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Background: Diverse health care leadership teams may improve health care experiences and outcomes for patients. We sought to explore the race and gender of hospital and health ministry executives in Canada and compare their diversity with that of the populations they serve., Methods: This cross-sectional study included leaders of Canada's largest hospitals and all provincial and territorial health ministries. We included individuals listed on institutional websites as part of the leadership team if a name and photo were available. Six reviewers coded and analyzed the perceived race and gender of leaders, in duplicate. We compared the proportion of racialized health care leaders with the race demographics of the general population from the 2016 Canadian Census., Results: We included 3056 leaders from 135 institutions, with reviewer concordance on gender for 3022 leaders and on race for 2946 leaders. Reviewers perceived 37 (47.4%) of 78 health ministry leaders as women, and fewer than 5 (< 7%) of 80 as racialized. In Alberta, Saskatchewan, Prince Edward Island and Nova Scotia, provinces with a centralized hospital executive team, reviewers coded 36 (50.0%) of 72 leaders as women and 5 (7.1%) of 70 as racialized. In British Columbia, New Brunswick and Newfoundland and Labrador, provinces with hospital leadership by region, reviewers perceived 120 (56.1%) of 214 leaders as women and 24 (11.5%) of 209 as racialized. In Manitoba, Ontario and Quebec, where leadership teams exist at each hospital, reviewers perceived 1326 (49.9%) of 2658 leaders as women and 243 (9.2%) of 2633 as racialized. We calculated the representation gap between racialized executives and the racialized population as 14.5% for British Columbia, 27.5% for Manitoba, 20.7% for Ontario, 12.4% for Quebec, 7.6% for New Brunswick, 7.3% for Prince Edward Island and 11.6% for Newfoundland and Labrador., Interpretation: In a study of more than 3000 health care leaders in Canada, gender parity was present, but racialized executives were substantially under-represented. This work should prompt health care institutions to increase racial diversity in leadership., Competing Interests: Competing interests: Dan Werb reports grants from the Canadian Institutes of Health Research and St. Michael’s Hospital Foundation, as well as a pending patent for a drug-checking device, outside the submitted work. Gillian Hawker is supported as the Sir John and Lady Eaton Professor and Chair of Medicine. Amol Verma reports salary support from the AMS Healthcare Fellowship in Compassion and Artifical Intelligence and the St. Michael’s Hospital Clinician–Surgeon Scientist Stipend Award, as well as part-time employment with Ontario Health as Provincial Clinical Lead for Quality Improvement in General Internal Medicine. Fahad Razak holds a salary award as the Graham Farquharson Knowledge Translation Fellow from the PSI Foundation and is an employee of Ontario Health. All competing interests exist outside the submitted work. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)