Dynamics of public health federalism in Canada.

Canada's federal structure is the institutional reality informing our system of public health. While there are advantages to this decentralization, it can also lead to fragmentation and inefficiencies. Calls for stronger federal leadership or better collaboration between jurisdictions are common, but they do not directly address the question of why there has been so little progress in moving in either of these directions. Through the lens of six key public health functions, this article describes contextual realities and disparate interests of the jurisdictions. These underpin a dynamic for public health decision-making in which rational decisions can lead to suboptimal outcomes collectively. Understanding the dynamics of federalism underlying public health in Canada can help us to identify and address barriers to a more effective public health system.