The role of leaders in implementing health reforms

Health reforms offer a revelatory context for exploring the enactment of political and policy leadership. We examine situations of reform in a publicly funded health system to understand how political and policy leaders navigate the highly institutional and plural healthcare environment and mobilize ideas, policy instruments and relationships to promote change. The exploration is informed by empirical data collected as part of a major study of reforms in seven Canadian provinces since 2000. We provide two examples (vignettes), looking at how leadership is enacted to achieve reforms around primary care and quality improvement in different provinces. The vignettes underline the importance of distal and proximal context - namely reformative ideologies like managerialism, and the role of influential groups such as the medical profession - as shapers of the trajectories of both political and policy leadership and of reforms. We find that political and policy leaders rely most often on soft instruments to achieve stakeholder buy-in and cannot easily impose a reformative agenda.