The complexities of multi-level governance in public health.

This article reviews some of the challenges to developing national public health programs, focussing on the distribution of constitutional authority for public health and governance challenges that arise from this. Constitutional authority for public health resides primarily with the provinces. The federal government has obtained the authority to legislate in this area primarily through its power over criminal law. Challenges facing the establishment of national public health programs include the ambiguity over constitutional responsibility, challenges in managing externalities and spillovers, and issues related to funding and data ownership. Policy-making is also complicated by the importance of municipal and supranational governments in public health. National programs need to be structured in a way that balances the advantages of regional approaches to public health challenges with the benefits of a coordinated central response. To do so, policy-makers need to address unique challenges to public health governance.