“Ich verstehe es nicht”: the necessity of integrating professional interpretation into the German healthcare system

Abstract

The migrant and refugee population in Germany continued to grow over the past few years, reaching a record high in 2024. As the second top destination, just after the United States, Germany has yet to incorporate professional interpretation into its healthcare system to overcome language barriers. While community integration is important for migrants to find a sense of belonging, communicating critical and even urgent information regarding one’s health in an unfamiliar language can have dire consequences. Under the International Human Rights Law, the government has an obligation to provide rights to healthcare for everyone living in the region. However, without an explicitly stated law that obligates the use of professional interpretation services, patients may experience more medical errors while providers and interpreters face additional work burden. Thus, we urge for the legal and structural integration of professional interpretation in healthcare, funded by the state or by health insurances.

Background

Since 2020, Germany has quickly become a country with the second largest migrant population of almost 16 million, with migrant defined as “any person who has changed his or her country of usual residence” [1]. Some of the most common migration routes in 2020 included Poland or Türkiye to Germany, or Ukraine to Germany among female migrants [1]. Additionally, Germany also hosts one of the largest displaced populations from Syria [2]. As none of these countries uses German, language can become a barrier to accessing quality healthcare in Germany [3–6]. A 2024 exploratory survey completed by 214 providers in Baden-Württemberg reported that about 12.1% of patients did not speak German in the past 12 months [3].

Professional interpreters are trained at educational institutions and certified via state exams [7]. While studies have shown numerous benefits of using professional interpreters [8], there are currently no federal laws in Germany that mandate the use of professional interpretation services in healthcare if providers and patients spoke different languages. Although Section 630e of the Civil Code (BGB) requires providers to ensure that the information conveyed is understandable for patients, there is no restriction on the type of interpreter used nor is there any requirement as to who will provide and fund professional interpretation [9]. Similarly, article six of the Asylum Seekers Benefits Act (AsylbLG) mandates the reimbursement of services essential for health if the coverage claim has been timely submitted by responsible entities such as healthcare providers and approved by relevant authority [10]. However, the criteria for these essential services are not clearly defined and reimbursement is not always guaranteed. Additionally, AsylbLG is only applicable for asylum seekers. Patients with limited German proficiency, who are not asylum seekers, would thus have to secure and pay for professional interpretation themselves.

In 2022, about 30 healthcare organizations within Germany advocated for the structural incorporation of professional interpretation, either funded by health insurance or covered by the health facility if the patient is uninsured [11]. Additionally, these organizations also asked for the inclusion of professional interpretation in relevant legislations, including SGB V and the Asylum Seekers Benefits Act (AsylbLG) [11]. Promisingly, in November 2024, Amendment 13 was proposed to add Section 140c, which asked for health insurance coverage on remote (including telephone and video call) interpretation services in healthcare, to the Social Code Book V (SGB V) [12]. However, the latest status of SGB V shows that the relevant section has been repealed [13]. Therefore, Germany’s healthcare remains linguistically inaccessible to those with limited German proficiency.

The systemic integration of professional interpretation in healthcare has been implemented in many countries with similar diverse profiles. The US, with the largest migrant population, had over 50 million foreign-born population by 2019 [1]. Given this diverse context, Title VI of the Civil Rights Act of 1964 guarantees access to professional interpretation services in programs that receive federal funding, including most healthcare facilities [14]. This law specifically regulates that professional interpretation is free of charge for patients, and providers can be reimbursed by the government using specific billing codes under Medicaid - a governmental health insurance for low-income populations. With the legal requirement of using professional interpretation, a cross-sectional survey for physicians reported that 78.7% of physicians have used interpreters for patients with limited English proficiency [15]. Similarly, the UK also faces language barriers with a growing foreign-born population, with more than a quarter of the population having limited English proficiency [16]. In the UK, the National Health Service (NHS) has legal regulations to ensure that patients have access to professional interpretation services, and specific guidelines on provision and funding are available for practitioners and facilities, such that the service is free for patients [17]. A pilot survey for South Asians in the UK found that 60% of the participants reported using professional interpreters at least once in healthcare [18]. Another example is Sweden, which has one of the highest ranked health outcomes among European countries with its universal healthcare coverage focused on social equity [19]. Moreover, the Administrative Procedure Act specifically details the utilization of professional interpreters for patients who do not speak Swedish [20]. As a result, a 2018 national survey found that when physicians encountered patients who do not speak Swedish, 90% of the physicians reported trying to hire an interpreter [20]. An interesting case is Denmark, which introduced an interpretation fee to the Danish Health Act in 2018 if the patient has been a resident for over three years [21], resulting in a 11% to 41% decline in the utilization of professional interpretation in healthcare across various regions in Denmark [22].

Given a considerable population of patients with limited German proficiency and best practices among other countries with high-quality care, we aim to discuss the consequences that various stakeholders – including patients, providers, informal and community interpreters, and health organizations – face to urge for the legal incorporation of professional interpretation for equitable care.

Consequences

Clinical consequences for patients

A lack of professional interpretation can result in clinical consequences for patients. Studies have shown numerous benefits of using professional interpreters [23–25]. One systematic review included seven studies that compared professional interpretation with informal interpretation, including family and friends as well as bilingual healthcare workers [24]. Four studies found significantly fewer interpretation errors when a professional interpreter was used compared to mostly family and friends, while the other three studies showed no significant difference between professional interpreters and bilingual staff. However, other studies showed that using bilingual staff can be problematic as it imposes additional work burden and can decrease work efficiency [3, 26, 27]. Moreover, when compared to informal interpretation generally, professional interpreters also made significantly fewer errors regarding severe conditions and more personal issues such as mental and reproductive health [24]. Similarly, one US study investigating Spanish-English interpretation in emergency room (ER) visits found that informal interpreters are twice more likely to make errors that can lead to clinical consequences than professional interpreters [23]. Interestingly, this study also found that the duration of training, instead of work experience, was significantly positively associated with fewer interpretation errors.

Another systematic review included 21 studies that compared professional interpretation to informal interpretation, which generally showed benefits on clinical outcomes when a professional interpreter was used [25]. Particularly, the review found that using professional interpretation can reduce health disparities caused by language barriers through increasing service uptake, referral, and retention in care. Furthermore, six of the 21 studies that looked at patient and provider satisfaction found significantly higher satisfaction with the use of professional interpretation, compared to either informal or no interpretation. It is also important to note that patients often have more motivation for treatment adherence if there is good communication with providers [24]. In Germany, some providers may even reject patients without the presence of an interpreter [4].

Consequences for healthcare workers

A lack of professional interpretation could also lead to additional work stress on providers. One qualitative study on providers’ experiences working with patients with limited Germany proficiency found that providers often found it more challenging to accurately diagnose and prescribe treatments due to the inability to understand patient symptoms if no interpretation was involved [3]. Often, a lack of professional interpretation also indicates more time spent due to ineffective communication. Moreover, providers also experience additional stress when they are unsure if patients can understand all the legal information they have provided. Not to mention that more conflicts could arise due to language miscommunication, especially in the ER [3].

Besides providers, healthcare workers who are bilingual or come from a migrant background may become informal interpreters when professional ones are unavailable. This could impose additional workload on these healthcare workers and unnecessarily prolong the appointment time due to waiting for the availability of the bilingual staff to provide interpretation. The quality of interpretation is also affected when bilingual staff are uncertain about what needs to be interpreted [26]. For certain specialties like the ER, relying on other healthcare workers for interpretation could further hinder their efficiency [3].

Consequences for informal and community interpreters

The lack of legal enforcement regarding the use of professional interpreters could negatively impact children and relatives. As the use of children as interpreters is not regulated in Germany [28], this common practice could also lead to undesirable outcomes for children, including adverse emotional health and more conflict with parents [24]. Other studies have also shown that children may also experience difficulties with processing information and the responsibility that comes with interpretation [28]. Not only do providers tend to downplay the severity of health conditions when a child interpreter is involved, family and friend interpreters may also omit information that pertain to serious diagnoses [3]. Overall, having family and friends as informal interpreters may upset power dynamics in their relationships, since patients have to completely rely on family or friends for their own health.

The lack of legal protection also heavily impacts community interpreters, which is a heterogenous group of interpreters who work in community settings and have varying degrees of training [8, 29]. This indicates that while some are professionally trained, others have not undergone such extensive training in interpretation. In Germany, some community interpretation programs are available but the curriculum is not standardized [29]. This unregulated profession could lead to undesirable working conditions [29]. Community interpreters as a whole are often underpaid as there is no regulation regarding funding, with a reported average hourly pay of 20 Euros across various community settings [29]. Furthermore, they may face discrimination from different parties partially due to a lack of legal recognition [29]. A nationwide survey found that more than one third of community interpreters experience at least moderate levels of psychosocial distress from interpreting, contributed by subpar working conditions and the unproportionate pay, especially for interpreters working in mental care settings [29].

Cost for health organizations

Another concern for the lack of professional interpreters is the additional cost incurred from the unnecessary diagnostics and treatments. Even though hiring professional interpreters seems to increase short-term costs, having professional interpreters may potentially bring long-term financial benefits, though more cost-effectiveness research is needed. One German study examined the cost of using interpreters in outpatient psychiatry and found that the total cost within a quarter, or three months, is less than 5000 Euros for 110 refugee patients, with an average of only 45 Euros per patient [30]. It’s worth noting that the additional 45 Euros spent on patients will likely result in less medical errors, thus reducing avoidable costs. For example, one systematic review with 11 cost and cost-effectiveness studies found lower diagnostic cost with the use of professional interpretation [31]. Additionally, there was a general decrease in ER visits and readmissions, and an increase in regular health appointments as well as any relevant health services with the use of professional interpreters [31].

Other considerations

Given these consequences on patients, healthcare workers, informal and community interpretations, as well as the broader institutional level of healthcare organizations, professional interpreters should be legally incorporated in Germany’s regulations to improve healthcare accessibility for patients with limited German proficiency.

Digital solutions

To further help bridge this gap, digital solutions including phone and video calls, could be implemented to connect interpreters with healthcare facilities. One example is a pilot video interpreting project in Austria, where advantages of remote video interpretation including timely availability of interpreters, easy-to-use technology, data security, ability to see interpreters, and cost efficiency were reported by healthcare workers [32]. This shows the potential of remote interpretation to further bridge the language gap that is sometimes a result of the unavailability and physical inaccessibility of interpreters. However, one study with 241 patients, 24 providers, and seven interpreters found that in-person interpretation was rated significantly higher in terms of satisfaction compared to telephone or video interpretation since it facilitated more comprehension and was more personal [33]. Additionally, one study also found that interpreters favored in-person interpretation because it helps build rapport with patients and physicians, especially those with more cultural differences [34]. Non-verbal’s are also an essential part of communication, which can be utilized more during in-person interpretation [34]. Therefore, to maximize the availability and efficiency of accessing professional interpreters, health facilities should consider prioritizing in-person interpretation but also have remote options available.

Another widespread use of digital language mediation is machine translation, which has gained popularity in healthcare settings in the absence of interpreters. One study looked at the use of ChatGPT in the specialty of Otorhinolaryngology and found promising results [35]. While the translation focused on English, Spanish, and Mandarin Chinese, they found no significant differences in the understandability between those languages. Another study examined both written and verbal communication in healthcare settings and found that machine translation is only effective for translating non-sensitive texts [36]. When compared to professional interpreters, AI models still show more errors that could cause clinical consequences (p < 0.001) [37]. Therefore, while AI shows promise, one needs to remain careful when using machine translation in healthcare at this stage.

Culturally-sensitive care

To further bridge the language gap, health systems should also consider using intercultural mediators, who also work to bridge the sociocultural gap between healthcare professionals and patients [38]. This includes not just translating languages but also explaining the embedded social and cultural norms regarding conditions, health behaviors, and treatments [38].

Conclusion

Professional interpretation should be legally and systematically incorporated in Germany’s health system to improve healthcare quality and access for migrants and refugees. A lack of professional interpretation could have unwanted consequences for patients, providers, community interpreters, and informal interpreters (children, relatives, other health workers). The International Covenant on Economic, Social and Cultural Rights under the International Human Rights Law specifically states that each individual has rights to the “highest attainable standard of physical and mental health,” and that the government will utilize the “maximum of its available resources” to fully achieve those rights. Furthermore, the government should also ensure that the attainment of those rights were without any kind of discrimination, including national origin and birth status [39]. While the social and cultural integration for migrants into the local community is important, accessing quality care should not be the context and motivation for learning German. The lack of professional interpretation in healthcare can prevent individuals with limited German proficiency from achieving their highest attainable standard of health as regulated by the International Human Rights Law. Additionally, a lack of formal interpretation can also hinder healthcare staff from providing culturally sensitive care that patients need. Thus, it is urgently imperative that policy makers and insurance companies integrate professional interpretation in Germany’s health system to take that first step towards achieving equitable care for all.

Abbreviations

BGB

Bürgerliches Gesetzbuch (German Civil Code)

SGB V

Sozialgesetzbuch Fünftes Buch (Social Code Book V)

AsylbLG

Asylbewerberleistungsgesetz (Asylum Seekers Benefits Act)

NHS

National Health Service

ER

Emergency Room

Author contributions

HL: prepared the original draft and contributed to reviewing and editing. SC: conceptualised the draft and contributed to reviewing and editing. CH conceptualised, supervised, reviewed, and edited the draft. All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

HL and CH declare no conflicts of interests. SC is a member of VKD, the German Professional Association for Conference interpreters. She did not receive any support (e.g. payment, financial benefit, or non-financial benefit) in relation to this work.