[The difficult steering of health system reform: the case of New Brunswick (Canada)]

In many developed countries, reforms of public healthcare systems are ongoing but do not always achieve desired results. In this article, we present the history of the healthcare system reform in the Canadian province of New Brunswick with the objective of analyzing its difficult steering by the state, in light of the dynamics between the actors involved. Qualitative methods were chosen. Data collection includes semi-structured interviews (N = 39) with representatives of the State, such as health ministers, and other relevant stakeholders, such as managers, citizens or health professionals. The stakeholders were compelled by various aspects of the reform, for example francophone health care services, that had consequences on the trajectory of change. To stay on target, the State must adapt to the dynamic interactions of the actors involved. Reforms take place over a long period of time and their programming by the State can be very difficult, as it requires the mobilization of different types of instruments at its disposal. In order to influence the behaviour of the actors concerned, the State must define a goal whose general orientations are agreed upon, succeed in forging bonds of trust and managing resistance, and finally, use standardized data in order to provide a normative framework and evaluate the progress of the reform project.