Master of Spatial Analysis thesis · Toronto Metropolitan University · 2026
Access Without Fear
Examining healthcare access for migrants with precarious immigration status in Canadian cities
- council & committee transcripts
- 15
- municipalities, 2013–2024
- 9
- healthcare facilities
- 142
- census tracts
- 582
- travel modes compared
- 3
Context
Immigration status exists along a spectrum of security and insecurity, and that position shapes access to healthcare and the other social determinants of health. The thesis looks at two groups along that spectrum.
Study one
Non-status migrants
People with no current legal status, for example those whose permits or visas have expired or whose refugee claims were unsuccessful or withdrawn.
Study two
Non-permanent residents
People with temporary legal status, including international students, temporary foreign workers and refugee claimants.
Research framework
Levesque et al., 2013
Healthcare access framework
- Approachability
- Acceptability
- Availability & accommodation
- Affordability
- Appropriateness
Intersectional lens
How overlapping identities and social positions shape experiences of healthcare access.
World Health Organization, 2010
Social determinants of health
- Employment & income
- Education
- Housing & safety
- Transportation
- Immigration status
- Social inclusion
Study one: how councils talk about it
“Access Without Fear”, often implemented through sanctuary city frameworks, aims to let people use municipal services regardless of immigration status, without fear of being reported to immigration authorities. But responsibility is split three ways: immigration policy and enforcement are federal, healthcare eligibility and delivery are provincial, and local services sit with municipalities.
- Federal Immigration policy & enforcement
- Provincial / territorial Healthcare eligibility & delivery
- Municipal Local services & Access Without Fear
- 01Council & committee meetings
- 02Meeting transcripts
- 03Critical discourse analysis
- 04Thematic coding
- 05Four key themes
- RQ1How is healthcare access for non-status migrants discussed within local governments in Canada?
- RQ2What barriers to healthcare access are identified?
- RQ3How are municipalities responding to these barriers?
Structural & financial exclusion
- Jurisdictional gaps and service exclusion
- Financial and employment barriers
- Preventable illness turned into life or death
Fear & deportation
- Everyday fear and isolation
- Gendered violence
Community & grassroots responses
- Ethnocultural and peer support networks
- Faith-based sanctuary and protection
- Grassroots advocacy
Calls for municipal action
- Concrete municipal action
- Staff training and clear guidelines
- Proactive inclusion and access to services
Community & grassroots responses
I’m here because I’m also aware that every day, my phone number … is the 911 of the undocumented communities. I don’t want to be anymore the 911 number.
Calls for municipal action
The first step is the declaration… The second step is to ensure that this translates into concrete actions at the level of the service offered… and then to help them through the process of regularization.
Key insights
- Policy ≠ access
- Implementation determines whether policies translate into meaningful access.
- Structural & financial barriers
- Eligibility and cost can restrict access to healthcare.
- Fear leads to service avoidance
- Fear of immigration consequences can discourage people from seeking care.
- Community networks provide support
- Community organizations help fill gaps in formal systems.
Study two: who can reach care
Spatial population data aren’t available for non-status migrants, so study two examines non-permanent residents, a census-based population with temporary immigration status. It does so while recognizing that non-permanent residents are not the same as non-status migrants.
- 012021 Census582 census tracts; non-permanent residents and total population
- 02Healthcare supply43 CHCs, 85 walk-in clinics, 14 ERs; weighted by weekly operating hours
- 0315-minute catchmentsWalking, driving and public transit
- 04Two-step floating catchmentCombines supply and demand
- 05Accessibility scoresNon-permanent residents vs total population
- RQ4How is spatial accessibility distributed across Toronto?
- RQ4aHow does accessibility vary by transportation mode?
- RQ4bHow does accessibility vary between non-permanent residents and the total population?
Healthcare accessibility for non-permanent residents by mode (2SFCA score)
Fig. 4Walking: higher accessibility in northern and eastern Toronto.
- correlation between non-permanent resident and total-population accessibility
- r = 0.08
- Moran’s I, non-permanent residents
- 0.25
- Moran’s I, total population
- 0.42
Accessibility is spatially uneven, differs by population, and changes with how people travel. Healthcare accessibility depends on where people live, the population being examined and how they get around.
Bringing the studies together
| Dimension | Study one | Study two |
|---|---|---|
| Context | Non-status migrants in Access Without Fear municipalities · 15 transcripts, 9 cities | Non-permanent residents across Toronto · 582 tracts, 142 facilities |
| Accessibility lens | Affordability · acceptability · accommodation · availability | Accessibility · availability |
| Social determinants | Immigration status · income & employment · housing & safety · social inclusion · education | Transportation · income & employment · housing/location · immigration status |
| Methods | Municipal transcripts · qualitative thematic analysis | 2SFCA · walking, driving & transit · spatial analysis |
| Key finding | Structural barriers and fear can prevent people from using services even when they exist | Geography and transportation can limit people’s ability to reach available services |
What it means in practice
Municipalities
Clearer guidelines, staff training and implementation practices can strengthen Access Without Fear policies and support safer access to services.
Healthcare & service providers
Spatial patterns can help identify where additional services, outreach or better connections may be needed.
Planners & transportation agencies
Differences across walking, driving and transit show that facility location alone does not determine accessibility.
Community organizations
Recognize and support organizations that help migrants navigate healthcare and respond to structural barriers.
Limitations
- Population data
- Non-status migrants are not captured directly.
- Potential accessibility
- Does not measure actual healthcare use.
- Healthcare supply
- Operating hours do not capture provider capacity.
- Model assumptions
- A fixed 15-minute catchment.
Future research
- Lived experiences
- Interviews with migrants and providers.
- Better supply data
- Provider capacity and services offered.
- Alternative methods
- Different catchments and accessibility models.
- Wider scope
- Other cities and time periods.