International Comparisons: An Overview of Access to Health Services for Language Minority Communities in Canada, Spain, Belgium and Finland

Transcription

1 International Comparisons: An Overview of Access to Health Services for Language Minority Communities in Canada, Spain,

2 International Comparisons: An Overview of Access to Health Services for Language Minority Communities in Canada, Spain, Research Report prepared by OLCDB - Official Languages Community Development Bureau November 2007

3 Her Majesty the Queen in Right of Canada, represented by the Minister of Health, 2009 Cat. : H14-47/2008E ISBN : Official Language Community Development Bureau 3

4 Table of Contents Introduction... 5 I. International Communities... 5 Brussels, Belgium... 5 Catalonia, Spain Finland less the Åland archipelago German-speaking Wallonia, Belgium II. Canadian Communities The Canadian Context Moncton, Canada New Brunswick, Canada Canada less Quebec Quebec III. Comparative Analysis Institutional structures and legal frameworks affecting language access to health services Language access initiatives in health services International approaches and the advancement of Canadian health care priorities Conclusion Official Language Community Development Bureau 4

5 Introduction This report provides an overview and comparison of access to health services in several international and Canadian official language minority communities. The international communities selected for analysis include Brussels, Catalonia, Finland less Åland and German-speaking Wallonia. The Canadian communities chosen for comparison include the city of Moncton, the province of New Brunswick, Canada less Quebec and Quebec. The assumption is that, based on demolinguistic similarities, Brussels can be compared to Moncton, Catalonia can be compared to New Brunswick, Finland less Åland can be compared to Canada less Quebec and German-speaking Wallonia can be compared to Quebec. The main features chosen for analysis and comparison include the following: institutional structures of the federal, regional and/or municipal governments; legal frameworks for language access to health services; and, language access initiatives in health services. The majority of the text is devoted to describing how the eight selected official language minority communities fare in relation to the above characteristics. This overview serves two main purposes: First, it shows how other countries are addressing the challenges of official language minority communities. Second, it provides a context for assessing Canadian policies and programs. The last part of the report offers a comparative analysis of the international and Canadian communities. In this section, the report shows that while the institutional structures of the federal states involved may vary, the diverse communities have nonetheless enjoyed considerable success in implementing language access initiatives. Several international initiatives that might be useful for advancing Canadian health care priorities are identified. The report concludes with a discussion of one significant point of divergence between the international and Canadian contexts; namely, the international communities, unlike the Canadian communities, have access to stable mechanisms that ensure the continued advancement of language access initiatives at the level of health service delivery. I. International Communities Brussels, Belgium Belgium, a country of 10 million, is constitutionally trilingual Dutch, French and German. Of the total population, the Dutch-speaking population represents about 59%, the French-speaking population about 40% and the German-speaking population about 1%. 1 Through decentralization of power, Belgium has evolved into a federal state with a highly complex structure. 2 In terms of governance, the constitution 1 United States. Department of State (2004). Country Reports on Human Rights Practices: Belgium, [available online], 2 According to the International Constitutional Law project at the University of Würzburg, Belgium has a four level structure comprising the federal level (House of (continued...) Official Language Community Development Bureau 5

6 divides the federal state into language communities and economic regions, each of which has been vested with distinct powers and territory. 3 An additional component of the Belgian federal structure is the linguistic region. 4 2 (...continued) Representatives, Senate, King), the community level (Flemish, French, and German Community Council, Joint Commission), the state-region level (Flemish and Walloon Region, Brussels-Capital), and finally the language-region level (Dutch-, French-, German-speaking, and Bilingual Region). See the University of Würzburg s International Constitutional Law project under Country Index: Belgium, [available online], indx.html. 3 Different geographical boundaries are associated with the language communities and the economic regions. To add to the complexity, in the case of German-speaking Wallonia, certain regional powers have been transferred to the language community. 4 In , Belgium was legally divided into four linguistic regions. The four linguistic regions are made up of communes or municipalities. Three of these linguistic regions are officially monolingual. One region, Brussels, is officially bilingual. K. Deschouwer describes the linguistic regions as follows: Belgium now contains four linguistic territories...the first one is the Dutch-speaking area or the Flemish region. The second one is the region of Wallonia, which is francophone. Actually Wallonia includes also an area in the east which was transferred from Germany at the Treaty of Versailles in 1918, and where the population of course speaks German. It is today formally recognized as the German-speaking territory, but for regional matters (see below) it belongs to Wallonia. The fourth area is Brussels, the limits of which have been set and fixed in That region is bilingual. It is on the basis of this territorial division that the Belgian federal state will be built, but in a rather complex way, since the Francophones defend mainly a division in three regions, meaning that Brussels should be a separate region, while the Flemings defend then idea of a bipolar federation, based on the language groups, which means that Brussels belongs territorially to Flanders. See p. 8 of the United Nations Research Institute for Social Development (2004). Ethnic Structure, Inequality and Governance of the Public Sector in Belgium, prepared by K. Deschouwer, [available online], C1D00383EEF?OpenDocument. The three language communities (French, Dutch and German Communities) and the three economic regions (Flemish, Walloon and Brussels-Capital Regions) exercise power in four linguistic regions. Geographically, the linguistic regions are defined as follows: the German-speaking Walloon Region (Wallonia), the French-speaking Walloon Region (Wallonia), the Dutch-speaking Flemish Region and the French and Dutch-speaking (continued...) Official Language Community Development Bureau 6

7 For the purposes of understanding how language laws and policies apply in the area of health, it is important to understand the role of the Belgian language community. As indicated, in Belgium, the language community is one of two fundamental components of the federal government structure. There are three language communities; the Dutch-speaking community, the French-speaking community and the German-speaking community. The second fundamental component is the economic region. There are three economic regions; the Flanders Region, the Walloon Region and the Brussels-Capital Region. Each language community, as well as each economic region, has its own parliament with a specified numbers of seats. Within specified territorial boundaries, or `linguistic regions, the language communities have jurisdiction over what are known as `community matters. Accordingly, language community representatives decide on such things as the use of language in the territories over which they have jurisdiction. This power extends to decisions on the language to be used in public administration, public education, workplace relations, corporate acts and other public documents. 5 In addition, the language communities have responsibility for all person-related matters concerning health. According to the Belgian government, this jurisdiction extends to health care and health policy, both inside and outside of hospitals, and includes health education, health promotion and preventive medicine. What this means, in practical terms, is that the language communities are responsible for numerous aspects of the health care system, including the application of existing agreements and standards, subsidization, preventive medicine, frontline care, inspections, sport and school medical controls and follow up programs for children. By way of contrast, the federal government is responsible for legislation, national health insurance, base rules for program standards, financing infrastructure and expensive medical equipment, and national agreement standards relating to financial requirements, health insurance, base rules and university hospitals. 6 The emphasis placed on facilitating decentralization, language community representation and participatory democracy in Belgium has led to a high level of administrative complexity in the country. This complexity has contributed to difficulties in the development of health care policy at the national level. 7 Despite these difficulties, language policy is recognized as an important element in health care delivery, and language-related initiatives have garnered support at both national and local levels. For (...continued) Brussels-Capital Region. The three economic regions are associated with the following geographical boundaries: The Brussels-Capital Region, the Walloon Region and the Flemish Region. See the International Constitutional Law project at the University of Würzburg (2004). Country Index: Belgium, [available online], indx.html. See the International Constitutional Law project, University of Würzburg (2004). Country Index: Belgium, [available online], indx.html. United Nations. Department of Economic and Social Affairs (1997). Social Aspects of Sustainable Development in Belgium, prepared by the United Nations Commission on Sustainable Development [available online], The details of this account were submitted to the United Nations by the Belgian government. 7 M. Defever (2000). Decentralisation of healthcare: the case of Belgium, eurohealth Vol 6 (4), p. 26, [available online], Official Language Community Development Bureau 7

8 example, in 1977, the national association of physicians adopted a linguistic policy, declaring that, in non-emergency situations, doctors should either speak the language of the patient or find a suitable alternative arrangement for the patient (i.e., an interpreter or an alternate physician), and that, in emergency situations, it is imperative that the physician speak the language of the region. 8 In addition, by 2002, Belgium had put in place a federal committee and a law on patients rights. 9 These provisions, coupled with a national-level program for inter-cultural mediation services, help to ensure that Belgians have access to health services in their mother tongue. 10 The Brussels capital region is a bilingual linguistic region with French and Dutch as its official languages. 11 Belgium stopped holding language censuses on a regular basis after 1947; however, recent estimates characterize the population of Brussels as 51.5% French only, 9.3% Dutch only and 19. 4% bilingual. 12 As a bilingual linguistic region, Brussels has adopted legislation, policies and programs appropriate to its mandate to support bilingual services. For example, since 1996, there has been a Linguistic Courtesy Agreement in place that requires public servants to demonstrate their bilingualism. In 2004, a new language accord was negotiated. This accord, which has already been applied by the courts to health care services, requires that staff holding positions in the public hospitals of Brussels satisfy the 8 Canadian Institute for Research on Linguistic Minorities (2006). Le Programme de contribution pour l amélioration de l accès aux services de santé pour les CLOSM: Revue de la litterature, pp. 28-9, prepared by E. Forgues,., C. Traisnel, and C. Létourneau World Health Organization (2007). International Digest of Health Legislation, [available online], e=xia&strrefcode=belg Inter-cultural mediators provide interpretive and translation services to members of ethnic minorities. For information on patients rights and inter-cultural mediators in Belgium, see Service public fédéral de la Belgique (2007). Santé publique, sécurité de la chaine alimentaire et environment, [available online], RTAL and RTAL. Brussels, which happens to be a linguistic region and an economic region, is governed by a joint community council that represents the French and Dutch language communities as well as a regional government. 12 R. Janssens (2007). Sociolinguistic: some methodological issues based on survey research in Brussels [consulted online in early October 2007], The paper is no longer available online. See also R. Janssens (1999). Aspecten van het taalgebruik in Brussel, published in Witte E., Alen A., Dumont H. et Ergec R. (red.), Het statuut van Brussel/Bruxelles et son statut, Brussels: Larcier, pp Official Language Community Development Bureau 8

9 legally binding linguistic requirements of the region. In effect, the agreement entitles residents of the capital region and patients receiving care in Brussels hospitals to access to the health care system in their own official language, i.e., Dutch or French. In addition, there is a permanent commission, the Standing Commission for Language Supervision, that helps to oversee the implementation of the language accord. This commission has representation on an administrative committee that governs the region s network of public hospitals (IRIS). 13 The bilingual health services legislated in Brussels are limited in number and scope. Nonetheless, strict rules regarding bilingualism are supposed to be applied, and the institutions involved are subject to administrative, political and judicial controls. 14 Particular emphasis is placed on bilingualism in emergency services and public hospital reception services. The main rules are as follows: 15 Emergency services, whether offered through public or private hospitals, must be provided in both official languages. The ratio of French to Dutch-speaking staff recruited for emergency services, a service run by the Brussels Fire Department, must be based on the volume of calls dealt with in each language. Presently, the staff ratio is 70%-30% French-Dutch. The department is also required to organize its services in a way that caters to language needs. Of the staff working in public hospitals, 25% must belong to the Dutch-speaking language minority community. With the exception of emergency services, university and private hospitals are free to provide bilingual or monolingual services as they choose. In order to ensure that these language requirements can be met, a number of language-related initiatives have been adopted in Brussels. These include: providing language training in Dutch, particularly for emergency staff; ensuring that there is Dutch language training in regional medical schools; attracting Dutch physicians and providing them with language training and incentives to stay; initiating a network of bilingual doctors; and, increasing the number of bilingual schools in the Brussels area. 16 Given the language policy adopted by Belgian physicians, it is no surprise that language studies are commonplace for students in the Brussels area intending to work in the fields of medicine. The content of the courses may be discipline-specific, though the courses themselves are often organized by the language departments of universities. There are also language centres that provide subject-oriented 13 Council of Europe. Parliamentary Assembly (2005). Language problems in access to public health care in the Brussels-Capital region in Belgium, [available online], m. 14 Ibid. 15 Ibid. 16 Ibid. Official Language Community Development Bureau 9

10 courses for doctors, pharmacists and other health professionals. 17 Though many of Brussels efforts to support bilingual services are focussed in areas linked to health service delivery or primary health care, in practice, patients have experienced difficulties obtaining health services in their own official language. Petitions regarding language problems in access to health services have been circulated in Brussels. The Council of Europe has thoroughly investigated the matter, concluding that, in the Brussels region the language access policies were adequate, but that additional effort would be needed to ensure successful implementation of the policies. 18 Catalonia, Spain Spain, a country of 45 million, is constitutionally monolingual. The official language of the country is Castilian, and, according to the constitution, all Spanish citizens have a duty to know and use Castilian. Despite this, Spain s Castilian-speaking population is estimated at only 74% of the national total. 19 In the mid-to-late 1970s, a new Spanish constitution was adopted. This constitution devolved powers to the regional level, recognizing a number of special regions, called autonomous communities. Spain empowered these communities to declare additional official languages and to develop independent language laws and policies. 20 Reinforcing this tendency, Spain ratified its original commitment to the European Charter for Regional or Minority Languages in The European Charter for Regional or Minority Languages, among other things, encourages the use of minority languages in public life and public administration. Hence, although Spain has only one official language, it recognizes minority language rights at the regional level particularly the Basque, Catalan and Galician languages. It is estimated that a substantial percentage of Spaniards about 17% speak Catalan. 21 In Catalonia, an P. Van de Craen (2001). Language Studies in Higher Education in Belgium, [available online], See also Pro Medicis Brussel (2007), a web site aimed at attracting medical students to Brussels. The site features information on Dutch-language instruction and is available at Council of Europe. Parliamentary Assembly (2005). Language problems in access to public health care in the Brussels-Capital region in Belgium, [available online], m. 19 Central Intelligence Agency (2007). World Factbook: Field Listing Languages, [available online], 20 A. Rico (2000). Health policy under asymmetric federalism: Twenty years of regional devolution in Spain, eurohealth Vol 6 (3), pp , [available online], 21 Central Intelligence Agency (2007). World Factbook: Field Listing Languages, (continued...) Official Language Community Development Bureau 10

11 autonomous community in Spain, Catalan is the mother tongue of about 48.8% of the population, while Castilian is the mother tongue of 44.3% of the population. Catalonia has declared itself a bilingual community and has developed legislation, policies and programs to support the use of Catalan. 22 Two items of Catalonia law apply solely to language. These stipulate the following: First, that all persons in Catalonia have the right to use the official languages of Castilian and Catalan and that all citizens have an obligation to know them. Second, that all persons have a right not to suffer discrimination on the basis of linguistic reasons and that all legal acts, whether in Spanish or Catalan, are valid and effective. 23 In addition to these laws, the Catalonian government has extended, as part of a citizenship and immigration initiative, a guarantee of proper communication between professionals and citizens particularly where a lack of understanding could compromise a person s basic rights. 24 As an autonomous community, Catalonia has control over policies and legislation related to health as well as language. In terms of health services, Catalonia has undertaken a number of initiatives designed to ensure that health services are accessible to those who speak Catalan. One such initiative is the 2004 study on the subject of language use in Catalonia s health centres. This study, which was published by Catalonia s Secretariat of Language Policy, found that Catalan is the language spoken most of the time in Catalonian health centres, i.e., about 86.7% of the time. Castilian, by way of contrast, is spoken about 12.7% of the time, although it is the mother tongue of 44.3% of the population. The same study yielded the following specific information regarding official language use in Catalonia s health centres: 25 Language use in Catalonia health centres (2004) Catalan Castilian image and labelling 92.3% 6.2% documents for external use 88.7% 10.1% external oral communication 80.4% 19.3% (...continued) [available online], Generalitat de Catalunya (2007). Info Catalunya, [available online], Canadian Institute for Research on Linguistic Minorities (2006). Le Programme de contribution pour l amélioration de l accès aux services de santé pour les CLOSM: Revue de la litterature, pp. 60-1, prepared by E. Forgues,., C. Traisnel, and C. Létourneau.. 24 Ibid. See also Catalonia s Citizenship and Immigration Plan [available online], 25 Generalitat de Catalunya. Departament de Sanitat I Seguretat Social. (2004). Els usos lingüístics als Centres sanitaris de Catalunya: Presentació dels principals resultat, prepared by the Secretaria de Política Lingüística, [available online], Official Language Community Development Bureau 11

12 Language use in Catalonia health centres (2004) Catalan Castilian external written communication 87.8% 12.0% internal oral communication 85.1% 14.7% internal written communication 86.0% 13.7% Though Catalan is clearly the predominant language in use in Catalonia s health centres, the study nevertheless makes a number of recommendations designed to maintain and/or improve access to services in Catalan. The study recommends attempting to maintain the level of Catalan in cases where knowledge and/or use of the language is between 90% and 100%. However, efforts at improvement are recommended in cases where knowledge and/or use of the language is falls below 90%. Since the publication of the 2004 study, Catalonia has developed a strategic plan for language policy in its health centres. The plan aims to increase and normalize the use of Catalan in health services. As stated in the 2005 Language Policy Report, Catalonia s plan aims in general to get Catalan to become the language habitually used in communicational situations that arise in health centres, services and establishments of the Catalan health network. 26 Specific initiatives identified under the section entitled Strategic Plan of Language Policy in Health Centres include the following: Statistical analyses of language situations at various health facilities and language plans tailored to institutional needs. The plans may include, for example, the development of a language protocol, language training for staff, initiatives to support managerial level commitment and special language training for doctors. The signing of agreements with organizations and institutions to promote language training and the use of Catalan in communications. Development of information and resources in support of linguistic services in health care such as a website, terminological dictionaries, spellcheckers and online language training. Additional strategies for implementing the strategic plan touch on areas such as language training, networking, city-specific needs-analyses and management commitment. Specific actions suggested for health centres by the Secretariat of Language Policy in 2005 include the following: 27 Conducting studies to assess the current language situation in the health centres of Barcelona, where Catalan is less often used. Creating action plans and recommendations based on study 26 Generalitat de Catalunya. Política lingüística a Catalunya. Informe de política lingüística (2005) Language Policy Report: Section IX, [available online], 27 Generalitat de Catalunya. Departament de Salut. Departament de la Presidència. Secretaria de Política Lingüística (2005). Pla estratègic de política lingüística als centres sanitaris, [available online], Official Language Community Development Bureau 12

13 results. Establishing a network, drawn from representatives of various areas of personnel, to collaborate on assessments of the current language situations in various institutions. Designating an individual, selected from within management, to be charged with overseeing the integration of specific and general elements of an institution s language plan. Working toward improvements in the use of Catalan in corporate images as well as in documents, communications and information systems. Improving the knowledge of Catalan among the personnel by requiring that knowledge of the language be part of the personnel selection process. Language training, including instruction in the correct use of terminology, should be included in job-related training. In addition, proof of language ability and contractual obligations to learn the language should be required. The use of Catalan in various contracts, subsidies, instructional manuals, and so on. Creating terminological and online resources, including an automatic translation service and a spellchecker. Catalonia has evidently taken strong measures to support the use of Catalan in public services and health services. The approach is not uncontroversial, and there have been complaints over the years charging discrimination against the use of Castilian in Catalonia. 28 Finland less the Åland archipelago Finland, a country of 5 million, is constitutionally bilingual. It has two official languages; Finnish and 28 United States. Department of State (2006). Country Reports on Human Rights Practices: Spain, [available online], According to this report, there were around 50 complaints about language in Catalonia in The data does not specify the number of complaints relating to health services: During the year the national ombudsman received approximately 50 complaints related to alleged discrimination in Catalonia, where both Castilian and Catalan are official languages, against the teaching of the Castilian language. During the year the Catalan ombudsman received 10 complaints related to discrimination against the teaching or use of the Castilian language and 33 complaints about the failure to use the Catalan language in Catalan official institutions (these complaints were from persons who wished to be served in Catalan but were served in Castilian), although the law requires that civil servants dealing with the public be able to speak both languages. Critics on one side asserted that limiting education in Castilian reduced opportunities for Catalans who wish to live or work outside Catalonia or who simply wish to speak Castilian, and circumscribed the opportunities of Castilian speakers in Catalonia. Others, however, insist on their right to be served in the Catalan language. Official Language Community Development Bureau 13

14 Swedish. Though officially bilingual, Finland is, in reality, substantially monolingual. About 89.4% of the population lives in its 399 Finnish-monolingual municipalities and the Finnish-speaking population of the country is estimated at 91.5% of the total. By way of contrast, the Swedish-speaking population of Finland is estimated at 5.5% of the total. 29 Despite the predominance of Finnish-speakers in Finland, the country has made a national-level commitment to protecting the rights of official language speakers. Indeed, the protection of language rights afforded to Swedish speakers in Finland is regarded as exceptional. 30 While the vast majority of Finland s municipalities are Finnish-monolingual, there are regions where Finnish is not the predominant language. Finland has recognized this variety in its constitution, which includes explicit definitions for monolingual and bilingual municipalities. A municipality is designated bilingual if at least 8% of its population speaks the minority language. Bilingual municipalities can become monolingual if the minority language community drops to less than 6% of the population. 31 There are about 44 official language bilingual municipalities in Finland and most Swedish-speaking Finns live in these bilingual municipalities. 32 There is also at least one multilingual municipality in Finland where non-official languages predominate. For example, the municipality of Ohcejohka/ Utsjoki is 70% Sámi. It has four main languages; three Sámi languages and Finnish. 33 As a signatory to the European Charter for Regional or Minority Languages in 1994, Finland has recognized not only the rights of its Swedish-speakers, but also the rights of its Sámi-speakers. 34 Finally, Finland s constitution also recognizes an independent Swedish-monolingual region, the Åland archipelago. This region represents 0.5% of the country s population. Finland has strong legal support in place to protect the language rights of its Swedish-speaking citizens particularly those living in official language bilingual municipalities. In general, Finland stipulates that bilingual municipalities must serve citizens in their own official language. This policy has likely been facilitated by the high level of bilingualism in the country. 35 Until 2005, Finland required a certificate of bilingualism for high school matriculation. The certificate has historically been a condition for university entrance and all civil servants with a university degree must have one. The policy is also supported by 29 Statistics Finland (2006). Finland in Figures, [available online], See also 30 J. LeClerc (2006). L aménagement linguistique dans le monde: Finland, [available online], 31 Finlex (2007). Legislation, [available online], J. LeClerc (2006). L aménagement linguistique dans le monde: Finland, [available online], Web- Oktavuohta.Digital magazine on sámiculture (2007). Sámi and Finnish - related to each other, [available online], 34 Note also that Finland s constitution prohibits discrimination on the basis of language, protecting the rights of speakers of Sámi and other languages. 35 This is the position taken by A. Ostern (1997) in The Swedish Language in Education in Finland, Leeuwarden, Netherlands, Mercator-Education. Official Language Community Development Bureau 14

15 Finland s federal Language Act, which requires that authorities realize the language rights of both Finnish and Swedish-speaking citizens. Municipal language policies and laws must conform to this federal Language Act, which means that Swedish speaking Finns have the right to use their mother tongue in communications, not only with federal authorities, but also with authorities in bilingual municipalities. The federal Language Act has specific implications for health care service. For example, the Act on the Status and Rights of Patients states that patients have the right to use, to be heard in and to obtain documents containing decisions in either the Finnish or Swedish languages. Moreover, the same act stipulates that an interpreter should be provided, if possible, in cases where there is a language barrier between a patient and his or her health care provider. 36 The Language Act is also cited in the Primary Health Care Act and the Act on Specialized Medical Care. 37 Respectively, these acts define the language requirements in primary health care centres and hospital districts. In primary health care centres, administration must be accessible in the languages of the municipality. In hospital districts, both administration and provision of care must be accessible in the languages of the municipality. In addition, the acts state that an effort should be made to accommodate citizens of Nordic countries in their own languages (e.g., Danish, Icelandic, Norwegian).The specific details are as follows: 38 For primary health centres: In monolingual municipalities, health services are in the language of the municipality. Citizens have a right to communicate and receive certain documents in their mother tongue and the right to an interpreter. In bilingual municipalities, service is provided in the official language of the patient. If a citizen speaks one of the languages of the municipality or a Nordic language, an effort must be made to provide services in his or her mother tongue. For hospital districts: Hospital districts linked to non-monolingual municipalities must have a committee to develop and integrate special language provisions and the training of personnel in the minority language(s). Management boards must have a minority language division to deal with language-related matters. Provisions must be made to care for citizens belonging to an official language groups in their mother tongue. Language may be a factor in decisions about the facility in which treatment will take place. There are also a few language and health-related initiatives in Finland that extend beyond the scope of the law. There is, for example, a Swedish language of medicine group consisting of a board and a reference group. The main purpose of the group is to develop correct Swedish medical language for use in Finland and to ensure that this terminology is consistent with that used in Sweden. 39 While there is some recent evidence of language-related complaints brought forward by speakers of Sámi Finlex (2007). Legislation, [available online], From an administrative point of view, health care in Finland can be divided into basic health care and specialist medical care. See Finland. Ministry of Social Affairs and Health (2007). Health Services, [available online], 38 Finlex (2007). Legislation, [available online], 39 The Finnish Terminology Centre (2004). Terminfo 4/2004 Summaries, [available online], Official Language Community Development Bureau 15

16 who now have the right to use Sámi languages in their dealing with Finland s administrative and judicial authorities and in various other spheres of public life there does not seem to be much evidence of complaints lodged in relation to the use of official languages in health services in Finland. One explanation for this may relate to the central role played by municipal governments in creating and implementing health policy guidelines. For, although Finland s language rights have been established through a top-down, legalistic structure that turns on a Language Act, health policy and its implementation are largely controlled at the municipal level. 40 It is possible then, that success or failure in implementations of language-related health policies turns on municipal-level decision-making and local action. It could be argued, however, that there is no need to suppose that any special effort on the part of local governments in relation to the implementation of language policy in Finland. Historically, there has been a high level of bilingualism in the country, and this could also explain a successful implementation. Indeed, Swedish is still a mandatory subject in Finland s schools, and, until 2005, the certificate of official language bilingualism was a condition of high school matriculation and university entrance. It is quite possible then, that the widespread knowledge of both Swedish and Finnish has helped to ensure the availability of bilingual services in the health centres and hospitals of Finland. However, pressures to relax bilingualism requirements in education may, in the long run, lead to lower levels of bilingualism among health professionals in Finland. Recent developments in Finland suggest that, as a result of consolidation of services, language has now become a barrier in emergency response services. A committee of experts appointed to review Finland s performance vis-à-vis the European Charter for Regional or Minority Language Rights has claimed that the 2006 reorganization of emergency services (including medical emergency services) has compromised access to service in Swedish. Specifically, the claim is that the transfer and consolidation of emergency services from the municipal-level to 15 state-run services has caused difficulties for the Swedishspeaking population of Finland. The government of Finland has denied the validity of these charges and has pointed out that efforts are being made to ensure adequate bilingualism and language training, especially in areas that include bilingual municipalities. However, if the committee s charges have merit, then this suggests that the administration of health services at the municipal level may be an important factor in the successful implementation of language policy. 41 German-speaking Wallonia, Belgium It is estimated that Belgium has approximately German speakers and is about 1% German. Most 40 N. Simonsen-Rehn, J. Øvretveit, R. Laamanen, S. Suominen, J. Sundell and M. Brommels (2006). Determinants of health promotion action: comparative analysis of local voluntary associations in four municipalities in Finland, Health Promotion International Vol. 21(4), pp See also M. Sihto and I. Keskimäki (2000). Does a policy matter? Assessing the Finnish health policy in relation to its equity goals, Critical Public Health Vol. 10, No Database for the European Charter for Regional or Minority Languages (2007). Database by State Party: Finland. Appendix II: Comments by the Government of Finland, [available online], SPComm.pdf. Official Language Community Development Bureau 16

17 of Belgium s German-speakers live in the country s southeastern German linguistic region, which is part of the larger economic region of Wallonia a predominantly French-speaking region also known as the Walloon region. The vast majority of the population in these nine German municipalities about 95% is German-speaking. 42 Not surprisingly, German is the language most often heard in German-speaking Wallonia this despite the fact that the territory falls within the bounds of a predominantly Frenchspeaking economic region. In recent years, the territory associated with the nine German-speaking municipalities of Wallonia the German-speaking linguistic region has been recognized as substantially autonomous. Both the German language community and the German-speaking linguistic region have been constitutionally recognized. Through this recognition, the German language community has been granted increasing authority in the linguistic region. For example, it exercises jurisdiction over the language of education, administration and public social relations in the German-speaking municipalities. Moreover, even though local authorities are representative of both the German language community and the larger Wallonia economic region, the German language community enjoys an extended range of competencies in virtue of agreements with the regional government. 43 Specifically, in the German-speaking linguistic region, the German language community governs not only over community matters, but also over certain `communitarized regional matters normally associated with the regional level of government. 44 In other words, some of the powers normally associated with the economic regions have been transferred to the German language community, which exercises these special powers in the nine municipalities that make up the German linguistic region. Historically, there have been difficulties as a result of the dual languages used in the greater Walloon region. For example, the government of the larger, predominantly French-speaking economic region has, 42 J. LeClerc, J L aménagement linguistique dans le monde: Belgique. See and 43 DG Live: Portal Site of the German Speaking Community (2007). The Institutional Development, [available online], 44 United Nations Research Institute for Social Development (2004). Ethnic Structure, Inequality and Governance of the Public Sector in Belgium, prepared by K. Deschouwer, [available online], C1D00383EEF?OpenDocument. Deschower writes that, The German-speaking Community parliament and government (25 seats). It issues decrees in Community matters, which are valid in the German-speaking area. The government is elected by the parliament. This Community parliament is directly elected. The Walloon parliament and government (75 seats). It issues decrees on regional matters valid in the Walloon region, including the German-speaking area. It also issues decrees over matters that were communitarized in In that case, those decrees do not apply to the German-speaking area. The government is elected by the parliament. Official Language Community Development Bureau 17

18 in the past, neglected to provide German-language documentation to its German-speaking community. Difficulties such as these have spurred the transfer of competencies from the larger economic region of Walloon to German-speaking Wallonia. For its part, the German language community has now established that members of the public in the German linguistic region have the right to send and receive communications with local authorities in the German language. 45 In addition, education in the linguistic region is primarily in the German language French being the second language of instruction. Moreover, as the language requirements for the Belgian public service stipulate, appointment and promotion in the public service depend on the ability to function in the official language of the region. Hence, public servants must be able to speak German. Nevertheless, the German-speaking territory is not in actuality entirely monolingual. The government of the larger Walloon economic region still has jurisdiction in some regional matters, and, in consequence, it is not uncommon to find instances of bilingualism or even French only in the public domain. One example of this is road signage. The end result of the dual governance system is that the language of service in German-speaking Wallonia varies as follows: 46 Both German and French: Public announcements, communications and forms. Official documents, e.g., certificates, declarations and licenses. In public contexts, German is usually spoken first, but choice of language is given. German only: German is used in official correspondence with individuals. German predominates as the language spoken in public service contexts. French only: Road signs may be bilingual or French only. Hence, though German is clearly the predominant and official language in German-speaking Wallonia, both French and German are in fact used in the region. It is reasonable to suppose that the history of dual governance has encouraged a certain level of bilingualism. There are, however, occasional telltale signs of the official language status of German. For example, the Saint Nikolaus Hospital in Eupen has a German-French bilingual website; however, its job postings are in German only. On the other hand, St- Vith s Klinik St-Josef has a German-French bilingual website, but posts its job ads in French and German. It would seem then, that both German and French are used in the public context in Germanspeaking Wallonia. In terms of the health services context, recall that in the Belgian system, the language communities, rather than the linguistic regions or economic regions, have jurisdiction in person-related matters concerning health. Hence, the German language community has jurisdiction in most matters of health in 45 Saint Nikolaus Hospital Eupen (2007). Divers: Offre d emploi, [available online], 46 US English Foundation. Official Language Research (2007). Belgium: Language in everyday life: The use of language in everyday life, e.g. education, broadcasting, and other, [available online], Official Language Community Development Bureau 18

19 the German linguistic region. 47 Given the above guidelines, a typical encounter in a health services context in German-speaking Wallonia might be as follows: Initial contact in German, with the expectation that French language communication might also be required. Web sites and public announcements would be bilingual, though advertisements for employment in hospitals and correspondence from hospitals might well be in German only. This scenario, however, would represent only a minimum requirement for public hospitals. In actual fact, the language access can differ, since private and university hospitals in Belgium are free to deliver services in the languages that they choose. According to the Fédération des Institutions Hospitalièrs (F.I.H.) of Wallonia, the public sector hospitals represent less than 45% of F.I.H. hospitals in Wallonia, including general, specialized and psychiatric hospitals. 48 Such a system can, in principle, result in either better or worse language access. Saint Nikolaus Hospital, for example, participates in the Euregio Meuse-Rhine (EMR), a multinational, crossborder network of hospitals and offers services in three languages German, French and Dutch. Hence, the hospital goes beyond the minimum language standards of the territory. According to an evaluation study of the EMR network, patients reported that language was an important factor in the decision to choose treatment at one of the participating hospitals: A further analysis by nationality and country of residence showed that also "waiting time", "language" and "recommended by a specialist" were important indicators for choosing or not choosing consuming health care in another Member State. 49 Hence, in this context, capacity in multiple languages is potentially an asset, and, perhaps for this reason, local government in the German municipalities of Wallonia has been trying to establish German-French bilingualism. 50 As for ethnic minorities, Belgium has language laws and policies at a federal level, including programs in 47 Centre de recherche at d' information socio-politiques (2007). Public Authorities in Wallonia, [available online], According to the web site, The policy for providing health care, in health institutions and outside, is a community matter, where the French Community has transferred its responsibilities for the French linguistic region to the Walloon Region, except for university hospitals. The policy for providing health care is thus the responsibility of the Walloon Region for the French linguistic region (except for university hospitals, which come under the French Community), and the German-speaking Community for the German linguistic region. 48 Belgian Fédération des Institutions Hospitalièrs (2006). La F.I.H. en Wallonie, [available online], 49 e-business W@tch: The European e-business Market Watch (2004). Case Study: Cross-Border Cooperation for Healthcare Provision in Euregio Meuse-Rhine, [available online], Look under Case studies from the health and social services sector/ Euregio Meuse-Rhine - Crossborder cooperation for healthcare provision 50 US English Foundation. Official Language Research (2007). Belgium: Language in everyday life: The use of language in everyday life, e.g. education, broadcasting, and other, [available online], Official Language Community Development Bureau 19