Promoting cultural diversity in Swiss hospitals

Interpreters are being used by some hospitals INTERPRET

Three years after the launch of of the government's Migrant Friendly Hospitals project, questions have been raised about how health institutions responded to the needs of immigrants and vulnerable groups.

This content was published on December 11, 2013 - 17:00
Abdelhafidh Abdeleli,

The project had been launched as part of a comprehensive programme for health and immigration, to better manage Switzerland's diversity in the health sector, and to offer fair treatment for all.

Now experts are also examining to what extent health institutions have lived up to the policy of non-discrimination for all residents in Switzerland, regardless of their legal status, cultures or origins.

A national conference in the capital Bern recently laid out a vision for expanding and developing the programme, which has so far been joined by five major hospitals.

The objective of this project is to “ensure that all social groups receive appropriate treatment”, says Serge Houmard of the Federal Health Office.

“It requires a successful communication process that overcomes the barriers of languages and cultures, enhancing the cross-cultural expertise and qualifications of employees in the sector, and encouraging research and investigation into issues related to health and immigration,” he explains.

Vulnerable groups

The programme has tried to take into account the results of a field study. It had revealed that foreigners and vulnerable social groups generally suffer from different problems that deny them access to necessary health services.

Many of these foreigners are at an educational and social level below the general population average, and their wages are lower than their Swiss counterparts. They are also more affected by poverty and unemployment.

At present, about 200,000 people in Switzerland do not understand any of the four national languages. There are about 700,000 Swiss residents with a mother tongue other than a recognised national language.

This leaves many of them in a desperate need for assistance during a stay in hospital, and requires adaptation of services and maintaining communication channels. This is indeed what Swiss hospitals seek to provide.

Tailored services

In cooperation with several specialist non-governmental organisations, canton Vaud is offering a package of services, including freeing up a group of male and female nurses to follow up on the health conditions of residents at asylum seekers' centres.

The University Hospital in Lausanne has boosted the community interpreting service at the Obstetrics Department, owing to the high rate of foreign women being treated there, including illegal female immigrants who do not have health insurance coverage.

The Children's Hospital in Lausanne also provides multilingual medical checks to ensure an accurate diagnosis of diseases and a successful communication between patients and doctors.

Pierre-Yves Maillard, director of health of social affairs in the Vaud cantonal government says: “All these services are handy for the most vulnerable groups, and are based on a strong partnership between the public and private sectors. They are aimed at reducing costs while ensuring effectiveness.”

Migrant friendly hospitals

The EU has been supporting the migrant friendly hospitals project since 2002. Its aim is to meet the special needs of patients, who have a different culture and health concepts, notably ethnic minorities and immigrants.

It also seeks to facilitate access to medical treatment and fair treatment for all.

Switzerland has allocated a budget of CHF2 million for the hospitals taking part in the programme.

It is part of the Immigration and Health initiative launched by the Federal Health Office in 2002 to boost the skills of immigrants in the healthcare sector.

Its focus is on prevention, education, qualification and enlisting the help of interpreters specialising in health affairs.

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Health costs

In neighbouring canton Geneva, university hospitals have launched the Treatment for All programme, covering those who have no health insurance or no means to pay for their health expenses.

Over the past three years, this special programme has cost hospitals CHF180 million ($197 million) representing 10% of their total budget.

The community interpreting service alone came to CHF945,000 for a total of 13,500 hours of work in 2009, according to Sophie-Dore Pierre, a physician in charge of the Department of Community Medicine.

“We had to appoint a nurse who served as a point of reference for all issues relating to immigrants. The native language was added to the health file of each patient, and we organised courses among employees to make them aware of the special needs of vulnerable groups and foreigners,” she adds.

Multicultural treatment

In German-speaking Switzerland – specifically in Zurich’s Children's Hospital, where a quarter of the newborns as well as every other patient is a foreigner – efforts have been made to improve diversity management.

One initiative was the establishment of a special “multicultural, multilingual treatment” unit, to help foreign patients get appropriate care, and to inform them of the resources available to them, says hospital director Markus Malagoli.

However, he cautions that there is no single hospital in Switzerland or abroad that is free from discrimination.

“What makes the difference is raising awareness and providing training, to enable foreigners to speak in their native language in order to understand, and make others understand.”

Malagoli believes that even this is not enough, unless it is accompanied by special efforts among personnel in health institutions, and unless the pluralism and diversity factor is considered when measuring the quality and effectiveness of health services.

There is certainly room for improvement, as a Geneva field study revealed in 2011.

A total of 15% of non-European patients said that they had felt discriminated against at university hospitals in Geneva because of their religion, colour or nationality, according to the survey.

At the same time, half of the staff at these hospitals complained about a shortage in interpreting services and a lack of knowledge about the conditions, needs and cultures of foreign patients.

Medical staff training

Diversity not only produces richness, but also brings new challenges for universities as well as medical and nurses training colleges to qualify future professionals to deal with a multicultural, multilingual environment.

As specified by the Federal Health Office, cross-cultural qualifications give the “ability to see the individuals and understand them within the framework where they live and in their own contexts, and to act towards them accordingly.”

“It is about a set of behaviours, knowledge and experiences which enables professionals in the health sector to provide treatment up to standard for patients of different origins,” explains Patrick Bodenmann, a driving force behind the Migrant Friendly Hospital project.

Several scientific articles by staff at the University Hospital of Lausanne about the nature of the qualifications required in cross-cultural treatments have been published and translated into the main Swiss national languages.

Lectures aimed at doctors and heads of departments in hospitals were organised to discuss how to conduct a tripartite dialogue (i.e. between doctor, interpreter and patient).


A pioneering learning tool at university and hospital levels is virtual education (e-teaching, remote communication).

These lessons are in high demand according to Bodenmann who works at the Vaud Cantonal Hospital in Lausanne.

“Because they can be followed via the internet, are not limited to a certain time, do not require moving to a faraway place, and all those involved can benefit from them without any cost.”

The aim is not to create a health system parallel to the existing one, but to fill the gaps in the existing system and improve it so as to take into account the needs of marginalised and vulnerable social groups.

These special skills should be given much more attention.

“It must not remain the concern of a small number of experts. It should be at the heart of the treatment process,” he continues.

Bodenmann calls for mandatory training courses and qualifications in cross-cultural healthcare expertise for employees working in the sector.

Facts and figures

In Geneva

Foreigners: 40% of the total population

Those who do not speak French: 25% of the total population

Geneva hospitals: 1,800 beds, and 10,000 health employees

Patients treated in Geneva: 51% foreigners from 180 countries

Interpreting service: 13,500 hours of work at a cost of CHF 945,000 (in 2009).

Treatment for All programme: CHF180 million over four years, representing 10% of the total budget.

In Vaud

Foreigners: 35% of the total population

Total cost of medical cover: CHF 2.2 billion

Programmes of the services directed at vulnerable groups: CHF2 million.

Interpreting: CHF290,000 for 2012

Psychological treatments for immigrants: CHF3.3 million

In Basel

Foreigners: 20% in 1987 to 33% in 2011

Proportion of foreign patients in Basel hospitals: 30%

Proportion of foreign employees: 43%

Interpreting service: initially in Turkish only, extended to 63 languages by 2011.

In Zurich

Interpreting services at Zurich’s Children Hospital (in order of importance): Arabic, Albanian, Serbian.

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Communication process

Another key concern is to ensure the channels of communication between patients of foreign origins and the medical and administrative staff in health institutions.

Many immigrants in Switzerland have problems integrating in society and communicating, and they suffer from poor health.

“There is a cause and effect relationship between the two cases,” says the Bern-based Community Interpreting Foundation.

The Swiss government, in cooperation with the Community Interpreting Foundation, set quality criteria for granting an interpreter diploma.

Trials are also underway in Solothurn’s and Aargau’s cantonal hospitals for participants in so-called tripartite communication processes.

“We have many ideas and suggestions, but we need stable and sustainable funding,” says Nadia Di Bernardo who supervises the project.

Next steps

The Migrant Friendly Hospital programme runs out in 2017, but participants are optimistic and plan to extend it from training into the field of research.

It is necessary to monitor forms of disparity and inequality in healthcare to draw the right conclusions at a later stage according to Bodenmann.

However, Switzerland’s system which divides powers among the federal and the national authorities, is complicating communication and funding, notably for the creation of a nationwide database.

Good management of diversity in the healthcare sector could pay out: It is not only immigrants that stand to benefit, but the whole Swiss population, says Jean-Pierre Zellweger, an expert in the field of infectious diseases, and former doctor at the Vaud University Hospital.

“Whoever reads the literature would think that the problem is related to immigrants and is not linked to the indigenous population. But I am not sure that a doctor from canton Vaud would completely understand a patient from canton Valais either.”

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