Vol. 19, #2 - Health Care In Canada: What Makes Us Sick?



December 2013

In 1843, Charles Dickens wrote "A Christmas Carol." Most of us remember Ebenezer Scrooge and his visits from the Spirits of Christmas Past, Present, and Future. It is the deep resonating voice of the Spirit of Christmas Present that makes me reflect on Christmas 2013. The dialogue between the Spirit and Ebenezer begins:

Spirit: Will you profit from what I have shown you of the good in most men's heart?

Ebenezer: I don't know, how can I promise?

Spirit: If it's too hard a lesson for you to learn, then learn this lesson (he opens his cloak to reveal two small destitute children)

Ebenezer: Spirit, are these yours?

Spirit: These are man's, they cling to me for protection from their fetters. This boy is ignorance, this girl is want. Beware them both, but most of all beware this boy.

Ebenezer: Have they no refuge, no resource?

Spirit: Are there no prisons, are there no workhouses, are there no prisons, are there no workhouses...

In 2013, some one hundred and seventy years later, the Canadian Medical Association has given a powerful message to Canadians in their report, "What Makes Us Sick?" They argue that poverty is the biggest barrier to good health; that it is the main issue that must be addressed to improve the health of Canadians. It seems ironic that on the eve of the Holiday Season, when families come together to celebrate, share good company over delicious foods, that Charles Dickens' Spirit of Christmas Present is still with us.

Joey Edwardh

Executive Summary

Throughout the winter and spring of 2013, the Canadian Medical Association (CMA) conducted wide-ranging consultations to gather input on Canadians’ views on the social determinants of health. Public town hall meetings were held in Winnipeg, Hamilton, Charlottetown, Calgary, Montréal and St. John’s and were accompanied by an online consultation at www.healthcaretransformation.ca.

The process was framed around four questions aimed at determining what factors beyond the health care system influence health, what initiatives offset the negative impact of these determinants, what governments and health care providers should be doing to address these social determinants, and how equal access for all to the health care system can be achieved.

In every phase of the consultation, four main social determinants of health were identified by participants:

  • income
  • housing
  • nutrition and food security
  • early childhood development

Several other social determinants of health were mentioned, such as culture, the environment, education and health literacy.

Participants stressed that society, governments and health care providers all have an obligation to address such problems as poverty, inadequate housing and nutrition.

Because the health of indigenous peoples in Canada was seen as being particularly influenced by the social determinants of health, the CMA held a town hall meeting to address the challenges facing Aboriginal people and communities.

Several themes from the town hall meetings were summarized by CMA President Dr. Anna Reid:

  • Poverty is the most important issue and must be addressed.
  • Poverty can cause multiple morbidities and even influence early childhood neurologic development.
  • Mental health issues remain “the elephant in the room” and underlie many of the social determinants of health.
  • Governments need to be pressured to take action, but there is a clear role for citizens, physicians and communities to help deal with the problems.
  • The capacity of non-profit organizations to help is reaching the breaking point.
  • There is a link between a healthy society and a healthy economy.
  • Social initiatives need specific funding and should be viewed as investments.
  • There is a need to look at why society is willing to accept disparities.
  • Social inequities are a major cause of stress and insecurity.
  • The medical profession has the authority and voice to take leadership on these issues.
  • Canadian society has suffered from a lack of imagination, will and leadership to address social inequities.
  • The guaranteed annual income is a compelling concept and can have a positive impact on health outcomes.
  • Structural racism keeps Aboriginal people in poverty; this must be addressed to improve health outcomes for these communities.
  • The cost of doing nothing is very large, so reallocation of existing spending is important.

Based on the input received, clear areas of action have emerged:

Recommendation 1: That the federal, provincial and territorial governments give top priority to developing an action plan to eliminate poverty in Canada.

Recommendation 2: That the guaranteed annual income approach to alleviating poverty be evaluated and tested through a major pilot project funded by the federal government.

Recommendation 3: That the federal, provincial and territorial governments develop strategies to ensure access to affordable housing for low and middle-income Canadians.

Recommendation 4: That the “Housing First” approach developed by the Mental Health Commission of Canada to provide housing for people with chronic conditions causing homelessness should be continued and expanded to all Canadian jurisdictions.

Recommendation 5: That a national food security program be established to ensure equitable access to safe and nutritious food for all Canadians regardless of neighbourhood or income.

Recommendation 6: That investments in early childhood development including education programs and parental supports be a priority for all levels of government.

Recommendation 7: That governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial–territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.

Recommendation 8: That the federal government recognize the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system.

Recommendation 9: That the federal government require a health impact assessment as part of Cabinet decision-making process.

Recommendation 10: That local databases of community services and programs (health and social) be developed and provided to health care professionals, and where possible, targeted guides be developed for the health care sector.

Recommendation 11: That the federal government put in place a comprehensive strategy and associated investments for improving the health of Aboriginal people that involves a partnership among governments, non-governmental organizations, universities and Aboriginal communities.

Recommendation 12: That educational initiatives in cross-cultural awareness of Aboriginal health issues be developed for the Canadian population, particularly for health care providers.

The full report “Health Care in Canada: What Makes Us Sick?” can be found at http://www.cma.ca/advocacy/what-makes-us-sick.


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Vol. 19, #1 - Do We Know Who We Are? Limitations Of The 2011 National Household Survey (NHS)



November 2013

The release of the much anticipated income data from the 2011 National Household Survey (NHS) in September has placed a chill over the planners and providers of social services, municipal services and economic development strategies. Good information is essential for the development of responsive and efficient social and economic infrastructure. Tragically, many of the concerns about the impact on the integrity of the Statistics Canada data as a result of the Government of Canada replacing the mandatory long form census with a voluntary National Household Survey have proven true (See Community Dispatch Vol. 18, No. 5). This Community Dispatch analyzes the limitations to the recently released data on income, homeownership and shelter cost of Canadians. The information is critical in understanding issues of income security and inequality across our land, province and communities. How do we answer the question: Do we know who we are?

Joey Edwardh

This Community Dispatch focuses on the limitations of the income data from the National Household Survey especially in data quality, data comparability and low income measures.

Data Quality

Due to the change in data collection methodology from a mandatory census to a voluntary survey the non-response rate of the NHS is significantly higher than those of the previous long form census. At the national level, the NHS Global Non-response Rate (GNR)1 is 26.1% compared to 6.5% with the 2006 long form census. In Ontario, the County of Peterborough has a high non-response rate of over 38%. A high non-response rate implies low data quality.

In addition to an overall lower response rate, certain population groups are less likely to respond to the survey such as high and low income individuals, Aboriginals, newcomers and visible minority groups. At this point, there is no way to determine their respective response rates. In order to maintain a high level of data quality, Statistics Canada suppresses data release in geographic areas with a non-response rate higher than or equal to 25% in previous censuses. However, given the high non-response rate and the associated non-response bias2 of the NHS, Statistics Canada raised the data suppression threshold from 25% to 50%. In doing so, data are released for more geographic areas but at lower data quality.

"We're concluding it [the NHS income data] pretty much is garbage," said Professor David Hulchanski, University of Toronto.3

The map shows the geographic distribution of the 2011 NHS Global Non-response Rate (GNR) by census tract4 for Halton Region. Although there is no census tract with a GNR over 50%, there are many areas (shaded in dark brown) with non-response rates equal to or over 25% (suppression threshold for previous censuses). Almost two-thirds (63%) of the census tracts recorded non-response rates equal to or over 25%. The map can serve as a reference point for data quality when interpreting NHS data by census tract in Halton Region.


Data Comparability

Although the 2011 NHS provides a snapshot of the income composition in Canada including income sources, government transfers, income redistribution and income by family types, the data should not be compared with those from previous censuses and other similar sources.

Previous long form censuses include usual residents in collective dwellings (lodging or rooming houses, hotels, nursing homes, hospitals, staff residences, jails and so on) and persons living abroad whereas the NHS target population excludes them. The census and NHS represent two different populations.

In fact, Statistics Canada warns users to use caution when comparing income estimates from the NHS to other household income surveys, administrative data or earlier censuses.5 The methodology of how the information was collected, the concepts used and response patterns can affect the comparability of income information.

One cannot establish reliable trend lines from previous censuses to see if Canadians are better or worse off in terms of their incomes. The data gap created between 2005 and 2010 (income data are collected a year prior to the census) precludes any assessment of the impact of the economic recession in 2008. This also includes potential impact of any government economic action plan.

"...the lack of comparability between the 2006 census and the 2011 NHS will make it very difficult for researchers and analysts to judge to what extent our social programs blunted the impact of the Great Recession on the incomes of many middle-class and working families..." said Andrew Jackson, Packer Professor of Social Justice at York University and senior policy adviser to the Broadbent Institute.6

Low Income Measures

In previous censuses, Statistics Canada employs Low Income Cut-offs (LICO) as a measure of low income. It is an income threshold below which families or unattached individuals spend 20% more than average on food, shelter and clothing needs. LICO thresholds are also set at income levels by family size and size of community.

For the 2011 NHS, instead of LICO, Statistics Canada chose the after-tax Low Income Measure (LIM-AT) as a measure of low income. Individuals are defined as having low income if the after-tax income of their households fall below 50% of the median adjusted household after-tax income in 2010.

While LIM is an important measure used broadly internationally, it is important that researchers have access to data flowing from both measures; LIM and LICO.

Low income estimates from the 2011 NHS compared to previous censuses show markedly different trends than those derived from other surveys and administrative data such as the Survey of Labour and Income Dynamics (SLID) or the T1 Family File (T1FF).7 As such, Statistics Canada stated that the NHS low-income estimates are not comparable to census-based estimates produced in the past.

The data gap on low income between 2005 and 2010 will hinder work on poverty reduction in Halton's local areas and neighbourhoods.


"The main finding of the NHS is that, with weaker ability to track change or measure a growing portion of society, we're losing sight of the Canada we're becoming." said Armine Yalnizyan, Senior Economist at the Canadian Centre for Policy Alternatives.8

Given the problems associated with data quality and comparability, the usefulness of the income data from the NHS is severely limited. Improper use of the data can lead to erroneous conclusions, faulty comparisons, spurious debate and, ultimately, unwise decisions.

At Community Development Halton, we will continue to assess other data sources to meet the data needs of CDH and our community partners.

In the meantime, CDH asks that the federal government reinstate the mandatory long form census for 2016 and beyond.


1. GNR combines the complete non-response (household) and partial non-response (specific questions) into a single rate

2. Community Development Halton, 2011 National Household Survey (NHS), Community Dispatch, Vol.18, No.5. June, 2013 – non respondents tend to have different characteristics from respondents. As a result, there is a risk that the results will not be representative of the actual population.

3. Grant, Tavi. 2013. Canadian income data 'is garbage' without census, experts say.

4. A Census Tract (CT) is a relatively permanent area with a population range of 2,500 to 8,000 and the greatest possible social and economic homogeneity.

5. Statistics Canada, Income Composition in Canada, National Household Survey, 2011, Cat. No. 99-014-X201100

6. Jackson, Andrew. 2013. Even a bad survey cannot blind us to income inequality. http://www.theglobeandmail.com/report-on-business/economy/economy-lab/even-a-bad-survey-cannot-blind-us-to-income-inequality/article14251936/

7. Statistics Canada, Persons Living in low-income neighbourhoods, National Household Survey, 2011, Cat. No. 99-014-X2011003

8. Yalnizyan, Armine. 2013. National Household Survey provides blurred look at housing.


  Community Dispatch PDF

Produced by Community Development Halton
860 Harrington Court
Burlington, Ontario L7N 3N4
(905) 632-1975, (905) 878-0955; Fax: (905) 632-0778; E-mail:
This email address is being protected from spambots. You need JavaScript enabled to view it.