This issue of HealthcarePapers tackles the challenging question about how to strengthen health system governance in Canada and helps to make sense of the wave of structural reforms underway across the country. The lead essay and commentaries in this issue provide the much-needed empirical and experiential evidence on the intended and unintended effects of reforms to governance, with a focus on the recent wave of centralization of regional authorities across provinces. This issue provides the necessary tools for health system leaders to maximize the potential of these new governing agencies.

Introduction

How Canada's health systems are governed is not usually at the top of our minds for patients, providers or system managers. Yet, each plays a role in governance, contributing in various ways to shaping and reforming the health system toward improved performance. One way to understand governance is through its functions: these include setting goals and targets for the system, formulating policy actions, designing or revising regulations, fostering collaboration with diverse stakeholders and supporting accountability relationships between payers, providers and the public. We can also understand governance by asking the question – who holds decision-making authority and for which parts of the system?

Over the past 20 years, Canada has experienced a myriad of system reforms that have affected governance functions and the locus of authority. The trend that has been referred to as “regionalization reversal” (Marchildon 2008) across several provinces raises questions about whether these changes had their intended effects of health system performance improvements, and why or why not?

These are the questions that motivated this special issue, and that were addressed by Jean-Louis Denis (2025a) in his aptly titled lead essay, “The Big Swing: Reforming Governance Authorities in Canadian Health Systems.” Denis (2025a) describes the periods of “enchantment and disenchantment” with recent policy changes that have, to various degrees, shifted the locus of authority from government to regions to province-wide agencies. He synthesizes the existing evidence to distill the key lessons learned from these policy changes, including the need to mitigate the risks of destabilization that can come with structural reforms. He draws on these local experiences along with the international literature on modes of governance and high-performing health systems to propose six recommendations for maximizing the benefits of these governance reforms.

The lead essay served as a springboard for nine local and international experts and thought leaders to reflect on the theoretical and practical implications of reforms to governance. The need for empirical examination of the impacts of these reforms is emphasized by Exworthy and Mannion (2025): they share useful tools and frameworks, including “TAPIC” (Transparency, Accountability, Participation, Integrity and Capacity) as an assessment tool (Greer et al. 2019) and the decision space analysis framework to help understand the level of authority held by new agencies, and for which domains, central control is maintained. Contandriopoulos (2025) also speaks about the need for conceptual clarity and empirical examination of governance reforms to inform versus legitimize decisions.

International Perspectives

Other commentaries from abroad share insights from what Levesque (2025) describes as the “hybrid” system of governance in the Australian state of New South Wales that combines local authority over hospital and community care (Local Health Districts) with centralized oversight at the state level and other functions such as digital infrastructure. Burau (2025) underlines the political and context-sensitive nature of health system governance, meaning policy learning across jurisdictions, even similar contexts to Canada, such as the decentralized tax-funded system of Denmark, needs to be done cautiously, considering the historical evolution of the system, and, importantly, the role and power of key stakeholders.

Provincial Governance Reforms

Provinces such as Saskatchewan have had several years of experience with their reformed governance structure, and the commentary by McIntosh et al. (2025) summarizes the results from their major evaluation of the impacts of this reform on rural communities. Their paper highlights the destabilizing effects of system change and the negative impacts on health workers and access to care in rural Saskatchewan.

Other provinces such as Quebec and Alberta are in the early implementation stage of large-scale health systems reforms. Notably, this includes the recent shift toward a sector-based approach to governance in Alberta after decades of attempts to integrate these sectors through a single province-wide agency. Smith and Church (2025) provide an insightful perspective on these reforms in Alberta, underscoring the importance of looking beyond the stated aims to uncover implicit aims, including increasing political control and facilitating increased private sector activity.

Similarly, in Quebec, Martin (2025) places the latest reform – establishing Santé Québec in 2024 – in the timeline of past major system reforms that have progressively shifted the locus of authority toward the centre. Martin emphasizes the need to strike a balance between central authority and local autonomy for innovation and experimentation, stakeholder engagement and population health planning.

Looking Forward

Kuluski et al. (2025) draw on their expertise in patient and public engagement in system reform and performance improvement to lay out some key recommendations for maximizing the potential of these new governance models, including the need for ongoing learning and adaptability through engagement and co-design, and to prioritize integration efforts.

Marchildon (2025) places the current wave of reforms in their historical context, and draws attention to the major and consistent gap in provincial health systems governance reforms – that provincial or regional authorities do not have authority for physician payments. Moreover, he cautions against further structural reforms, since, as also mentioned by others, this risks further destabilizing the system and distracting from pressing issues such as the crisis in primary care.

This collection of papers will leave readers well informed about the reforms under way, the benefits and pitfalls of structural system reforms and the necessary questions to ask ourselves and collaborators in our various roles in health systems governance.

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