Canada: Social Determinants and Health Equity

Share of Household Income, 2010-2019
– Bottom 40%: 20%
– Top 20%: 41%
– Bottom 20%: 7%
Gini Coefficient, 2010-2019: 30
Palma Index of Income Inequality, 2010-2019: 1.1

Note: Gini coefficient – Gini index measures the extent to which the distribution of income (or, in some cases, consumption expenditure) among individuals or households within an economy deviates from a perfectly equal distribution. A Gini index of 0 represents perfect equality, while an index of 100 implies perfect inequality.
Palma index of income inequality – Palma index is defined as the ratio of the richest 10% of the population’s share of gross national income divided by the poorest 40%’s share.

Source: United Nations Children’s Fund, The State of the World’s Children 2023: For every child, vaccination, UNICEF Innocenti – Global Office of Research and Foresight, Florence, April 2023.

Population aged 15 years and over rating their own health as good or very good, by income quintile, 2021
– Highest quintile: 93.0%
– Lowest quintile: 80.0%
– Total: 88.3%

Source: OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris, doi.org/10.1787/7a7afb35-en.

“In Canada, like many countries around the world, health systems do not serve everyone equitably; thisis evidenced by the different access to and outcomes of health care experienced by various population groups [15–18]. Inequities in health status can be attributed to many factors, much of which surface as a result of the historical and ongoing manifestations of colonialism, neoliberalism, and white supremacy [15]. Historical practices of the segregation of Indigenous peoples from the larger population, provision of substandard care to racialized communities, and contemporary experiences of prejudice and discrimination due to health care racism have led to lingering feelings of distrust in health care providers and the larger health care system [19–21]. The impact of social and structural processes of marginalization (e.g., white supremacy, settler colonialism, systemic racism, ableism, ageism, etc.) facilitate control over, exploitation of, and harm to disadvantaged groups and individuals [22]. In recognition of the influence of these intersecting systems that confer advantage and disadvantage to particular communities with respect to health care, we refer to communities characterized by relative disadvantage as structurally marginalized by health care systems.”

Source: Shahid, S., Hogeveen, S., Sky, P. et al. Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study. Int J Equity Health 22, 44 (2023). https://doi.org/10.1186/s12939-023-01849-y

“Although barriers to access for structurally marginalized communities and their underlying causes are well documented in the literature, health equity was not a universal priority concern during the rapid virtualization of care. The unexpected crisis and the rush of the pandemic left little time for health care organizations to implement virtual care in an equitable way, as their priority was to maintain continuity of care. This strategy may have inadvertently contributed to increasing inequities within the most structurally marginalized communities.

“Our research project has illustrated a number of important themes related to the infrastructure for virtual care, organizational capacity to engage with virtual care in meaningful ways, and existing inequities in the broader health care system. However, even as organizations begin to familiarize themselves with the evidence base and shift their attention towards equitable service delivery, it is apparent that these inequities are persisting and are embedded in inequitable systems. Any effort to develop a plan for the sustainability of virtual care services requires an understanding of the potential consequences for members of structurally marginalized communities who may have precarious access to many virtual care initiatives. A lack of awareness and engagement of these existing inequities simply meant these challenges also manifested in virtual care delivery. Ultimately, individual providers and organizations are unable (and do not have the power) to solve system-level challenges on their own.

“As health systems in Canada and elsewhere work towards comprehensively integrating virtual care into care delivery, local and national governments will need to work collaboratively to ensure that an equitable and sustainable approach to virtual care delivery is in place. Our analysis points towards the policy recommendations arising from Budhwani et al. [57], related to recommendations aimed at the individual, technological, health system, and social/structural determinants level. In addition to the strategies outlined above, governments can consider investing in subsidized options for cellular phone service and high-speed Internet to promote equitable access to the connectivity required to engage in virtual visits [2] and commit to ensuring that high-speed Internet and cellular service is made available across the entire geography of a region. Governments, health systems, and health care leaders can also invest in educational content to build capacity in understanding equity, inclusion, diversity, and anti-racism in health care organizations [2]; and to advocate for the systematic and comprehensive inclusion of equity, diversity, and anti-racism education into the formative training of health care providers and managers.”

“We conducted a review of documents that articulated policies affecting primary care in Canada and were published between January 2018 and June 2022. While the majority of documents we reviewed recognized health disparities or equity deserving groups, this was not the case in primary care-focused documents. Though broader health system documents did recognize health inequities, the primary care component of these documents was rarely explicitly connected to the health disparities or equity deserving groups that were acknowledged elsewhere in the document. Or, if the articulated policy was clearly connected to a recognized health inequity, rarely did the document include details about the policy’s plan for implementation, indicators for measuring the equity impact of a policy, or timelines for completion. Similarly, any indication of plans for evaluating a policy were most often focused on a policy’s successful implementation rather than evaluating improvements in health equity. Overall, while inequities are recognized and discussed, this has not translated into explicit primary care policy responses.

“Despite acknowledging disparities, corresponding primary care policy responses were rarely targeted to the specific needs of communities experiencing disparities or to primary care structures which produce or exacerbate those inequities. For example, several policies included initiatives such as provider incentives, increased education opportunities, or funding to increase access to primary care services. These policies, however, did not identify processes to ensure new resources go to communities or regions with the greatest need or would be otherwise directed to address inequities in primary care. Similar policy issues have been documented in the UK where, despite a strategy to establish primary care networks to improve access to primary care and reduce health inequalities [38], ongoing evaluations find inequitable distribution of the primary care workforce in more deprived areas [39,40]. Investments in health infrastructure, workforce, or services with no mechanism to align with need may exacerbate inequities, contradicting current literature suggesting that targeted policies or universal policies with targeted components are more successful in addressing inequities [14,17,18]. Where policies do not directly target those experiencing health inequities, individuals experiencing structural marginalization may be among the last to benefit, even when those individuals would benefit most from new interventions [41].”

Source: Sarah Spencer, Tai Hollingbery, Aidan Bodner, Lindsay Hedden, David Rudoler, Erin Christian, M Ruth Lavergne, Evaluating engagement with equity in Canadian provincial and territorial primary care policies: Results of a jurisdictional scan, Health Policy, Volume 140, 2024, 104994, ISSN 0168-8510, doi.org/10.1016/j.healthpol.2024.104994.

“Our study found that 8% of CLSA [Canadian Longitudinal Study on Ageing] participants used home care services within the previous 12 months, with large variations in use by functional ability. Our unadjusted analysis found significant variations in home care use by sex, gender, income, rurality, immigration history, social support and education. However, after adjusting for health status factors related to home care need, only income, immigration history, education and social support were associated with significant differences in home care use. In general, we found that participants with greater income and education were more likely to use home care, recent immigrants were less likely to use home care compared with earlier immigrants and non-immigrants, and those with less social support were more likely to use home care.

“Our unadjusted analysis showed declines in home care use as income increased across all functional status levels. These findings are consistent with other Canadian studies using home care survey data.⁵ However, adjusting for health status variables largely reversed this trend, resulting in a positive gradient in home care use that increased with income in the no and mild functional impairment groups. One potential explanation of this finding is that individuals living in lower-income neighbourhoods have less access to home care, an issue known to exist for other care services.⁴⁴ Another explanation is that those with higher incomes are more likely to purchase private home care. It has been estimated that a quarter to a third of home care in Ontario is privately purchased,^{6 45} and other studies have found that private home care use is dependent on income.^{16 22 46} These studies suggest that higher income individuals may be using private home care services to top up publicly funded services or, having become dissatisfied with publicly funded services, solely use private care.²¹ This may explain in part the inconsistency we observed in the relationship between income and home care use in the highest functional impairment strata. These individuals would have been far more likely to be eligible for publicly funded care, reducing the opportunities for ability to pay to influence access. High levels of unmet home care need paired with a large private home care industry exacerbates income-based health inequalities, allowing those who can afford to pay to exhibit more autonomy in how and where they age.^{9 21 47}“

Source: Lee J, Watt JA, Mayhew A, et al. Equity in home care use in Canada: a cross-sectional analysis of the Canadian longitudinal study on ageing. BMJ Public Health. 2024;2(2):e000812. Published 2024 Aug 21. doi:10.1136/bmjph-2023-000812

“But key observations from international comparisons point to a decades-long struggle with wait times for some elective care and inequitable access to services outside the traditional Medicare strength of hospitals and doctors.⁶⁷ Average life expectancy also masks variations in vulnerable groups, most notably Indigenous populations: First Nations people have a projected life expectancy of 73–74 years for men and 78–80 years for women; for the Inuit, living in the far north, life expectancy was 64 years for men and 73 years for women as of 2017.⁶⁸

“What is most distressing to many observers of the Canadian system is the persistence of its problems over time.⁶⁹ Change in Canada is often slow and incremental, by contrast with the major and rapid transformations often observed in reforms of the UK’s National Health Service.⁷⁰ It is thus most accurately described not as a system in crisis, but a system in stasis.⁷¹ Within that context, and considering the complex needs of many segments of the Canadian population, three crucial problems require action.”

Source: Martin D, Miller AP, Quesnel-Vallée A, Caron NR, Vissandjée B, Marchildon GP. Canada’s universal health-care system: achieving its potential. Lancet. 2018;391(10131):1718-1735. doi:10.1016/S0140-6736(18)30181-8.

“The link between racial discrimination and health and wellbeing of African Canadian adolescents were assessed using the 2018 dataset. Bivariate logistic regression models were used to assess the association of racial discrimination with self-rated health, experiences of stress, access to health services, substance use, sexual intercourse without the use of adequate protective tools, among others. The findings reveal that self-rated health was poorer for adolescents who reported racial discrimination, and they had a higher likelihood of engaging in behaviours that could put them at risk for adverse health outcomes compared with those who did not report racial discrimination (Table 5). These adolescents who reported racial discrimination were 48 and 46% more likely to have ever smoked a cigarette or used any substances (e.g., cocaine, heroin, e.t.c.) respectively, compared to those did not report experiencing racial discrimination. Additionally, adolescents who experienced racial discrimination were 97% more likely to have considered suicide and more than two times as likely to have attempted suicide (p < 0.5) than adolescents who did not report experiencing racial discrimination. These adolescents also significantly reported extreme stress and not receiving needed emotional and mental health services, 68 and 121% respectively.

“The results show that experiences of racial discrimination were significantly associated with engagement in behaviours that expose young people to health risks for both boys and girls, but adolescent boys had the worst health outcomes (Table 6). African Canadian boys who experienced racial discrimination were significantly more likely to have ever smoked a cigarette (p < .05), and used other substances, such as cocaine, and heroine (p < .01). The boys also significantly reported general poor health, extreme stress, suicidal attempt, and were more likely to be sexually experienced, e.g., having had sex, given, or received oral sex (p < .05), compared to adolescent girls. While adolescent girls who experienced racial discrimination were two times as likely to have considered suicide compared to those who did not report racial discrimination, boys were three times more likely to have attempted suicide (p < .05). Regardless of gender, African Canadian adolescents who experienced racial discrimination were significantly less likely to have received emotional and mental health services (p < .01), compared to those who did not report experiencing racial discrimination.”

Source: Okoye, H.U., Saewyc, E. Fifteen-year trends in self-reported racism and link with health and well-being of African Canadian adolescents: a secondary data analysis. Int J Equity Health 20, 108 (2021). doi.org/10.1186/s12939-021-01446-x.

“Our study, not surprisingly, corroborated that racial discrimination is also associated with several adverse health outcomes among African Canadian adolescents. Those who experienced racial discrimination had a higher likelihood of reporting poorer health, psycho-emotional health issues, not receiving needed emotional and mental health support. These adolescents also engaged in behaviours that can negatively affect their health and well-being compared to those who did not report racial discrimination. These results match the findings of other studies that have documented that experiences of racial discrimination among adolescents are associated with depressive and internalizing symptoms, externalizing behaviours, condom less sex, and having had multiple sexual partners [5, 12, 35, 36, 45, 51]. Hence, there is a need to address not only interpersonal racism, but also all forms of systemic racism and barriers that continue to jeopardize the health and well-being of Black Canadian adolescents, and other racialized groups in Canada [18, 38]. Governmental and non-governmental actions are needed to promote antiracist laws, regulations, and policies as well as attitudinal change at multiple levels of the society that will reduce the social and health inequities experienced by Black Canadian adolescents.

“Furthermore, the greater use of substances among those who reported racial discrimination, necessitates that approaches for reducing harms that are associated with drug use consider the social circumstances of people who use drugs. A health equity lens will illuminate the understanding about the broader societal factors that are the major drivers of drug use among young people [32, 57]. This approach is more likely to inform interventions that address the social conditions of African Canadian adolescents’ daily lives, including experiences of racial discrimination. Also, the findings reveal that adverse health outcomes related to the experiences of racial discrimination were different for boys, girls, immigrant, and Canadian-born African adolescents. Boys in this study experienced greater mental health issues and poorer emotional well-being. This finding is consistent with other studies that have shown that Black males experience greater socioemotional disturbance related to racial discrimination, which also predicts poorer health outcomes in adulthood [3, 5, 59].

“Although Canadian-born adolescents reported poor health outcomes, immigrant African adolescents had worse health outcomes, which corroborates poorer health outcomes for immigrants that have been documented in previous studies [52]. Given the selective immigration policies, community support for new immigrants, the healthy immigrant effect has been shown to be protective for most immigrant population. However, the better health among immigrants compared to the larger population tend to wane with longer years of living in the host country [16, 47]. This evidence was supported by the findings of the current study, as most of the African adolescents have lived in Canada for more than six years. Hence, it is not surprising that immigrant African adolescents reported the worst health outcomes.

“Furthermore, African Canadians who experienced racial discrimination were less likely to receive mental and emotional health services compared to those who did not report racial discrimination. This finding is consistent with other studies that have found poor health seeking behaviour among individuals with emotional problems, particularly racial and ethnic minorities [13, 61]. Although racial socialization and parental support improve coping and emotional well-being, evidence indicate that many adolescents who experience racial discrimination may not receive the emotional support from their families to deal with the negative mental health issues associated with racial discrimination [31, 42].”

“Populations marginalized by gender identity and sexual orientation have, for the most part, been excluded from mainstream health promotion research, policy and practice. Documents submitted to the federal government have attempted to design models that capture targeted populations (e.g. age, sex, socio-economic status, Aboriginals), but have not included sexual minorities [7, 8]. Two latter reports included lesbians and bisexual women [9] and gay men [10, 11]. Yet in the Canadian blueprint report Building on Values: The Future of Health Care in Canada [12] LGBT populations are completely neglected in the discourse on diversity where other minority groups are addressed (including aging Canadians, those dwelling in rural communities, those of lower socio-economic status, ethnic groups, culturally diverse groups, men and women, visible minorities, people with disabilities, and new Canadians).

“The Canadian Institute for Advanced Research (CIAR) and members of its Population Health Program were highly influential in the emergence of the population health approach in Canada. This perspective considers “processes by which system-level variables influence the health of populations” [13]. Health Canada went on to describe the approach as a means “to maintain and improve the health of the entire population and to reduce inequalities in health between population groups” [14]. Despite this, there continues to be a heavy emphasis on targeting the ‘entire population’ with regard to maintaining and improving health and less so on reducing “inequalities in health between population groups” [14]. Critics charge that the population health approach has been narrowly focused on individualized characteristics and processes as measured by large-scale surveys (i.e. National Population Health Survey, Canadian Community Health Survey). This approach has tended to position ‘risk factors’ only as correlates to individualized attributes and behaviours, consequently holding to account affected/diseased individuals [13, 15]. Meanwhile qualitative, community-based research methods and findings are paid very little attention. Because population health as an approach is not addressing social/structural determinants, it provides weak direction on solutions and social change. Population health policies are devoid of guiding values that call for participation, community development or rectifying social injustices [13]. The implications of this are detrimental to those seeking the implementation of health equities and policy change (i.e. the gender and sexually diverse among other populations) [3, 13].”

Source: Mulé, N.J., Ross, L.E., Deeprose, B. et al. Promoting LGBT health and wellbeing through inclusive policy development. Int J Equity Health 8, 18 (2009). doi.org/10.1186/1475-9276-8-18.

Canada: Social Determinants and Health Equity - Healthcare - National Policies - Gini Coefficient, Palma Index, household income - World Health Systems Facts

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Page last updated April 12, 2025 by Doug McVay, Editor.