Health system reforms in mature welfare states: tales from the north

Jean-Louis Denis, Susan Usher, Johanne Preval, Élizabeth Côté-Boileau


Objective: This article has the objective show an essay on emerging themes in health system reforms, based on experience in Canada. Data synthesis: Reforms are the privileged mode of social change used by modern democratic societies. Persistent dysfunction and failure to adapt to emerging health needs and priorities within health systems in Canada provide a strong policy rationale to search for alternative strategies that might produce much-needed reforms. Three persistent challenges and opportunities for reform in Canadian health systems are discussed: the design of effective governance arrangements, the large-scale development and implementation of improvement and transformative capacities, and the leadership and engagement of the medical profession in working toward broad system goals. In exploring these challenges, we identify tensions that seem relevant to better understanding health system reform in mature welfare states. Conclusion: Addressing these tensions will require both a reinforcement of state and government capacities and stronger capacities at all levels of the health system to design and support change.


Health Systems; Health Care Reform; Health and Welfare Planning.

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Lazar H, Forest PG, Church J, Lavis JN, editors. Paradigm freeze: why it is so hard to reform health care in Canada. Toronto: McGill-Queen's Press-MQUP; 2013.

Canadian Institute for Health Information. How Canada compares internationally: a health spending perspective, 2017: International Chartbook [Internet]. 2017; [2018 Jan 12]. Disponível em:

Noreau P, Laborier P, Rocher G, Rioux M. Les réformes en santé et en justice. Le droit et la gouvernance. Québec: Les Presses de l'Université Laval; 2008.

Pollitt C, Bouckaert G. Continuity and change in public policy and management. Cheltenham: Edward Elgar Publishing; 2011.

Jenkins JC, Brents BG. Social protest, hegemonic competition, and social reform: a political struggle interpretation of the origins of the American welfare state. Am Sociol Rev. 1989;1:891-909.

Davies PS, Favreault MM. Interactions between social security reform and the supplemental security income program for the aged. Washington: The Urban Institute; 2003.

Howlett M. Governance modes, policy regimes and operational plans: A multi-level nested model of policy instrument choice and policy design. Policy Sciences. 2009;42(1):73-89.

Canadian Institute for Health Information. Physicians in Canada, 2016 [Internet]. 2017 [cited 2018 Jan 12]. Available from:

Maynard A. Health care rationing: doing it better in public and private health care systems. J Health Polit Policy Law. 2013;38(6):1103-27.

Lewis S. A System in name only--access, variation, and reform in Canada’s provinces. N Engl J Med. 2015;372(6):497-500.

Health Council of Canada. Fixing the foundation: an update on primary health care and home care renewal in Canada. Toronto: Health Council; 2008.

Health Council of Canada. Progress timeline 2003 – 2013: highlights of health care reform [Internet]. 2014 [cited 2018 Jan 12]. Available from:

Schoen C, Osborn R. The commonwealth fund 2010 international health policy survey in eleven countries. London: Commonwealth Fund; 2010.

Nasmith L, Ballem P, Baxter R, Bergman H, Colin-Thomé D, Herbert C; et al. Transforming care for Canadians with chronic health conditions: put people first, expect the best, manage for results. Ottawa (ON): Canadian Academy of Health Sciences; 2010.

Denis JL, Davies HT, Ferlie E, Fitzgerald L, McManus A. Assessing initiatives to transform healthcare systems: lessons for the Canadian healthcare system. Ottawa: Canadian Health Services Research Foundation; 2011.

Pierre-Gerlier F, Martin D. ‘Fit for Purpose: findings and recommendations of the external review of the Pan-Canadian Health Organizations’. Ottawa: Health Canada; 2018.

Saltman RB, Cahn Z. The financial crisis means that Europe will need to look beyond the public sector to provide its healthcare needs. LSE European Politics and Policy (EUROPP); 2013.

Coiera E. Why system inertia makes health reform so difficult. BMJ. 2011;342:d3693.

Sinclair DG, Rochon M, Leatt P. Riding the third rail: the story of Ontario's Health Services Restructuring Commission, 1996-2000 [Internet]. 2005 [cited 2018 Jan 15]. Available from:

Saltman RB, Duran A. Governance, government, and the search for new provider models. Int J Health Policy Manag. 2016;5(1):33-42.

Durán A, Saltman RB. Governing public hospitals. In: Kuhlmann E, Blank RB, Bourgeault IL, Wendt C, editors. The Palgrave International Handbook of Healthcare Policy and Governance. London: Palgrave Macmillan; 2015. pp. 443-61.

Denis JL, Usher S. Governance must dive into organizations to make a real difference: comment on “Governance, government, and the search for new provider models”. Int J Health Policy Manag. 2017;6(1):49-51.

Saskatchewan Ministry of Health. Backgrounder: Health Region transformation across Canada [Internet]. 2017; [cited 2018 Jan 10]. Available from:

Lewis S, Kouri D. Regionalization: making sense of the Canadian experience. Healthc Pap. 2004;5(1):12-31.

Hurley J. Regionalization and the allocation of healthcare resources to meet population health needs. Healthcare Papers. 2004;5(1):34-9.

Denis JL, Contandriopoulos D, Beaulieu MD. Regionalization in Canada: a promising heritage to build on. Healthcare Papers. 2004;5(1):40-5.

Osborne SP, editors. The new public governance: emerging perspectives on the theory and practice of public governance. London: Routledge; 2010.

Noseworthy T, Wasylak T, O’Neill B. Strategic clinical networks in Alberta: Structures, processes, and early outcomes. Healthc Manag Forum. 2015;28(6):262-4.

Brault I, Denis JL, Sullivan TJ. Using clinical governance levers to support change in a cancer care reform. J Health Organ Manag. 2015;29(4):482-97.

Batalden M, Batalden P, Margolis P, Seid M, Armstrong G, Opipari-Arrigan L; et al. Coproduction of healthcare service. Qual Saf Health Care. 2016;25:509-17.

Bohmer R. The Instrumental value of medical leadership. London: White Paper - The King’s Fund; 2012.

Nelson EC, Batalden PB, Huber TP, Mohr JJ, Godfrey MM, Headrick LA; et al. Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Patient Saf. 2002;28(9):472-93.

Baker GR, MacIntosh-Murray A, Porcellato C, Dionne L, Stelmacovich K, Born K. High performing healthcare systems: delivering quality by design. Toronto: Longwoods Publishing; 2008.

Chattergoon S, Darling S, Devitt R, Klassen W. Creating and sustaining value: building a culture of continuous improvement. Health Manag Forum. 2014;27(1):5-9.

The Health Foundation. Using clinical communities to improve quality [Internet]. 2013; [cited 2016 March 18]. Available from:

Langley A, Denis JL. Beyond evidence: the micropolitics of improvement. Qual Saf Health Care. 2011;20(Suppl 1):i43-6.

Verma JY, Denis JL, Samis S, Champagne F, O'Neil M. A Collaborative approach to a chronic care problem. Health Pap. 2016;15:19-38.

Alberta Health Services. Strategic Clinical Networks: A primer and working document [Internet]. 2012; [cited 2018 Jan 13]. Available from:

Dyck D. Strategic clinical networks in Alberta. Montreal: Conference of the MUHC-ISAI; 2017.

Marchildon G. Implementing Lean health reforms in Saskatchewan. Health Reform Observer - Observatoire des Réformes de Santé. 2013;1(1).

Adler PS, Borys B. Two types of bureaucracy: enabling and coercive. Adm Sci Q. 1996;41:61-89.

Ferlie E, Gerry Mcgivern, FitzGerald L. A New mode of organizing in health care? governmentality and managed networks in cancer services in England. Soc Sci Med. 2012;74(3):340-7.

Denis JL, Baker R. Medical doctors and health system improvement: synthesis results and propositions for further research. In: Kuhlmann E, Blank RB, Bourgeault IL, Wendt C, editors. The Palgrave International Handbook of Healthcare Policy and Governance. London: Palgrave Macmillan; 2015. pp. 88-103.

Denis JL, Baker GR, Black C, Langley A, Lawless B, Le Blanc D; et al. Exploring the dynamics of physician engagement and leadership for Health System Improvement: prospects for Canadian Healthcare Systems [Internet]. 2013; [cited 2016 Mar 18]. Available from:

Baker GR, Denis JL. Medical leadership in health care systems: from professional authority to organizational leadership. Publ Money Manag. 2011;31(5):355-62.

Dickens P, Fisman S, Grossman K. Evaluation of the Physician leadership development program at Schulich. Canadian Journal of Physician Leadership. 2016;2(3).

Specialist Services Committee. British Columbia. Physician quality improvement initiative [Internet]. 2018; [cited 2018 Feb 02]. Available from:

Hutchison B, Glazier R. Ontario’s primary care reforms have transformed the local care landscape, but a plan is needed for ongoing improvement. Health Aff. 2013;32(4):695-703.

Marchildon GP, Hutchison B. Primary care in Ontario, Canada: new proposals after 15 years of reform. Health Policy. 2016;120(7):732-8.

Wranik D, Katz A. A Typology of pay-for-performance programs in publicly funded primary healthcare systems. Health Syst Policy Res. 2015;2(1):6.

Hutchison B, Lévesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011;89(2):256-88.

Denis JL, van Gestel N. Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Serv Res. 2016;16(Suppl 2):158.

Canadian Nurses Association. Nurse Practitioners: untapped resource [Internet]. 2017; [cited 2018 Feb 03]. Available from:

Canadian Pharmacists Association. Scope of practice [Internet]. 2015; [cited 2018 Feb 02]. Available from:

Canadian Association of Physician Assistants. National report card [Internet]. 2017; [cited 2018 Jan 09]. Available from:

Pollitt C, Bouckaert G. Public management reform. A comparative analysis - Into The Age of Austerity. Oxford: Oxford University Press; 2017.

Bevir M, Waring J, editors. Decentring health policy: learning from British experiences in healthcare governance. London: Routledge; 2017.

Townley B, Cooper DJ, Oakes L. Performance measures and the rationalization of organizations. Organ studies. 2003;24(7):1045-71.

Aucoin P. New political governance in Westminster systems: impartial public administration and management performance at risk. Governance. 2012;25(2):177-99.

Bryson JM, Crosby BC, Bloomberg L. Public value governance: moving beyond traditional public administration and the new public management. Pub Adm Rev. 2014;74(4):445-56.

Hood C. A public management for all seasons? Public Adm. 1991;69(1):3-19.

Osborne D, Gaebler T. Reinventing Government. New York: Taylor Francis; 1992.

Rhodes RAW. Understanding governance: policy networks, governance, reflexivity and accountability. England: Open University Press; 1997.

Forest PG, Denis JL, Brown LD, Helms D. Health Reform Requires Policy Capacity. Int J Health Policy Manag. 2015;4(5):265-66.

Denhardt JV, Denhardt RB. The new public service: serving, not steering. London: Routledge; 2015.

Breton M, Lévesque JF, Pineault R, Lamothe L, Denis JL. Integrating public health into local healthcare governance in Quebec: challenges in combining population and organization perspectives. Healthc Policy. 2009;4(3):e159-78.

Ansell C, Gash A. Collaborative governance in theory and practice. J Public Adm Res Theory. 2008;18(4):543-71.

Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Large‐system transformation in health care: a realist review.Milbank Quarterly. 2012;90(3):421-56.

Wang J, Jacobs P, Ohinmaa A, Dezetter A, Lesage A. Public expenditures for mental health services in Canadian provinces: dépenses publiques pour les services de santé mentale dans les provinces canadiennes. Can J Psychiatry. 2018;63(4):250-6.

Canadian Home Care Association. Better home care in Canada: a national action plan [Internet]. 2016; [cited 2017 Nov 18]. Available from: Accessed at:

Denis JL, Forest PG. Real reform begins within: an organizational approach to health care reform. J Health Polit Policy Law. 2012;37(4):633-45.

Alford R. Health care politics. Chicago: University of Chicago Press; 1975.

Pierson P. Increasing returns, path dependence, and the study of politics. Am Polit Sci Rev. 2000;94(2):251-67.

Naylor D, Francine G, Mintz JM, Fraser N, Jenkins T, Power C; et al. Unleashing innovation: excellent healthcare for Canada : report of the advisory panel on healthcare innovation [Internet]. 2015; [cited 2017 Nov 18]. Available from: Accessed at:

Fitzgerald L, McDermott A. Challenging perspectives on organizational change in health care. New York: Taylor & Francis; 2017.

Herzlinger RE. Why Innovation in Health Care Is so Hard. Harvard Bus Rev. 2006;84(5):58.

Paina L, Peters DH. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy Plan. 2012;27(5):365-73.

Atun R. Health systems, systems thinking and innovation. Health Policy Plan. 2012;27(suppl 4):iv4-8.

Dougherty D. Bridging social constraint and social action to design organizations for innovation. Organ Stud. 2008;29(3):415-34.

Buchanan DA, Fitzgerald L, Ketley D. The sustainability and spread of organizational change: modernizing healthcare. London: Routledge; 2006.

Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581-629.

Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A’Court C; et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res. 2017; 19(11):e367.

Shaw J, Shaw S, Wherton J, Hughes G, Greenhalgh T. Studying scale-up and spread as social practice: theoretical introduction and empirical case study. J Med Internet Res. 2017;19(7):e244.

Van de Ven AH, Polley D, Garud R, Venkataraman S. The Innovation Journey. Oxford: Oxford University Press; 1999.

Kyratsis Y, Ahmad R, Holmes A. Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. Study protocol.Implement Sci.2012;7:22.

Rogers EM. Diffusion of Innovations. New York: MacMillan Publishing Co; 1995.

Edler J. Demand oriented innovation policy. The Theory and practice of innovation policy an international research handbook. Cheltenham: Edward Elgar; 2010.

Thakur R, Hsu, SHY, Fontenot G. Innovation in healthcare: issues and future trends. J Bus Res. 2012;65(4):562-9.

Denis JL, Langley A, Sergi V. Leadership in the Plural. Acad Manag Annals. 2012;6(1):211-83.

Slaghuis SS, Strating MMH, Bal RA, Nieboer AP. A Framework and a measurement instrument for sustainability of work practices in long-term care. BMC Health Serv Res. 2011;11(1):314.

Bekkers VJJM, Edelenbos J, Nederhand J, Steijn AJ, Tummers LG, Voorberg WH. The Social Innovation Perspective in the Public Sector: Co-Creation, Self-Organization and Meta-Governance. New York: Palgrave Macmillan; 2014.

Vries H, Bekkers V, Tummers L. Innovation in the Public Sector: A Systematic review and future research agenda. Public Adm. 2016;94(1):146-66.

Milat AJ, Bauman A, Redman S. Narrative review of models and success factors for scaling up public health interventions. Implement Sci. 2015;10:113.

Knorr Cetina K. Les épistémès de la société: l’enclavement du savoir dans les structures sociales. Sociol Soc. 1998;30(1):39-54.

Feldman MS, Orlikowski WJ. Theorizing practice and practicing theory. Organ Sci. 2011;22(5):1240-53.

Dougherty D. Organizing practices in services: capturing practice-based knowledge for innovation. Strateg Organ. 2004;2(1):35-64.

Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P, Trow M. The new production of knowledge: the dynamics of science and research in contemporary societies. Newbury Park: Sage Publishing; 1994.

Weick KE. Sensemaking in organizations. Newbury Park: Sage Publishing; 1995.

Callon M, Lascoumes P, Barthe Y. Agir dans un monde incertain. Essai sur la démocratie technique. Paris: Le Seuil; 2001.

Nowotny H, Scott P, Gibbons M. Re-thinking science: Knowledge and the public in an age of uncertainty. Cambridge: Polity; 2001.

Cohen WM, Levinthal DA. Absorptive capacity: a new perspective on learning and innovation [Internet]. 2016; [cited 2017 Nov 18]. Available from:

Lane PJ, Lubatkin M. Relative absorptive capacity and interorganizational learning. Strat Mgmt J. 1998;19(5):461-77.

Zahra SA, George G. Absorptive capacity: a review, reconceptualization, and extension. Acad Manage Rev. 2002;27(2):185-203.

Alvesson M. Organizations as rhetoric: knowledge‐intensive firms and the struggle with ambiguity. J Manag Stud. 1993;30(6):997-1015.

Alvesson M. Knowledge work: ambiguity, image and identity. Hum relat. 2001;54(7):863-86.

Friedland R, Alford RR. Bringing society back in: symbols, practices and institutional contradictions. Chicago: University of Chicago Press; 1991.

Clemens ES, Cook JM. Politics and institutionalism: explaining durability and change. Annu Rev Sociol. 1999;25(1), 441-466.

Garud R, Hardy C, Maguire S. Institutional entrepreneurship as embedded agency: an introduction to the special issue. Organ Stud. 2007; 28(7):957-69.

Greenwood R, Suddaby R. Institutional entrepreneurship in mature fields: the big five accounting firms. Acad Manage J. 2006;49(1):27-48.

Lockett A, Currie G, Waring J, Finn R, Martin G. The role of institutional entrepreneurs in reforming healthcare. Soc Sci Med. 2012;74(3):356-63.

Zietsma C, Lawrence TB. Institutional work in the transformation of an organizational field: the interplay of boundary work and practice work. Adm Sci Q. 2010;55(2):189-221.

Grenier C, Denis JL. S’organiser pour innover: espaces d’innovation et transformation des organisations et du champ de l’intervention publique. Rev Politiq Manage Public. 2017;34(3-4):191-206.

Lehoux P, Miller FA, Daudelin G. How does venture capital operate in medical innovation? BMJ Innovations. 2016;2(3):111-7.

Clayton MC, Raynor ME, McDonald R. What is disruptive innovation. In: Interaction Design Fundation. The Encyclopedia of Human-Computer Interaction [Internet]. 2016; [cited 2017 Dec 18]. Available from:

Clayton MC, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Business Rev. 2000;78(5):102-12.

Clayton MC, Overdorf M. Meeting the challenge of disruptive change. Harv Business Rev. 2000;78(2):66-77.

Hwang J, Clayton MC. Disruptive innovation in health care delivery: a framework for business-model innovation. Health Aff. 2008;27(5):1329-35.

Coombs R, Metcalfe JS. Organizing for Innovation: co-ordinating distributed innovation capabilities. In: Foss N, Mahnke V. Competence, governance, and entrepreneurship. Advances in economic strategies research. Oxford: Oxford University Press; 2002

Moore M, Hartley J. Innovations in Governance. Public Manage Rev. 2008;10(1):3-20.

Hartley J. Innovation in governance and public services: past and present. Public Mon Manage. 2005;25(1):27-34.

Friedman CP, Allee NJ, Delaney BC, Flynn AJ, Silverstein JC, Sullivan K; et al. The Science of learning health systems: foundations for a new journal. Learn Health Syst. 2017;1(1).

Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking interactions, the diffusion of innovations in health care. Hum Relat. 2002;55(12):1429-49.

Tuohy CH. Reform and the politics of hybridization in mature health care states. J Health Polit Policy Law. 2012;37:611-32.

Pollitt C, Bouckaert G. Public management reform: a comparative analysis. New York: Oxford University Press; 2004.

Pierson P. The limits of design: explaining institutional origins and change. Governance. 2000;13(4):475-99.

Christens BD. Vehicles of change: context and participation in power-based community organizing [thesis]. Nashville: Vanderbilt University; 2008.

Pollitt C, Bouckaert G. Continuity and change in public policy and management. Cheltenham: Edward Elgar Publishing; 2011.

MacCarthy D, Kallstrom L, Kadlec H, Hollander M. Improving primary care in British Columbia, Canada: evaluation of a peer-to-peer continuing education program for family physicians. BMC Med Educ. 2012;12:110.

Cavers WJ, Tregillus VH, Micco A, Hollander MJ. Transforming family practice in British Columbia: The General Practice Services Committee. Can Fam Physician. 2010;56(12):1318-21.

Closson T. The Goldilocks principle and Canadian healthcare system governance [Internet]. 2014; [cited 2017 Dec 14]. Available from:


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