$22M is a beginning — governance is the test

In 2017, the Canadian Institute for Health Information ranked St. Boniface Hospital’s cardiac sciences program among the best in Canada.

Low mortality. Low readmission rates. High volumes. A multidisciplinary team organized around the patient’s journey, from first presentation to definitive care and back to the community.

Manitoba had built something genuinely excellent, and the evidence said so.

That program no longer exists in the form that earned those results.

The question the 2026 budget must answer is not whether Manitoba can spend $22.1 million on cardiac care. It is whether the conditions that produced excellence in 2017 can be rebuilt and protected this time from the institutional pressures that gradually dismantled them.

The budget announcement is welcome. Heart Care Manitoba, with 18 new beds, a cardiac assessment unit, and a cardiologist in the emergency department, represents a serious commitment.

But Dr. Anita Soni, who leads cardiac sciences at St. Boniface, identified the structural problem precisely: cardiac care in Manitoba has never operated under a clearly defined provincial mandate.

That is not a funding gap. It is a governance gap, and it has never been filled.

Manitoba has commissioned expert reviews before. The Koshal report in 2003 created the cardiac sciences program and made 43 recommendations. Most operational recommendations were implemented.

The governance recommendations, including a detailed accountability relationship between St. Boniface and the Winnipeg Regional Health Authority, protected bed capacity under direct program management, and clear performance measures with consequence remained outstanding or were deferred.

A decade later, the University of Ottawa Heart Institute conducted a detailed consultation of the same program. Its dominant finding was the same: diffuse authority, misaligned accountability, no single body carrying end-to-end responsibility for cardiac outcomes across the full continuum of care.

Two reviews. Two decades apart. The same structural gaps. A bridge requires foundations on both sides.

The program that earned national recognition in 2017 was built despite that ambiguity, not because it had been resolved.

Concentrated excellence in the cardiac surgical ICU, developed within cardiac sciences under Dr. Rakesh Arora and the late Dr. Dean Bell, became in a few short years a world-class example of clinical care and research. The 2017 CIHI results reflect their work directly.

That unit has since been reabsorbed into critical care within the department of medicine. Not dismantled. Absorbed. That distinction matters.

Institutional gravity does not require a dramatic decision. It requires only that excellence built without structural protection will, over time, return to the structures that surround it.

When broader institutional pressures reasserted themselves, the parts of the program without protected mandate absorbed the consequences. The patient absorbed them too.

One gap neither review resolved, and which the 2026 budget does not yet address, is the role of the University of Manitoba.

A clinician who does not submit work to the critical review of peers is not accountable to evidence. Clinical excellence and academic rigour are not parallel obligations; they are the same obligation, expressed in different rooms.

A program of genuine excellence is not only a clinical operation. It is a teaching and research environment that attracts talent, generates knowledge, and trains the next generation of cardiac specialists. Cardiac sciences in Manitoba has never achieved the university standing that would give it the authority and resources to do that work.

The governance barriers to that standing are not accidental. They are structural, and they have never been formally confronted. Until they are, recruitment, research, and the capacity to build careers worth choosing in Manitoba will remain constrained regardless of clinical funding.

This is the harder workforce question the budget does not ask. Manitoba has framed its cardiac staffing challenge primarily in terms of how many people can be trained and how much they should be paid.

The more important question is what makes a career in cardiac care in Manitoba worth choosing and worth sustaining. Compensation matters. But what drives attrition over decades is the absence of a supported, meaningful clinical and academic environment where excellence is structurally protected rather than dependent on the goodwill of institutions whose priority, like that of all institutions, is self-preservation.

Two expert reviews have now identified the same governance gaps, separated by two decades. The findings were discussed. The operational recommendations were implemented. The structural ones were not. Before the $22.1 million in this budget is committed, Manitoba’s leadership and its public should ask why. Not as an accusation, but as a structural question: what institutional arrangements have consistently prevented governance reform from taking hold, and does the plan for Heart Care Manitoba address them?

Acknowledging a problem is not the same as acting on it.

Acting is not the same as being accountable for results. Accountability requires consequence: a clear answer to the question of what follows when outcomes are not met.

Manitoba’s health system has demonstrated considerable facility with acknowledgment. The investment in this budget is an opportunity to demonstrate the rest.

Heart Care Manitoba has the potential to restore and grow what Manitoba built and lost.

The 2017 results were not an accident. They were the product of deliberate decisions about governance, investment, and the organization of care around the patient, from first presentation to definitive care and back to the community.

A clearly defined provincial mandate. Governance alignment across Shared Health, the Winnipeg Regional Health Authority, St. Boniface, and the University of Manitoba. Protected capacity. Transparent public reporting of outcomes benchmarked nationally. These are not new ideas. They are the conclusions Manitoba’s own reviews have already reached and not yet acted on.

The answers are not unknown. The question is whether this time the structures will change, or whether the investment will once again be absorbed by the same institutional arrangements that made the question necessary.

Structures exist on paper. Patients experience care in real time.

Dr. Alan H. Menkis writes from Winnipeg.