Roma Health a Focus at European Public Health Conference

In Malta last month the fifth European Public Health Conference convened more than 1,000 delegates from around the world to address the theme of “All inclusive public health.” The notion of inclusion is timely. The current economic crisis–the worst in Europe in 70 years–has yielded austerity measures that have imposed savage cuts to health and welfare services, thereby undermining efforts to close health care gaps and tackle inequalities.

The crisis particularly threatens Roma, as the largest ethnic minority and demographically youngest population in Europe. They have long experienced systematic discrimination and social exclusion, which has led to a lower standard of health than most Europeans. Reports from Roma NGOs across Europe raise consistent problems with accessing health care services, poor or low quality treatment, and discriminatory attitudes by health providers. There has been poor progress on health within the framework of the Decade of Roma Inclusion (2005-2015), an initiative of 12 governments to improve the socio-economic status of Roma people, and a lack of concrete actions toward the National Reform Strategies for Roma Integration submitted to the European Commission in 2011. In light of this it was encouraging that Roma issues had a high profile at this year’s conference.

Open Society Foundations played an important role at EUPHA to this end. In her presentation, Alina Covaci, Program Officer of OSF’s Roma Health Project, discussed ways of making vaccination programs more inclusive and effective. As in past years, the Roma Health Project sponsored six Roma students and advocates who presented posters on their health research, which included access to care, smoking behavior, awareness about tuberculosis, reproductive health, and discrimination by health-care professionals (there will be more on this in a subsequent post). And in conjunction with OSF’s Law and Health Initiative, the Roma Health Project presented a workshop highlighting international conventions that set out rights and legal mechanisms to ensure compliance or redress when Roma are systematically denied access to – or are violated within the context of – health care.

Recently Open Society Foundations has begun work on several new initiatives we look forward to discussing at future EUPHA conferences. For example, we have funded several NGOs that will explore legal mechanisms for addressing violations in Roma health rights, including:

  • The European Roma Rights Centre (ERRC) will research whether infant mortality rates in Roma communities in Romania are disproportionately high compared to the general population. They also aim to require the government to collect ethnically disaggregated data as a means of ensuring that health inequalities can be tackled effectively.
  • The Macedonian NGO LIL seeks to monitor the implementation of the Patients´ Rights Law on behalf of Roma. It will make formal complaints to various ombudsmen and tackle specific cases of failed reimbursement, unlawful detention of Roma patients for non-payment of fees (particularly new mothers) and seek dialogue with stakeholders to resolve administrative barriers to care.
  • Macedonian NGO HERA currently supports a local center that provides the only reproductive health care for Roma women in the town of Suto Orizari. They advocate for financial incentives from the government to encourage more providers and gynecologists to offer services there. And they litigate on behalf of Roman women who lack the right to choose between gynecologists in the area due to lack of providers.
  • In Romania, the NGO Romani Criss aims to prevent all forms of health discrimination against Roma by building the capacity of local activists to recognize and report violations of health rights. Their data collection will provide evidence needed to advocate for legal and administration provisions to enforce patient rights.

Finally, as we leave this year’s EUPHA conference, we can highlight progress within the conference structure itself. The EUPHA’s Section on Ethnic Minority and Migrant Health has decided to allocate a seat on their steering committee to an academic or researcher working on Roma health issues. Section members–and EUPHA participants broadly–have rightly recognized that Roma health is an issue that demands more attention and further study.

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Indeed, EUPHA was a success for Roma health. Roma health issues were highlighted at a high level and to diverse audiences: policy makers, academics and practitioners in the field of public health and health services. There is now increasing understanding of the barriers that Roma face in trying to access health care as well as the lack of effective redress mechanisms for violations of their human rights.

One of the most fundamental challenges in Roma access to health care and the wellbeing of the Roma community is their invisibility in the official statistics. The fact that Roma do not have IDs (birth certificate, identity card, etc.) is hindering them from meeting their needs as citizens. A related issue is that while governments already collect data for official purposes, they do not disaggregate this data by ethnicity to the data being collected. NGOs do not have the capacity or mandate to take on collection of ethnic data which should be a state responsibility. Once the ethnic data is collected, it should be made public so that it can be used to benchmark the performance of public services.

During multiple presentations at EUPHA, we could see the existence of a close link between the legal framework in a country and health outcomes for Roma. Important aspects of this legal framework include citizenship rights (which govern who is entitled to access healthcare services) and what the health professional standards and the ethics that must be met in healthcare institutions. The experience of many Roma in Europe shows that having a strong legal framework is not enough; laws need to be properly implemented with a robust monitoring system. When violations of health rights occur, legal strategies can be useful to highlight and challenge this but they need to be combined with public debate, media outreach and advocacy towards other parts of government.

The study should not only include health of Roma in stable populations in their home countries, but also those who have emigrated. It should include studies of their helath and how it has improved in places such as England and Canada dut to their integration and job situations. It should also show how it has deteriorated below that of their fellows in their home countries in cases where they are excluded from the labour and housing markets as in France. The cost of treating them with preventitive medicine as full European citizens versus the cost to society...What happens when children are not allowed to be inscribed in school, do not receive immunization, when parents live in illegal camps and other health issues such as TB, stress of constantly moving or living on the streets, and other diseases, what is the cost to the public at large when these people are allowed to live on the margins of society and carry diseases that have been virtually eradicated in teh 20th century? The health issues of homeless Roma working illegal jobs in France and Italy are an issue for all of society.

This is an excellent post Tamsin! It is great to see Roma advocates and NGOs using legal strategies to pursue redress for health rights violations. I wanted to add that many of these organizations are also using community monitoring to aggregate Roma experiences with health service delivery and push for improvements in public services, including immunization, antenatal care and emergency medical services using community generated evidence. This is another approach to ensuring government commitments are met in Roma communities.

Thanks for these useful comments. Attention to Roma health is long overdue, particularly given the growing body of evidence showing the impact of poverty and social exclusion on individual health.
Accurate data is crucial for policy-making because it reveals areas of greatest need and where welfare and health services are currently failing. Governments tend to collect census information on age and gender precisely because of this but they need to go further and add ethnic data. Some countries claim that it is not possible or legal to do so because of data protection issues, but many legal experts disagree and indeed some countries do collect and use this data.
As Alina pointed out in her comments, the lack of basic ID documents is a real barrier for Roma to access public services that they are entitled to as citizens. Participants at the Conference found this fact very surprising and explained that it can be hard to imagine how vulnerable you are if you literally do not exist for the State because of a lack of paperwork.
Bill makes an excellent point in his comment about the importance of tracking the experience of Roma when they travel to other EU countries. Despite the fact that Ministers of Health adopted a document which says that their health systems have shared values of universal access and equity, several EU countries exclude migrants from healthcare or other social services. This has inevitable consequences in terms of poor health outcomes.
In this period of continued austerity and cuts to public budgets, health spending is coming under pressure. The OECD data shows that in 2010 there was a cut in health budgets - the first such reduction since 1975. For policy-makers there are hard choices ahead about how to allocate scarce funds. This is a critical time to make sure that Roma are both visible to public authorities and their health needs recognised. There is still much work to do in this respect and it is good to see an interest by the public health community and the activism by Roma NGOs.

As Alina pointed out in her comments, the lack of basic ID documents is a real barrier for Roma to access public services that they are entitled to as citizens. Participants at the Conference found this fact very surprising and explained that it can be hard to imagine how vulnerable you are if you literally do not exist for the State because of a lack of paperwork.
Jhonson

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