The governance of publicly funded health systems in Canada has attracted attention for decades. Governance refers to the steering of the whole health system and goes beyond the role of healthcare boards for hospitals or regions. In this article, we analyze the potential of system-level reforms of governance that have been implemented in seven Canadian provinces since 2008. These reforms involve a movement toward greater centralization of the governance of health systems with the creation of province-wide governing agencies. These reforms of governance are not, by design, a panacea nor an absolute policy mistake. The potential of these governance reforms, as with any structural changes, will largely depend on how actors in power inhabit these new agencies and how patients, citizens, non-governmental organizations and communities relate to them. To assess the potential of these reforms, we first review works on challenges faced by these new health authorities. We then explore the literature on high-performing health systems and on contemporary approaches to governance, offering guidance for leaders of these organizations.

Introduction

The governance of publicly funded health systems in Canada has attracted attention for decades. Governance refers to the steering of the whole health system and goes beyond the role of healthcare boards for hospitals or regions. It focuses on the coordination and integration of interdependent providers and organizations that may pursue diverging interests and values, to achieve the broad system's goals (Pyone et al. 2017). Governance performs a set of system functions defined as the enactment of a vision, the incorporation of stakeholder voice in health policy decisions, the support for evidence-informed decisions and the promulgation of legislation and regulations to improve system performance (Papanicolas et al. 2022). In recent years, governance also refers to the promotion of equity, diversity and inclusion within health systems. Growing attention is paid to Indigenous governance; issues of intersectionality and anti-racism policies within the health system (Gilson et al. 2017; Marchildon et al. 2021; Massaquoi 2023; Young et al. 2020).

Various approaches to improving the governance of health systems have been proposed. Promoters of the New Public Management argue that the importation within health systems of more corporate forms of governance, including a diminishing role for government, can improve their performance (Lægreid 2017). They insist on the importance of having performance targets, clear expectations and accountability, competition and incentives, risk-sharing and public-private partnerships to improve performance. Network governance recognizes the need for governments to cooperate with and engage a wide range of organizations and actors, so-called traditional and non-traditional policy actors, to face current and future health system challenges (Wang and Ran 2023). Networks rely on trust, reciprocity, negotiation and mutual interdependence among actors to better coordinate their activities, share resources and tackle priority problems. Another approach to governance suggests paying more attention to the refinement and diversification of tools used by governments to influence the behaviours of organizations and providers and improve the delivery of care and services (Salamon 2000). For the sake of illustration, tools for governance can be grouped around four broad categories: organization, regulation, financing and information (Lavis and Hammill 2016). In practice, the governance of a health system will probably rely on a mix of approaches and tools. Contemporary views on governance recognize that formal authority and transactional mechanisms (e.g., mandates and contracts) are important but insufficient to steer the system in the right direction (Pyone et al. 2017).

In this article, we analyze the potential of macro-level reforms of governance that have been implemented in seven Canadian provinces since 2008. These reforms involve a movement toward greater centralization of the governance of health systems with the creation of province-wide governing agencies. Alberta was a precursor of this type of reform with the creation of Alberta Health Services in 2008 and was a source of inspiration for many other provinces. Prince Edward Island, the smallest province in Canada, followed closely with the creation of its single health authority in 2010. Five other provinces engaged to various degrees in similar reforms since 2015, namely, Nova Scotia (2015), Saskatchewan (2017), Ontario (2018), Newfoundland and Labrador (2023) and Quebec (2024). In addition, Manitoba created Shared Health in 2018 to plan and coordinate provincial health services. These reforms respond to a growing dissatisfaction of governments with governance of the health system in many Canadian jurisdictions (Usher et al. 2021). Essentially, governments look for better results considering the level of resources allocated to the system.

Enthusiasm and disenchantment have been the landmarks of governance reforms in healthcare in Canada. In 1997, the Canadian Medical Association Journal published four papers by Lomas et al. (Lomas, Woods and Veenstra, 1997; Lomas, Veenstra and Woods, 1997a, 1997b; Lomas, 1997) on devolution policies within the Canadian health systems. Devolution was about devolving powers to regional authorities and was adopted by nine provinces out of 10, except for Ontario. However, despite the popularity of regionalization policies at the time, skepticism was already rising around the pay-off of these policies. In 2000, former Federal Minister of Health Monique Bégin wrote that governance is one of the weakest parts of our health system (Angus and Begin 2000). In this journal, my colleague Greg Marchildon, in an article on regionalization, underlined that regional authorities in Canada lack strong integrative mechanisms, significantly limiting their impact on health system performance because, among other things, paying physicians were left out of regional health authority (Marchildon 2016). He also concluded on the lack of research-informed evidence to guide governance policies.

The skeptics won, and since 2008, many provinces decided to repatriate some of the power devolved to regions or healthcare organizations into more centralized governance authorities (Usher et al. 2021). Regionalization is now a story of the past, with just Manitoba (5 regions) and British Columbia (6 regions) that have maintained a strong role for regional boards and health regions. All other provinces have moved away from devolution and decentralization and aim to operate the health system with more centralized governing authorities. It is important to note – putting aside the question of the management of health human resources, which was less an issue in the nineties – that the creation of more centralized governance authorities has been driven by similar objectives than the one pursued by regionalization but with a more explicit managerial tone (Devlin et al. 2019; Donaldson 2010; Fierlbeck 2018; Gouvernement du Québec 2022). These objectives were around improving access and responsiveness of the health system, controlling cost and getting a better return on investment, improving the health of the population and achieving better integration of care and services. It is also interesting to note that these reforms of governance have taken place in jurisdictions of various scales, from the smallest province, Prince Edward Island, with a population of 154,331 (2021), to the largest one, Ontario, with 14,031,755 (2021). Moreover, these reforms are implemented in some jurisdictions that already have a significant degree of structural integration in the system. For example, the 2015 health reform in Quebec has merged local health territories into 22 large delivery entities called Integrated Health and Social Services Centres and Integrated University Health and Social Services Centres. As part of the enthusiasm-disenchantment pendulum that characterizes governance reforms in Canadian health systems, Alberta, the precursor in moving away from regionalization, dismantled its centralized agency (Alberta Health Services [AHS]) in 2024 with the creation of four specialized agencies to govern its health system.

These reforms of governance are not, by design, a panacea nor an absolute policy mistake. There is no point in lamenting that these reforms should not have happened. They are there to stay for a while, and no one hopes for other major reforms of governance in the short term. However, the potential of these governance reforms, as with any structural changes, will largely depend on how actors in power inhabit these new agencies and how patients, citizens, non-governmental organizations (NGOs), and communities relate to them. There is also a risk that major reorganizations keep policy makers, decision makers and front-line providers busy accommodating the new structure rather than improving the system (Fierlbeck 2018). How much of these accommodations will culminate in health system improvements is an empirical question.

In this article, we ask the following question: what can we expect from this switch to a more centralized form of governance in healthcare in Canada? To answer this question, we look in the first part at provisional lessons that can be extracted from some published works on recent reforms of governance in Canada. In the second part of this article, we look at a broader set of insights gained from the literature on health system improvement to derive some guidance for governors of these new agencies.

I: Reforms of Governance as Structural Changes

In a recent analysis, we have classified reforms of governance in Canada into two main models (Denis et al. 2023). One predominant model comprises the creation of a single health authority to fully operate the health system (Alberta, Prince Edward Island, Nova Scotia, Saskatchewan, Newfoundland and Labrador and Quebec). In these cases, the new governance authority has superseded existing governing bodies within the system. A second model, a more marginal one, comprises implementing a new centralized coordinating agency for the health system while maintaining an autonomy of governance in regions (Shared Health in Manitoba) or for hospitals (Ontario Health). These two models of governance may impact differently on the ability to coordinate and integrate providers and organizations across the system. The implementation of the more centralized model of governance was accompanied in most cases by the creation of health zones (e.g., Nova Scotia and Alberta) accountable to the new agency. In the end, despite movement toward more centralization, there seems to be a recognition of the role of intermediary organizations at the regional or local level in the governance of the system.

What have we learned from these recent reforms of governance despite the limited available research evidence? We rely on various reports and some empirical studies of health system reforms in Canada to identify provisional learnings from these governance reforms (AHS 2019a, 2019b; Denis et al. 2023; Fierlbeck 2018; Usher et al. 2021). First, and it is the case for any structural changes, the long temporality of change and improvement in health systems suggests that the implementation of these agencies will not produce an instantaneous positive impact on the system and may even lead to some short-term negative impact due to destabilization. The creation of a new governance authority is a discrete change. Transformation and improvement are a long and cumulative process characterized by trial and error and numerous policy adjustments. Second, it is important that these agencies predefine clear improvement goals or identify priority areas for improvement, monitor progress toward these goals, identify the responsibilities of providers and organizations in achieving these goals and report publicly on success and difficulties. The development and implementation of strategic clinical networks in various sectors of care by AHS after 2010 may be a good illustration of a systematic approach to improvement (AHS 2019a, 2019b) developed in the context of a more centralized governance authority. Similar networks have been studied in other jurisdictions and seem to produce some positive impact on clinical care and outcomes (Brown et al. 2016; D'Alleva et al. 2019; Vindrola-Padros et al. 2021).

Third, it is important that the government in charge (or politicians) understands that the creation of new centralized health authorities also represents a significant change for them. The government must now grant autonomy to these agencies so that they can operate the system to achieve priority goals. Again, based on the experience of Alberta, it took time after the creation of AHS to stabilize a senior leadership team that can work with less political interference (Church and Smith 2022). The creation of arm's-length governance agencies implies that the ministry of health reconfigure its roles and responsibilities. In the case of Alberta, public battles have been observed between the government, the chief executive officer and the board of AHS around diverging views on policies for the health system. Lack of clarity in the role of the ministry of health and that of AHS was an important factor in the difficulty to secure stable leadership in the early years of the new agency (Church and Smith 2022). A consideration also raised by Fierlbeck (2018) in her analysis of governance reforms in Nova Scotia. Moreover, the recent change in the Alberta health system suggests that political intervention may, from time to time, destabilize the governance of a system (Church and Smith 2024).

Fourth, because of the inherent complexities in reforming governance, preparing the transition to the new model appears crucial. This is even more important for jurisdictions that have opted for the more centralized model with the creation of a single health authority in charge of operating the whole system. The lack of preparedness at the time of the creation of AHS in 2008 was seen as a limiting factor. The attention paid to preparedness for the transition to a new model of governance in Manitoba and Newfoundland and Labrador may have increased the acceptability and the readability of the change for providers and organizations within the health system and for the population. These provinces did things differently, but they both developed a systematic strategy to prepare for the transition to the new governance model, even if they chose in the end a different model. For example, Newfoundland and Labrador puts in place a systematic engagement strategy with the population of the province through a diversity of means such as town halls, meetings with different stakeholders and public polls, in the process of preparing the Health Accord for Newfoundland and Labrador final report (Health Accord NL 2022). Manitoba's blueprint for change identified six work streams and three waves of change to renovate the governance of its health system, providing space for participation among a diversity of stakeholders (Government of Manitoba 2018). Quebec government took a different approach and focused on issues of transition and transformation after having adopted the legislation that created its new single health authority, Santé Québec, which may mean a more destabilizing effect on the system, specifically in a period of austerity.

Fifth, it appears important to invest in engagement strategies with communities, organizations and patients affected by the change in governance. The creation of health zones and patient or community councils (e.g., Alberta and Nova Scotia) was a way to reassure concerned publics with this major change. Health zones are accountable to the new centralized agencies, but may help to contextualize decisions made to operate the system. Patient or community councils have a consultative role, which may limit their impact on governance reforms (Fierlbeck 2018).

Sixth, one of the most important lessons is to see structural change as a starting point and not as an endpoint. Change in governance implies that people in charge inhabit the new structure differently than before. Early reports from Alberta's quality councils and by the auditor general in 2012 (Denis et al. 2023) and analysis by Fierlbeck (2018) on the case of Nova Scotia underlined the persistence of policy or managerial culture that may limit the ability of these new agencies to achieve their goals. To support changes in policy and managerial cultures, the ministry of health may choose to allocate resources to these new governing agencies through a broad and limited number of envelopes with clear indications for accountability in exchange for more operational flexibility. This was the case for AHS before the recent reorganization.

Seventh, the domain covered by the new governing authorities will influence its ability to produce results. For example, the non or insufficient incorporation of primary care, and more specifically, physicians within the new agency, may limit the ability to integrate care and services. Agencies such as Nova Scotia Health (NSH) and AHS have a portal to support patients in their knowledge of available resources and in accessing primary care providers. NSH operates a department of primary care, and Ontario Health has a vice-presidency of primary care and person-centred measurement. The ministry of health in each jurisdiction that has engaged in reforms of governance has kept its role as negotiator of the collective agreement that determines the working conditions of physicians.

In summary, based on these recent experiences, it appears that reforming the governance of health systems in Canada is a demanding task. The risk that governments (ministries of health or departments) did not change their governing roles and practices is present. For jurisdictions that have opted for a more radical change in governance, the risk that organizations and providers pay more attention to adapting the new governing structure rather than to programmatic efforts to improve the system is also present. In many jurisdictions such as Nova Scotia, Quebec and recent reform in Alberta, a key trigger for governance reform was around human resources issues and the perceived need to reduce the number of bargaining units in the system and, to a certain extent, to reduce the power of unions and professional associations (Church and Smith 2024; Fierlbeck 2018). The impact of new governing agencies on the health human resources situation, considering current workforce shortages, remains an important question.

From these experiences, it appears that the process of bringing changes in governance may be eased by systematic planning of the transformation and transition, some sense of continuity between reforms and past initiatives to improve care and services and a clear focus on clinical outcomes and health improvement. While intuitively the scale of the system may play a role in choosing a governance model, Newfoundland and Labrador and Quebec opt for a similar model, and Ontario and Manitoba opt for a less concentrated one. The scale and complexity of a health system may be an important dimension to consider when engaging in reforms of governance. For larger systems (e.g., Ontario and Quebec), it may be even more important to rely on a model of governance that recognizes an important role for regions or zones.

We suggested previously that the impact of governance reforms will largely depend on how influential actors and a diversity of publics (patients, communities, NGOs, citizens) will inhabit these new structures. In the next section, we will look at some scholarly works and grey literature on health system improvement to identify some additional elements to consider for the implementation of governance reforms.

II: Reform of Governance as a Large-Scale Improvement Strategy

As I argued earlier, reforms of governance observed in many provinces are not a good or bad idea; they carry uncertain benefits, which is a trait of structural changes. Real reforms (Denis and Forest 2012) of governance are more about the development of new relations among the components of a system and new practices than about structural changes. The new governing agencies, the more and less concentrated ones, will achieve their goals by intervening at a distance within the delivery side of the health system (Denis and Usher 2016).

Two approaches to governance can be a source of inspiration for these new governing agencies. The experimentalist approach (Sabel and Zeitlin 2012) proposes that governance is about goal setting established with concerned actors that are located centrally and locally within a system. These goals must be revised according to experience to ensure that their pursuit is contributive. The Scottish National Health Service used a mix of experimentalist and hierarchist approaches to target setting, implementation and accountability for the improvement of their health system (Schang and Morton 2017). In a domain characterized by uncertainties regarding means and ends relationships, such as in the care for older people, the Scottish National Health Service relied more on an experimentalist approach. In the context of high certainty, such as the prevention of infections, they have adopted a more hierarchical approach. Closer to us, the adaptation of the Ontario Health performance indicators and metrics by the different organizations in the system appears similar to an experimentalist approach. According to this approach, organizations and providers are given autonomy and discretion to achieve these shared goals. In exchange for this autonomy, they must report periodically on their progress in achieving them and demonstrate efforts in developing strategies to improve their performance. Finally, indicators and metrics are collectively and periodically revised to ensure that they focus on important dimensions for patients and citizens. In summary, from an experimentalist standpoint, governance is a dynamic intervention on a system that depends on the quality of relationships between governors, organizations and providers, the ability to dialogue and share views and a common understanding of expectations, accountability and reporting requirements.

While the experimentalist perspective insisted on moving away from a predominantly hierarchical model of governance, the second perspective focuses on the roles of tools in governing the system (Salamon 2000). According to this perspective, the capacity of governors to achieve their goals depends largely on the relevance and sophistication of the tools they select for that purpose. Barbazza and Tello (2014) did a review of governance tools in the health system. Hierarchical authority is only one example of many tools in the hands of governors to improve the health system. For example, performance-based contracts as found in accountable care organizations and pay-for-performance as implemented for various sectors of care in the NHS-England are examples of governance tools to strengthen accountability of providers or organizations. Information systems and common workforce training can be used to enhance collaboration and integration of care. Standards and accreditation processes can be used to support quality improvement within the health system. The message here is that a variety of tools can be used by governors to influence providers and organizations according to the broad system's goals.

In the past 25 years, attention has been paid to the attributes of high-performing health systems. High-performing health systems are entities that pursue systematically and deliberately goals that are summarized by the quintuple aims, namely, improving patient experience, patient outcomes, provider experience and health equity at lower costs. These works provide a repertoire of tools for governors to intervene within the systems and achieve better results (e.g., Ahluwalia et al. 2017; Baker and Axler 2015; Baker et al. 2008, 2011, 2016; Bates et al. 2008; Blumenthal et al. 2024; Bohmer 2011; Levesque and Sutherland 2017; Mannion et al. 2005; Molloy et al. 2016; Smith et al. 2023). The objective here is to open the black box of health and social care delivery (Denis and Usher 2016) by looking at tools to support continuous improvement.

Works on high-performing health systems were highly diffused among the health policy and health management communities, and there is no need to go into details here. They suggest that governors increase their chance of improving the health system if they rely on context and, in a coherent way, on a diversity of tools. No single lever, be it pay-for-performance or training, will be sufficient to face the challenges of improving health systems.

These works underlined the importance of the vision promoted by governors to steer the system. A distinction is made here between a population health vision of the health system and one that is strictly centred on the production of care and services (Buck et al. 2018). For example, the efforts made by the Montefiore health system in New York to promote a vision based on a recognition of the social determinants of health within the delivery of care and services (Collins 2018). The availability of adequate information infrastructure and data analytics to support the delivery of care and services also play a crucial role for system improvement. The Gesinger health system in the US, with the development of ProvenCare, is often mentioned as a good example of how information can support care improvement (Davis et al. 2021). Brach (2017) uses the notion of health literacy to explore how health systems develop people's capacities to navigate the system and use information and services to manage their own health.

The promotion of organizational norms and strategies that focus on improvement and the quality of patient and provider experiences by the senior leadership of these new agencies appears fundamental to minimizing governing by crisis or in reactions to short-term events and media coverage. In their study of high-performing health systems, Baker et al. (2008) insisted on the importance for organizations to develop buffers that protect them from pressures of the moment while staying agile to manage the unexpected. Allocation of resources and incentives in line with broad improvement goals also appears crucial to support the work of providers and organizations. However, it is important to note that financial incentives would probably not be the main driver of improvement (Hurley and Li 2015).

Leadership capacities, as in any major policy changes, play a crucial role in the development and operations of these centralized health authorities. By leadership capacities, we mean having within the new agency people in leadership roles (formal and informal) that incorporate the diversity of expertise and influence that are required to face current and future challenges in a comprehensive way. Concretely, it is important that the leadership configuration of the governing authorities incorporate a mix of clinical and managerial leaders and representatives of a diversity of groups that play a crucial role in renovating the governance of the health system. Leadership here is both evidence-informed and relational. Emphasis on the relational dimension of governance suggests that the role of core leaders (or governors) is similar to that of an orchestrator. Adapted from the work of Lusiani and Langley (2019), orchestrators enable the production of coherence across the diversity of actors and tools to govern the health system. To do so, they work at negotiating a shared vision among members of the governing agencies around priority objectives and approaches to achieve them. They also mobilized key players within the delivery side of the system to frame and share priorities and approaches to improvement. In this process, they pay attention to how specific tools help create connections among providers and organizations within the health system. For example, the sharing of information on care pathways and clinical outcomes helps generate conversations on improvement strategies. Orchestrators intervene to channel the expertise and influence of a wide variety of players while leaving, at the same time, space for reformulation and negotiations (Hurmelinna-Laukkanen and Nätti 2018).

Going back to the experimentalist approach to governance, it becomes clear through this article that leadership is de facto collective and distributed in the sense that it is based on a strong complementarity between policy, managerial and clinical leaders in collaboration with concerned publics such as payors, patients and citizens. Tools to govern the system are focusing as much on process as on substantive goals or outcomes. For example, contemporary emphasis on co-production or co-creation as a tool to support the joint development of innovative policies and increase their acceptability fits nicely with an experimentalist approach to governance (Voorberg et al. 2015).

While these agencies have been created with the hope that they will minimize politicization, in the sense of undue interferences by governments in the day-to-day functioning of the system, the health system is by essence pluralistic, and commands deliberate strategies to orchestrate a wide diversity of views, priorities, values and interests that necessarily co-exist. One must hope that these new agencies will not only strive to harvest low-hanging fruit but will also address difficult questions such as how to rebalance the system and the allocation of resources to reduce demands in the mid and long term, to minimize wasted care and to make space for new voices (patients, caregivers and citizens) in policy making. Attention to reducing health inequality does not only depend on the work done by these agencies, but they can reposition their stewardship of the system toward producing more health and not only producing more care.

There is no magic recipe, and governing health systems is a matter of judgement and insights in context. However, based on these works on high-performing health systems and contemporary approaches of governance, we suggest the following guidance to increase the impact of these agencies:

1. A configuration of tools used strategically and with a clear view of the objectives pursued is fundamental. Governing health systems implies pursuing simultaneously a wide range of objectives through a diversity of tools such as incentives, capacity development and implementation of new roles and practices for health system improvement.
2. A growing interest in incentives (monetary and nonmonetary) may help, but with an awareness that incentives are an enabler and must act in synergy with other tools.
3. Mechanisms for improvement are embedded in the reasoning and behaviours of people who make decisions and intervene in the day-to-day life of a health system. Works on high-performing clinical units underlined the importance of co-location of a diversity of professionals working in a team that has access to information on their performance and benefits from a learning culture that is aligned with care improvement.
4. Health systems have persisting vulnerabilities and need innovations, including in terms of tools to steer the system. Experimentations and co-production that help to develop and test new strategies for improvement appear essential to better equip the health systems to face demands and challenges. For the sake of illustration, examples of co-production in social care can be found on the site of the Social Care Institute for Excellence (Social Care Institute for Excellence 2025).
5. Predefined goals, priority settings and transparencies in showing and arguing around goal achievement must be further developed to avoid governing behind the curtain. While the benefits of public reporting of performance data are not clearly established in the academic literature, works on governance suggest that shared improvement goals, the capacity to monitor goals' achievement and to adjust them according to evolving challenges and opportunities can contribute to higher adaptation and performance.
6. Leadership capacities for large-scale improvement imply that leaders of governing agencies are knowledgeable of research-informed evidence and sensitive to the importance of nurturing collective and distributed leadership across the system. It is important that the leadership of these new agencies incorporate in its leadership policy, managerial and clinical expertise and the voices of patients, citizens and more marginalized groups to face the challenges of improving at scale health systems.

Conclusion

The years to come will tell us if it was a good idea to move away from regionalization and devolution and reap off benefits of these reforms for payers, citizens and patients. I also suggested that structural change is a starting point and not an end one. Reorganizing the system may have potential, but there is no guarantee of benefits. I argue that despite the situation of limited research-informed evidence on the impact of these governance reforms, available knowledge on health system improvement and on governance approaches and tools is of great importance to theoretically assess the potential of these reforms. This knowledge helps in understanding how governors can inhabit these new agencies and potentially have a high impact on the system.

To assess the potential of these new agencies, I suggest paying attention to the following questions: Are governors and these agencies in a better position than before to design and implement large-scale improvement strategies? Do governors and these agencies have required capacities, including in terms of access to and mobilization of tools, to design and implement large-scale improvement strategies? Are governors and these agencies in a better position to innovate and transcend persisting vulnerabilities within our health systems? Does the creation of these agencies help to clarify the roles of the different players involved in the governance and improvement of the health system? Answers to these questions are empirical and depend on context, timing, capacities, institutional rules and predominant cultures within a given jurisdiction and health system.

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