Towards sustainable mental health access: identifying mechanisms of the inverse care law

Abstract Background Even universal health systems based on free and equal access face challenges with accessibility and usability. The inverse care law particularly affects people in vulnerable situations. To better understand what shapes trajectories of health and social care access, this qualitative study examines the interplay between health and social care services and social interactions involving people with mental health problems in Denmark. Methods We conducted a qualitative study, collecting 12-semi-structured interviews with users, 22 individual and focus group interviews with professionals, and 15 observations (lasting between 30 minutes and 4 hours) of social interactions between users and professionals. We analysed the material using the concept of candidacy, defining access as continually constructed through negotiations within local and system contexts. Results The users were part of an intersectoral team programme aiming to offer integrated access in a fragmented system of specialised and community-based health and social care services. Nevertheless, accomplishing access required considerable and continuous work and was not always successful. For example, users struggled to recognise and assert eligibility, shaped by prevailing norms of self-sufficiency. Similarly, health professionals continuously reassessed users’ eligibility for specific services through monitoring and team meetings, though this did not necessarily align with users’ perspectives. Conclusions Our findings show that access is not automatic, even in integrated programmes. It requires ongoing work by users and professionals, shaped by broader social norms and system structures. Consequently, understanding access as a negotiated process helps identifying the mechanisms underpinning the inverse care law. The findings also highlight the need for system changes to better support users’ candidacy over time if we are to achieve sustainable mental health access. Key messages • Access to health and social care is shaped by ongoing negotiations, explaining why barriers to access persist even in integrated care programmes. • Supporting users’ candidacy over time is crucial for achieving sustainable, equitable access to health and social care services.