Building consensus on what to include in public health expenditures: A modified Delphi study in Canada

An accurate understanding of expenditures on public health in Canada is necessary to assess value for money and advocate for sustainable public health systems. Our objective was to determine a consensus-based list of public health expenditure items.

We conducted a two-round, online modified Delphi study with public health physicians from across Canadian provinces. Participants rated the extent to which expenditure items in existing Canadian expenditure records should be classified as public health. In round 1, 78 expenditure items were assessed. In round 2, only items lacking consensus were reappraised considering the group's earlier ratings.

Twenty-two public health physicians across Canada participated in round 1. Consensus was reached for 46 items, most (37 items) judged outside of public health. In round 2, the 32 items without prior consensus were returned for reassessment, and consensus was reached for 20 items, again with most (17 items) excluded from public health. Screening programs and health emergency preparedness were judged within public health expenditures, while chronic disease management and primary care services were judged outside.

Public health physicians agreed that most items they rated (54 of 78) belong in funding streams other than public health. Current estimates of public health expenditures may therefore be overstated, with implications for the sustainability of public health systems in Canada.