Update: 03.06.2016

Lack of funding for community interpreting: one reason for inadequate psychiatric support of traumatised refugees

Many refugees are traumatised by what they have experienced in their home country and while fleeing and are in urgent need of psychiatric support. The use of qualified intercultural interpreters and intermediaries facilitates understanding across linguistic and cultural barriers. This is especially important in psychiatry, since psychotherapy works mainly through language. The importance and necessity of community interpreting is recognised but payment for interpreters in psychiatric therapy is not defined. As a result, Switzerland lacks several hundred places in treatment programmes and mentally ill refugees sometimes have to wait months or even years for adequate treatment.

Legal entitlement to community interpreting

Outside court rooms, Swiss law does not include direct entitlement to interpreting services offered by the state. This applies to patients’ basic right to interpreting in the healthcare sector. Specifically, the right to interpreting services can be derived from the patient’s right to sufficient information and the right to consent before every medical intervention that are the foundation for cantonal medical law.

According to a study by the Federal Office of Public Health, further entitlements to state interpreting services in the medical sector stem from the right to healthcare in Article 12 of the UN Covenant on Economic, Social and Cultural Rights. No one can be deprived of medical treatment because they lack language skills. All health-relevant information must be accessible for the patient in a language which he or she understands.

Switzerland would therefore be obliged to provide free interpreting services in all hospitals or other medical institutions. But the rights guaranteed in the UN Covenant on Economic, Social and Cultural Rights are not directly enforceable before the courts in Switzerland. In the Federal Supreme Court’s view, the guarantees of the UN covenant only provide a mandate to the legislator and no subjective, enforceable rights.

Political and legal consensus is lacking on a Federal level to define an enforceable right to health in the Federal Constitution (see our article in German “Ablehnung der Justiziabilität der Sozialrechte in der Schweiz”).

Not covered by health insurance

With the necessary political willpower, it would be possible to compensate the costs for community interpreting during therapy through mandatory health insurance. Mandatory insurance handles services for diagnosing or treating illnesses and their effects. The treatment of an illness only includes diagnostic, therapeutic or nursing measures. According to the jurisdiction by the Federal Supreme Court, (cf. judgement of 31 December 2002 in German) interpreting does not constitute a medical service and therefore financing it through the Health Insurance Act is currently impossible. But this obstacle could be removed by simply changing the respective ordinance in the Health Insurance Act.

Parliament has already discussed the right to interpreting in the health sector, and the question of the availability of a necessary interpreting infrastructure has been addressed twice. This happened because of a parliamentary initiative in 2006 and a motion by Luc Recordon in 2008. Both political requests were unsuccessful.

Insufficient patchwork financing

The Confederation and the cantons contribute financially to community interpreting within their respective jurisdictions. Community interpreting is a focus of the National Programme on Migration and Health. The national competence centre INTERPRET for quality assurance and public relations in the field of community interpreting on location or over the phone, the national telephone interpreting service and various training workshops receive financial support from authorities. Numerous studies commissioned by the FOPH show further qualitative, legal and financial aspects of community interpreting.

In addition, community interpreting has become an established part of cantonal integration programmes since January 2014. The cantons must demonstrate how they plan to assure the provision of high-quality offers in this field. For example, institutions that work in the field of qualified community interpreting are financially supported (e.g. “comprendi?” - Fachstelle für qualifiziertes interkulturelles Dolmetschen im Kanton Bern or “AOZ Medios” - Interkulturelles Dolmetschen Stadt und Kanton Zürich). Contributions from the integration promotion are used for quality management. Some cantons finance community interpreting in hospitals through the service agreement with the Conference of Cantonal Health Directors (e.g. in the cantons Bern, Solothurn, Uri, Vaud, Zug and Zurich).

Michael Müller, the head of the specialist organisation INTERPRET, has called for national regulation financing for community interpreting in order to remedy the unjust patchwork financing. Upon request by humanrights.ch he has asked for “the financing of interpreting services not to be covered by mandatory health insurance as a medical service but as an indispensable additional service. This is the only way that equal treatment and equal, sufficient access to therapeutic offers can be guaranteed.”

Therapy for traumatised refugees

The Outpatient Clinic for the Victims of Torture and War of the Swiss Red Cross founded in 1995 was the first therapy centre for torture victims in Switzerland. Because of the high demand for suitable treatment units, four additional therapy centres were opened, joining together as the “Support for Torture Victims” association.

The Federal and cantonal financial contribution to the costs of community interpreting is by far too small. Since the costs of community interpreting are not paid by mandatory health insurance, established psychiatrists and psychotherapists have to include the use of translation personnel in their regular hourly rate. The therapy centres specialised in the treatment of traumatised refugees indirectly feel this cost pressure. Carla Benedetti, head of operations and quality assurance of the Outpatient Clinic for the Victims of Torture and War of the Swiss Red Cross (SRC) in Bern says that “many patients with insufficient language skills are registered with the SRC outpatient clinic, because there the translation costs are borne by the SRC.” She assumes that this is one of the main reasons why there are more applications than free places at the outpatient clinic.

According to its personal resources, the Outpatient Clinic for the Victims of Torture and War of the Swiss Red Cross in Bern cares for and supports between 250 and 320 patients. In addition, it organised between 3,000 and 4,000 consultations, and two thirds of the therapy sessions require an intercultural interpreter.

According to Matthis Schick, head of the Outpatient Clinic for the Victims of Torture and War in Zurich, all outpatient clinics are experiencing capacity problems. In an interview with the NZZ he stated that “demand far exceeds resources.” As a result, patients in Zurich have to wait for around one year for their first consultation.

There are other reasons there is insufficient care for traumatised refugees besides the lack of interpreting cost coverage by health insurance companies. Switzerland is presently experiencing a severe lack of trained psychiatric staff, and pressure to cut costs in the healthcare sector has a strong effect on regular psychiatric institutions. The SRC outpatient clinic and the “Support for Torture Victims” association will try to draw the attention of politicians and healthcare stakeholders to these problems at a convention on 7 December 2016 in Bern.

A pilot project as a solution

In March 2016, the State Secretariat for Migration SEM commissioned the pilot project “Zugänge schaffen – Dolmetschunterstützung für traumatisierte Personen in der Psychotherapie“ (create access – interpreters’ support for traumatised persons in psychotherapy) which aims to increase cooperation between psychotherapeutic services, psychiatric services and interpreters in the field of trauma treatment. The project will support interested institutions that have not yet or rarely worked with intercultural interpreters with a lump sum payment for interpreting between summer 2016 and spring 2018 in order to raise awareness among professionals. Michael Müller, head of the specialist organisation INTERPRET, is cautiously optimistic about the project: “In this way no long-term financial hurdles are created but it will be possible for institutions and specialists to gain concrete experience with interpreters.”

The SEM project offers an opportunity for many involved parties to gain more experience with interpreters in therapeutic everyday work. Unfortunately, the structural problem concerning the lack of funding for interpreting services will probably continue for longer than the project’s duration. Unless the mandatory health insurance takes on these costs.

Further information

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