Beyond Crisis: Rethinking Health System Governance in Canada
About the project
How is the concept of governance used in health policy in Canada? In our project, we mapped the way in which the term “governance” has been used within Canadian health-care discourse over time and across jurisdictions. We trace the frequency of papers on Canadian health governance longitudinally, which provinces are studied and which aspects of governance are addressed in these papers. Governance has at least two quite distinct meanings, although they are often used interchangeably. The first refers simply to how a system is organized and run, while the second is informed by normative judgments and generally addresses qualities a system should ideally exhibit.
Within this context, we focused on stewardship (the act of looking after resources on behalf of the public to serve the public interest over time), accountability (the expectation that public authorities must explain and defend actions taken by virtue of authority delegated to them), integration (the extent to which related functions are coordinated and work to best advantage within a larger system), engagement (bringing in a more comprehensive array of voices), equity (the extent to which all individuals and groups are able to access and enjoy health-related resources), the quality of decision-making (the robustness of the evidence base underlying health-care decision-making), and health outcomes.
To what extent were these concepts reflected in discussions of health policy literature in Canada over time and across jurisdictions? When health-care systems and policies are discussed, how is governance conceptualized?
Key findings
- Our search yielded 151 articles published between 1978 and 2025. The majority were published between 2010 and 2025, with peaks observed in 2004, 2010, 2012, 2014, 2016, 2018–19 and 2023. Twenty (14%) articles addressed Ontario’s health system, 17 (11.9%) addressed Quebec, while the remaining were distributed across other provinces and the Northwest Territories. There were no case studies in New Brunswick, Nunavut or the Yukon. Eighty-six (60.5%) of the papers focused more generally on health system governance in Canada; the remainder focused more narrowly on specific aspects of governance.
- The overarching finding was that discussions of health-care governance in Canada are disjointed, inconsistent and lacking in cohesion. While other jurisdictions are increasingly attempting to articulate how health care ought to be organized and evaluated, Canadian policy literature tends to use governance in broad, descriptive terms or focus narrowly on one aspect of governance. Accountability (76.1%) and stewardship (74.1%) were the aspects of governance most frequently addressed in the literature; patient engagement, though widely studied, was rarely situated within the broader framework of health-care governance.
- Within the wider rubric of governance, regionalization was mentioned to some extent in 96 articles (63.5%). Regionalization papers more frequently discussed stewardship (73.2%) and accountability (75.9%), whereas articles not focused on regionalization more frequently discussed engagement and equity issues.
- Scholars began studying governance structures of regional health authorities (RHAs) shortly after their implementation in the early 1990s. In a sense, RHAs were a key element in focusing health policy literature on the topic of governance, simply because the establishment of RHAs created a clearer distinction between governance as the process of agenda setting and management as the day-to-day work of fulfilling that agenda.
- A major theme in Canadian health-care governance was the relationship between federal, provincial and territorial (FPT) governments regarding health transfers and Canada Health Act (CHA) conditions. Key issues focused on balancing provincial and territorial autonomy with federal accountability as co-funders, and challenging the relevance of the CHA in increasingly digital and pluralistic health systems.
- Another notable theme is the structure and delivery of primary care. Across FPT governments, there is broad consensus on the need to strengthen primary care through system integration, interprofessional teams, and greater accountability of primary care practitioners to funders.
Policy implications
- In Canada, the theoretical discourse on health-care governance is quite limited and focuses more on specific thematic topics rather than larger questions of what kinds of objectives health-care governance ought to address overall. There is very little deliberation regarding more contemporary theoretical governance models such as soft governance, adaptive governance or anticipatory governance in the field of health care. Discussion of health-care governance is very reactive: when a new policy development emerges (such as regionalization), there is a more robust period of debate over governance, but as these models recede, so too does discussion about health-care governance more widely.
- To determine how well a health-care system is working, it is important to be able to identify and apply clear and specific evaluative criteria. This is especially true as provinces begin to experiment with new organizational and regulatory initiatives. To support a rigorous and consistent critique of how (and how well) Canadian health care works, it would be useful to adopt a comprehensive account identifying qualities that define good health-care governance.
- Less is known about health system governance outside of Ontario and Quebec, especially in the Atlantic Provinces, Manitoba, Saskatchewan and the territories. As provincial and territorial governments develop new ways of organizing aspects of their respective health-care systems (such as in primary care, including the development of Indigenous health authorities), it is useful to remain aware of novel initiatives that are undertaken by less-studied jurisdictions.
Contact the researchers
Katherine Fierlbeck, Professor and McCulloch Research Chair, Department of Political Science, Dalhousie University: K.Fierlbeck@Dal.ca
Sara Allin, Director, North American Observatory on Health Systems and Policies; and Associate Professor, Institute of Health Policy, Management and Evaluation, University of Toronto: sara.allin@utoronto.ca
Further information
Read full report (Coming soon)