Migration status is a social determinant of health that is intimately associated with healthcare provision entitlement in Chile and Latin America. Access to healthcare is the result of a complex group of determinants. It depends on the extent to which a society is able to create an environment that supports immigrants to overcome the socioeconomic and the cultural or psychological barriers that may limit people's ability to receive care[45, 46]. This study finds evidence that some international immigrants in Chile continue to be exposed to socioeconomic risks for health and, even after the equity-centred healthcare reform of 2003, experience limitations to adequate use of healthcare services. The associations between migration status, SES and access to healthcare were substantial. Distinctive patterns in entitlement to different healthcare provisions and the use of primary care services were found among immigrants by SES in this study.
This study indicated an increase in self-reported immigration status in Chile between 2006 and 2009, an increase in the proportion of male immigrants and an increase in income inequality between extreme quintile groups among immigrants. There was a decrease in the rate of immigrants reporting no healthcare provision over time, and an increase in reporting of private healthcare provision entitlement. In contrast to what might have been expected, the international immigrant population reported higher rates of use of several primary services and no difference in the use of the Pap smear programme or the number of attentions received in the last three months than the Chilean-born. They reported, however, a lower use of well-baby care. It is possible that a lack of such services in the countries from which migrants originate mean that they are less likely to make use of these services when in Chile. It is also possible that pregnant immigrant women prefer to return home to deliver their babies and therefore use less well-baby care than might be expected.
Significant differences in healthcare provision entitlement were found between the immigrant and Chilean-born populations living in the poorest income quintiles. Immigrants in the bottom income quintile were around four times more likely to report no healthcare provision than the Chilean-born and this was consistent across 2006 and 2009 surveys. Disabled immigrants were also more likely to have no healthcare provision compared to the disabled Chilean-born. In addition, a range of socio-demographic factors were associated with the type of healthcare provision immigrants were entitled to, including sex, urban/rural status, education and country of origin. Factors associated with the use of the Pap smear programme service among immigrants were marital status and contractual status.
There was no increase in the proportion of female immigrants coming to Chile over time. Female immigrants, however, continue to experience significant limitations to their access to healthcare. They were more likely to be entitled to the public free of charge provision type than men, which is by definition a measure of absolute poverty. A large proportion of immigrants in the poorest income quintile were women and almost all immigrants working in domestic services were women. Even though immigrant women seemed to use most primary care services at similar rates to Chilean-born women, they appeared to consistently use the well-baby care programme less frequently, despite reporting about four times more use of antenatal care than the Chilean-born.
There is a growing interest in the migrant female population worldwide and in the region, as their vulnerability to socioeconomic deprivation, discrimination and ill-health has been confirmed on several occasions[47, 48]. There are some studies of the deskilling effects of migration among women in Latin America, for example Bolivians in Argentina and Latin migrants in London. Further analysis needs to be conducted to disentangle the complex relationship between gender, migration, SES and access to and use of healthcare services in Chile and the Latin American region, and how they then relate to health status and perceived wellbeing. This study provides the first repeated cross-sectional analysis on access to and use of healthcare among immigrants in Chile using population-based estimations, and could be expanded to understand further gender issues in the future.
One of the most salient findings from this study was the close relationship between SES and access to and use of healthcare among immigrants in Chile, a similar pattern was also found for the Chilean-born population. Household income, educational level and contractual status were the most prominent dimensions of SES associated with the outcome variables of interest. Educational level was a significant factor associated with healthcare provision entitlement and use of healthcare services in this study. Proposed explanations of the association between greater education and use of healthcare are likely to include better health knowledge and better ability to navigate the healthcare system. Those with higher educational attainment may also have more social contact with physicians, both in university and afterward, than those with lower educational attainment. Preferences and expectations play an important role in accounting for the variation in the use of specialist services between those in high and low social position[52, 53]. In this sense, the less educated or poor may be less able to express their need for care. In addition, those in higher social positions may have different attitudes about the benefits that can be realised by accessing care and so may be more motivated to seek opportunities. It is possible then, as stated by Dunlop et al., that those with higher SES can access and thereby benefit more effectively from the health care system than those of low SES.
Although people who migrate are often healthier than native-born residents because of the various selection processes they face, migrants are usually exposed to health risks. Moving to an unfamiliar environment does affect access to healthcare services[55, 56]. A growing body of literature indicates that immigrants face individual, socio-cultural, economic, administrative, and political barriers when using health services[57–59]. These can be formal barriers (language, geographical distance, complexity of the structure and processes of the healthcare system) or informal ones (less tangible barriers like perceived discrimination)[60, 61]. Providers' attitudes have also been reported as perceived barriers by immigrants and studies have pointed out that stereotypes about migrants' health held by providers often stand in the way of providing the best quality care[57, 62, 63]. Immigrants, on the other hand, may have different expectations of health and perceptions of appropriate care, based on experiences with the health system in their country of origin. Most of these factors have been reported among Latin American migrants in the region and elsewhere. Such evidence comes predominantly from small qualitative studies and this study complements those data with population-based estimates of relevant demographic and socioeconomic factors associated with access to and use of healthcare by immigrants in Chile.
Findings from this study need to be interpreted cautiously in at least two key aspects. First, we have compared two separate surveys, the CASEN 2006 and 2009. These datasets allow us to explore general migration patterns at different time points, but not to follow the same individuals through this period of time as longitudinal analysis would do. Therefore, we cannot assume that changes in patterns between 2006 and 2009 represent changes within the same individuals, but only to the populations under study as a whole. Second, those that preferred not to report their migration status in both surveys were excluded from this analysis. They might represent undocumented immigrants in fear of prosecution and, hence, might experience very different patterns of access to and use of the healthcare system[65–67].
According to Dias et al., understanding the issues related to migrants' health and their utilization of healthcare services is challenging because of gaps in databases, heterogeneity of immigrant populations, and uncertainty about how migration affects health. This study has important strengths but also some limitations. Due to the cross-sectional nature of this study, we cannot determine whether migration is a cause of poor access to some healthcare provision or well-baby care. Nonetheless, the causal relationship between migration and access to healthcare has been considered extensively in past decades, and some evidence suggests a link between them[68, 69]. There is also the risk of self-report bias in this study, not only in relation to migration status, but also SES and other measures. Although some limitations of these measures have been recognized in recent decades, they are considered robust measures and are widely used in health research. Findings from this study cannot be extrapolated to the 15% of the population that did not respond to the CASEN survey. Issues related to recruiting hard to reach populations, including undocumented immigrants, will need to be considered by this survey in the future[71, 72]. Also, we do not have information on second generation immigrants. For that reason, acculturation processes across generations of immigrants will not be captured in this study, as second generation immigrants might experience larger acculturation effects than first generation ones. This in turn might create diverging health-risk factors that will need to be taken into account separately when such data is available.
The relationship between SES and healthcare provision entitlement among immigrants appears to be significant, however, other factors should also be included in analysis in the future in order to better understand this link, such as legal status, health status, stigma and discrimination, and others[52, 57, 73–75]. The Chilean health care system does not provide full universal coverage irrespective of migration status. This is a major issue to tackle in the country, especially for well-baby care that showed very low use rates among immigrants, but it is not likely to be sufficient to solve inequity in healthcare. International research suggests that the introduction of universal coverage better supports the distribution of healthcare services according to need, but it does not solve inequity and remove socioeconomic gradients in use. Glazier et al. found that universal health insurance appears to be successful in achieving income equity in primary care, but not in specialist care. Moreover, even in countries where access to health care is guaranteed, immigrants do not always take full advantage of services available[57, 59, 63]. Equal access for equal need presumes that individuals are given equal opportunities to access services. Inequity in utilization may not solely reflect inappropriate or unfair differences in service use, as utilization is affected by personal characteristics such as individual preferences, expectations and beliefs, and past experiences of stigma and discrimination[76, 77]. There is much more to untangle, understand and improve in this field.