The programs and budgets of Toronto Public Health have become a big news item in the past week, since the city announced it had been notified abruptly by the province of immediate funding cuts.

The discussion has not been calm, with Councillor Joe Cressy, the chair of the city’s board of health, saying bluntly “Torontonians will die,” while Premier Doug Ford has responded that Cressy and others “either don’t understand public health or are intentionally lying.”

Exactly how much is being cut, and what follows from those funding changes, remains a subject of heated debate. But just to follow the debate, a lot of us could use a primer on just what exactly Toronto Public Health is and some clarity on what the heck is actually going on.

What is Toronto Public Health?

The department was born in 1883 after the Upper Canada legislature gave municipalities the authority to create such boards to help contain outbreaks of smallpox and typhoid and to deal with rampant water-borne illnesses due to horrendous sanitation. Toronto Public Health is mandated with prevention of illness and promotion of health — a mission the current medical officer of health, Dr. Eileen De Villa, has said means an excellent outcome from their work “looks like nothing is happening.” An epidemic does not spread, water does not poison people, restaurant customers do not suffer food poisoning. Its success may be difficult to measure or fully appreciate for many because of this “paradox of prevention.”

What programs does Toronto Public Health provide?

Quite a few, in a series of areas. Some are straightforwardly aimed at direct illness prevention, such as food safety programs (including the DineSafe restaurant inspections) and water safety monitoring programs, or direct infectious disease control, including vaccination and immunization management and needle exchanges. Others are aimed at promoting good health, including school nutrition programs, preschool dental screening programs, tobacco cessation programs (and smoke-free workplace enforcement), and diabetes and skin cancer prevention programs.

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Who pays for it?

Under the current arrangement, the provincial and municipal governments each fund large parts of Toronto Public Health’s work (with some bits of funding from other sources). Some programs right now are mandated by the provincial government — meaning Toronto Public Health has no choice but to provide them — and 100 per cent of the cost of some of those programs is paid by the province. Others are “cost shared” and are funded 75 per cent by the province and 25 per cent by the city.

Looking at the big picture, before any of the recent changes were announced: the total Toronto Public Health budget was $255 million. The provincial government paid just over $170 million of that. The city’s contribution was $65 million. The small remainder came from federal funding, donors, fees and other sources.

What are the proposed funding changes?

The bottom line is a matter of some dispute.

According to the city’s understanding, the province is cutting all of its contributions — both the ones it now funds 100 per cent of and the ones it now covers 75 per cent of — to a 50 per cent share. The cuts are being phased in over four years, but this year’s cuts are retroactive to April 1.

The city’s calculations, shared by Cressy’s office with the Star, show they expect the combined impact of the shift in funding to mean a reduction of $65 million in the provincial contribution this year, phased in to a total reduction of $107.6 million in 2022 and the years beyond. About $1 billion over 10 years.

The provincial government disputes these numbers. While it has not been willing to publicly share its detailed breakdowns, it estimates the impact on the city’s budget to be closer to $33 million this year and $42 million per year once fully phased in.

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Examining the math on the city’s estimates seems to suggest a reason for the difference. The city’s financial impact estimates assume that the city contributes no more in the future than it does now. In that case, it shows programs now funded 100 per cent by the province losing all of their funding and the province’s contribution on the programs it funds 75 per cent of falling to match the city’s current 25 per cent contribution.

In contrast, it appears the province, in proposing a 50/50 cost share on all of these programs, assumes the city will increase its own funding to cover half of current spending levels. This would amount to a decrease in provincial funding of roughly what the province is estimating the impact to be. This represents an assumption by the province that the city increase its contributions to maintain current service levels under the new funding formula.

The actual impact, then, depends on how the city reacts, with a refusal to increase its funding contribution at all seeing a $107 million per year decrease in provincial funding and total program spending, while if the city increases its contribution to match half of current program spending levels, then it would amount to roughly $40-$50 million in lost provincial funding made up for by the city with no change to programming.

An email sent by city manager Chris Murray to members of council on Thursday said that the city staff had still not received any written details of the new proposed arrangement. Murray did say that the province indicated verbally in a conference call that “despite the cost-sharing changes, health units/regional public health entities are to maintain current service levels and accountabilities,” which may suggest the province expects the city to increase funding to maintain current service levels.

However, Murray’s email also reiterated that the city’s impact assessments assume no increase in the city’s contribution of $43 million.

How much money is $40-$50 million in the city’s budget?

A property tax increase of 1 per cent generates roughly $29 million in revenue. So raising taxes to make up the difference would mean an increase of roughly 1.5-2 per cent, which is roughly $45-64 per year for the average homeowner.

Raising taxes could be an option in the years ahead. Of course, how to deal with the shortfall this year is harder, since the city passed its budget and mailed out tax bills months ago, and doesn’t have any obvious sources of revenue mid-year. Likely funds would have to be found from another source, by cutting spending in some other area.

How do they fund public health elsewhere?

Cressy emphasizes that Ontario is the only province in which public health is not funded 100 per cent by the provincial government.

Is Toronto being treated differently? Why?

Yes. The other regional health authorities are having a different funding split proposed for them. Larger ones would see costs split 60/40, while smaller ones would see a 70/30 split — with the province paying the greater share in both cases. Only Toronto is asked to pay 50 per cent of costs. Murray’s email to councillors says “there is no confirmed rationale from the government for the differences between the cost sharing models and the unique model proposed for Toronto.” A provincial spokesperson at city hall Wednesday suggested it has to do with the “economies of scale” available to the province’s largest city.

Correction - April 30, 2019: This article was edited from a previous version that mistakenly said the cost of Toronto Public Health programs that are mandated by the province are fully funded by the province.

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