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In recent weeks, Canada's two longest-serving health ministers have stepped down. Quebec's Philippe Couillard and Ontario's George Smitherman served for about five years each.

They were political heavyweights overseeing health budgets of $23.8-billion and $40.4-billion respectively.

But can anyone outside a tiny circle of policy wonks identify a single lasting accomplishment of Dr. Couillard or Mr. Smitherman?

Did delivery of health care improve markedly - or at all - during their tenures? Did either of these provinces show leadership in making medicare - our publicly funded health insurance program - more efficient or sustainable? Did either man leave a legacy?

While this seems harsh, it is not a knock on them personally. Rather, it speaks to the failure of the political process.

In Canada, we talk ceaselessly about health care. But we never ask one of the most important questions of all: What is the role of a health minister?

The role should be one of leadership, policy guidance, strategic direction and stewardship of medicare.

The reality is that health ministers do nothing of the sort. Rather, they find themselves trying to micromanage a massive system that cannot be micromanaged.

Health minister is the most challenging and thankless post in government because the poor sap in that portfolio is responsible for everything that happens (and doesn't happen) in health care, from the ever-increasing share of public funds that it gobbles up, through to the little old lady left too long on a stretcher in a hospital corridor.

Yet, for all their answerability, health ministers have remarkably little power to make change. They are firefighters equipped with squirt guns as blazes erupt around them.

The most important policy document for a health minister is the daily press clippings package - and that's a pretty poor guide to running a health system, arguably the most vital service offered by government.

While critics often describe the Canadian health system as centralist, the reality is that spending and decision-making are incredibly diffuse.

The most bedevilling problem in Quebec health care is the organization of the workplace. The issue is not that workers are unionized, but rather the overwhelming number of classifications and labour units that make it virtually impossible to have a functional workplace.

Dr. Couillard vowed to change things, but his efforts were shot down from within government and outside interest groups.

On the funding front, Dr. Couillard tried getting hospitals away from block funding, a move that could dramatically alter the health landscape in the years to come, but he will never get any credit.

Mr. Smitherman, for his part, finally dragged Ontario into the era of regionalization, with the creation of Local Health Integration Networks (LHINs).

But the efforts were ultimately half-measures because hospitals in the province remain too powerful. He also made some real strides on human resources planning and changes in the scope of practice of health professionals but, again, the benefits will not be seen for many years.

What will be remembered are the failings that occurred during their terms.

In both provinces, there are outbreaks (verging on epidemic) of C. difficile, a persistent little bug that has laid bare the lack of investment in infrastructure and mindless cuts to janitorial services.

Both continue to struggle with wait times despite massive investments. And Canada's two biggest provinces remain stubbornly resistant to transparency in the health sector - with Ontario rejecting calls to give the Ombudsman the power to investigate health complaints and Quebec petulantly resisting participation in numerous federal-provincial health bodies (notably the Canadian Institute for Health Information).

These are areas where ministers should be concentrating their efforts.

Yet, the greatest achievement of both Dr. Couillard and Mr. Smitherman seems to have been longevity.

They brought stability to jobs that are often a revolving door. (Or perhaps a more apt metaphor would be meat grinder.)

Both men survived and flourished because they have strong personalities. In a job where there is an unreasonable and unrelenting demand to explain and defend the actions of others, both were superb with the media: Dr. Couillard the calm voice of reason, and "Furious George" Smitherman the ever-quotable pit bull.

The two were also fiercely loyal to their respective premiers despite harbouring leadership ambitions themselves.

While Dr. Couillard and Mr. Smitherman were successful in political terms, they largely failed in public policy terms.

Between them, they managed to oversee $300-billion in health care spending over five years. They put out a lot of small fires, but did little of great substance.

They did not plant seeds for the future. They did not demonstrate a vision for medicare.

Until our health ministers are allowed to be leaders, the health care system itself will remain rudderless.