Healthcare access depends on where services exist and whether people can reach them. Traditional models concentrate care in hospitals and large clinics, often in central locations that serve those with transportation and time but fail those without. Community clinics embedded in neighbourhoods and mobile units that bring care to people offer alternatives that can reach populations underserved by conventional healthcare infrastructure.
The Access Gap
>Not everyone can easily reach traditional healthcare facilities. Transportation barriers—no car, limited public transit, inability to afford fare—prevent many from reaching appointments. Physical barriers in healthcare buildings exclude people with mobility disabilities. Hours of operation that assume non-working patients exclude those who can't take time off. Cultural barriers make clinical settings unwelcoming for some populations.
>The access gap falls unevenly. Rural and remote communities may lack nearby healthcare at all. Low-income urban neighbourhoods may have fewer healthcare resources than wealthy areas. Indigenous communities, immigrant populations, and other marginalized groups face access barriers reflecting historical and ongoing exclusion.
>The consequences of access gaps are health consequences. Delayed or forgone care leads to worse health outcomes. Conditions that could be managed with timely care become emergencies. Prevention that requires regular contact doesn't happen. The access gap is a health gap.
Community Health Centres
>Community Health Centres (CHCs) provide primary care embedded in communities they serve. They typically operate on salary models rather than fee-for-service, which aligns provider incentives with patient needs rather than visit volume. They often provide services beyond clinical care—health promotion, social services, community development.
>CHCs in Canada emerged from community movements in the 1960s and 70s. Ontario has the most developed CHC system, but community-based primary care exists across provinces in various forms. Funding models and governance structures vary, but the principle of community-embedded care is consistent.
>The CHC model serves marginalized populations particularly well. By locating in underserved communities, providing integrated services, and engaging community governance, CHCs reach people who fall through gaps in mainstream healthcare. Populations that distrust conventional healthcare may engage with CHCs that reflect their communities.
>Interprofessional teams in CHCs provide comprehensive care. Physicians, nurse practitioners, nurses, social workers, dietitians, and other professionals working together can address health needs that single-provider practices can't. This team approach is especially valuable for complex needs.
Mobile Health Services
>Mobile health units bring care to where people are rather than requiring people to come to care. Vehicles equipped for clinical services travel to underserved areas, providing care at locations accessible to people who can't reach fixed facilities.
>Mobile units serve various purposes. Some provide primary care—checkups, vaccinations, chronic disease management. Others focus on specific services—dental care, vision screening, tuberculosis testing. Some target specific populations—people experiencing homelessness, rural communities, Indigenous communities.
>The mobile model has advantages. It eliminates transportation barriers entirely. It can reach communities too small to support permanent facilities. It can respond to changing needs by changing routes. It can provide care in familiar settings that people find less intimidating than clinical environments.
>Limitations exist too. Mobile units can't provide all services that fixed facilities can. Continuity of care is harder when providers aren't always present. Space and equipment constraints limit what's possible. The efficiency of fixed facilities may exceed mobile alternatives.
Indigenous Community Health
>Indigenous communities face particular healthcare access challenges. Many reserves lack adequate health facilities. Jurisdictional complexity between federal and provincial responsibility creates gaps. Historical trauma makes healthcare systems unwelcoming. Cultural differences affect what care is appropriate and acceptable.
>Indigenous-led healthcare services address these challenges. Nursing stations on reserves provide basic care locally. Indigenous health centres in urban areas serve Indigenous people in culturally appropriate ways. Traditional healers provide care that Western medicine doesn't. Self-determination in healthcare means Indigenous communities defining what health services they need and how they should be delivered.
>Funding for Indigenous health remains a contested issue. Federal funding through Indigenous Services Canada doesn't always meet needs. The principle of Jordan's Principle—that jurisdictional disputes shouldn't delay services for Indigenous children—represents acknowledgment that funding gaps have harmed Indigenous health.
Rural and Remote Healthcare
>Rural and remote communities face fundamental healthcare access challenges. Population density doesn't support the same infrastructure urban areas have. Healthcare professionals are harder to recruit and retain. Distance to specialists and hospitals can be enormous.
>Creative solutions serve rural needs. Telehealth extends specialist access across distance. Nurse practitioners and other extended-scope practitioners provide care that physician scarcity would otherwise prevent. Volunteer transport programs help people reach distant services. Community paramedicine models expand the role of emergency services to include preventive care.
>The northern healthcare reality is especially stark. Nunavut, Northwest Territories, and Yukon face access challenges unmatched in southern Canada. Air transport is often required for specialized care. Recruitment of healthcare workers to remote northern communities is a chronic struggle. Northern residents face healthcare access inequities that reflect broader northern challenges.
Integrating Services
>Community clinics often integrate health services with social services, recognizing that health determinants extend beyond clinical care. Housing assistance, food programs, income support navigation, and social connection all affect health. Integrating these with clinical care serves people more holistically.
>Wrap-around services at community clinics can address barriers to care itself. Childcare during appointments, transportation assistance, translation services, and help with forms and paperwork all enable care access that the clinical service alone doesn't guarantee.
>Mental health integration is particularly important. Community clinics that include mental health professionals provide access to mental healthcare that standalone mental health services may not achieve. Co-located services reduce barriers to mental health help-seeking.
Funding and Sustainability
>Community clinics and mobile units require sustainable funding that fee-for-service models don't provide. Capitation funding (payment per patient), global budgets, or grant funding can support community-based care that doesn't fit physician-billing models.
>Start-up costs for mobile units—vehicle purchase and outfitting, equipment—require capital funding that operating budgets may not cover. Ongoing operating costs depend on service volume, routes, and staffing models.
>Competition for healthcare dollars means community-based alternatives compete with hospitals and specialists for limited funds. Advocating for community health investment requires making the case that preventive community care saves costs downstream—a case with evidence but not always political traction.
Community Governance
>Community health centres often include community governance—boards that include community members influencing service direction. This governance model keeps services accountable to communities served rather than only to funders or professional hierarchies.
>Meaningful community governance requires capacity-building. Community members may need support to participate effectively in healthcare governance. Power dynamics between professionals and community members must be managed. Governance structures must enable rather than merely symbolize community voice.
>Community engagement beyond governance—advisory committees, feedback mechanisms, participatory program design—extends community voice throughout operations. Services shaped by community input reflect community needs better than services designed externally.
Questions for Reflection
>How should healthcare resources be distributed between centralized facilities with comprehensive services and distributed community-based care with better access? What principles should guide this allocation?
>What services should mobile units prioritize? Primary care, dental, vision, specific screening programs, or combinations based on community need?
>How can community governance of health services be meaningful rather than tokenistic? What conditions enable genuine community voice in healthcare decisions?