Roma Health Concerns: The View from Bulgaria

At the start of the twenty-first century, millions of Roma across Europe still live in conditions of deprivation in access to basic healthcare.

Despite persistent effort by a variety of actors, the Roma community remains the poorest in Bulgaria, the most segregated and unprivileged. In their struggle for survival, healthcare has become a primary social good for the Roma.

Roma NGOs and international institutions alike have shone a spotlight on a number of issues of concern to Roma: access to education, employment, social services and housing; the promotion of human rights and women’s rights; and community development are all priorities. But access to healthcare is neglected as a human rights issue by most actors, including the government.

Why is this so?

The issue is complex and has roots in the past: healthcare in post-communist countries was until recently free of charge for all citizens, including Roma.

This has now changed: the Bulgarian healthcare system has been reformed and is undergoing privatisation. Naturally enough, everyone now has to pay for health examinations, treatment, and medicines.

Today, the lives of those to poor to pay for these services are literally at risk. This is especially true for many Roma, who lack health insurance and are often unaware of their rights.

The issue of Roma access to healthcare is interlinked with other problems. Factors both external and internal to the Roma community must be considered. In my view, external obstacles are the more problematic and urgent. These include:

Lack of information about health reforms. Adequate information about reforms to the Bulgarian healthcare system has not been made available to the population at large. For Roma the problem is more acute, as no effort has been made to send information through the right channels, and in an appropriate manner, to reach the community.

Unemployment. Accurate data on the number of unemployed among Roma is lacking, but most estimates put the figure near 80% of the Roma workforce. Many unemployed Roma do not register and have no health insurance. Most are not aware that it is possible to be insured without employment – and Bulgarian municipalities generally insure only registered unemployed, who have rights to social benefits. The ensuing lack of resources to pay for medical examinations, and the higher fees for hospital treatment and medicines, are a direct result of the unstable economic and financial situation of the Roma community.

Bad infrastructure of Roma settlements. Roma settlements typically suffer from catastrophic standards of basic infrastructure, including bad potholed roads or dirt-tracks (paramedics frequently refuse even to enter Roma neighbourhoods), an absence of telecommunications, shortages of transport, and little or no access to clean water.

Discriminatory attitudes. Staff in medical institutions near Roma settlements often display negative attitudes towards Roma.

Widespread poverty and the resulting bad living conditions negatively impact the quality of nutrition available to many Roma, leading in turn to epidemics of infectious diseases.

Documentation. An absence of official identity documents can lead to severe delays in obtaining healthcare services, and may make health services entirely inaccessible.

Research. Little or no in-depth research has been conducted at local levels, to allow for the design of appropriate strategies to combat the specific problems of access faced by Roma. This stems largely from an absence of appropriate governmental policy. A number of NGOs have taken up the issue of Roma access to health care, but the problem is so widespread that it is clear that governmental policies and actions are needed.

Obstacles internal to the Roma community include the fact that health does not have pride of place in the Roma cultural value system. In their struggle for survival, Roma tend to seek out medical assistance only in emergencies.

Like the majority of the Bulgarians, Roma tend to view public health purely in terms of the provision of medicines. This is also true for Roma NGOs who, additionally, do not consider themselves competent to take on the larger issues of public health. This can be addressed through a combination of awareness-raising and capacity building of Roma NGOs, training mediators and promoting access to information.

The health indicators of the Roma community are difficult to measure, for reasons partly related to census taking (establishing the true size of the Romani community is a fraught issue). But anyone on the ground can make out certain clear distinctions between the Roma population and the rest of Bulgarian society:

The life expectancy of Roma is reckoned to be lower.

Infant mortality rates are higher. Vaccinations are no longer obligatory for all children. As a result many children are never vaccinated, either because their families do not have a family doctor or the children do not attend school, or because mothers are simply unaware of the importance of vaccination.

Infectious diseases are widespread, as are certain other conditions, such as cardiovascular diseases, diabetes or hypertension.

In recent years there has been a significant increase in the number of cases of tuberculosis.

Drug abuse, a phenomenon unknown to Roma during the communist period, now appears to be widespread among Roma youth. For example in the course of its work in the “Fakulteta” neighbourhood in Sofia, the Foundation for Promotion of the Roma Youth has come across many young Roma drug users. This was not the case some 10 years ago.

Reproductive health. Abortion remains the most popular method of contraception among Roma. In comparison with other cultures, Roma societies are patriarchal and conservative the level of promiscuity is comparatively low. Nevertheless, as traditions and values change it is important to promote knowledge about sexually transmitted infections. This should not obscure the fact that primary healthcare is, in my view, a more urgent consideration than reproductive health.

Solutions to the problems described in this article will not be easy to find. All concerned actors must start work without delay … because tomorrow will be too late to save the lives of our children – and our parents.

And I am sure that all are agreed on one thing. Faced with a choice between the isolated efforts of individual NGOs and comprehensive policies designed and implemented by all relevant actors, the second option is the better way forward.

Alexandra Raykova is Director of the Foundation for Promotion of the Roma Youth based in Fakulteta, Sofia, and has been working on Roma issues since 1994.