The Roma of Europe have long been persecuted and excluded from the societies they’ve lived in. The ethnic group originated from northwestern India and migrated to Europe in the eighth and tenth centuries A.D. They were specifically targeted during the Holocaust and saw one quarter of their population murdered in Nazi-perpetrated genocide. Today, the more than 10 million Roma in Europe still suffer from systemic exclusion that is the legacy of centuries of discrimination. They are severely disadvantaged when it comes to housing, education, employment, all of which contribute to what is termed the Roma health gap.
Indeed, the Roma communities’ health is significantly worse than that of the majority population of any country they live. Roma populations have on average a life expectancy that is 10 years shorter and are at much higher risk of suffering from “communicable and non-communicable diseases” compared to the rest of a state’s population. Roma also face several systemic barriers to accessing healthcare. Barriers such as a widespread lack of health insurance and personal documentation, geographic isolation from healthcare facilities, lack of awareness, cultural and linguistic barriers, and rampant discrimination in healthcare towards Roma patients contribute to exacerbating this situation.
Other factors that perpetuate poor Roma health are bad environmental health and prevalent bad habits. Comprehensive studies of informal Roma settlements in Hungary, where more than a quarter of Hungarian Roma reside, found a “lack of sewage and gas mains, garbage deposits, waterlogged soil and lack of water mains” to be extremely common. Studies with Slovakian Roma communities also show Roma have on average significantly poorer eating habits, physical activity habits, higher alcohol consumption, and higher smoking rates compared to the majority of the Hungarian population.
Much of this “Roma health gap” can be linked to social determinants of health, such as education, employment, housing, lack of access to healthcare, and discrimination faced in healthcare settings. This comes as no surprise to those aware of the generalized exclusion Roma face in Central and Eastern European (CEE) societies, where they constitute the largest ethnic minority.
In an attempt to combat Roma exclusion, many CEE states and the EU have launched several initiatives over the past decade that aim to accelerate the social inclusion of this marginalized ethnic group.
The Decade of Roma Inclusion was an ambitious joint initiative between the Open Society Initiative, the World Bank, the European Commission, 12 European countries, and others. It lasted from 2005 to 2015 and sought to drastically improve the “social inclusion and economic status of Roma people” by concentrating on the priority problem areas of education, housing, employment, and health.
Concretely, the campaign sought to eliminate barriers to access to healthcare Roma face through mechanisms like public information campaigns, insurance enrollment programs, and making CEE health systems more inclusive. It also sought to better the quantity and depth of knowledge available on Roma communities, to help improve the effectiveness Roma public health initiatives.
Moreover, the EU framework for national Roma integration strategies (NRIS), launched in 2011. The framework served as EU level coordination of national strategies in all EU member states that sought to accelerate the inclusion of Roma communities. It focused on the same four priority areas as the Decade of Roma Inclusion: education, housing, employment, and health.
Years later, the results of these ambitious efforts have been mixed.
The 2017 midterm review of the EU framework for NRIS concluded that while significant improvements in the area of self-perception of health among Roma communities have occurred, “basic social security coverage remains a challenge” in countries with the highest Roma populations (i.e. Bulgaria, Romania) where almost half of the minority community still lack basic coverage.
The Decade for Roma Inclusion similarly yielded mixed results. Despite noting improvements in certain areas like literacy levels and primary education completion, Roma still lag considerably behind majority populations on metrics like secondary education completion, unemployment, and extreme poverty.
As one can imagine, these factors have an important effect on the health of Roma communities. A 2017 analysis of Hungarian Roma living in informal settlements show that while reports of discrimination in healthcare settings diminished and usage of health systems increased, Roma remain “severely disadvantaged,” especially in areas like alcohol consumption and obesity.
On the other hand, perhaps one of the greater successes of these Roma inclusion efforts was the expansion and establishment of Roma health mediators (RHM) programs across CEE states.
These workers are Roma professionals trained to serve as links between segregated Roma communities and national health systems. They help surmount many of the aforementioned systemic barriers to healthcare Roma face, helping them navigate administrative and bureaucratic hurdles, enroll in health insurance, combat discrimination, raise awareness about health issues, and bridge cultural and language barriers.
While RHM programs were largely successful, challenges remain. An analysis of RHM programs in 6 CEE countries shows that financing, training, and management issues plague these programs, leading to low salaries and employment insecurity for mediators. RHM programs also fail to effectively use the extensive knowledge these professionals have. This knowledge could be used to address the systemic barriers to healthcare and socioeconomic determinants of health, that are the root cause of the health gap.
Much has also been written about the inefficiency and corruption surrounding the implementation of these strategies. For instance, in Romania, funds earmarked for Roma inclusion efforts were squandered in “inflated salaries and exorbitant rents and expenses” by some government and NGO officials, according to an extensive investigation by BIRN, the Balkan investigative reporting network.
Future initiatives seeking to close the Roma health gap must take into account the failings of previous efforts, and implement more effective approaches to Roma public health.
The next wave of inclusion efforts must take greater care to address socioeconomic issues-housing, poverty, employment-as being fundamentally public health issues as well. Policies seeking to eliminate the Roma health gap must be comprehensively “aligned with education, economic, labour market, housing, environmental and territorial development policies” in order to be effective, as public health researchers point out in the journal Health Policy.
Improvements to housing and infrastructure in informal Roma settlements, for example, do not only address the issue of substandard housing conditions, but are also a critical public health initiatives. Indeed, housing improvements mitigate the important environmental health risks these settlements currently present. Similar cross-problem issues must be highly prioritized in future inclusion efforts.
Future initiatives must also make greater strides to prevent the misuse of funds and the ineffective allocation of the scant resources dedicated to Roma inclusion. Further engaging Roma communities in national and European efforts to improve the health of their communities is key to the long-term success of these inclusion campaigns.
Indeed, it is “only when the excluded and the exploited are a constituent part of setting priorities for public institutions and funds will we experience a change” writes Zeljko Jovanovic, director of the Open Society Roma Initiatives Office. For instance, the knowledge gathered by Roma health professionals through RHM programs is crucial in identifying and prioritizing key problem areas, and using this knowledge more effectively must be emphasized in future inclusion efforts.
Finally, while socioeconomic determinants of health are some of the strongest factors affecting Roma public health, cultural differences must also be considered when constructing public health initiatives that target these communities. Much of the Roma health gap cannot be entirely attributed to lower socioeconomic status, as ethnic gaps remain even when factors like income are controlled for.
For example, when developing anti-smoking campaigns to reduce the disproportionately high rates of smoking among Roma communities, understanding the “smoking behaviour of Roma from a comparative perspective” and tailoring anti-smoking campaigns accordingly is crucial in order for them to be effective. This further reinforces how much Roma communities must be more involved in future public health policy development.
Fortunately, these inclusion campaigns have brought greater awareness within CEE societies of the challenges minority Roma communities face. In 2016, 26 European and national organizations from multiple CEE nations published a statement demanding “urgent policy actions” to remove the “systemic barriers” Roma still face when accessing healthcare. In 2015, the Serbian government, in collaboration with UNICEF in Serbia and Telenor Serbia, Serbia’s largest telecommunications firm, renewed their partnership to further expand RHM programs in the country. Such actions show that continued commitment to improving Roma public health does exist on European, national, and even corporate levels. While it remains one of the more important social challenges in CEE states, the future looks bright.