Authors: Susanne Bartig, Dorina Kalkum, Ha Mi Le und Aleksandra Lewicki; commissioned by the Federal Anti-Discrimination Agency (FADA) Year of publication: 2021

Brief overview

The study reviews the state of social science research on discrimination risks and discrimination experiences in the healthcare sector. By this, it takes stock of the current state of knowledge on discrimination risks in the healthcare sector in its capacity as both service provider and employer, and identifies research gaps. The overview comprises an examination of all grounds of discrimination protected under the General Equal Treatment Act (AGG) as well as of the categories socio-economic status and body weight. Herein, the following questions are considered:

• What are the types and causes of discrimination in the healthcare sector and how prevalent are they?
• Who is affected? To what extent does patient discrimination relate to several characteristics at once or occur intersectionally?
• Which cross-characteristic exclusion mechanisms occur in which relevant healthcare situations and during which key healthcare processes?
• What role does institutional discrimination play in the healthcaresector?
• What findings are there on the discrimination risks and prevalence in the healthcare sector in its capacity as an employer?

The study focuses on outpatient and inpatient healthcare including rehabilitative facilities. It largely builds on research findings concerning Germany from the years 2010 to 2020, complemented by interviews with experts.

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Main results

The analysis of current research on discrimination in healthcare in Germany shows, discrimination risks exist for all grounds examined regarding the access to as well as the use (diagnosis, treatment, rehabilitation) of healthcare services.

Discrimination occurs both as discriminatory behaviour by medical staff and through institutional practices or processes, leading to unequal treatment of specific patient groups. The authors identify the following overarching patterns:

• discrimination risks due to the healthcare system’s insufficient accessibility (spatial as well as communicative),
• discrimination risks on the level of communication and interaction,
• discrimination risks due to lacking expertise and insufficient awareness by the health and nursing care personnel concerning specific needs of certain patient groups,
• institutional discrimination risks due to standardised procedures and routines and the resulting time and efficiency pressures,
• insufficient diversity-orientation in the services offered by the healthcare system.

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Options for action

Based on the research reviewed and the interviews held with experts, the following cross-characteristic research needs on discrimination risks in the healthcare sector were identified:

• theory-based, conceptually sound research on discrimination risks in the healthcare sector, which not only points out existing differences between individual groups, but also sheds light on the underlying mechanisms of an unequal healthcare system,
• systematic research, to show to what extent the outlined differences in the use of healthcare services are caused by potential discrimination (risks) through access barriers,
• systematic documentation of the types of interpersonal discrimination as well as their effects on access to healthcare, diagnosis and treatment in the individual healthcare areas with regard to patients as well as healthcare staff,
• documentation of institutional discrimination risks in inpatient care, including interactions and relations between institutions and the legal framework,
• longitudinal studies examining to what extent the quality of healthcare and thereby also health outcomes are influenced by discrimination,
• increased focus on intersectional discrimination risks in the healthcare sector,
• analyses of sub-groups within the grounds of discrimination mentioned in the AGG, which allow a differentiated view on the respective discrimination risks and their influence on the health care situation.
• In addition to the grounds of discrimination mentioned in the AGG as well as body weight and socio-economic status, further groups of persons (such as homeless people) need to be taken into account when assessing discrimination risks in the healthcare sector. Another key risk factor for discrimination regarding access to healthcare is health literacy, which includes not only knowledge about the healthcare system, but also about the legal situation in Germany.
• systematic research on discrimination using different methodological approaches, such as direct observation of processes, and experimental designs,
• examination of the frequency of use and effectiveness of the diverse and numerous complaints systems for patients, who experienced healthcare-related discrimination.

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