.
- Indication of treatment failure.
- Event represents a significant public health risk even if no or very few human cases have been identified.
- Cases reported among health care staff
- The population at risk is extremely vulnerable (children, elderly, etc.)
- Event in an area with high population density.
- Concomitant factors that may hinder or delay the public health response (natural catastrophes, unfavourable weather conditions
If the answer to either Q6) or Q7) is yes, then the health event is determined to have a serious adverse impact on the health of the population
... potentially require a coordinated response.
Q. 8) Is assistance needed to detect, investigate, respond and control the health event, or prevent new cases?
The following are examples of when assistance may be required:
- Inadequate human, financial, material or technical resources, in particular:
- Insufficient laboratory or epidemiological capacity to investigate the event (equipment, personnel, financial resources)
- Insufficient antidotes, drugs and/or vaccine and/or protective equipment, decontamination equipment
- Existing surveillance is inadequate to detect new cases in a timely manner.
If the answer to Q8 is yes, then potential assistance and/or a coordinated response may be required.
In view of the foregoing:
A “yes” response by a jurisdiction to any one of Parts I - IV would indicate that a Public Health Riskexists.
A “yes” response to any two of Parts I - IV would indicate that: a Public Health Emergency exists.
Principles for Mutual Aid Adopted by the Federal /Provincial /Territorial Deputy Ministers of Health
- Recognition that F/P/T governments have varying degrees of public health capacity and that collaboration could be beneficial when a Jurisdiction is unable to manage by itself during an emergency or public health crisis;
- That sharing existing capacity and resources is a more efficient and effective way to provide surge capacity that results in little to no duplication in resources and activities;
- That F/P/T governments can support one another, facilitated through the Public Health Network, to assist any Jurisdiction(s) dealing with a public health event/crisis that is beyond its capacity;
- That each Jurisdiction can establish the procedures necessary to provide assistance during public health emergencies, including working towards accommodating mechanisms to enable emergency responders from one Jurisdiction to work in other Jurisdictions during public health emergencies; and
- That the provision of assistance will not endanger or severely limit public health capacity in any Jurisdiction providing assistance.
Checklist of Intra-Jurisdictional Coordination and Implementation
It is the intent of the Jurisdictions to each facilitate the implementation of this MOU internally by working to develop or provide when possible or feasible, the following:
- Protocols to warn adjacent Jurisdictions of possible Emergencies.
- An inventory of available Health Resources and protocols for the inter-jurisdictional loan and delivery of those Health Resources.
- Protocols for hazard identification and risk assessment, continuity of operations and emergency response plans to support local / jurisdictional management of Emergencies. Jurisdictions may have additional plans in place as appropriate.
- Protocols to: (i) identify levels at which Mutual Aid should be sought; and (ii) seek assistance from the health care sector to respond to a request for Mutual Aid.
- Protocols to document all requests and offers of assistance for Mutual Aid.
- Protocols to identify the individual(s) with authority to request or agree to provide Mutual Aid under this MOU and to communicate this information to the other Jurisdictions.
- Protocols to identify the appropriate contact persons, including position, title, and contact information on a 24/7 basis; and to communicate this information to other Jurisdictions.
- Public health emergency management systems to expedite planning and decision-making that are comparable or interoperable with other Jurisdictions.
Requests for and Provision of Mutual Aid
A Receiving Jurisdiction may request Mutual Aid from a Sending Jurisdiction. A request may be made verbally or in writing by an authorized individual of a Receiving Jurisdiction to an authorized individual(s) of another Jurisdiction, but if made verbally, the initial request will be confirmed in writing as soon as practical and not later than fifteen (15) calendar days.
A request for Mutual Aid will contain the following information:
- Description of the Emergency
- Nature and type of Health Resources that are needed
- Time and date that request was made
- Name and position of authorized individual making the request
- Other matters relevant to the Emergency
The Receiving Jurisdiction will:
- Identify the appropriate persons within the Receiving Jurisdiction, including position, title and contact information and communicate this to any Jurisdiction to whom a request for Mutual Aid has been made
- Identify the Health Resources requested with as much detail as possible:
- Health Care Personnel: including skill sets required (e.g. immunization; critical care respiratory therapists, paramedics, forensic dentist, etc.); approximate numbers required; specific names where appropriate,
- Health Care Material and Supplies: including equipment types (e.g. oxygen-powered ventilator); inter-operability requirements; numbers; and type and volume of supplies
- Identify the timeframe for the request, e.g. in 72 hours will need ventilators for an anticipated 30 people
- Identify the drop site for the Health Resources and the contact person at the drop site
- Identify whether the Health Resources are being requested as loans or otherwise
- Provide appropriate accommodations, meals, personal protective equipment and other operational supports as appropriate to any incoming Health Care Personnel and identify a local manager to oversee provision of these operational supports.
The Sending Jurisdiction will:
- Identify the appropriate contact persons within the Sending Jurisdiction, including position, title and contact information, and communicate this information to the Receiving Jurisdiction
- Provide a timeframe within which it will advise the Receiving Jurisdiction of the Health Resources available
- Coordinate the provision of available Health Resources within its own Jurisdiction, including those beyond the purview of the government
- Monitor the use of Health Resources being offered.
Response - Any Jurisdiction requested to render Mutual Aid undertakes to respond as soon as possible.
Domestic Needs - In rendering Mutual Aid, a Jurisdiction may take into account the Health Resources that it may require to provide protection to its own population.
Recall – Any Sending Jurisdiction may, at any time, recall Health Resources that may be required to provide protection to its own population.
Ending Mutual Aid -The Receiving Jurisdiction is responsible for informing the Sending Jurisdiction when Mutual Aid will no longer be required.
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