Aim <p>This study examines the association between trust in doctors, income-based perceived fairness, income-based access inequality in healthcare, and self-reported psychological distress, considering individual perceptions and country level socioeconomic context.</p> Methods <p>ISSP 2021 Health and Health Care data were analyzed (<i>N</i> = 26 023; 21 countries). A multilevel logistic regression model was estimated. Country level indicators included income inequality (Gini coefficient), Human development index (HDI) and average confidence in the healthcare system.</p> Results <p>Compared with neutral trust, trusting doctors was associated with lower odds of distress (OR = 0.78, 95% CI 0.72–0.84), while distrust was associated with higher odds (OR = 1.14, 95% CI 1.01–1.30). Strong perceptions of healthcare injustice were associated with elevated distress, reflected in higher odds among those rating the system as very unfair (OR = 1.26 95% CI 1.16–1.37) and those perceiving access as harder for the poor (OR = 1.30 95% CI 1.20–1.41). At the country level, higher income inequality (OR = 1.26, 95% CI 1.10–1.44) was associated with higher distress, whereas HDI and average confidence in the healthcare system was not significantly related to distress.</p> Discussion <p>Overall, the findings highlight that psychological distress is closely linked to both individual-level institutional perceptions and broader societal inequalities, with trust in doctors emerging as a particularly strong psychosocial resource.</p>