Quebec’s Over-Centralized Health System is a Cautionary Tale

To: Quebec healthcare observers
From: Tingting Zhang
Date: February 17, 2026
Re: Quebec’s Over-Centralized Health System is a Cautionary Tale

Quebec is living a primary-care paradox.

It has more family physicians per capita than most provinces and in the past two decades has spent billions on healthcare reforms and built hundreds of interdisciplinary care teams. Yet today, 26 percent of Quebecers don’t have a regular health care provider – the highest level in the country, bar PEI. About three-quarters of Quebecers report difficulty accessing same-day or next-day appointments and after-hours care. Emergency rooms are overwhelmed,

This isn’t a resource problem. It’s a design failure with important lessons for all provinces.

My recent C.D. Howe Institute Commentary shows that over the past 20 years Quebec has designed and operated primary care centrally – an approach that has failed to improve access over the long term, despite some temporary gains.

In 2002, the province introduced “family medicine groups” as a single organizational template, despite vast differences between Montreal, rural areas and northern communities. Later, it determined where physicians should practice using regional medical workforce plans. Specific medical activities then presumed bureaucrats know the optimal time allocation between hospital and community settings.

Bill 10, adopted in 2015, implied that the most efficient way to deliver goods and services was with hierarchical, top-down management. Later, Bills 20, 83 and 2 escalated coercion of providers with quotas, penalties and practice restrictions – in the misguided belief that centralized rules can successfully modify complex professional behaviours. Enrolment targets treat practice sizes as administrative variables rather than clinical realities shaped by patients’ requirements.

The result? A rigid, one-size-fits-all system ill-suited to diverse communities, unresponsive to local needs and unappealing to new family physicians.

High-performing countries do the opposite. The Netherlands and Germany set broad goals and funding centrally, then grant local teams the autonomy to design delivery. They measure outcomes – access rates, patient satisfaction, health results – not processes. This maintains accountability and enables innovation tailored to community needs.

Quebec’s access crisis isn’t about doctor shortages; it’s about how doctors are used. Quebec family doctors spend 35 percent of their time in hospitals, compared with just 20 per cent nationally. Mandatory 12-hour-a-week hospital shifts pull young physicians away from the primary care that helps patients avoid hospital visits in the first place. Regional staffing quotas, while successfully redistributing doctors to underserved areas, create artificial urban shortages and push medical graduates toward specialties or private practice, which aren’t subject to such restrictions.

Quebec has more interdisciplinary primary care teams than any other province. But physicians and other health professionals struggle to collaborate within them. The problem is fee-for-service payment, which still governs two-thirds of physician compensation. When doctors are only paid for services they personally deliver, they have little incentive to delegate tasks to teammates, such as nurse-practitioners or pharmacists.

Genuinely team-based care requires payment reform. Flexible payments per patient that can vary with case complexity, chronic disease burden and administrative overhead would better align incentives with comprehensive care and encourage true collaboration.

Bill 2, the latest centralized intervention, aims to overhaul payment models, but its rigid targets and financial penalties risk worsening access. After strong pushback from the province’s two medical associations, the bill was suspended and its most coercive provisions were repealed or amended. The forced assignment of 1.5 million patients was replaced with voluntary incentives for 500,000, while a new health minister is negotiating a revised pay agreement. The lesson is clear: you cannot coerce your way to better primary care.

Quebec needs three fundamental changes. First, it should separate planning from operations. Let the province set goals and funding parameters; let local teams design delivery. Second, it should replace fee-for-service with blended payments that reward teamwork and comprehensive care. Third, it should reduce mandatory hospital services and rigid staffing rules to let physicians do primary care.

These three changes would require rethinking long-held assumptions. But tweaks have failed for 20 years. Training more doctors or raising pay won’t fix a broken system – it will only make it more expensive.

Quebec’s two decades of good intentions but poor results offer one clear lesson: Without structural reform that empowers local teams and aligns payment with outcomes, access will continue deteriorating regardless of how many doctors you train.

Ontario is currently pursuing ambitious primary care reforms involving regional allocation and team-based care. Alberta is restructuring its system, too. Both risk repeating Quebec’s mistakes if they centralize design excessively.

Quebec has world-class clinicians and the resources to succeed. What it needs is a system that lets its professionals do their jobs effectively.

Tingting Zhang is a policy analyst with the C.D. Howe Institute.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.

A version of this Memo first appeared in the Financial Post.