This presentation provides insight on the pre-conditions required to achieve health equity. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Pre-Condition to Health Equity: Breaking
Down Language Barriers
Bob Gardner
Healthcare Interpretation Network AGM
September 22, 2009

2. Key Messages
• free and equitable access to high quality interpretation is
– vital to an equitable and well-performing health system
– an indispensable pre-condition for achieving equal opportunities
for good healthcare for all
– especially in an increasingly diverse society
– crucial to breaking down barriers to good health care for
disadvantaged and marginalized populations
• building high quality interpretation services is a crucial
element of an overall progressive health equity strategy
© The Wellesley Institute 2
www.wellesleyinstitute.com

3. Outline
• that promise – of how ensuring equitable access to high-
quality interpretation will help create an equitable
healthcare system -- is theme of my remarks:
– addressing barriers -- language and culture as among most
important barriers to equitable access and quality of care
– levers – how interpretation can be built into health providers’
incentives, expectations and requirement
– drivers – linking interpretation to system drivers like safety,
quality, managing ER, ALC and other bottlenecks, risk
management
– opportunities for innovation
– connections – where building interpretation services intersects
with – and underpins – an overall equity strategy
© The Wellesley Institute 3
www.wellesleyinstitute.com

4. Crucial Pre-Condition for
Health Equity
• language is one of most crucial barriers to access to
care
• like most barriers it can be addressed through good
policy and services →
– need high-quality trained interpretation services available to all
who need them
– need continuum of responsive and consumer-centred
interpretation services
– where and when people need them
• how to ensure services are available and accessible =
crucial challenge for equitable and efficient system
– high on Toronto Central LHIN agenda and on province’s
© The Wellesley Institute 4
www.wellesleyinstitute.com

5. Use Existing Levers
• need to define clear equity-focussed expectations:
– all providers will deliver sufficient high-quality interpretation
services to meet the needs of the people, communities and
catchment areas they serve
• then build requirements to meet these expectations –
and targets and indicators to measure progress -- into
performance management systems:
– accreditation requirements and processes
– Service Accountability Agreements between LHINs and
providers
– health profession Colleges and other professional regulatory
mechanisms
© The Wellesley Institute 5
www.wellesleyinstitute.com

6. Connecting the Dots and Driving
Change: Building Interpretation
Into Performance Management
• for providers to meet these requirements, they will need
to:
– know the language needs of the communities they serve
– this is far more than the languages of those who come to them for
services – but do need to collect that data
– also need to know who is not coming in because of language and other
barriers = unmet need
– and it doesn't mean just basic demographic data on languages spoken
– it means what language people are most comfortable receiving care in
• so demand/drive for accessible interpretation → built into
performance mgmt → providers assessing community
needs far better
© The Wellesley Institute 6
www.wellesleyinstitute.com

7. Connecting the Dots and
Driving Change II: Equity-
Focussed Data
• driving change through performance management will require better
data on language and other needs of community
– need far better social determinants type data across the health system
• need to also collect data on service delivery
– range of clients served and their gender, socio-economic and
cultural background → contributes to building up better picture of
community needs
– impact of interpretation services – comparing re-admission rates,
satisfaction, post-hospital recovery, infection, etc. → builds case
for investing in interpretation
• need to ensure interpretation practitioners and experts
are at planning tables and equity-focused indicators and
data collection systems are being worked out
© The Wellesley Institute 7
www.wellesleyinstitute.com

8. Building on Existing System
Drivers
• key things that worry EDs and CEOs:
– reducing risk and enhancing safety
– delivering high-quality care efficiently
– meeting provincial priorities – wait times, mental health or diabetes, ALCs
• access to interpretation underlies all of these system drivers:
– poor communication between provider and patient due to language or cultural
barriers can contribute to misdiagnoses and inappropriate prescriptions
– inability to read or understand instructions can lead to medication errors → safety
and cost implications
– support for self-management for diabetes and other chronic conditions has to be
delivered in languages of communities to be effective
– promising indications that good interpretation helps keep people out of hospital
and gets them out sooner
• aligning to such drivers and incentives = crucial to build support for
interpretation strategy
© The Wellesley Institute 8
www.wellesleyinstitute.com

9. All About Culture
• interpretation is never just about words, but culture
– skilled high-quality interpretation is one part of ensuring culturally
competent care
– part of inter-related changes needed to ensure inclusive health
service providers and healthcare system
– cultural sensitivity and competence – just as equity overall –
need to be built into core fabric of daily working cultures of
service providers
• so cultural competence and interpretation must be
central to wider equity and diversity-focussed
organizational and system transformation
• and need to build on the many local community-based
initiatives and front-line innovations who are doing just
© The Wellesley Institute 9
that www.wellesleyinstitute.com

10. Build on Front-Line
Innovation
• peer ambassadors – local initiatives out of CHCs:
– members of specific ethno-cultural communities who help others navigate
through health system or deliver health promotion programs
– ambassadors often work within the language of the community/consumer
– need to be well trained and supported
• Edmonton Multi-Cultural Health Brokers Cooperative
– provides navigation, counselling and other support to people, who because of
language or cultural barriers have trouble making their way through the health
system
– arose from a grass-roots recognition that these barriers were increasingly
important but not being addressed
– jointly developed by the local regional health authority, public health and other
stakeholders
– many of the brokers were internationally trained providers -- doing this work
allowed them to use their skills and become familiar with the provincial system as
they waited for recognition of their qualifications.
© The Wellesley Institute 10
www.wellesleyinstitute.com

11. Building Equity-Focussed
Innovation Into System
Change
• these examples highlight innovative ways in which a seamless and
responsive continuum of care can be filled out
• another opportunity for innovation is learning from other jurisdictions
– e.g. who have developed centralized interpretation resources and systems within
health authorities
• more generally, this kind of local community-based and front-line
innovation is key to driving equity-focussed health reform
• LHINs and Ministry need to support widespread experimentation
and front-line service innovation
• but to realize potential of innovation, also need infrastructure to:
– systematically trawl for and identify interesting local innovations and experiments
– evaluate and assess potential beyond the local circumstances
– share info widely on lessons learned
– scale up or implement widely where appropriate
• all to create a permanent cycle and culture of front-line driven
innovation on equity © The Wellesley Institute 11
www.wellesleyinstitute.com

12. © The Wellesley Institute 12
www.wellesleyinstitute.com

13. Contact Us
• these speaking notes and further resources on policy
directions to enhance health equity, health reform and
the social determinants of health are available on our
site at http://wellesleyinstitute.com
• my email is bob@wellesleyinstitute.com
• I would be interested in any comments on the ideas in
this presentation and any information or analysis on
initiatives or experience that address health equity
© The Wellesley Institute 13
www.wellesleyinstitute.com