Canada is known for its publicly funded health-care system, offering services to all citizens - but access is far from universal.
Disparities are especially evident when it comes to reproductive health care, including services related to sex, reproduction and gender-related care.
"We like to think we have one health-care system, when in reality we have 13," says Jenna Quelch, a University of Toronto PhD candidate studying the differences in funding and access to gendered health services across provincial and territorial borders.
"The provinces and territories design their own systems: they decide what will be covered."
Quelch, who is pursuing her PhD in the department of political science in the Faculty of Arts & Science with a collaborative specialization in public health policy at the Dalla Lana School of Public Health, says people are often surprised by the variation in what each jurisdiction considers worth funding. Gender-affirming care, for instance, is covered across the country, but the specific services included under that umbrella vary from place to place.
Take fertility, for example. "B.C. recently announced that it's going to be funding in-vitro fertilization (IVF)," Quelch says. "But Ontario's been funding it for years, so has Quebec. And Alberta doesn't fund it at all."
Abortion, while theoretically available nationwide, has significant practical barriers. In Prince Edward Island, the procedure was unavailable until 2017 - nearly 30 years after it was decriminalized in Canada. Access to Mifegymiso, the brand name for the abortion pill in Canada, also varies. While most provinces cover it, people in some areas may have to pay out of pocket or rely on private insurance.
What explains these differences? Quelch's research points to a range of factors.
"Procedures such as IVF, gender-affirming care and abortion are contentious," she says. "These are things that can be prickly politically and contested medically. Depending on what province you live in, you're going to have a pretty different level of access to health care, especially for those services that are linked to the reproductive body."
But it's not just about which political party is in power. Quelch notes that both B.C.'s NDP government the conservative Saskatchewan Party have recently introduced policies to fund IVF, albeit through different mechanisms.
Other factors include a nationwide doctor shortage and the rural-urban divide.
"A small town like Celista, B.C. is not going to open an IVF centre - and that makes sense," Quelch says. "It's very expensive: You need the technology and you need specialists. And there's a shortage of these things. So, this is not something that's going to be accessible everywhere.
"That said, some provinces do a good job with travel funding, so that people who live in smaller places can get to these clinics if they need to."
Quelch's research aims to provide a comprehensive look at health-care services across Canada and explore the reasons behind existing gaps.
"I first built an index to capture what the variation looks like - scoring provinces and territories and using policy documents to piece together a map of the health-care landscape, province to territory. Until now, research has been sort of piecemeal, with one thing studied at a time.
"We don't currently have a big-picture view."
She then conducted a survey of health-care consumers. "We got about 2,000 responses across six provinces, trying to quantify how people understand medical necessity when it's linked to women's health or reproductive health care," she says.
"And coming this fall I'll interview policymakers to see if that group understands medical necessity the same way. How did a province or territory decide to fund something? Are they getting pushed by other political parties? Are provinces and territories learning from each other?"
Quelch hopes her work will become a resource for policymakers.
"I'm cognizant that our health-care system is under a lot of strain and Canadian provinces and territories are trying to get their dollars in the right place," Quelch says.
"But these are procedures that can change your identity, and what your family looks like. I think the fact that we're seeing so many gaps in reproductive health care speaks to the fact that these issues have to be looked at more thoughtfully."
