Local, regional and national journeys to cultural and linguistic competence

The Long Road to Reducing Social and Cultural Inequality in Health – A Personal and Collective Journey While Health Inequality is to be found in all countries, the background to its development and the processes required for its reduction will depend very much on the country's history, its changing demographic makeup including the impact of large-scale migration, and the structure and functioning of its social services. The reality that developed in Israel, a country with National Health Insurance since 1995, and the experience gained in attempting to reduce socio-cultural health disparity is the subject of this presentation.

This personal journey began a decade ago when a graduate from a developing country, in the International MPH Program of the School of Public Health in Jerusalem, stated that his academic public health training had not helped him in handling the major public health problem he had in his country - growing health inequity. Why did he say this? He indicated that he had studied epidemiology including the importance of poverty and cultural background to health, and the possible reasons for this, but he had never learnt what he, as a public health professional, could do on a practical level, to reduce the health gaps. This was a challenge that could not be ignored and the attempts to meet it are summarized here.  This journey has been traveled with many others and reported for them as well.

Stage 1: The diagnostic process began with the collation of the considerable data available in Israel on health disparities. This revealed that they existed in life expectancy, general and infant mortality, morbidity, risk factors (biological and behavioural) , accidents, access to and quality of health services. They were by most of the major characteristics of the very heterogeneous Israeli population –ethnicity, religion and degree of religiosity, educational level, employment, social/economic status, gender, age, and geographic area of living.
Especially significant was the fact that in many of the measures the disparity had increased in recent years. The data was presented to numerous service, academic and decision making frameworks. It created an interest and more invitations to lecture but little or no action, either policy-related or intervention.

Stage 2: This diagnosis prompted the need to know how aware the health care and other social systems were of the problem. Did they see a role for themselves in tackling the issues, and why was little being done? A qualitative study was performed, with a team in the Brookdale Institute in Jerusalem, in which both the leaders (decision makers) in the health care system and outside of it, and professionals in the field were interviewed in depth. They knew of the disparities but we found a dearth of knowledge on the extent of the problem, its widening, and the possibilities for their reduction. There was little appreciation of their potential for change or that of their institution. Acknowledging the substantial international experience the project included an extensive review of what was known and done internationally including visits to North America and Western Europe.

Stage 3: Armed with the quantitative assessment of the problem and the qualitative understanding of the knowledge and attitudes of those responsible for action, we moved to preparing a coordinated program for addressing the subject at a national level. A second project, in the Taub Center in Jerusalem, further developed the details and content of the integrated National Policy and Action Program. These recommendations included:
1. Informing decision makers and health professionals at all levels of the health care system of the problem's existence, its extent, its social, economic and health care implications, and their potential role in its reduction.
2. National recognition at Government level (especially the Ministry of Health) of the seriousness of the issues and the urgent need to frame policy aimed at preventing further widening of health inequalities and in the longer run their reduction.
3. This national policy should be paralleled by acceptance by all health care institutions of their responsibility to develop the most appropriate interventions that will meet the needs of the population.
4. Accepting that the greatest change would result from reducing overall socio-economic disparities in the country our major efforts were directed towards interventions within the health care system. These included:
v Addressing the needs of the geographic periphery in order to correct the serious differentials in service frameworks as compared to the center of the country.
v Addressing the financial obstacles to access to care especially changes in the co-payment requirements which have resulted in lower SES persons not obtaining recommended medicinal treatment or consultant services. In addition there is a differential uptake of supplementary insurance, the cost of which is not income or needs linked.
v Addressing the substantial obstacles that many in the multi-cultural population face when they are in need of health care. This includes:
· Professional appreciation of varied understanding of health and disease and the implications for utilization of medical care
· Information supplied in the major languages and in a culturally appropriate manner– signage in health institutions; educational and logistical information
· Professional interpreter services
· Introduction of training in Cultural Competence for all levels of health professionals

Stage 4: ACTION
1. Recognising the central importance of cultural disparity to health inequality an International Workshop on "Culturally Appropriate Health Care by Culturally Competent Health Professionals" was organized in October 2007 by the Israel National Institute for Health Policy and Health Services Research and attended by invited international experts. The meeting discussed a Position Paper on the "Cultural Appropriateness of Health Services: Definition of Standards for Health Services and for the Training of Health Professionals in Cultural Competence (CC), with the Objective of Reducing Health Inequality". The final document has been distributed to health care providers in the country.
2. The Israel Medical Association has decided that the medical profession should have an important role in the reduction of health disparities. Recognising that there was not sufficient awareness of the issues amongst health professionals it commissioned a booklet that has been distributed to all Israel physicians. In addition a special committee has framed and published a policy document on Health Inequalities, the need to act for their reduction and the ways to do it. This included the training of all health professionals in relation to Health inequalities and Cultural Competence. The policy document and its recommendations were made public at a news conference that received wide media coverage.
3. Two of the major HMOs have declared 2008 as the year in which they will be planning their role in reducing health inequality.
4. In addition to these activities, on a national level, programs have been developed by healthcare institutions to answer specific culturally related issues – diabetes in Ethiopian immigrants, mammography in the Arab population and ultra-religious Jews – to name only a few. The road ahead is a long one, success (reduction) not yet achieved but there is movement in the right direction.