Focusing events — sudden, relatively uncommon events that can be reasonably defined as harmful or portending of greater future harms (Birkland 1998), such as infectious disease pandemics — can push problems onto decision-making agenda leading policy-makers to formulate and adopt responses. Occasionally, in the process of responding to such crises, policy-makers also address long-standing related or tangential problems because they have come to understand the old problems in new or different ways, additional stakeholders are lobbying to address the lingering issues, or because a window has finally opened to make change (Kingdon 1995).

Due to its rapid and severe spread — it was first detected in China in late December 2019, reported in Canada on 25 January 2020, and deemed the cause of deaths on multiple continents by the end of February — the coronavirus disease 2019 (COVID-19) outbreak led policy-makers and health leaders in Canada to act quickly to try to contain the virus’ spread and treat cases while maintaining emergency and primary health care services. The first Canadian death in early March 2020, rapidly multiplying cases of illness, and successive infection waves eventually prompted a broader set of measures. Until the World Health Organization declared on 4 May 2023 that COVID-19 was no longer a public health emergency, federal, provincial and territorial, First Nations, regional, and municipal jurisdictions in Canada adopted and implemented thousands of policies and system reforms pertaining to public information, personal protective equipment, restrictions on public and private gatherings and travel, health system governance, health care financing and payment, care delivery, vaccines and immunization, access to care, the health workforce, research and data infrastructure, COVID’s impact on other sectors like education, and the pandemic’s impact on household and community social and economic well-being (Canadian Institute for Health Information [CIHI] 2022). These policies and reforms took many possible forms, including local public health orders, new advisory committees, vaccine “passports,” and cash payments to individuals. They were both narrow in scope and broadly applicable; some were short-lived, and others made permanent.

Leveraging the variety of responses to the evolving pandemic that were seen across the country in terms of their nature and timing, this special issue documents how and why specific policy and system reforms were adopted and implemented; their effects, successes and failures; the lessons they offer; and implications for Canada’s health system — which consists of thirteen provincial and territorial publicly-funded health insurance plans, federal programs, and pan-Canadian organizations like Canada’s Drug and Health Technology Agency — moving forward. The collection does not attempt to present a comprehensive review or assessment of Canada’s COVID-19 response; consistent with the approach of the Health Reform Observer – Observatoire des Réformes de Santé, the papers in this issue analyze a specific policy or reform in a single jurisdiction or similar reforms across jurisdictions. The policy and system reforms described in the papers and their outcomes and implications are best understood in historical context. An in-depth profile of the Canadian health system compiled just prior to the COVID-19 outbreak concluded that it was consuming a growing share of Canada’s economy and had notable gaps in physician and nurse supply, insurance coverage for other services (for example, prescription drugs, dental, and mental health care), data infrastructure, and health outcomes, particularly for Indigenous peoples (Marchildon, Allin, and Merkur 2020). It was also facing concerning challenges in the form of wait times for specialist and elective surgical care, primary care performance, and care fragmentation (Marchildon, Allin, and Merkur 2020). These challenges were quickly exacerbated by the pandemic, and they undermined the ability of the system to respond to and manage its impacts (Clark et al. 2023).

The six articles in this issue that were published between February and October 2023 — two comparative papers and four that focus on a single jurisdiction — analyze an interesting range of reforms at the national, provincial, and, in one case, local levels. Reibera and Nauenberg (2023) implement a framework for analyzing the cost-effectiveness of the economic stimulus package and containment measures in the United States and outline how it could be extended to Canada. Fitzpatrick et al. (2023) conduct a cross-case analysis of their comprehensive case studies of the vaccination campaign rollouts of four diverse provinces (British Columbia, Nova Scotia, Ontario, and Saskatchewan); Joseph et al. (2023) review the process by which Hamilton, Ontario community members built the first COVID-19 vaccination clinic for those experiencing systemic racism and other barriers to health care access; Côté et al. (2023) examine the transformation of primary care in Quebec through six practices, including the creation of liaisons for the homeless, to reach more vulnerable populations; Myles et al. (2023) performed a SWOT (strengths, weaknesses, opportunities, and threats) analysis of Ontario’s temporary expansion of the scopes of practice of regulated health professionals when working in hospital settings; and Sketris et al. (2023) described how Nova Scotia’s gradual expansion of community pharmacists’ scope of practice over the previous decade enabled community pharmacies to play important roles in the province’s COVID response.

Each of the papers offers practical lessons for members of policy communities interested in pursuing similar reforms in the future. Rebeira and Nauenberg (2023) suggest data and methodological improvements that would not only enable comparison of the effectiveness of Canadian and American stimulus and containment strategies, but more importantly, as Berman also suggests (2023) in a separate commentary, would enable dynamic policy-making that could balance public health and economic objectives. Fitzpatrick et al. (2023) identify characteristics of provincial vaccination campaigns that seemed to facilitate uptake: clear coverage goals; centralized vaccination booking and delivery sites; and, flexibility for regional and local public health units and practitioners to add targeted booking and delivery strategies for hard-to-reach populations. In “The Restoration House COVID-19 Clinic” paper, Joseph et al. (2023) document how community members’ prioritization of racialized and disabled populations was the key to establishment of clinics that delivered nearly 6,000 vaccinations to marginalized Hamiltonians between April and November 2021 alone. The Sketris et al. (2023) paper explains that Nova Scotia’s development of centralized booking and other information technology systems in conjunction with successive policy changes since 2011 led to community pharmacies being the province’s leading providers of COVID-19 vaccines. In contrast, Myles et al. (2023) show that Ontario’s imposition of an emergency order without consulting regulators created confusion, stress, and uncertainty that will need to be carefully addressed in further discussion with health profession communities. Similar to the Ontario experience, the lesson of Quebec’s primary care reforms (Côté et al. 2023) was that their rapid implementation created opportunities to deliver care in new ways in the future, including by increasing tolerance of risk, but added to health workers’ burdens such that their future must be pursued in close collaboration with intersectoral stakeholders.

The COVID pandemic plus record population growth have placed additional strains on the Canadian health care system such that the pre-existing gaps in health workforce, access, equity, and quality have widened. Hospitals, including emergency departments, are frequently over capacity and there are long waits to get care in clinics and other facilities (CIHI 2023). COVID-19 remains a threat (Public Health Agency of Canada [PHAC] 2023a) but vaccination rates, particularly for booster doses, are lagging (PHAC 2023b). The initial post-COVID strategies of Canada’s premiers to address their failing systems were to demand an increase in the federal share of health funding and to expand efforts to recruit health workers from across Canada and the world (Canada’s Premiers 2022). However, the readout from the premiers’ recent health summit in which they exchanged examples of health system innovations from their jurisdictions indicates that there may be a realization that the provinces will need to improve health service delivery through incremental evidence-informed changes to their delivery systems (Canada’s Premiers 2023). The papers in this issue provide useful evidence for policy development and transfer to improve vaccine coverage, primary care, and health workforce supply.