Structural flaws affect health-care performance

The record is not background. It is the forecast.

Past performance is the best available indicator of future performance. That principle belongs to every field in which the conditions producing a result are more durable than the result itself.

It belongs equally to health system governance. When the structural conditions that produced failure remain intact, the failure is not a risk. It is a probability.

Manitoba’s cardiac care program has been examined repeatedly and formally reviewed twice by the profession’s own experts, separated by more than a decade.

The Koshal review in 2003 identified the governance gaps. The University of Ottawa Heart Institute consultation in 2014 identified them again. In both cases, the operational recommendations were implemented and the structural ones were not. The program that received the $22.1 million announced in the 2026 budget sits in the same governance arrangement as the program that received the investment in 2003.

The architecture has not changed. The forecast has not changed.

The 2017 results confirm what structural protection can produce. St. Boniface Hospital ranked among Canada’s best revascularization programs for cardiology and cardiac surgery that year.

Those results were not an accident. They followed deliberate decisions about governance, investment and the organization of care built from the patient outward. By 2022, the data infrastructure that made those results visible had been dismantled. The program had been reabsorbed into the institutional arrangements surrounding it.

The 2026 funding is a partial recovery, not a renewal. It restores some capacity but not the structures whose loss made 2022 a dismantling: that same data infrastructure and the multidisciplinary safety committee that once governed the program’s performance.

The 2017 peak and the 2022 disinvestment are not a random fluctuation. They are the documented pattern of what happens to a program without structural protection when institutional priorities shift.

The WRHA accountability agreement makes the structural condition visible in a single comparison. CancerCare Manitoba is named in that agreement as a governance object: a Cancer Authority, clinical standards established by that authority, a governance architecture that reflects the population-level obligation cancer care carries.

Cardiac care appears as a volume target. Cardiac surgery, interventional cardiology, at St. Boniface Hospital: a number of cases per year, similarly for pacemaker, ICD, TAVI, and others. No program designation. No outcome standard. No named accountability for the integrated program that serves tens of thousands of Manitobans annually across surgery, cardiology, cardiac critical care, heart failure, mechanical circulatory support, structural heart disease and the complex cases that require multiple disciplines at the same table.

The accountability agreement does not see the program. It counts procedures. Consider one patient: a person with poorly controlled diabetes who needs heart surgery. Their safe passage depends on cardiology, endocrinology, anesthesia, the surgical team and the nurse-led navigation that organizes their hand-off back to the community, all working from a single plan, before the operation, during it, and through the recovery.

The schedule counts the operation. It cannot see the co-ordination the outcome depends on. Co-ordination, when no one is accountable for it, is the first thing to erode.

How can there be appropriate governance infrastructure in the absence of co-ordinated expertise governing the delivery of cardiac care?

That asymmetry has not been explained. It has not been publicly addressed. It is the structural condition that makes the forecast reliable.

The current arrangements have reaffirmed the academic and institutional silos that produce conflicting priorities and divided loyalties and these continue to work against the co-ordinated care that cardiac patients depend on.

There is a second condition that makes the timeline shorter than a decade.

A program without structural protection does not merely underperform in normal circumstances. It is the first thing consumed when the system comes under pressure. Fiscal constraint. Workforce crisis. Pandemic. Natural disaster.

Each of these compresses the institutional calculus in the same direction: protect the core, defer the periphery, absorb the specialty into the structures that surround it. An unprotected program survives good conditions and is dismantled by difficult ones. Manitoba has demonstrated this once already. The conditions that will test it again are not hypothetical.

Every level of the system below the minister has been asked the governance question. The accountability agreement places cardiac care as a volume line in a regional funding schedule. Shared Health, the co-ordinating body above the regional authority, has acknowledged the governance gap and acknowledged that resolving it is not within its authority to decide. That acknowledgment now locates the question correctly. It has an address.

The minister holds the authority and the accountability agreement confirms it. The agreement’s escalation clause places the determination of consequence with the minister: where patient safety is threatened or where it is in the public interest, the minister may act.

But that power is a backstop. It is activated only after one or more failures and the agreement provides no data and no mechanism for early warning. It can respond to harm, not prevent it. The governance that would sit between the minister and the patient, and catch the forecast before it arrives, has not been built.

Cardiac care is the most fully documented instance of a failure that is not unique to it.

The question for the minister is not whether Manitoba’s cardiac care program deserves the governance structure that would protect it. That question has been answered, twice, by the profession’s own experts. It was not acted on.

The same recommendations have repeatedly met the same institutional resistance and authority that is not exercised against that resistance is indistinguishable from no authority. The question is whether this investment will be structurally protected or whether it will follow the forecast.

But a forecast is conditional. It describes what happens if the governing structure is left unchanged, not what must happen. The structure can be built.

The patients who depend on cardiac care are not asking for more than the duty owed to them requires. They are asking for a structure equal to that duty. The minister is the only person in the chain with the authority to build it.

For the patient, where does the buck stop?

Alan H. Menkis, MD, writes from Winnipeg.