DOI: https://doi.org/https://doi.org/10.57187/s.4245
Recent events, such as the increase in the number of refugees worldwide and the COVID-19 pandemic, have unmasked the unequal distribution of health and illness in the Swiss population [1–3]. Social determinants of health such as low income and education, communication difficulties or an uncertain residence status are associated with impaired health and an increased risk of physical and mental illness. Avoidable differences in health status resulting from social inequalities are called “health inequities” [1]. They originate from increased exposure to various stress and risk factors (e.g. unhealthy living and working conditions) and a lack of resources. Typically, these factors do not exist in isolation but in combination, which significantly limits an individual’s ability to influence their health or deal with an illness in the best possible way. In addition, according to the “inverse care law”, disadvantaged populations receive fewer health services than more privileged ones despite having higher levels of unmet needs [3]. However, measures to promote public and individual health and prevention can only be successful if all members of a population are reached equitably [4]. According to the Federal Office of Public Health (FOPH), the Swiss health system is based on the principles of solidarity and openness and must therefore be accessible to all [5].
People with a migration background are disproportionately likely to face an accumulation of social risk factors and limited access to the health system [1]. Living in deprived residential areas, a lack of social integration, and limited access to education, the labour market or leisure activities can all affect the health status.
The proportion of the permanent resident population in Switzerland with a migration background has increased steadily in recent years, reaching 40% for the first time in 2022; of these individuals, 80% were born abroad (first generation) [6]. The migrant population is highly heterogeneous and includes people with low to very high socioeconomic status. The individuals negatively affected by social determinants of health do not represent a marginal group but a relevant proportion of the population that is seen by health professionals of all disciplines in regular medical care. Consequently, barriers to healthcare access can have far-reaching effects (see table 1 for details [1, 7, 8]).
Table 1Consequences of access barriers to equitable health care for patients with a migration background.
| Level | Consequences |
| Society | Loss of productivity due to sick leave |
| Reduced potential for social inclusion | |
| Health system | Additional costs due to multiple avoidable consultations or hospital stays |
| Additional costs due to a lack of, incorrect or delayed treatment of illnesses | |
| Health professional | Insufficient knowledge of the patient’s medical history (incomplete assessment) |
| Reduced quality of diagnosis and treatment | |
| Accumulation of medical errors | |
| Impossibility to comply with medico-legal requirements | |
| Frustration, insecurity, dissatisfaction | |
| Patient | Progression/chronification of untreated or incorrectly treated illnesses |
| Uncertainty, mistrust towards health professionals or health system | |
| Under-utilisation of health services | |
| Reduced adherence/compliance | |
| Increased psychological distress |
Communication, building a trusting relationship and continuity of care can be challenging in the treatment of patients with a migration background [9]. These challenges need to be considered in the context of both the specific local health system and the patient.
Communication difficulties are among the most relevant barriers to access to care. When these difficulties arise, (intercultural) interpreters should be involved in consultations to avoid the risks associated with the use of lay interpreters. Unfortunately, there is no standardised regulation throughout Switzerland regarding remuneration for this service. This particularly affects the outpatient sector, where, depending on the canton, either the patients or the hospitals and private practices themselves are expected to cover the costs. Additionally, a lack of understanding during the consultation on the part of the patient and/or the healthcare professional can have serious consequences (see table 1). In the field of mental health, appropriate treatment is not possible without sufficient linguistic and transcultural understanding [8]. In addition, the legal obligation to provide information and obtain “informed consent” cannot be guaranteed without a qualified translation.
Apart from language barriers, the use of stereotypes or prejudices, a lack of understanding of the patient’s cultural background and medical anthropological aspects (the patient’s understanding of health, illness and the treatment required) represent important barriers to adequate care. Factors such as religion, tradition and education can play an important role. For example, not everyone is familiar with the concept of mental health or midwife-led antenatal care as it is applied in Switzerland. In addition, stigmatisation, for example, related to abortion, contraception and consulting a psychologist, can lead to social exclusion. Insufficient familiarity with the Swiss health system or the experience of discrimination can also lead to deliberately or unconsciously refraining from using health care services.
Concerning the provision and remuneration of (intercultural) interpreting services and medical care, including for undocumented migrants, inter-cantonal regulations at the federal level are needed to ensure equitable access to the health care system throughout Switzerland. This also includes adapting information and prevention strategies to the needs and living conditions of the target groups [10]. The often complex living situations and various social determinants of health of patients with a migration background require the consistent alignment of health care towards the biopsychosocial model, appropriately trained professionals, interprofessional collaboration and the establishment of a network of closely cooperating health professionals [11].
To identify and successfully address barriers, systematic and continuous data collection on health inequity is essential to make equitable access measurable and thus verifiable. At present, data describing barriers to health care access in Switzerland (e.g. language barriers/need for interpreters, information on socioeconomic or residence status) are not systematically collected or reported. Within this context, various actors, such as the Swiss Health Network for Equity, university hospitals and the FOPH, are advocating for the use of standardised indicators to record health equity in Switzerland [12].
There is a need to raise awareness of equity and migration health-related topics across all levels and institutions (including medical schools, universities of applied science and hospitals) and health-related disciplines. This will require the use and expansion of established education and training programmes and the provision of needs-based support to strengthen the migration and health workforce. In larger institutes and hospitals, it may be useful to establish a central point of contact for equity- and migration-related topics who can provide advice and access to training opportunities and facilitate the use of interpreting services, among other things.
Authors’ contributions: Concept, writing, preparation of the original draft: AJ; writing, review, editing: all authors. All authors have read the submitted manuscript and are jointly responsible for all aspects of the work.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflict of interest related to the content of this manuscript was disclosed.
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The German version of this article is available for download as a separate file at https://doi.org/10.57187/s.4245.