Academic Health Sciences Centres (AHSCs) are an enduring feature of health systems in all developed countries. In Canada, despite the lack of precise definition and standardized organizational arrangements, the educational services and programs in health sciences offered by AHSCs, and the caregiving organizations they embrace, are critical components of the national health system. Yet, the past decade has been a period of profound change in the Canadian health system. The pace of this change and the nature of the demands on the system are unlikely to abate in the near future. Given that many of these changes have directly impacted on AHSCs, or their component parts, it is timely to review these entities and to understand more fully how these organizations have been, or may be, affected in the future.

This paper identifies many of the unique attributes of AHSCs that have arisen from their threefold mission of patient care, teaching and research. The authors describe many of the most critical issues confronting AHSCs in the current era: diminishing financial support;increasing demands on the system, with little prospect of new resources; new forms of care delivery such as regional models; alternative plans for physician compensation; and new models for research funding.

The paper also examines AHSCs' interactions with organizations outside the traditional axis of health sciences faculties and related caregiving organizations. The authors point to the changing relationship between AHSCs and their parent universities as a critical element for redefinition. The mutual lack of comprehension within AHSCs and government concerning their roles and responsibilities is discussed, and new models of interaction are proposed. Given the national nature of the role of AHSCs, a closer relationship between the federal government and AHSCs is described. Dynamic changes in the traditional role of AHSCs in patient care are explored. The rapid expansion and dispersion of new technologies, the expensive nature of care, and the incongruence between specialization and the need to provide all services for educational purposes is seen as both a constraint and a threat to AHSCs. In the matter of education, the fundamental instability of offering a diverse range of educational programs without secure and understandable funding is explained, while also highlighting the potential changes that could arise from Alternative Payment Plans (APPs).

AHSCs are an excellent example of the enduring nature of relationships founded on shared purposes and goals. As organizational entities, AHSCs fail the most basic tests for accountability and transparency, since they are often too complex and loose to be described fully - even by those who are leading them. Yet, the authors contend that continued support and improved organizational understanding are essential to the vitality of the future of the Canadian healthcare system. AHSCs are here to stay, but changes are needed to ensure that they improve on the delivery of the key processes of research, care and education that rest at the heart of their social contract.

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