Purpose The purpose of this paper is to articulate the shifts in the theoretical conceptualization of, and the practice of leadership in health care in Canada that are happening as a response to challenges of system transformation; and the implications of those shifts for individual leaders, for health services delivery, for research into health system leadership, and for leadership development approaches in university and health agencies. Design/methodology/approach The paper begins with an analysis of the historical, contemporary, and futuristic context that shapes the conceptualization and practice of leadership now and into the future. The context consists of two parts. First, the need for leadership in health systems in Canada will be established. Second, a conceptual and practical exploration of leadership in health care, beginning with a review of the literature and moving on to exploration of two key projects pertaining to health leadership and health leadership development in Canada, commissioned by senior leaders in health care, will be analyzed for their contribution to defining leadership. Findings The findings outline key shifts in leadership that must take place to respond to changes in the national health environment and be proactive in shaping it. A typology of those shifts in order to show the constituent elements framing the evolution of leadership is outlined. Research limitations/implications Further research on different models and approaches to leadership being promulgated in Canada, their impact on health system capacity building for change, and on new models of education for leaders, is needed. Practical implications As the speed of change in health service delivery grows, the form of leadership required to steward it in a productive fashion changes. As a lag grows between “old” models of leadership and “new” models, leaders themselves experience frustration at their ability to be effective in creating system change. This has implications for our expectations of, and ability to practice leadership; and for our developmental approaches to developing leadership. Originality/value The paper helps to explain what kind of leadership is required to truly transform health systems on a national scale. It also contributes to the international dialogue around health systems transformation, capacity building, and improving health service delivery. © 2009, Emerald Group Publishing Limited