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Fahad Razak is an internist at St. Michael’s Hospital and an associate professor at the University of Toronto. Anjali Sergeant is an internal medicine resident at the University of British Columbia. Camille Orridge is a senior fellow at the Wellesley Institute and former CEO of Toronto Central Local Health Integration Network. Tom Closson is a former hospital and regional health authority CEO.

Signs of strain in the health care system have become increasingly apparent, from patients receiving treatment in hallways in prepandemic times, to waves of burnout and resource rationing throughout the COVID-19 crisis. With many difficult decisions on the horizon, it’s important to ask who sets the direction of our health system as we move forward.

To start answering this question, we completed Canada’s largest study examining the gender and racial diversity of our health care leaders. Specifically, we looked at provincial and territorial ministries of health and staffing at our country’s 135 largest hospitals, accounting for more than 3,000 health-system leaders in total.

We have three major findings. First, gender parity exists among health care leaders in Canada, and this extends all the way up to the highest tiers, including deputy ministers of health and hospital chief executive officers. Of course, this representation should not mask other forms of significant gender discrimination that still exist, such as wide disparities in pay.

In contrast, our second finding is that no racialized people are currently acting as deputy health ministers in Canada, and less than 6 per cent of health care CEOs are racialized. When we look at the racial composition of a province’s population and compare this with its health care leadership, a stark picture emerges. In Ontario, about a third of the province’s population is racialized, whereas hospital leadership is only 12-per-cent racialized (a gap of about 20 per cent).

Our third major finding is most discouraging. When examining hospitals and their locations, we found that as neighbourhoods become more racialized, the gap between the diversity of a given neighbourhood and the diversity of its local hospital leadership widens rather than narrows. In other words, hospitals in the most racialized neighbourhoods have the least representative leadership.

Why is diversity in health care leadership a desirable goal?

Health care receives the single largest allocation of Canadian tax revenue, and leaders set the system’s priorities. Their choices profoundly shape our lives. Who do we prioritize for vaccinations? Do we invest scarce resources into providing basic health care for marginalized communities, or focus on the most advanced cancer treatment? Often there is only limited data available to guide these consequential decisions, and so the lived experiences and identities of our leaders become paramount.

So what do we do when the leadership of a health care system doesn’t look like the population it serves?

First, we need robust data and targets. In our research, we coded people into racial and gender groups based on names and photos available online, and demonstrated that this process could be done with a high level of precision. This idea of “perceived” rather than self-reported race and gender is important, as evidence suggests that what people perceive to be your racial identity affects your likelihood to access greater career opportunities, including promotions. However, there is the potential danger of misclassifying individuals. For example, for many Indigenous people, identity is self-determined, and the external assignment of identity perpetuates colonial constructs. Canadian health care should follow other industries in making the self-reporting of racial and gender identity mandatory among leaders, and with this data should come requirements for representation among executives.

Second, we must recognize that diversity is not a blanket phrase. For example, it’s possible that the push to increase diversity in leadership has been a driving force for the ascendancy of women into these positions. But it’s notable that this effect has been largely realized by white women, as our study showed that racialized women, like all racialized people, are woefully underrepresented. Similarly, a push to increase the number of racialized people in leadership may disproportionally benefit South Asian and East Asian individuals, who are already well represented in health care, potentially to the detriment of underrepresented groups such as Black, Indigenous and Filipino Canadians. Diversity is not as simple as “white male versus ‘other,’” and we must employ an intersectional approach to diversity in health care leadership.

Third, we have to prioritize the problem. The finding that women are equally represented in health care leadership is remarkable and worth celebrating given the large gender disparities that still exist in many other sectors. But it also is a lesson. Diversity policies in health care institutions are long-standing, and the pipeline of health care professionals has progressed to the point that about 50 per cent of all medical school students in Canada have been women for more than two decades. We need a similar pipeline for racialized people.

Fourth, we need to call out gaps as we see them. The term “manel” is now used to describe a panel of speakers devoid of women. But we do not have a similar and commonly used term for the exclusion of racialized groups from organizational leadership, nor has the exclusion of these groups achieved the same recognition in the collective psyche.

It’s been more than 50 years since the landmark Royal Commission on the Status of Women in Canada – do we need to have a similar panel to recognize the plight of racialized people?

The status quo of health care leadership excludes many Canadians. We must reduce the diversity gaps between health care leaders and the populations they serve.

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