Reflections on the Access of Roma to Health Care
Health is a complex process and should not be seen only as condition of absence of diseases. One concept of health launched by the World Health Organization (WHO) at the 1986 Ottawa Conference defines health as including the following components: "the capacity for each human being to identify and achieve his/her ambitions, satisfy his/her needs and be able to adapt to his/her environment, which should include decent housing, normal access to education, adequate food, stable job with regular income and sufficient social protections2".
Social exclusion of Roma in Central and Eastern Europe is a major factor which conditions their lack of access to the prerequisites for good health as defined by the WHO. Moreover, widespread prejudice and discriminatory treatment by medical practitioners and health authorities has a significant role in depriving Roma of access to adequate health care. Access to health care should not be seen as something which Roma should apply for or something which depends on the good will of the health authorities. Access to health care is a basic human right and a key element in ensuring better health. Ensuring an equal standard of health for Roma is a process which cannot be separated from eliminating the barriers to access to adequate housing, social protection, education and employment. This process is achievable only through a multi-sectoral approach to the issue of Roma health, meaning that access to all other basic human rights should be ensured as well.
In this article I will outline some major barriers for Roma equal access to health. I have become aware of them both in the course of my medical practice and in my work as an ERRC attorney, dealing among others with cases of discrimination of Roma in access to health. As a paramedic working at an emergency unit in my hometown of Haskovo, Bulgaria, I was responsible for three villages with high numbers of Roma. The main problems I have identified were poverty among Roma and a reluctance to seek medical help due to fear of negligent treatment and/or humiliation by non-Romani doctors. Once I diagnosed a health problem of a Romani patient, I would prescribe a medicine. The Roma would often ask me how much the medicine cost and if possible to prescribe something cheaper because he or she could not afford to buy a costly medicine. Then I faced the dilemma: should I prescribe a cheaper medicine which is less effective but affordable for my patient, or a more expensive one, which is also more effective but in order to get it, the patient would have to walk 3 kilometers from the Romani settlement to the village and then take the bus for another 20 kilometers to the city pharmacy? In many cases I chose to prescribe the cheaper medicine although the treatment would take longer and it was likely that the patient would question my professionalism in case there was no immediate effect. In this case, however, I was sure that the Romani person would buy the prescribed medicine, while I knew that if I prescribed the expensive medicine, the Romani patient would not go to the city because he/she cannot afford the cost of the medicine and the transportation, and most likely the illness would become a chronic condition.
In a number of cases, when I diagnosed a Romani patient and recommended that he/she seek specialised medical examination or laboratory test, I realised that my patients were reluctant to do so due to fear of humiliation and an arrogant attitude on the part of the medical personnel. For example, Ms G.A., a Romani woman living in a village near Haskovo, was pregnant for a second time when I advised her to visit a specialist in the main hospital of the city. She refused to go because every time when she went to the hospital for regular medical control she was verbally abused. She complained that the medical staff made humiliating jokes about her and sometimes they even slapped her on the face when she was trying to resist because of a strong pain during the examination.
In another case, a Romani man who injured his hand at his workplace went to the clinic in Haskovo to seek medical help. The doctor was rude to him and told him that Roma are irresponsible, drink all night and in the morning go drunk to work. The man was offended. He tried to explain that he did not drink at all, but the doctor became aggressive and told him that he did not believe him and that Roma did not take care of their own health. After this incident, this Romani man always refused to go to this hospital and asked me to treat him in my office.
High levels of poverty among Roma have a deleterious effect on their health status, not only because Roma do not have enough money to buy medicines. Poverty affects their entire life, causing permanent stress as a result of the insecurity of a life without means; many Roma suffer chronic poor nutrition and live in precarious housing conditions. Romani settlements have substandard and sometimes inhuman living conditions which are often themselves the cause of diseases. Romani settlements are usually located on the outskirts of the city or village with no infrastructure and limited access to public services. They lack clean water, electricity, sewage system and access to roads. Moreover, for some isolated Romani communities, health care facilities are practically out of reach due to lack of such facilities in the settlement and lack of public transportation connecting the settlement to the nearest town or village. Such settlements are not regularly visited by health care workers, because of poor roads and often because of the refusal of the medical staff to work with Romani patients.
In some countries health insurance policies have created great barriers for Roma and have a disproportionate impact on Roma. In Bulgaria for example, for the socially vulnerable health insurance is contingent on the system of social benefits. As long as a person is entitled to social benefits he/she is also entitled to health insurance provided by the state. Many Roma do not receive social benefits, regardless of the fact that they fall in the category of the socially vulnerable, and consequently do not qualify for health insurance from the state either. Many unemployed Roma for example are not registered as unemployed in the respective services due to a range of reasons, including discriminatory refusal by the respective authorities to register them. Such persons also do not have access to health insurance. Roma who do not have health insurance avoid seeing a doctor because they cannot afford to pay for the check-ups. The lack of adequate information and knowledge among Roma is one of the main reasons for Roma to be administratively invisible.
Roma access to health care is further limited by unprecedented discriminatory attitudes on the part of many medical practitioners. Often the perception among non-Roma is that Roma are the main source of infectious diseases or that they are more exposed to infections than other groups and are responsible for spreading these diseases. Many doctors, nurses and other medical workers feel hostility towards Roma. It is a real problem in some Romani communities where GPs refuse to assign Roma as their patients. Roma who do not have personal doctors have very limited access to specialised medical treatment. In Bulgaria for example, if specialised treatment is not prescribed by a GP, the patient should pay for it. In most cases the cost of such treatment is prohibitive for Roma.
Segregation of Roma in medical facilities is also a serious barrier to effective and adequate medical treatment. Segregation in hospitals and maternity wards is a common practice in many countries in Central and Eastern Europe. Romani patients are often placed in Roma-only rooms and sometimes use different bathrooms and eating rooms than the non-Romani patients. Many Roma complain that they have been intentionally segregated by the hospital staff and they believe they receive lower-quality medical treatment and less attention that non-Romani patients.
Cultural differences can also raise barriers between Roma and the health care institutions. Roma who are not fluent in the majority language are at an automatic disadvantage in accessing health care.
To date, governments in Central and Eastern Europe have not undertaken to implement comprehensive programmes to tackle exclusion of Roma from health care. Government action tends to focus on preventive health care such as vaccination campaigns or training of medical personnel. The structural problems affecting Roma health, however, remain largely unaddressed. Governments should take a multi-sectoral approach to addressing discrimination, as well as to tackling problems related to social benefits, education, living conditions and housing.
Discrimination in access to health services should be prohibited by law and the implementation of anti-discrimination law vigorously pursued. The approach for elimination of barriers to health care will be more effective if governments include Roma in the process of conceiving, designing, implementing and monitoring the policies and programs aimed at improving their health situation.
- Ivan Ivanov is staff attorney of the ERRC. He has medical training and worked as a paramedic in Bulgaria.
- Toward a New Public Health, Ottawa Conference, WHO, Geneva, 1986.