This paper links the “provisional learnings” outlined in Denis's lead article to the results of a mixed-methods study of the state of rural healthcare in Saskatchewan to examine the manner by which the province centralized health system governance in 2017. While the study has limitations that preclude any hard and fast conclusions about those changes, there is evidence to suggest that the reforms were undertaken with insufficient attention to the particularities of rural healthcare organization and delivery. Amalgamation is not the sole cause of Saskatchewan's current crisis in rural healthcare, but the way it was implemented (with little consultation with rural communities, without clear goals and without sufficient planning in advance) may have exacerbated an already worsening situation.

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