Two decades of change: The evolution of Canadian public health organizations in chronic disease prevention, 2004–2023

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BACKGROUND: Over the past two decades, Canada's public health system has undergone transformative structural changes that may impact chronic disease prevention (CDP). PHORCAST is a unique national study of CDP organizations in Canada that documents trends in organizational characteristics, funding, and priorities across the public health system. METHODS: PHORCAST conducted national censuses of CDP organizations in 2004, 2010, and 2023, including governmental and non-governmental organizations (NGOs) that develop and deliver CDP activities (classified as "resource" and "user" organizations, respectively). A standardized questionnaire captured organizational characteristics, populations served, staffing, funding, and activities. Descriptive statistics and stratified analyses were used to describe 20-year trends. RESULTS: Data from 258 organizations in 2004 (92% response), 239 in 2010 (90%), and 267 in 2023 (89%) revealed: (i) a shift toward more centralized delivery of CDP activities, with fewer organizations serving local populations and more serving provincial/territorial or national jurisdictions; (ii) a growing role of NGOs, the presence of which increased from 39 to 62% among resource organizations and from 36 to 51% among user organizations; (iii) declining prioritization of CDP especially among governmental user organizations (from 43% in 2004 to 26% in 2023); (iv) reduced reliance on federal/provincial funding and increased reliance on municipal and private sources; (v) persistent gaps in evaluation with only 19-22% of resource organizations reporting adequate staffing or budget; and (vi) a broadened CDP focus, particularly among NGOs, to include mental health and underserved populations. CONCLUSIONS: Canada's CDP landscape has become more centralized, increasingly NGO-driven, and financially unstable, with shrinking government prioritization despite rising chronic disease burdens. Strengthening system-wide capacity, evaluation infrastructure, and stable, equity-oriented funding models will be essential for building a resilient and effective CDP system.

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