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BACKGROUND: There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers' interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry-a balance that is essential to HiAP governance. METHOD: We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada. RESULTS: In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature. CONCLUSIONS: We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments.

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Recent work on health system strengthening suggests that a combination of leadership and policy capacity is essential to achieve transformation and improvement. Policy capacity and leadership are mutually constitutive but difficult to assemble in a coherent and consistent way. Our paper relies on the nested model of policy capacity to empirically explore how health reformers in seven Canadian provinces address the question of policy capacity. More specifically, we look at emerging representations of policy capacity within the context of health reforms between 1990 and 2020. Based on the exploration of the scientific and grey literature (legislation, annual reports of Ministries, agencies and organizations, meeting minutes, press, etc.) and interviews with key informants (n = 54), we identify how policy capacity is considered and framed within health reforms A series of core dilemmas emerge from attempts by each province to develop policy capacity for and through health reforms.

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In publicly funded health systems, reform efforts have proliferated to adapt to increasingly complex demands. In Canada, prior research (Lazar et al., 2013, Paradigm Freeze: Why is it so Hard to Reform Health Care in Canada?, McGill-Queen's Press) found that reforms at the end of the 20th century failed to change the fundamentals of the Canadian system based on physician independence and assured universal coverage only for medical and hospital services. This paper focuses on reforms since the turn of the millennium to explore the transformative capacities developed in seven provinces within this system architecture. Longitudinal case studies, based on scientific and grey literature, and interviews with key informants, trace the patterns of reform in each province and reveal five objectives that, to varying degrees, preoccupied reformers: (1) address chronic disease, (2) align health system actors with provincial objectives, (3) shift from hospital to community-based care, (4) integrate physicians, and (5) develop improvement capacities. The range of strategies adopted to achieve these objectives in different provinces is compared to identify emerging pathways of reform and extract lessons for future reformers. We find significant cross-learning between provinces, but also note an emergent dimension to reforms, where multiple strategies aggregate through time to create unique patterns, presenting their own set of possibilities and limitations for the future.

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BACKGROUND: Implementing research findings into healthcare policy is an enduring challenge made even more difficult when policies must be developed and implemented with the help and support of multiple ideas, agendas and actors taking part in determinants of health. Only looking at mechanisms to feed policy-makers with evidence or to interest researchers in the policy process will simply bring partial clues; implementing evidence-based policy also requires organisations to lead and to partner in the production and intake of scientific evidence from academics and practical evidence from one another. MAIN BODY: This Commentary argues for the need to better understand the capacities required by organisations to foster evidence-based policy in a dispersed environment. It proposes a framework of 11 brokering capacities for organisations involved in evidence-based policy. Eight of these capacities are informed by streams of research related to the roles of knowledge broker, innovation broker and policy broker. Three complementary brokering capacities are informed by our experience studying real-life evidence-based policies; these are capturing boundary knowledge, trending know-how on scientific and practical evidence-based policy, and conveying evidence outward. CONCLUSIONS: Previous guidelines on brokering capacities focused on the individual level more than on the organisational level. Beyond the individual capacities of managers, designers and implementers of new policies, there is a need to identify and assess the brokering capacities of organisations involved in evidence-based policy. The three specific organisational brokering capacities for evidence-based policy that we present offer a means for policy-makers and policy designers to reflect upon favourable environments for evidence-based policy. These capacities could also help administrators and implementation scholars to think about and develop measurements to assess the quality and readiness of organisations involved in evidence-based policy design.

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OBJECTIVE: To compare the conceptualization of performance underlying different accreditation manuals. DATA SOURCES: Accreditation manuals were selected from the 2003 WHO report titled 'Quality and Accreditation in Healthcare Services'. We used manuals from WHO-listed countries that most influenced the standards: Canada, France, the USA and Australia. The fifth manual is published by the Pan American Health Organization (PAHO). EXTRACTION METHODS: Standards from each manual were classified by two independent reviewers. The coding grid, which was based on a Parsonian-based integrative framework on performance, was composed of performance dimensions and their interlinks/alignments. PRINCIPAL FINDINGS: The four dimensions of quality, goal-attainment, adaptation to the external environment and values, along with their alignments, were given differing levels of importance in the five manuals. The Australian manual emphasizes all four dimensions and their alignments. The PAHO accreditation focuses mainly on quality. The manuals from Canada, France and the USA fall somewhere between the two accreditation extremes of complete versus one-dimensional. Finally, we present a taxonomy of the conceptualization of performance in accreditation manuals that distinguishes between quality-oriented and alignment-oriented accreditation manuals. CONCLUSIONS: Specific conceptualizations of performance underlying accreditation manuals may not be neutral. Perhaps, more normative accreditation manuals are associated with authoritative management styles, or more balanced accreditation manuals with comprehensive management styles. Our comparative analysis is a first step toward better understanding the relationship between the conceptualization of performance and the management style adopted in a particular healthcare organization. This relationship could help explain the variation observed in healthcare organization performance.

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