The ability to think in terms of a system is critical to achieving common direction, alignment, and commitment in highly distributed health systems. In Canada, provincial and territorial ministries of health provide leadership on the direction of health reform while leadership to align system levels is determined by a far more distributed group of actors. There is a natural tension between organisational (or "tribal") identity and loyalty and a system-wide loyalty and identity. A major research project in Canada reveals that the challenge for health system leaders is to find the most constructive balance within this tension.