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It is valuable to reflect on what progress the federal, provincial and territorial governments have made on implementing the Advisory Panel on Healthcare Innovation Report's recommendations. The recommendations offered by Manns et al. (2025) are a good starting point but are too modest. New entities need assurances of independence from federal, provincial and territorial governments; scale system interventions; ability to influence provincial and territorial health system funding policies including physician remuneration models; and capacity to integrate with regional priorities. To pursue the sought innovations, political will for reforming the structure of pan-Canadian healthcare organizations is needed.

Ten years ago, the Advisory Panel on Healthcare Innovation, chaired by C. David Naylor, gave its prescription to strengthen Canada's healthcare systems. Unfortunately, the report fell victim to politics and shifting government priorities. This commentary argues that key barriers to healthcare improvement in Canada - particularly siloed structures that prevent collaboration, a lack of political will to challenge the status quo and a myopic federalism paradigm - continue to bedevil Canada's health systems, and that the recommendations of the Naylor panel, particularly the proposed healthcare innovation fund and federal healthcare innovation agency, are as relevant today as they were in 2015.

In December 2024, Santé Québec (SQ), a province-wide agency overseeing health and social services delivery, was launched. Denis's essay offers an insightful and valuable lens to analyze the reform's underlying assumptions and to reflect on the opportunities and challenges ahead. SQ aims to separate policy making and planning from service delivery, a distinction that may prove difficult in practice. Moreover, the infrastructure for meaningful decentralization might be lacking, given Quebec's health system legacy of extensive structural integration. Nonetheless, existing assets - such as health regions, population-based responsibility and local health and social services networks - could prove to be valuable tools for stakeholder engagement and innovation.

Health governance is political as it is tied to goals specific to individual health systems. The best health governance is context-specific. Health governance is a collective practice that involves stakeholders across levels and sectors. The universality of health governance offers great opportunities for learning across jurisdictions. The view across borders is best at inspiring self-reflection about what is good enough health governance in one's health system. Health governance affords political and administrative crafts(wo)manship, drawing on in-depth knowledge of one's health system, excelling at collaboration and being open to experiences from other jurisdictions as a tool of self-reflection.

Analysis of any healthcare reform is complex and multi-faceted. Given the hierarchical levels in health systems (regarding funding and accountability, etc.), a key analytical dimension is between decentralization and centralization. Reforms can be justified on either, often for the same criteria (such as equity or economy). The impact of decentralization/centralization can be assessed by determining "what" is being (de)centralized and from/to whom. This article appraises the analysis of Canadian healthcare reform by Denis, in terms of the TAPIC (Transparency, Accountability, Participation, Integrity and Capability) and decision space frameworks. It draws attention to the importance of incentives, context and implementation in this (and other) reform program.

The governance of healthcare systems is inherently complex and often leads to recurring debates about the advantages and pitfalls of centralization and decentralization to address politicization in healthcare. The international experience provides insights to reflect on the analysis of the recent reforms in the Canadian context, such as the one by Jean-Louis Denis. In this commentary, we argue that creating massive structures to shield operational management from political interference generates challenges related to the multilevel nature of decision making and the re-creation of siloes. Hybrid approaches may provide checks and balances and achieve the objectives of both centralization and devolution.

This commentary builds on Jean-Louis Denis' comprehensive review of the Canadian health governance literature to explore three interpretations of its function: as an analytical tool, a guide for structural reform and a symbolic or divinatory discourse. While the built-in flexibility of the concept of governance enables cross-provincial comparisons in structurally diverse systems, its high level of abstraction risks diluting its practical value. As a guide for reform, the literature struggles to offer cumulative, actionable knowledge. The commentary then examines the possibility that governance discourses serve more to legitimize political decisions than to inform them, functioning rhetorically rather than empirically.

Over the last several decades, Alberta has led Canadian provinces in waves of healthcare system reform: first to regionalize, first to replace regions with a province-wide health authority and, in 2024, first to blow up such an authority for a new combination of functionally based organizations. Yet behind the flux in organizational forms lies a consistent set of storylines. On the surface, reforms have continually tried to find ways to facilitate the transfer of resources from the acute care sector to other components of the health system. Less openly, changes from the Klein government onward appear to be intended to facilitate greater political control over health bureaucrats and professionals, and to pave the way for an expanded private sector role.

This paper links the "provisional learnings" outlined in Denis's lead article to the results of a mixed-methods study of the state of rural healthcare in Saskatchewan to examine the manner by which the province centralized health system governance in 2017. While the study has limitations that preclude any hard and fast conclusions about those changes, there is evidence to suggest that the reforms were undertaken with insufficient attention to the particularities of rural healthcare organization and delivery. Amalgamation is not the sole cause of Saskatchewan's current crisis in rural healthcare, but the way it was implemented (with little consultation with rural communities, without clear goals and without sufficient planning in advance) may have exacerbated an already worsening situation.

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.