14 The problem of failing to provide culturally and linguistically appropriate healthcare

attending isolated and remote health services) will be of a non-English speaking background.

ABORIGINAL HEALTH

Before continuing we wish to clarify that although the issues raised in this chapter are of relevance to Aboriginal and Torres Strait Islander communities, we have not sought to consider them from an Australian Aboriginal and Torres Strait Islander People’s perspective. The reasons for this stance are twofold. First, in recognition of the tragic and confronting history of ‘race, politics and power’ in Indigenous health and health research domains (see, in particular, Anderson 2002, Henry et al. 2004; Humphery 2001; Thomas 2004) we are respectful of the wishes of Indigenous Peoples to ‘speak for themselves’. Second, we are cognisant of the fact that Indigenous Peoples do not wish to be ‘lumped’ in with people who are otherwise ‘newcomers’ to their lands (for example, colonisers, immigrants, refugees and asylum seekers) because there are particular issues that Indigenous people face as Indigenous people, which ‘newcomers’ do not face (Eckermann et al. 2006). Thus, while many of the issues considered in the context of this chapter are of relevance to Aboriginal and Torres Strait Islander People, just what those issues are, how important they are, and whether they will be taken up by Aboriginal and Torres Strait Islander People, is ultimately a matter for them to decide. Accordingly, although there is a discrete body of policy texts pertinent to Indigenous health, these have not been considered in this chapter. Chapter 22 discusses current problems in Indigenous health.

IDENTIFYING THE PROBLEM

Over the past 30 years numerous multicultural policies and programs have been developed and implemented that have been pertinent to achieving the positive value of ensuring equity, reducing disparities, and ensuring the equal participation of non-English speaking migrant communities in local healthcare services. Further, as Australian research has shown (Johnstone & Kanitsaki 2005), there is much to suggest that as a result of these policies and programs, and the steadfast commitment of certain individuals and organisations to promoting the standards and principles of culturally and linguistically appropriate healthcare services, significant changes have been made across the healthcare sector. The overall responsiveness of healthcare services to the complex health needs of patients from diverse cultural and language backgrounds has improved. Despite the gains that have been made, however, there is emerging evidence and increasing recognition by those in the field that people of minority¹ cultural and linguistic (‘ethnic’)² backgrounds in Australia (including Indigenous Australians) are generally underserved by local healthcare and other social services, experience unequal burdens of disease, confront cultural and language barriers to accessing appropriate healthcare, and receive a lower level and quality of care when they do access healthcare compared to the majority population (Allotey et al. 2002; Centre for Culture Ethnicity & Health 2003, 2006, Correa-Velez et al., 2005; Johnstone & Kanitsaki 2006, Murray & Skull 2005, Proctor 2004, Stolk et al. 1998, Thomson et al. 2004).

It is also being acknowledged that, as Australia’s migrant population ages,³ as shifting international migration patterns to and from Australia have an impact on the demographics of hospital patient groups (Centre for Culture Ethnicity & Health 2003), and as the poor health of ‘new arrivals’ (for example, refugees and asylum seekers) becomes reflected in official figures on population health in Australia, it is likely that disparities in ethnic health will become more pronounced, as will the need for Australia’s health system to respond effectively to these disparities. There is scope to suggest that as ethnic disparities in health receive greater public attention, critical questions will be raised about the probable causes and consequences of these disparities, and the overall responsiveness of the Australian healthcare system to the needs of Australia’s minority racial and ethnic groups compared with that seen in other multicultural countries. Examples include: the 12 European countries (Austria, Denmark, Finland, France, Germany, Greece, Ireland, Italy, The Netherlands, Spain, Sweden, and the United Kingdom) participating in the Migrant Friendly Hospital Project⁴ (Bischoff 2003, Novak-Zezula 2005) and the United States, where the US Department of Health and Human Services (DHHS) has developed and is implementing national standards for culturally and linguistically appropriate services in healthcare, and has set an agenda for research on cultural competence in healthcare (Department of Health and Human Services [DHHS] 2001a, 2001b, DHHS and Agency for Healthcare Research and Quality 2004).

These and related observations of what has been described in the international literature as ‘racial and ethnic disparities in healthcare’ (Smedley et al. 2003) cannot be ignored. Neither can the fact of the observed ‘remarkable consistency of racial and ethnic disparities across a range of illnesses and healthcare services’ (Smedley et al. 2003 p 5) be ignored. When placed against the various international instruments (conventions, covenants, treaties) to which Australia is a signatory, and which recognise with considerable authority the right of all people to the highest attainable standard of health (for example, as articulated in General Comment 14, article 12 of the International Covenant on Economic, Social and Cultural Rights), the imperatives of redressing these disparities is underscored (World Health Organization [WHO] 2002). Fundamental questions arise: Why, despite over 30 years of multicultural policies and programs, people of ‘ethnic’ backgrounds in Australia, or whose English proficiency is insufficient to enable them to navigate the healthcare system, do not enjoy the same level of access to safe and high-quality services and related health outcomes as does the broader community? And what can be done to improve the status quo?

Getting the problem on the policy agenda

The problem of policy and program failures in the area of ethnic health in Australia is not new. Those at the forefront of delivering multicultural healthcare services have long highlighted the policy and practice deficits in the field of healthcare and have long argued (in some cases, for over 40 years) for a more proactive response to ensuring the development and delivery of culturally appropriate, responsive and effective healthcare services to Australia’s multicultural/multilingual population.

The capacity and success of various entities to achieve real change in the delivery of effective healthcare services to Australia’s culturally and linguistically diverse communities has been mixed. Underpinning this mixed response are the largely unacknowledged layers of resistance to the principles and practice of cultural diversity in healthcare that, in turn, are underpinned by the largely unacknowledged phenomenon of ‘new racism’, also called cultural racism (Barker 1981, Goldberg 1993), and of what might be described as ‘the illusion of non-racism’ that rests on the frequently articulated belief that ‘there is no racism here’ or ‘racism is not an issue anymore’ (Fredrickson 2002 p 4). Because of the insidious nature of new racism and the relative ease with which it can (and has) become embedded in the ‘commonsense’ of individuals and the ‘culture’ of institutions (institutionalised racism), it is extremely difficult to challenge and change. These and other processes have made it difficult for those at the forefront of delivering health services to culturally and linguistically diverse communities to ‘make a case’ to policy makers, persuading them that existing healthcare services are not as responsive as they should be to the health and care needs of the multicultural population. Making a case supporting the need for a more robust strategic and systematic approach to ensuring equity, reducing disparities, and ensuring the equal participation of ‘ethnic’ minority groups in healthcare services has also been difficult – not least because of a lack of ‘hard data’ demonstrating the inequities and disparities that those at the forefront of service delivery directly observe and experience every day (Johnstone & Kanitsaki 2005).

The policy responses

Policy responses to improving the appropriateness, responsiveness and effectiveness of health services to Australia’s multicultural/multilingual population have come from many sources. Key among the ‘policy actors’ are those on the ‘frontline’ of health service management and delivery, ethnic welfare organisations and consumer advocacy groups, academic researchers, progressive government bureaucrats and politicians, and an array of Australians working at the cutting edge of social policy change. The work of these entities has seen many reports developed over the years that have continually and consistently reiterated broad support for four key principles of ‘living with cultural diversity’ in Australia, notably: civic duty, cultural respect, social equity, and productive diversity (National Multicultural Advisory Council 1999).

A cursory review of core cultural and language diversity policy texts published by state and territory governments over the past 5 years suggests that, despite the rise of what Hage (2003) calls ‘paranoid nationalism’, there is nonetheless a strong public commitment to ‘cultural diversity’. The Victorian Government, for example, has not only stated its public commitment to ‘cultural diversity’, but is also promoting it ‘as a hallmark of the State’ (Victorian Office of Multicultural Affairs [VOMA] 2003).

Victoria’s commitment to cultural diversity is noteworthy in that through its various departments and offices (such as the Department of Human Services [DHS], Department for Victorian Communities [DVC], Office of the Health Services Commissioner [HSC], Victorian Multicultural Commission [VMC] and Victorian Office of Multicultural Affairs [VOMA]), the government has overseen the development and implementation of a number of strategies and initiatives aimed at enhancing access and equity of racial and ethnic minority groups to publicly funded human services in Victoria. Notable among the diversity initiatives developed and promoted over the past few years has been the Victorian government’s Cultural diversity guide: planning and delivering culturally appropriate human services (DHS 2004) and the Health service cultural diversity plans (DHS 2006). The latter initiative is significant in that it requires every Victorian health service to develop and implement a health service cultural diversity plan (HSCDP) that, in turn, must be lodged annually with the director of the department’s Quality and Safety Branch. Also significant is the stated key purpose of the HSCDP, which is to:

• identify current policy directions and evidence, key result areas and strategies for action to improve health service responsiveness to CALD [cultural and linguistic diversity] issues
• document, evaluate and promote best practice ‘multicultural’ examples across the health service
• offer a central coordinating mechanism for responding to and initiating CALD planning at the local health service level
• support the Victorian government’s whole-of-government reporting framework on responsiveness to cultural diversity
• integrate CALD issues into the broader planning mainstream of the health service through the quality and safety plan framework, quality reporting requirements and appropriate serviced delivery plans (DHS 2006).

The various cultural diversity policy texts that have been developed and disseminated by different government bodies and departments over the past few years have tended to articulate a strong policy position advocating values such as: the recognition and valuing of diversity; respecting and understanding difference; and the need to improve the overall responsiveness of healthcare services to people from diverse cultural and language backgrounds as a core aspect of quality service provision. Despite the apparent ‘strength’ of these cultural diversity policy texts, however, significant weaknesses are evident. Ironically, one of the main weaknesses of these policy documents lies in their ‘Trojan horse’ element.

Some critics claim that no matter how ‘progressive’ cultural diversity policy processes might appear to be, they are still a ‘Trojan horse’ of the dominant culture – and of institutional racism – on account of being insidiously deployed by policy makers as a ‘tokenistic gesture’ meant to placate proponents of cultural diversity while preserving intact the status quo⁵ (Brandt 1986, Essed 1991). This is perhaps most evident in the deployment of such terms as, ‘cultural diversity’, ‘ethnic diversity’, ‘pluralism’, ‘justice’, and ‘equality’, in policies which could have functioned as textual devices capable of generating:

widespread support (and reassure diverse groups that their interests were taken into account) when in fact their meaning was shifting and imprecise, so that power-holders were not constrained by any meaningful directives with clear practical consequences.

(Gillborn 2000 p 479)

The ‘Trojan horse’ aspect of cultural diversity policy is further exemplified by their use by dominant cultural elites as a ‘hidden agenda’ to advance the dominant culture’s ‘agenda of agendas of racial and ethnic domination’ and the reproduction of racial and ethnic inequality (Essed 1991 p 187). Thus, while cultural diversity policies might appear to be a ‘gift to the field’, in reality their purpose and effect is to undermine the principles and standards of inclusiveness and equity encompassed by multiculturalism as a social policy framework. When consideration is given to the palpable lack of and/or under-resourcing of cultural diversity services in healthcare (the lack of funding of credentialed language services is an example) there is considerable scope to question the bona fide purpose, intent and potency of the policy texts that have been developed and adopted ostensibly to improve the delivery of culturally and linguistically appropriate health services in local contexts.

FUTURE DIRECTIONS FOR POLICY DEVELOPMENT

The demonstrable consequences of the policy failures guiding and governing the delivery of culturally and linguistically appropriate healthcare services in Australia, highlight the need for a more strategic and systematic approach to health service delivery to diverse cultural and language groups. It is clear that the principles and standards of culturally and linguistically responsive and effective healthcare need to be embedded not just in the ‘commonsense’ (infrastructure) of institutions, but in the commonsense of individuals working at all levels of the system. Equally important, the principles and standards of culturally and linguistically responsive healthcare need to be framed and encompassed as the norm not the exception, and as being integral not adjunct to effective health service delivery. To these ends, and commensurate with emerging overseas trends, we contend that sustained and focused attention needs to be given to a number of strategic policy frameworks and guidelines (see Boxes 14.1–14.2).

It is also important to set as a national priority the alignment of cultural safety and cultural competence initiatives with national and local organisational clinical risk management programs and related patient safety and quality care initiatives.Quality monitoring, using existing (quality) metrics as levers to highlight problem areas, keeping quality (and subsequently inequities) discussion at the forefront of organisational discourse, and annual reporting against key performance indicators must be included (Johnstone & Kanitsaki 2005, 2006).

To what extent policy development in the above areas can make progress remains open to question. One of the most significant obstacles to progressive policy is the current federal government’s longstanding antipathy toward and abandonment of multiculturalism (and reconciliation) as a social policy framework (Hage & Couch 1999, Kalantzis & Cope 2001, Markus 2001, Stratton 1998). This stance does not augur well for states and territories which are otherwise dependent on federal funding of their health and human services. State and territory initiatives are constantly under threat because of the federal government’s declininginterest; the lack of mandated standards and policy compliance monitoring; and the general undervaluing of ‘cultural diversity workers’ – particularly health interpreters and translators whose terms and conditions of employment are being constantly eroded. This threat is accentuated in contexts where public officials have a vested interest in retaining ‘a certain degree of ambiguity of objective, program implementation, and “collateral purposes” ’ (Lo Bianco 2001 p 23). In regard to this point, Lo Bianco explains that public officials:

see advantage in keeping meanings and intentions ambiguous. This is because there are multiple and overlapping agenda being developed simultaneously, because timelines can be melded or renegotiated, because contexts and circumstances are highly dynamic, and because the basis of monitoring what they do and its outcomes is intensely political. Policy is, after all, a cognate of politics.

(Lo Bianco 2001 p 23)

Despite the restrictive policies of government over the past three decades and the revival of the 1950s assimilationist agenda by the Howard federal coalition government, health services have emerged as significant sites of resistance to the political processes that are currently in play to dismantle multiculturalism as a progressive social policy. One of the reasons that health services (and the state and territory governments regulating them) have emerged as significant sites of resistance is that the federal government and public officials do not have ultimate control of ‘the space of practice’ in institutional settings. Thus, as Lo Bianco explains, if practitioners ‘who occupy the critical points of delivery of policy intention’ are half-hearted about policy – and withhold their cooperation and continue to practice diversity – this can be sufficient to undermine and even cause the policy to fail (Lo Bianco 2001 pp 40–1). However, since this can also work in favour of a conservative anti-diversity policy agenda, there is an equal risk of progressive cultural diversity policies and programs similarly being overturned at the critical points of delivery. The point is, that if those who occupy critical points of delivery of policy withhold their cooperation and refuse to practice cultural and language diversity, even the best of policy intentions can be undermined and subverted. This risk also highlights the difficulties involved in expecting lone individuals within a system to shoulder the responsibility of implementing an organisation’s cultural diversity agenda. As in the case of patient safety, it needs to be recognised that delivering culturally and linguistically responsive and effective healthcare is everybody’s responsibility, not the responsibility of an enlightened few.

Towards a new agenda

There are new and emerging processes that are likely to have a significant impact on policy initiatives concerning the delivery of culturally and linguistically appropriate and effective health services in Australia. Notable among these are the renaissance of the global health and human rights movement, currently being spearheaded by WHO (2001, 2002, 2003, 2005a), and the development and operationalisation of a global agenda for improving the safety and quality of healthcare, endorsed by WHO, the World Health Professions Alliance (WHPA), and a long list of WHO member nations (WHO 2004, 2005b, 2005c, 2006).

A feature of these developments is the authoritative recognition encompassed in various international policy documents that all people have the right to the highest attainable standard of health (the right to health) and the highest attainable standard of safety and quality of care (the right to safe and quality care). As stated above, the right to health, recognised in numerous international instruments to which Australia is a signatory, was first reflected in the World Health Organization Constitution (1946), reiterated in the Declaration of Alma Ata (1978) and, in 1998, adopted by the World Health Assembly (WHO 2002). The normative content of the right to health has been articulated in General Comment 14 (article 12 of the International Covenant on Economic, Social and Cultural Rights), endorsed in 2000 by the UN Committee on Economic, Social and Cultural Rights (CESCR). The General Comment 14 identifies four key criteria for evaluating the right to health (Box 14.3). Also relevant is the Covenant’s proscription of:

any discrimination in access to health care and underlying determinants of health, as well as to means and entitlements for their procurement, on grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation and civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health.

(CESCR 2000)

WHO has clarified that the right to health does not entail the right to be healthy, which unlike other social goods, cannot be bestowed (WHO 2002). In recognition of the complex linkages that exist between health and human rights and the fact that ‘vulnerable and marginalised groups in society tend to bear an undue proportion of health problems’, the right to health has been interpreted as entailing a claim to ‘a set of social arrangements – norms, institutions, laws, an enabling environment – that can best secure the enjoyment of this right’ (WHO 2002 pp 9, 11). This, in turn, has been interpreted as requiring governments and public authorities to ‘put in place policies and action plans which will lead to available and accessible healthcare for all in the shortest possible time’ (WHO 2002 p 9).

It is beyond the scope of this chapter to provide a critical examination of the progressive stance taken by WHO on the issue of health and human rights and the related rights of patients to safe and quality care. But, there is scope to suggest that given Australia’s positioning as a signatory to the various conventions, covenants and treaties underpinning the rights to health and to safe and quality care, and given the clinical, legal and moral imperatives of upholding these rights, it is clear that government at all levels and in all jurisdictions has a responsibility to ‘put in place policies and action plans which will lead to available and accessible health care for all [including people of minority cultural and language backgrounds] in the shortest possible time’ (WHO 2002 p 9).

The prevalence of ‘new racism’ (cultural racism) in healthcare imposes an additional requirement on future policy initiatives; notably, as well as articulating a pro-diversity stance, they must also clearly articulate an anti-racism stance. Unless the problem of new racism in healthcare is made explicit, it will remain difficult to contain, as will its insidious influence on undermining processes aimed to redress racial and ethnic disparities in health and healthcare. Racism is fundamentally about power and, in particular, ‘the ability to construct others as different in order to exclude or ignore or exploit them’ (Hollinsworth 1998 p 279). Combating racism requires considerably more than merely ‘valuing diversity’ or ‘advocating tolerance’. Rather, as Hollinsworth (1998 p 279) contends, ‘it demands a deconstruction of the ideological and material power inherent in racist discourse, structures and practices’. An arguable first step in deconstructing racism in healthcare is first to name it and then break the culture of silence that otherwise surrounds it (after Freire 1972), and expose its insidious influence on service delivery.

Finally, there is the important point that education qua education must not be portrayed or promoted as the panacea for all the flaws and failings detected in cultural diversity policies and programs in healthcare. This is because education alone, without a robust strategy and a systematised approach supported by a sound infrastructure, is insufficient for achieving the substantive and sustainable changes that are needed in order to improve the cultural and linguistic appropriateness and effectiveness of local healthcare services. While education might make individuals more aware, awareness alone does not necessarily translate into practice and/or into the proactive responses that are necessary by individuals and institutions to improve the delivery of culturally and linguistically appropriate and effective services to people of diverse cultural and language backgrounds.

Progressive policy texts are needed, and their nature, content, and purpose in fostering the values of cultural and linguistic diversity in healthcare remain important to achieving a reduction in the incidence and harmful impact of otherwise preventable racial and ethnic disparities in healthcare. For those in multicultural healthcare and working actively to reduce disparities in the health and care of culturally and linguistically diverse groups, this is not just a matter of social policy, it is about supporting the values of social justice in achieving a just healthcare system and a just society for everyone.

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