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Health System Performance: What
Matters
(A Case Study of Canada and the United States)
Clyde Hertzman
HELP, CHSPR, HC&E
Female Life Expectancy in Canada vs
the United States
65
70
75
80
85
1950 1952 1954 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Life Expectancy at
Birth, in Years
Canada
United States
Male Life Expectancy in Canada vs the
United States
60
62
64
66
68
70
72
74
76
78
1950 1952 1954 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Lif
e E
xp
ec
ta
nc
y a
t B
irth
, In
Ye
ars
Canada
United States
Infant Mortality in Canada vs. The United
States, 1960-2002
0
5
10
15
20
25
30
1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Death
s P
er
1,0
00 L
ive B
irth
s
Canada
United States
Infant Mortality in Canada and Among Whites in the
United States
0
20
40
60
80
100
120
1921
1924
1927
1930
1933
1936
1939
1942
1945
1948
1951
1954
1957
1960
1963
1966
1969
1972
1975
1978
1981
1984
1987
1990
1993
1996
Year
Death
s p
er
1,0
00 L
ive B
irth
s
Canada
USA-Whites
Infant Mortality in Canada and Among Whites in the
United States, 1970-1998
0
2
4
6
8
10
12
14
16
18
20
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
Year
Death
s p
er
1,0
00 L
ive B
irth
s
Canada
USA - Whites
Infant Mortality
0
2
4
6
8
10
12
14
16
18
20
1971 1976 1981 1986 1991 1996
Q1 - Richest
Q2
Q3
Q4
Q5 - Poorest
per 1,000
Mortality by Neighbourhood Income in Urban Canada, Wilkins R, Berthelot JM, Ng E, March 2001
Infant Mortality Rates: US vs Canada,
1996
Canada US
Poorest 20% 6.5/1000 ---
Second 5.2 ---
Third 5.1 ---
Fourth 4.7 ---
Richest 20% 3.9 ---
Overall 5.2 7.8
Quantitative Literacy Scores for Youth Aged 16-25.
International Adult Literacy Study, 1994
-1.5
-1
-0.5
0
0.5
1
1.5
6 7 8 9 10 11 12 13 14 15 16 17
Parents’ Level of Education
Sweden
Switzerland
Netherlands
Germany
Belgium
Canada
USAPoland
IrelandN Ireland G Britain
New Zealand
Organisation for Economic Co-operation and Development and Statistics Canada. (1995) Literacy, economy,
and society: results of the first international adult literacy survey. OECD/Ministry of Industry Canada, p 151.
0.15 0.19 0.23 0.27
Median Share of Income
200
300
400
500
600
Rate per 100,000 PopulationWorking Age (25-64) Mortality by Median Share
U.S., Canadian, and Australian Metropolitan Areas
Mortality Rates Standardized to the Canadian Popluation in 1991
FlorenceSC
JacksonvilleNC
SiouxCityIA
MonroeLA
ChicagoIL
TuscaloosaAL
Prince George
WashingtonDC
Oshawa
NewYorkNY
LosAngelesCA
NewOrleansLA
BryanTX
McallenTX
SiouxCityIA
AppletonWI
PortsmouthNH
PineBluffAR
FlorenceSC
MonroeLA
AugustaGA
Montreal
Vancouver
Toronto
Barrie
Oshawa
Shawinigan
US Cities (weighted linear fit)
CAN Cities (weighted linear fit)
AUST Cities (weighted linear fit)
SydneyMelbourne
Geelong
Brisbane
Canberra-Queanbeyan
GS8 Nov. 27, 2000 11:09:06 AM
Working Age (25-64) Mortality by Median Share
U.S., Canadian, and Australian Metropolitan Areas
National Expenditure on Health in
Canada vs the United States
0
2
4
6
8
10
12
14
16
1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
% o
f G
DP
Canada
United States
Socioeconomic Gradients in Medically
Avoidable Deaths, Canada, 1971-1996
“……from 1971 to 1996, the disparity [from income
quintile 1 to 5] for causes amenable to medical
intervention diminished 60% (1287 age-standardized
expected years of life lost per 100,000) in men and 78%
(1264 SEYLL per 100,000) in women………”
Ref: James, Wilkins, Detsky, Tugwell, Manuel, JECH, 2007.
Purchasing Power Parity Adjusted Gross
Domestic Product Per Capita: Canada Vs.
The United States
0
5000
10000
15000
20000
25000
30000
35000
40000
1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
Cu
rren
t In
tern
ati
on
al D
ollars
Canada
United States
Unemployment Rates: Canada Vs. The
United States
0
2
4
6
8
10
12
14
16
1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000
% U
nem
plo
yed
Canada
United States
Gini Coefficient of Income Inequality:
Canada vs the United States
25
27
29
31
33
35
37
39
1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999
Gin
i C
oeff
icie
nt
Canada
United States
Public Social Expenditure in Canada vs
the United States
0
2
4
6
8
10
12
14
16
18
20
1980 1990 1998
% G
DP
Canada
United States
Redistribution in Canada vs the United States:
The Impact of Taxes and Transfers on
Inequality
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Early 80s
Redistribution
Late 80s Early 90s Late 90s
Ch
an
ge in
Gin
i C
oeff
icie
nt
(In
eq
uality
in
Mark
et
Inco
me -
In
eq
uality
in
Dis
po
sab
le In
co
me/In
eq
uality
in
Mark
et
Inco
me)
Canada
United States
Postmaterialist Values in Canada vs the
United States, 1990-1991
10
12
14
16
18
20
22
24
26
28
30
Canada United States
Trust in Canada vs the United States
0
10
20
30
40
50
60
1981
Trust (% Trusting)
1990 1995/97
Perc
en
t T
rusti
ng
Canada
United States
Factoid
……..until 1979, the rate at which
immigrants from specific countries of origin
obtained citizenship in Canada and the
United States was approximately the
same….thereafter, the rate in Canada went
up and the rate in the US went down, for all
groups except Vietnamese……….
Ref: Bloemraad
Percentage of Unemployment Insurance Beneficiaries to
Total Unemployed for Canada, Germany & USA,1976-2006
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
CAN UI/UE
USA UI/UE
GER UI+UA/UE
GER UI/UE
Sources: Canadian Data: Statistics Canada Cansim II Series V384606, V385120;
American Data: US Department of Labor & Bureau of Labor Statistics;
German Data: Schneider 2004 Table 5, p 113
After-Tax Income Gap is Bigger than Ever for
Families Raising Children in Canada (ratio of after-
tax income in deciles 10 and 1, 1976-2004)
Yalnizyan, 2007
7.0
7.5
8.0
8.5
9.0
9.5
10.0
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Earnings
Percentage of Students Vulnerable on One or More
scales of the EDI Based on Provincial cutoffs, Wave 1
Percentage of Students Vulnerable on One or
More Scales of the EDI Based on Provincial cutoffs, Wave
2
Take home lesson 1
• Societal institutions that are determinants of health, and therefore, de facto, integral to the ‘health system’, evolve over historical time, and their impact on health status emerges gradually, too
• Thus, societies can (unwittingly) undermine population health through policy change
Take home lesson 2
Despite strides in population-based, longitudinal,
person-specific data systems, we do NOT have a
measurement regime that:
• is based upon a consensus as to the societal
characteristics that support or undermine health
• monitors these characteristics in an
internationally consistent way
• identifies and monitors ‘leading outcome
indicators’ such as ‘gradients’ in health/ socially
sensitive populations
• adequately accounts for the element of time