Devolution--a solution for Ontario: could the lone wolf lead the pack?

In response to what we describe as the "accountability gap" in healthcare, nine provinces have embraced the devolution of management responsibility and authority from central government administrations to regional health authorities. Ontario, Canada's most populous province, is the lone wolf. This commentary focuses on the consequences of Ontario's reluctance to adopt devolution. The authors argue that devolution is an important first step in improving the lines of accountability within publicly funded healthcare; however, as a reform initiative, devolution must form part of a series of interlocking initiatives. These complementary reforms include refocusing the debate from funding (money) to governance, clarifying the governance roles of both the federal and provincial governments and developing an incentive- and information-based system that is geared more to rewarding gains in healthcare outcomes as opposed to the delivery of health services. With a new government in Ontario, there is now a window of opportunity to capitalize on the experiences and failures of other provinces and for Ontario to emerge as the leader of the pack, rather than the lone wolf.