During the 1970s and 1980s policymaking in the complex area of regulatory legislation of the health disciplines became both increasingly important and increasingly difficult for the Canadian provinces. In this comparative study Joan Boase traces the evolution of relationships among governments and health care interest groups in four provinces - Ontario, Quebec, Nova Scotia, and Alberta - and finds that, although they have faced similar problems, they have responded in different ways. She employs several theoretical approaches to explain these different responses, including community/policy networks, institutionalism, and state traditions, and uses case studies to illustrate the intense interest group activity that has occurred in this sector. Boase reaches three conclusions: (1) with the development of a national health insurance plan there has been a shift in the actions of government from reliance on interest group liberalism towards concerted efforts to plan the structure of the welfare system; (2) the different systems of interest intermediation that evolved in the provinces reflected the underlying political and administrative culture and institutional structures within the provinces; and (3) the unique proactive approach taken by Ontario in the 1980s was a deliberate effort to modify the institutional arrangements through which groups had traditionally influenced policy. Boase suggests that the complexities of modern government and the move towards redistributive politics will lead the state to make extraordinary efforts to control its environment in the future. Shifting Sands will be of particular interest to health care specialists, policy-makers, and legislators as well as activists.