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