Recommendation Rec(2006)18
of the Committee of Ministers to member states
on health services in a multicultural society

(Adopted by the Committee of Ministers on 8 November 2006
at the 979th meeting of the Ministers’ Deputies)

The Committee of Ministers, under the terms of Article 15.b of the Statute of the Council of Europe,

Considering that the aim of the Council of Europe is to achieve a greater unity between its members and that this aim may be pursued in particular by the adoption of common rules in the public health field;

Recalling Article 11 of the European Social Charter (ETS No. 35) on the right to protection of health, and recalling Article 3 of the Council of Europe’s Convention on Human Rights and Biomedicine (ETS No. 164) on equitable access to health care of appropriate quality;

Noting, in this context, that inequalities with regard to health care affecting ethnic groups are linked to problems of access, the lack of culture competence in health care providers, lack of essential provisions (such as interpreter services or translated health education material), all of which may be structural barriers to quality care;

Recognising that, in an increasingly diverse and multicultural Europe, understanding and addressing the needs of a multicultural population is becoming a growing challenge;

Considering that respect for human rights and the dignity of the individual requires that this diversity is taken into account in the equitable delivery of health services;

Recognising that socio-economic factors, such as poverty, unemployment, unhealthy living conditions and occupational hazards are unevenly distributed within the population and may very well account for most of the health disparities;

Aware, in this context, that ethnic minorities seem to be most vulnerable to health problems within every socio-economic class;

Recognising that a general diversity-based approach – that is, one that takes into account all sources of diversity that may be relevant to health and health care issues – is preferable to an approach that is limited to dealing with minority-linked cultural diversity;

Recognising that the reduction of health inequalities in multicultural societies requires the development of a diversity-based policy examining ideas, policies, programmes and research to assess their potentially different impact on specific gender and age groups;

Aware that the issue of diversity and its management is not exclusively related to the presence of ethnic minorities in present-day Europe but should rather be viewed as a feature of the European population as a whole;

Adopting a broad definition of culture that recognises cultural subcategories based on shared attributes (such as gender) or shared life experiences (such as education, occupation, socio-economic status, trauma, homelessness, being without ID papers);

Aware that cultural factors are often used as a universal and unique explanation when no other factors can be called into account for observed health disparities between different ethnic groups;

Concerned that a narrow focus on cultural issues denies the importance of class or socio-economic status, age, sexual orientation, gender, religion, geographic location, physical and mental ability that may all distinctly affect any group’s health needs, interests and concerns;

Noting that migration factors related to the migratory experience have been shown to be linked with health problems of ethnic groups;

Having regard to Recommendation No. R (2000) 5 of the Committee of Ministers to member states on the development of structures for citizen and patient participation in the decision-making process affecting health care;

Concerned in this context that patients’ rights cannot be respected nor protected when health care providers and patients cannot communicate effectively;

Convinced that the development of culture competence or cultural responsiveness would add to the effectiveness of health care provision not only for ethnic minorities but also for the public at large;

Aware that the development of an integrated social and health policy should go beyond the adaptation of health care services to cultural diversity;

Having regard to the Charter of Fundamental Rights of the European Union,

Recommends that the governments of member states:

i. consider issues related to the improvement of access and quality of health care services in multicultural societies as one of the priority areas of action in health care policy;

ii. develop coherent and comprehensive policies and strategies addressing health care needs in multicultural societies, including prevention;

iii. promote an intersectoral and multidisciplinary approach to health problems and health care delivery in multicultural societies, taking into consideration the rights of multicultural populations;

iv. promote the involvement and participation of all parties concerned (researchers, policy makers, local health authorities, health professionals, representatives of ethnic minority groups and non-governmental organisations) in the planning, implementation and monitoring of health policies for multicultural populations;

v. embed health issues of multicultural populations in the legal framework as an integral part of the general health system;

vi. develop a knowledge base on the health of multicultural populations through systematic data collection and research;

vii. promote the inclusion of ethnic minority groups in culturally appropriate/adapted programmes promoting health and prevention, and in research and quality management;

viii. provide further support to the exchange of experience and good practice between member states and promote international networking between organisations, research institutions and other agencies active in the field of the health of multicultural populations;

ix. produce regular reports on actions taken in the country to improve the health of multicultural populations;

x. to this end, whenever feasible, carry out the measures presented in the appendix to this recommendation;

xi. support an active, targeted dissemination of this recommendation and its explanatory memorandum, accompanied where appropriate, by a translation into the local languages.

Appendix to Recommendation Rec(2006)18
of the Committee of Ministers to member states
on health services in a multicultural society

A. General considerations

1. When adapting the health care services to the needs of multicultural populations, governments of member states should base their policies on values propounded by the Council of Europe – human rights and patient’s rights, human dignity, social cohesion, democracy, equity, solidarity, equal gender opportunity, participation, freedom of choice – balanced by the obligation to help individuals look after their own health.

Member states should apply a systematic approach to issues related to responding to cultural diversity. Guidelines and standards for the provision of good services in multicultural populations should be developed.

Developing coherent and comprehensive policies and strategies addressing health care needs in multicultural societies, including prevention, should include:

– protecting human dignity and preventing social exclusion and discrimination;
– promoting delivery of high quality, linguistically appropriate, culturally sensitive, equitable and appropriate health care services;
– promoting changes in the conduct of health authorities at the national and local level and of health and social professionals to adapt their response to the health needs of multicultural populations;
– developing cultural competence in health care providers (meant as the ability to provide effective health care services taking into consideration the individual’s gender, sexual orientation, disability, age and religious, spiritual and cultural beliefs).

2. Health disparities in multicultural societies may have different causes, including external ones. These include cultural and socio-economic factors, migrant status and discrimination. Member states should pay attention to those factors in the appropriate policy settings as part of a comprehensive, coherent overall policy approach that focuses on eliminating the external causes of disparities in the health field.

2.1. Biological/genetic factors.

2.2. Cultural factors. Explaining health differences between ethnic groups using cultural factors bears a risk of blaming the “victim”, reification and gross oversimplification. Cultural factors seem to be used when no other factors can be called into account for observed health disparities between different ethnic groups.

2.3. Material factors. Socio-economic factors may very well account for most of the health disparities concerning ethnic groups, ethnic minorities being the most vulnerable to health problems within every socio-economic class.

2.4. Migration factors may influence the health of migrants.

2.5. Racism. The experience of racism and discrimination may have a direct and negative impact on health.

2.6. Selective impact and quality of health care: inadequate handling of cultural differences may affect the quality of care; the development of culture competence or cultural sensitivity would add to the efficiency of health care provision to ethnic minorities.

3. The reduction of ethnic (and other) inequalities in health requires the development of a diversity-based analysis policy to assess their potentially different impact on specific gender and age groups.

B. Strategies for improvement of health and health care for multicultural populations – Non-discrimination in access to health care

1. Promoting non-discrimination and respect for patient/human rights

1.1. Governments should develop and implement anti-discrimination policies and practices that effectively prevent (in)direct discrimination in access to health care services of good quality.

1.2. Governments should entrust an independent body with the assessment of the accessibility of the health care system for multicultural populations.

2. Access to health care

2.1. Equitable access to health care services of appropriate quality should be promoted and monitored. In order to achieve the objective of equal access to health care, member states should develop strategies for eliminating practical barriers for multicultural populations to access health care, including linguistic and cultural hurdles.

2.2. Governments should increase awareness of policy makers, health care providers and the general public of possible health care disparities between ethnic groups.

3. Improving quality of communication – Language barriers

3.1. Removing barriers to communication is one of the most urgent, evident and straightforward areas in which interventions are needed; a general policy that facilitates the learning of the language of the host country for ethnic minority members and immigrants should also be developed.

3.2. Professional interpreters should be made available and used on a regular basis for ethnic minority patients who need them, whenever appropriate.

3.3. Linguistic diversity should be taken into account, including appropriate legal measures.

3.4. Health care professionals should be made aware that linguistic barriers have negative effects on the quality of health care. They should be trained to work together with interpreters in an effective way.

3.5. Training programmes are needed for interpreters working within the field of health care. Besides basic interpreting skills, these should include medical terminology, courses on the structure of the health care system, ethical interpreting practice, culture competence and culture brokerage. Interpreters working in mental health care settings ought to be specially trained to perform their tasks in the context of psychotherapeutic or psychiatric interventions. Public health authorities should be encouraged to monitor the quality of medical interpreter services for ethnic minorities.

4. Sensitivity to health and socio-cultural needs of multicultural populations

4.1. Adequate assessment and analysis of the health problems of ethnic minorities is needed.

4.2. Member states should find appropriate answers to the objectively demonstrated added value of health care services that are specifically adapted to particular health (care) needs of a multicultural population. Ideally, all health care institutions should be equipped to treat health problems of all citizens; however, for very specific health problems it may be necessary to temporarily or even permanently create specialised services that respond to particular health care needs.

4.3. Measures should be taken that make it possible for the health care system to respond to the cultural diversity of the population.

5. Patient education, empowerment and participation

5.1. Patient training programmes should be developed and implemented to increase their participation in the decision-making process regarding treatment and to improve outcomes of care in multicultural populations.

5.2. Culturally appropriate health promotion and disease prevention programmes have to be developed and implemented as they are indispensable to improve health literacy in ethnic minority groups in terms of health care.

5.3. Ethnic minority groups should be encouraged to participate actively in the planning of health care services (assessment of ethnic minorities’ health needs, programme development), their implementation and evaluation.

6. Implications for health facilities and health care providers

6.1. Effective strategies should be developed to increase (ethnic) diversity among health professionals and social workers. Therefore, member states should ensure that ethnic minorities get access to the social and medical professions. Adequate measures have to be taken to make it possible for ethnic minority health professionals who have been trained abroad to get the qualifications needed to exercise their profession in the host country.

6.2. Multidisciplinary team approaches should be encouraged to reduce health and health care disparities between multicultural populations. Collaboration between social workers and social services on the one hand, and medical professionals on the other should be more widely implemented.

6.3. Member states should encourage the development of intercultural mediation programmes:

– adequate training and supervision programmes have to be developed for intercultural mediators;

– research on the effects of intercultural mediation programmes, preferably within the framework of international collaboration, should be encouraged and member states should engage in the development of standards of good practice for intercultural mediators.

6.4. A population diversity perspective should be incorporated into the basic training curriculum of all health care professionals and social workers, as well as in the continuing education of these professionals. It is important that such courses do not only focus on knowledge, but also on attitudes (cultural sensitivity, influence of prejudices, (subconscious) rejection of ethnic minority patients), and cross-cultural skills, in order to avoid stereotyping of ethic minorities. Intercultural communication training has to be included in all culture competence training programmes.

Inclusion of programmes dedicated to this subject in the training of health professionals has to be carefully thought about to be efficient, and should be offered in schools but also as continuing education throughout their careers, after having acquired some hands-on experience in the field and the ability to approach the topic more in depth. Enquiries should be done at the health professionals’ level too, in order to assess their needs, perceptions and problems with patients of different ethnic backgrounds.

6.5. Health professionals should be made aware of possible structural discrimination and racist practices in the health care system and their effects. They should be taught how to detect and address these issues within the health care system. In addition, they ought to be made aware of the effects of discrimination and racism experienced by ethnic minorities in society at large on the interaction of these groups with the health care system.

6.6. Exchange programmes with the countries of origin of the migrants should be encouraged, focusing on new migrants and refugees, following the experience of countries of southern Europe and their southern neighbours (Barcelona Declaration).

7. Development of a knowledge base on the health needs of multicultural populations and the health care they receive

Identifying ethnic minorities in research and administrative health data

7.1. Member states should develop strategies that allow for appropriate data collection on the health needs, health determinants and the health care received by multicultural populations.

7.2. Relevant data should be analysed and reported to influence policy and service designers, service evaluation and to allow for the development of strategies for the improvement of the quality of health care services in multicultural societies.

7.3. Strategies ought to be developed to avoid the abuse of data collected on ethnic minorities and their stigmatisation, and thus guarantee their safety.

Inclusion and proportional representation of ethnic minorities in research

7.4. Whenever relevant, member states should develop legislation which foster a true representation of ethnic minorities in clinical and health services research. In the case of research financed through public funds, researchers should be asked to provide an adequate scientific explanation whenever ethnic minorities are excluded.

7.5. Research data have to be analysed with the possible effects of (cultural) diversity kept in mind. In the presentation of the results, attention should be drawn to diversity issues that are relevant for the organisation of health care services.

7.6. Further research is needed to determine how and why ethnic health patterns and health care disparities occur, and to develop intervention strategies and to assess their impact. Where no adequate systems of monitoring of ethnic groups in the fields of health and health care exist, research will have to be conducted to provide information on the health status of ethnic minorities, their access to care and the existing health care disparities.

7.7. Further research is needed to fully exploit the potential role of civil society and to develop methods of preparatory training for interested citizens. University students should be encouraged to study these issues in their final study dissertation.



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