Inequities in mental health outcomes in Chile
According to the Burden of Disease and Attributable Burden Study (Estudio de Carga de Enfermedad y Carga Atribuible) conducted in 2008 by the Ministry of Health of Chile, 23.2% of the Years of Life Lost because of disability or death were due to neuro-psychiatric conditions [37]. In 2016, the OECD attributed 25.5 deaths per 100,00 inhabitants to mental and behavioural disorders in Chile [38] and for the same year, the suicide rate was 10.7 per 100,000 inhabitants [39]. However, the burden of disease and prevalence of disorders described in the data presented in the previous paragraph may not be shared equally among the population, and inequities in mental health outcomes can originate from different, sometimes interacting layers of social vulnerability. This section examines the main social determinants of mental health and the dimensions of social vulnerability in Chile identified in the existing literature.
Dimensions of social vulnerability and inequities of mental health outcomes
With regards to demographic characteristics, it seems that in Chile, gender, and particularly being a woman is a determinant of mental health status, as women are two to three times more at risk of developing suicidal behaviour [40]. Furthermore, women tend to use the psychiatric sick leave provision of FONASA more than men, and their leave periods are 12% longer on average [41]. With regards to age, the prevalence of psychiatric disorders is high among children and teenagers [42].
In line with existing global evidence [43], socioeconomic background and status seem to act as a social determinant of mental health in Chile, as socioeconomic status was found to be significantly associated with a low prevalence of anxiety disorders [42], and a higher prevalence of common mental disorders was found among the most socially disadvantaged groups, in particular after a recent income drop [44]. More specifically, with regards to education, there is a strong inverse association between educational attainment and the prevalence of common mental disorders and there is an inverse relationship between levels of education and suicidal behaviour, and between income and suicidal behaviour [40].
Another aspect of social vulnerability, beyond socioeconomic background and status is social capital. In the Chilean context of a highly unequal society with a rigid social and occupational class structure [45], social capital is positively associated with job market attainment, and there is a relationship between socioeconomic background, social capital, and status attainment through direct and indirect associations [46]. More particularly, social capital, can be used as an “umbrella term” encompassing social cohesion, support, integration and participation and has been positioned among the social determinants of physical and mental health [47]. Under that broad definition, the relevance of social capital for mental health can be brought back to Durkheim’s study of suicide and the notion of social suicide rate, whereby suicide rates can be explained in relation to social integration [48]. In general terms, regarding the effect of social capital on mental health status and the effect of mental health status on social capital, Sartorius highlights the effect that social capital might have on low self-esteem and self-confidence as a consequence of mental disorders [49]. A systematic review of primary research found that individual social capital, usually measured through individuals’ participation in social relationships and perceptions of the quality of these relationships, tended to be negatively assessed by respondents suffering depression and anxiety disorders. Conversely, at ecological level, there is no clear evidence of an inverse relationship [50]. While few studies regarding the general population in Chile have been conducted, there is evidence of strong associations between social capital indicators and depression [51], and of a positive relationship between social capital and mental health status in low-income urban communities, suggesting that social capital has indeed an impact on mental health [52].
With regards to occupation and mental health, retail workers in Chile are the most likely to ask for sick leave for psychiatric reasons, while construction workers are the least likely to do so [41]. In the domestic work sector, poor mental health among female domestic workers is linked to self-esteem and the perception they have, and are given, that their work is undervalued and shameful [53]. This becomes relevant especially in relation with the evidence presented on socioeconomic background and social capital.
The existing literature in Chile provides us with a context on the inequities of mental health outcomes where variables such as gender, age, socioeconomic background, social capital and more specifically occupation create what we can call “layers of social vulnerability”. Having examined the inequities in mental health outcomes, we can now turn to describing the evolution of the Chilean Mental Healthcare Model.
Evolution of the Chilean mental healthcare model
National mental health programmes and plans: towards a community approach to mental health in primary healthcare
In line with the Caracas Declaration of 1990, WHO recommendations, as well as standards of human rights, the Chilean mental healthcare system is largely decentralised, based on community mental health teams [54, 55] and integrated in primary healthcare [56]. Efforts to address the mental health of the general population in Chile started in the 1960s with the launch of the National Mental Health Programme (Programa Nacional de Salud Mental) and subsequent initiatives to implement programmes of community-based psychiatry [57], which were interrupted by the military coup of 1973 [58].
After democracy was re-established in 1990, the government took measures aimed at reinforcing the healthcare system and put emphasis on the social and psychological dimensions of health, with the creation of the Mental Health Unit in the Ministry of Health and a network of mental health professionals [59]. Additionally, the need to address mental health more widely and systematically came into light through surveys aimed at primary healthcare users undertaken in the early 1990s [56]. This culminated in the approval, in 1993, of the First National Mental Health and Psychiatry Plan (Primer Plan Nacional de Salud Mental y Psiquatría), which established the basis for the integration of mental healthcare in primary healthcare [59].
The 2000 Mental Health and Psychiatry Plan (Plan de Salud Mental y Psiquiatría) was built upon the experience and approach of the previous Plan in terms of the integration of mental healthcare in primary healthcare [60] and decentralisation through the strengthening of networks of healthcare centres providing mental healthcare [54]. This focus on providing mental healthcare through primary healthcare allowed to expand its reach [55] and increase the detection, diagnosis and treatment of mental disorders [54]. Additionally, the inclusion of mental healthcare in primary healthcare was taken a step further with the National Depression Treatment Programme of 2001 [61, 62]. In that sense, mental health policy was aligned with the main recommendations of the WHO World Health Report 2001 – Mental Health: New Understanding, New Hope [63], which stressed the importance of primary healthcare and the community approach to mental healthcare [64].
The current National Mental Health Plan, the Plan Nacional de Salud Mental 2017–2025 launched in 2017, introduces seven strategic lines of action aimed at improving alignment with standards of human rights, defining guidelines and strategies to improve access to mental healthcare according to the needs of the population; developing a plan for sustainable and efficient funding for the implementation of programmes to promote mental health; improving systems for quality management, monitoring and investigation; increasing the amount of mental healthcare workers and improving their work conditions; promoting the participation of civil society in policy-making; and promoting an intersectoral approach to mental health. The Plan emphasises the community-based approach to mental healthcare as well as adherence to standards of human rights [37].
The inclusion of mental healthcare in broader health policy
In the last 15 years, broader healthcare policies and policy instruments have also explicitly included mental healthcare, such as the Chile Crece Contigo programme in 2008, which includes the promotion of mental health from pregnancy until the child is 9 years old [32]. With regards to general health, the National Health Strategy 2011–2020 (Estrategia Nacional de Salud para el Cumplimiento de los Objetivos Sanitarios de la Década 2011–2020) also includes, among 50 health goals, four goals related to mental health [65].
Although there is no specific law for the promotion of mental health, several existing laws address issues linked to mental health [66]. In terms of access to mental healthcare, the 2004 Law N°19.966 on AUGE and GES stands out, as it guarantees that both the public and private insurance schemes must ensure basic treatment for 80 prioritised illnesses, among which schizophrenia, depression, alcohol and drug abuse and bipolar disorder [56, 65,66,67]. Access to treatment for depression increased after the introduction of AUGE/GES, especially among women and socioeconomically disadvantaged groups [68].
Persisting gaps: funding, social determinants of mental health and inadequacy
Funding and prioritisation
In the context of the segmented healthcare system, lack of financial resources allocated to mental healthcare is a recurring topic among the existing literature on mental healthcare in Chile [63, 67, 69,70,71]. Particularly with regards to the public system, the WHO-AIMS 2014 report on the Chilean Mental Healthcare System reported that the percentage of the healthcare budget allocated to mental healthcare was 2.16% in 2012, whereas the average in upper-middle income countries was 2.38% and 5.10% in high income countries [66].
On the other hand, mental healthcare specialist Alberto Minoletti and colleagues show the progress made in terms of funding for mental healthcare. The allocation of specific funds for mental health in primary healthcare since 2000 allowed for programmes to be rolled out all over the country and to reach parity of mental health funding mechanisms with regards to physical health in primary healthcare since 2015. However, they admit that funding remains insufficient [60]. Moreover, it is important to note that the issue is not limited to the public sector, as most plans in the private health insurance system offer a much more modest coverage for mental healthcare than physical healthcare [65].
Beyond lack of financial resources, the AUGE/GES has been criticised for the inequities it might unintentionally create, as the prioritisation of certain diseases represents the “rationing” of the right to health [14]. Only four mental disorders are currently included among the 80 diseases prioritised, and only half of the disorders that had been prioritised in the 2000 Mental Health Plan is covered by AUGE/GES [65]. In that sense, mental health does not appear to be a priority and equal access to treatment is limited.
Finally, the Mental Health Plan for 2017–2025 recognises the urgent need for a Mental Health Law in Chile in order to bring together and harmonise the existing norms, promoting the social inclusion of people with mental diseases, community-based mental healthcare, and intersectoral measures to address the social determinants of mental health, in line with human rights standards and principles [37]. According to the Plan, provisions should also be made regarding the funding of mental healthcare in order to fill the existing gaps in terms of promotion, prevention, diagnosis, treatment and recovery, eliminate discrimination based on affiliation to the public or private sector and ensure that mental disorders be given the same priority as other disorders.
Scarcity of funding is not a standalone factor however and the existing literature also points to the intersection between structural and individual factors that determine access to mental healthcare in the context of a segmented healthcare system.
Social vulnerability and segmentation: social determinants of access to mental healthcare
Following the social determinants of health framework, policies and contextual factors at national level can exacerbate social vulnerability at individual level, when for instance, eligibility for a more comprehensive healthcare insurance is directly linked to wealth and health status, as is the case in the Chilean segmented system, which leads most of its critics to focus on the inequities created by segmentation.
In that sense, with regards to inequities in mental healthcare, data from the 2010 National Health Survey (Encuesta Nacional de Salud, ENS) shows that 21% of patients suffering depression were receiving antidepressant treatment at the time of the survey, and 48.9% had received treatment at some point in their lifetime [72], suggesting a gap between needs and treatment. However, this gap may not be experienced equally by everyone, with differences in consultation rates between patients covered by public FONASA and private ISAPRE, which are in turn greater among those with the most severe symptom or a high degree of disability [7], as well as geographical inequities, where the “level of accessibility, quality of care and the community orientation depends primarily on where a person lives (page 765)” [55].
Considering the segmented healthcare system, and the fact that those who might not have access to private ISAPRE due to low income as well as higher health needs, have, to borrow Araya et al’s words, “little choice other than to remain in the underfunded public sector, where they are least likely to receive professional help (page 113)” [7]. Finally, other cultural factors, such as stigma towards mental illness [73], which might have an effect on seeking and accessing treatment especially within lower-income groups [74] or the idea that mental health might be seen as a private issue which should be dealt with by the individual and their family, rather than becoming a policy priority [65].
Access to mental healthcare is thus inequitable and conditional to several, sometimes intersecting social determinants. Furthermore, access does not necessarily guarantee the adequacy of the service and treatment received.
Inadequacy of mental health services
Mental healthcare in Chile is largely integrated in primary healthcare, which arguably improved access, considering that FONASA beneficiaries receive free mental health attention in primary healthcare centres [70]. There is, however a lack of strategy for monitoring quality and promoting improvement within primary healthcare, meaning that some patients might receive inadequate treatment with regards to both their needs and the existing scientific evidence [56, 60]. There is, additionally, a lack of efficient monitoring mechanisms to follow-up clinical outcomes and adherence to treatment [60].
Although broadly promoted at policy level, the community approach to mental healthcare is limited in practice, as there is a lack of agency and participation of the communities involved and a subsequent lack of utilisation of local and cultural resources and knowledge to improve mental healthcare [56], as well as limited approach to wider social interests in the democratisation of mental healthcare [75]. Furthermore, psychologists in primary healthcare centres find themselves focusing on their daily work and immediate individual assistance, with little space left for a more holistic approach around prevention and protection including family members, communities and risk groups [76].
In terms of the adequacy of therapy, it is important to note that although the AUGE reform and GES law have been praised for improving access to treatment, they include pre-established protocols for the treatment of the prioritised diseases. In that sense, although a patient might be diagnosed with one of the four prioritised mental health diseases, they might require a different treatment than that specified in the protocols [15]. For instance, the treatment for schizophrenia defined in the 2005 guide established by the Ministry of Health was mainly centred on antipsychotic drugs while psychosocial interventions were administered complementarily [77], and although the guide was updated in 2017, clinician’s adherence was higher for the former than for the latter in the application of the 2005 guide [72]. In that same line, a highly biomedical and individual approach to mental healthcare remains, and the role of social determinants of health in mental health status and outcomes is underplayed, despite efforts to integrate it into community-level healthcare [78].
Despite incremental policy efforts to increase funding for mental healthcare in the public system and reduce barriers to access to care for a number of mental health disorders through the implementation of AUGE/GES and the expansion of the network of mental health professionals in primary healthcare, the Chilean mental healthcare model displays persisting gaps for equitable access due to the exacerbation of social vulnerability in the context of a segmented health insurance system and the inadequacy of certain aspects of the delivery of mental healthcare. In this context, social determinants of health have an effect on both mental health status and access to mental healthcare.
Inequities in mental health outcomes for international migrants in Chile
Although the pre-departure and transit phases are crucial in determining the mental health outcomes of migrants, the data on the socioeconomic background of international migrants prior to their departure to Chile is scarce and so is the work on conditions of transit. In that sense, our review focuses on processes of acculturation in the receiving country and their link with mental health. Following the concept of social layers of vulnerabilities, international migrants may experience the factors leading to inequities in mental health outcomes described in the dedicated section for the general population in Chile. The factors described here are specific to international migrants and are considered in addition to the other social determinants of mental health in Chile.
Acculturation and mental health outcomes
The concept of acculturation is defined by Berry as the cultural changes resulting from the encounter and processes of adaptation of individuals who have developed in a given cultural context in a new context as a result of migration, as a result of which individuals might experience psychological acculturation, or psychological changes [79]. Acculturation strategies are integration (retaining the culture of origin while adopting the host culture), assimilation (withdrawing from the culture of origin and adopting the host culture), separation (retaining the culture of origin and rejecting the host culture) and marginalisation strategies (rejecting both cultures) [80, 81].
These strategies result from two attitudes towards acculturation: striving for cultural maintenance or the extent to which contact and participation are considered, which in turn can be determined by the attitude of the “receiving” group towards the other, one of which can be discrimination [79]. In turn, acculturation strategies can have an impact on mental health status, in the form of acculturative stress as defined by Berry et al. as a reduction in psychological health status at individual level as a result of processes of contact with the “dominant group”, or society of settlement [82, 83].
A systematic review of papers on common mental disorders among immigrants around the world was conducted, and its results indicated that the prevalence of these disorders increases with perceived discrimination and low levels of acculturation, among other factors [84]. The link between discrimination and the mental health of immigrants and ethnic minorities has been defined around variables such as time since arrival [85], ethnicity [86], and the experience of discrimination and humiliation [87, 88].
Discrimination, acculturation strategies and mental health in Chile
In the case of Chile, several studies highlight this link, and international migrants may experience both social vulnerability, reporting discrimination, and psychosocial vulnerability, with symptoms of anxiety and depression [89]. One of them, focused on Peruvian migrants in Santiago, found that perceived individual discrimination was a stressor and determinant of poor mental health, especially for women [90]. There is, furthermore, a positive relationship between discrimination and anxiety and depression, as found among Peruvian and Colombian migrants in Arica, Antofagasta and Santiago, which can however be mitigated by self-esteem [91].
In relation with acculturation, integration can lead to better psychological wellbeing, and assimilation can lead to better overall wellbeing, as found among South American migrants in Antofagasta y Calama in Northern Chile, albeit with differences among nationalities [92]. With regards, specifically, to strategies of acculturation and mental health, a study found that Peruvian migrants, who usually employ strategies of assimilation or bicultural integration, tend to display more symptoms of common mental disorders than Colombians, who employ strategies of separation. This is explained by the difference in terms of the possible negative experience of discrimination and rejection that migrants who choose to assimilate or integrate might face when in contact with the mainstream local culture [93]. A similar study found that sources of acculturation stress include discrimination and perceived rejection, as well as other factors of social vulnerability [94].
No comparable study exists to date about Venezuelan and Haitian immigrants in Chile, although they now constitute two of the main groups of international migrants in the country following recent waves of migration. However, Rojas Pedemonte et al. describe strategies of avoidance and negation of racism and exclusion by Haitian migrants in Santiago [95]. Further research on possible impacts on mental health could be conducted for these specific groups.
Evolution of the policies for migrants’ access to mental healthcare in Chile
International migrants’ right to health care in Chile
All foreigners with a valid residence permit have access to healthcare in Chile [96], however their affiliation to either the public or the private system depends on health status and wealth, as for the Chilean-born population. The first direct measure taken towards the inclusion of migrants into healthcare regardless of legal status was the Oficio Circular N°1.179 of 2003 granting access to undocumented pregnant women through a specific visa [97]. A more recent breakthrough is the Decree N°67 (Decreto N°67) that came into force in June 2016, giving irregular migrants equal access to FONASA with regards to nationals if they have no source of income [4].
As immigration peaked in Chile, with 438,223 residence permits granted in 2018 [16] and migrants’ health as a matter of public health gained more attention, the Ministry of Health launched the International Migrant Health Policy (Política de Salud de Migrantes Internacionales) the same year. The Policy recognises migration as a social determinant of mental health in terms of the discrimination migrants suffer in Chile, the negative narratives around migration, as well as the loss of family relationships and difficult living and working conditions. In that sense, it specifies the inclusion of migrants as a group whose members might experience different forms of social and socioeconomic vulnerability into strategies for the promotion of mental health in one of its strategic guidelines on the inclusion of international migrants’ health into public health programmes and interventions [98].
Addressing the mental health of international migrants
The International Migrant Health Policy recommends developing cross-cultural capacities to improve mental healthcare for this particular group. Moreover, the current National Mental Health Plan (Plan Nacional de Salud Mental 2017–2025) recognises that mental healthcare must consider the inclusion of a cross-cultural approach more specifically for Native communities (pueblos originarios), while highlighting the inclusion of cross-cultural and language facilitators in primary healthcare [37].
Migrants’ access to mental health care in Chile is an emerging topic and the existing literature is relatively limited. However, recent research has described access to mental healthcare and identified the barriers that migrant populations are facing. This strand of literature shows that migrants’ access to mental healthcare is affected both by the systemic gaps in the Chilean mental healthcare system described previously and by the specific barriers to healthcare that they face as foreigners.
Barriers to international migrants’ access to mental health care in Chile
Funding, prioritisation and discrimination: specific challenges for international migrants
The review of the literature on the overall mental health care model in Chile showed that lack of funding and prioritization of mental health was an issue especially for the public sector, although coverage gaps for mental health in the private health insurance system meant that access is limited, overall. For international migrants, there are additional systemic barriers in the overall public health care system, such as lack of information regarding the number of international migrants and their healthcare needs of international migrants, leading to a lack of resources allocated to already underfunded public healthcare centres to address the needs of that specific population group [99]. In that sense, it is possible that both funding gaps intersect to hinder to international migrants’ access to mental healthcare.
With regards specifically to mental health, Astorga-Pinto et al. provide an overview of the main barriers to access faced by immigrants based on a secondary analysis of qualitative data collected between 2014 and 2016 among migrants and healthcare professionals in eight socially and economically vulnerable areas. One of the barriers identified at systemic level and consistently with the literature on mental healthcare in Chile, is the limited availability of mental health professionals as a consequence of low funding, and low prioritisation of mental healthcare [25]. This barrier was also identified in a study conducted with migrant teenagers in 2019 in the Independencia, Recoleta and Santiago boroughs of the Metropolitan Region of Santiago, where the reason given by the interviewees for not seeking mental healthcare or not adhering to treatment, was that it was not adequate quantitatively, in terms of the length and frequency of the therapy sessions received [100].
Low prioritisation of mental healthcare specifically for international migrants may also be reflected in situations of discrimination and complex perceptions of who is entitled to care in a context of scarcity, as international migrants reported perceived discrimination and fear of being turned down when asking for mental healthcare when needed, based on the perception that they cannot claim entitlement to healthcare in Chile, which is in turn linked to a feeling of not fully belonging [25]. Likewise, perceived and real discrimination may be exacerbated depending on country of origin or ethnicity, following patterns of structural racism and anti-immigrant narratives, whereby international immigrants may be hierarchised according to underlying beliefs and perceptions regarding their country of origin, language and ethnicity, leading to health inequities [101]. Further research should however be undertaken with regards to instances of discrimination in mental healthcare, with a special focus on international migrants from different countries and ethnic backgrounds.
Social vulnerability and segmentation: social determinants of access to mental healthcare for international migrants
Regarding the social determinants of health identified in the previous section and their relation to the Chilean segmented healthcare system, female immigrants are more likely to be beneficiaries of the public system than men, 68,4% and 61,7% respectively [21]. Although there has been a decrease in the rate of immigrants reporting having no health insurance, immigrants with disabilities are more likely to report no healthcare or insurance than Chileans, indicating horizontal inequity (less attention and resources despite similar needs). Sociodemographic factors also play a role in the type of provision, with female immigrants living in rural areas being the most likely to be covered only by the most basic provision of the public system [102].
Similarly, socioeconomically deprived immigrants are usually located in areas of the Northern regions of Tarapacá and Antofagasta and the Metropolitan Region of Santiago, where the local population also experiences socioeconomic deprivation [103], which, following the factors of inequities to access to mental healthcare in Chile identified previously, means they may not have de facto access to sufficient and adequate mental healthcare. The first epidemiological study on migrants’ mental health status and access to care in Chile was conducted by Rojas et al. between 2007 and 2008 and focused on adults, youth and children in the Independencia borough in Santiago found that 36% of parents perceiving that their child suffered from a mental disorder reported cost, perception that the issue would resolve itself and lack of knowledge around the Chilean healthcare system as reasons not to seek help. Moreover, when the study was conducted, 30% of the migrants interviewed reported not having access to health insurance, citing this as another important barrier [104]. Considering that that the study was conducted before Decree N°67 came into force, it could be expected that administrative barriers would have been reduced.
There is, however, no evidence that the Decree eliminated all administrative barriers for access to healthcare. In that sense, migrants and health professionals alike report administrative barriers linked to irregular status, despite Decree N°67, as both groups lack knowledge and awareness regarding irregular migrants’ right to access healthcare [105]. Another aspect of social vulnerability linked to migratory status is the fear of deportation reported by international migrants as a reason not to seek mental healthcare [25].
Language and culture as barriers to access and acceptability
Our review on the subsisting gaps in the overall Chilean Mental Healthcare Model identified lack of adequacy and flexibility in established mental health treatments, meaning that patients might receive inadequate treatment with regards to their needs, as well as a limited engagement with the community around patients, in terms of participation, prevention and protection. In that overall context, international migrants experience barriers to access to mental healthcare, which are sometimes linked to their perception of relevance and acceptability of the care provided in terms of culture and language.
The issue of intercultural understanding with regards to mental health may begin even before mental healthcare is delivered. A study carried out in 2016 focused on a programme aimed at promoting access of the migrant population to primary healthcare (Programa de Atención Inicial a Migrantes), found that very few of the programme participants were referred to mental healthcare units despite the fact that they had been assessed for suicidal behaviour and symptoms of depression. A possible explanation put forward by the authors is that there are different conceptions of mental illness across different cultures, whereby international migrants might not find receiving attention necessary [21]. Similarly, but with regards to healthcare in general, there are cultural barriers regarding perceptions and beliefs around health as reported by health professionals [99]. Further research should be carried out with regards to cultural perceptions around mental health in the context of international migration in Chile, and its impact on access to mental healthcare and cross-cultural care.
Language barriers have been identified as a main obstacle to healthcare in general, [99] and are undoubtedly relevant for mental healthcare. Although the majority of international migrants in Chile are native Spanish-speakers, Chilean Spanish is characterised by distinctive colloquial phrases which are used across social classes and usually regardless of the setting, including, in this case during medical consultations, and may not be understood by other native Spanish-speakers [106].
In terms of the adequacy of the care provided, negative perceptions on healthcare, both physical and mental, as reported by international migrants in Chile focus on the lack of cultural pertinence as well as the failure to address their perceived needs. They cited the lack of cross-cultural understanding between themselves and healthcare professionals, leading to misunderstandings and frustration from both sides, as well as the lack of knowledge and training to deliver mental healthcare relevant to the causes of the mental health disorders they were facing, especially factors linked to forced migration [25, 105]. In addition to providing culturally relevant care and improving mental healthcare professionals’ cross-cultural knowledge and approach, mental healthcare should be focused on addressing these specific factors [107].
Although the evidence on barriers to migrants’ access specifically to mental healthcare in Chile is scarce, and there are limitations, especially with regards to instances of discrimination and perceptions of mental health across cultures, in this section we have situated the barriers to migrants’ access to mental healthcare in the overall model of access to mental healthcare and context of migrants’ access to healthcare. The gaps in the overall mental healthcare model described in the existing literature were categorised into funding and prioritisation, social vulnerability and segmentation, and inadequacy of mental health services, and the barriers faced by international migrants to access mental healthcare were categorised the same way in order to identify intersections and highlight the ways in which international migrants may experience specific layers of vulnerability linked to migration as a social determinant of health, nested in a system that exacerbates social vulnerability.