What counts as public health expenditures? A comparative case study of Australia, Canada, and England

The current lack of clarity with what public health budgets are spent on globally impedes research and informed resource allocation. This study aimed to examine the extent to which disaggregated public health expenditures data is publicly reported and determine which core public health functions are funded in three countries. A targeted search of government websites was conducted to identify datasets of disaggregated public health expenditures at timepoints before and during the COVID-19 pandemic. Public health expenditures datasets (including financial statements and budgets) were searched for at national, subnational, and local levels in three high-income countries with comparable public health systems: Australia, Canada, and England. Expenditures were then categorized into the five WHO Core Essential Public Health Operations to enable comparison across jurisdictions. No current disaggregated public health expenditures were publicly available in Australia. Disaggregated public health expenditures data were limited in public availability in Canada, available only at the federal level, in one province (Quebec), and one local Public Health Unit (Toronto). In England, local authorities’ disaggregated public health expenditures are standardized and reported by the Ministry of Housing, Communities, and Local Government, and the (now dissolved) national public health agency (Public Health England) budgets were published until 2020-21. Public health expenditures covered all five Essential Public Health Operations in both countries. When combining all levels of governments’ expenditures on public health, England focused most of its resources on one category (Health Promotion), while Canada spent more evenly across different categories (Health Protection, Health Promotion, and Disease Prevention). Expenditures on Response to Health Threats functions increased sharply during the pandemic. Public health functions also seem to be divided to some extent between levels of government. Our analysis suggests that it is difficult to know which programs are funded by public health expenditures, with England and Quebec’s publicly reported standardized datasets as the exception. Improved public reporting and standardization of disaggregated public health expenditures however is critical to informed resource allocation and should be conducted in close collaboration with public health practitioners to ensure accurate representation of public health activities.