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 researcher at the Wellesley Institute and former CEO of the Toronto Central Local Health Integration Network. Tom Closson is a former CEO of a hospital and regional health authority.
Signs of strain in the healthcare system have become increasingly apparent, from patients receiving treatment in hallways in the pre-pandemic era, to waves of burnout and resource rationing throughout the COVID-19 crisis. . With many tough decisions on the horizon, it’s important to ask who is setting the direction for our healthcare system as we move forward.
To begin to answer this question, we conducted the largest study in Canada examining the sexual and racial diversity of our healthcare leaders. Specifically, we looked at provincial and territorial departments of health and staffing at the 135 largest hospitals in our country, with a total of more than 3,000 health system leaders.
We have three major findings. First, gender parity exists among health care leaders in Canada, and this extends to the highest levels, including deputy ministers of health and hospital CEOs. Of course, this portrayal should not mask other important forms of gender discrimination that still exist, such as stark wage disparities.
In contrast, our second finding is that no racialized person currently holds the position of Deputy Minister of Health in Canada and that less than 6% of healthcare CEOs are racialized. When we look at the racial makeup of a province’s population and compare it to its leadership in health care, a bleak picture emerges. In Ontario, about one-third of the province’s population is racialized, while only 12% of hospital leadership is racialized (a gap of about 20%).
Our third major discovery is the most disheartening. When examining hospitals and their locations, we have found that as neighborhoods become more racialized, the gap between the diversity of a given neighborhood and the diversity of its local hospital leaders widens rather than it does shrink. In other words, hospitals in the most racialized neighborhoods have the least representative leadership.
Why is diversity in healthcare leadership a desirable goal?
Health care receives the largest share of Canadian tax revenue, and leaders set system priorities. Their choices profoundly shape our lives. Who do we prefer for vaccinations? Are we investing limited resources to provide basic health care to marginalized communities or are we focusing 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 if the leadership of a health care system does not resemble the people it serves?
First, we need solid 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 performed with a high level of accuracy. This idea of ”perceived” rather than self-reported race and gender is important, as evidence suggests that what people perceive as your racial identity affects your likelihood of accessing greater career opportunities, including promotions. However, there is a potential danger of misclassifying individuals. For example, for many indigenous peoples, identity is self-determined and the external attribution of identity perpetuates colonial constructs. Health care in Canada should follow other industries in mandating self-declaration of racial and gender identity among leaders, and with that data should come representation requirements among executives.
Second, we must recognize that diversity is not a generic word. For example, it is possible that the desire to increase diversity in leadership has been a driving force behind the rise of women in these positions. But it should be noted that this effect was 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 positions may disproportionately benefit South Asian and East Asian people, who are already well represented in health care, potentially to the detriment of underserved groups. represented such as Black, Indigenous and Filipino Canadians. Diversity is not as simple as “white man versus ‘other’” and we need to take an intersectional approach to diversity in healthcare leadership.
Third, we need 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 is also a lesson. Diversity policies in health care settings have been around for a long time, and the pool of health care professionals has grown to the point that approximately 50% of all medical students in Canada have been women for more than two decades. We need a similar pipeline for racialized people.
Fourth, we need to report shortcomings as we see them. The term ‘manel’ is now used to describe a stakeholder panel that does not include women. But we don’t have a similar, commonly used term for the exclusion of racialized groups from organizational leadership, nor has the exclusion of these groups gained the same recognition in the collective psyche.
More than 50 years have passed since the Royal Commission on the Status of Women in Canada. Do we need a similar committee to recognize the plight of racialized people?
The status quo of health care leadership excludes many Canadians. We need to close the diversity gaps between healthcare leaders and the populations they serve.
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