Producing vulnerability: A qualitative analysis of health equity impacts of budget cuts to intercity public transportation - evidence from saskatchewan, Canada

Introduction: Transportation is a critical determinant of health particularly for chronically ill patients yet Canadian evidence on intercity transportation barriers for healthcare access remains scant. In 2017 the Saskatchewan Government eliminated a 70-year-old bus company, the Saskatchewan Transportation Company (STC), as part of austerity measures aimed at saving $85 million. No health equity impact analysis was conducted by the government, yet the bus served 253 communities and provided medical passes for chronically ill patients and families prior to the closure. We explored health equity impacts of the decision and how this decision produces vulnerability for those in marginalized social positions. Methods: Drawing on intersectionality theory and the politics of health, we interviewed 100 former bus riders seeking healthcare and other services and conducted six focus groups with 24 stakeholders including physicians, nurses and Indigenous health system organizations' staff. We used qualitative case study methodology to inform analysis and ensured rigour through a synthesized member checking. Results: Many patients were female (68%) and self-reported living with disabilities (27%). The closure has limited access to specialized care especially for those with chronic conditions such as HIV/AIDS, Diabetes etc. Reduced healthcare access is experienced unequally depending on people's social and geographical locations (gender, age, (dis)ability, geography and ethnicity). The closure produces unique vulnerabilities for patients and community members through five key pathways: the ability to drive, vulnerable geographies, poverty, safety (especially for Indigenous women) and lost freedom (for those with disabilities), and these vulnerabilities are worse for those experiencing intersecting oppressions. Conclusion: Austerity, disinvestment and budget cuts to public transportation create unique vulnerabilities and health inequities. Countries such as Canada, need integrated public transportation systems to promote healthcare access. Transportation-related austerity decisions ought to be assessed through a health in all policies (HiAP) framework to protect vulnerable populations from pathogenic public policies.