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Every government that sets out to fix its health system eventually reaches for the same instrument. It centralizes. It consolidates authority, clarifies who is accountable and standardizes how things are done.
The logic is sound and Quebec, like much of Canada, had real reasons to want a clearer line of sight from policy to performance. In 2023, the province passed a law that created Santé Québec, a Crown corporation that further centralized Quebec’s regional health networks, to oversee the day-to-day operations of the province’s health and social service institutions. The move was to make the system run more efficiently.
But centralization solves one problem while quietly creating another. While it can make a system easier to run, it cannot, by itself, make the system better. These are different capabilities and confusing them is the most common way health reforms end up disappointing the people who were promised results.
The remedy is not to abandon central stewardship. It is to pair stewardship with a small number of recognized innovation hubs: bounded, accountable, time-limited environments where new clinical, digital and organizational models are tested in real care settings before they are scaled.
Testing care where it’s delivered
A modern health system improves the way any complex organization does. It tries new approaches in real conditions to learn what works. It discards what doesn’t work and spreads successes. This requires somewhere to do the trying. A government that centralizes without deliberately protecting space for experimentation ends up with a system that is easier to direct but slower to improve.
This matters because health care is a complex adaptive system. Interventions that look obvious on paper collide with workflows, incentives and human behaviour in ways no one can fully predict. A staffing model that succeeds in one hospital fails in another. An algorithm that dazzles in a vendor demonstration behaves differently against messy clinical data. The only reliable way to know whether something works is to test it where care is delivered, measure the result honestly and adjust before going further.
Centralized systems are structurally tempted to skip this step. Under pressure to demonstrate uniformity, they standardize before models are proven. The result is familiar to anyone who has worked inside one: lowest common denominator thinking, in which the safest defensible option is adopted and the system drifts toward mediocrity rather than excellence.
Standardizing a promising idea too early is how you scale its weaknesses along with its strengths. The instinct toward sameness shows even in branding: Quebec’s central agency is replacing the distinct names of the institutions it absorbed with a single uniform label — its own name followed by the region — a small but revealing preference for sameness over the local distinctiveness on which learning depends.
International systems show the way
Quebec isn’t alone in going down this route. In 2022, New Zealand merged its 20 regional health boards into a single national agency, promising economies of scale and clearer accountability. Within two years the new body was running a deficit forecast in the billions, its board had been replaced by a government-appointed commissioner and ministers had concluded that the system was, in their words, too centralized, with too many decisions made by people far from the problems clinicians were trying to solve. The government is now unwinding much of that 2022 reorganization to move planning and budgeting back closer to the front line.
England has arrived at a comparable verdict from the other direction, legislating to abolish the arm’s-length national body that ran its health service for more than a decade and fold it back into the central department. The specifics differ, but the lesson rhymes: large structural reorganizations consume years and money, and the centre cannot manufacture the learning that only happens close to care.
Other systems show a better way. Australia ran a national digital health test-bed program inside live clinical environments. Danish regions treat certain hospitals as embedded living laboratories and scale successful pilots nationally. Singapore’s public-hospital clusters operate as sanctioned testing grounds aligned with ministry priorities. Israel couples strong public stewardship with institutions that test and scale continuously.
In each case the centre kept its authority. What it added was a licensed place to learn and, where these designations were taken seriously, the documented gains were concrete: shorter stays, better co-ordination and real savings, all achieved within public governance rather than around it.
A more disciplined method
A recognized innovation hub is not an exception carved out of the public system, and it is not a step toward privatization. It is a method, and a disciplined one. Its defining features are modest: a clear and time-limited mandate; a scope restricted to innovation; operation within existing budgets; rigorous and independent evaluation; and a duty to share findings so that proven models travel.
A hub is permitted to take measured risks precisely so that the wider system does not have to. It absorbs the cost of failure in one place, cheaply, instead of discovering failure everywhere, expensively. Because the mandate is time-limited, it is also reversible: a hub that does not deliver simply lapses, which is a far less costly way to be wrong than a province-wide rollout that must be unwound.
The alternative is already visible wherever reform has been centralized without this safeguard. A system that can scale but cannot learn becomes a delivery mechanism for untested theory. Decisions rest on what should work rather than on what has been shown to work. Innovation does not stop, but it goes underground, becoming informal, fragmented and undocumented, which is riskier than doing it in the open.
And the people a health system most needs — the clinicians, researchers and digital leaders drawn to places where they can build — begin to leave for jurisdictions that let them. Reform then stalls, not for lack of effort, but for lack of a learning engine.
None of this requires choosing between centralization and decentralization, the tired binary that consumes most health policy debate. A government can hold the centre firmly and still grant a few institutions the structured freedom to experiment on its behalf.
The two are complementary. Strong stewardship decides where the system should go. Innovation hubs work out how to get there without betting the whole system on an untested guess.
Quebecers, like citizens everywhere, are not asking for a particular governance model. They are asking for shorter waits, better access and credible evidence that the system is improving. These results do not flow from the structure of a reform. They flow from a system’s capacity to find what works and spread it.
In a period of fiscal restraint, this capacity is not a luxury; a hub costs little because it works within existing budgets, and it pays for itself the first time it prevents a costly province-wide mistake.
A reform that centralizes authority but neglects to build that capacity will be judged — fairly — on the distance between its promises and what patients actually experience.
The choice in front of us is not whether to centralize. This choice has been made. The real choice is whether a centralized system will give itself permission to learn. Designating a small number of accountable innovation hubs is the most practical and lowest-risk way to do exactly that, and to ensure the reform is judged by the only standard that matters: better care, better value and a system that keeps getting better over time.
