The model proposed by Gardner, Fierlbeck and Levy offers an innovative and compelling framework for moving past the dysfunction of the current intergovernmental relationship in health. It provides a viable role for the federal government and a means to shift our attention on improving health outcomes relative to past provincial performance. At the same time there are important questions about how both federal leadership and population health is understood and justified within the model. The history of federal leadership in health reform is questioned as to both its necessity and its effectiveness. One must also confront the possibility that federal disengagement from contentious intergovernmental issues may be emerging as a more permanent feature of federal–provincial relations in Canada. For the focus on population health to be effective, it must, in the first instance, take into account the necessity of focussing population health interventions for the most marginalized populations and the need to focus those interventions on the socio-economic determinants of health that exist outside of the healthcare system.
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