Healthcare Policy and Provision for Roma in Slovakia and the Czech Republic
15 December 2004
James Grellier and Katarína Šoltésová1
There is a general consensus among international organisations, state governments and non-governmental organisations (NGOs) that Roma have a lower health status than majority populations in the region. There is much less consensus as to the causes behind their poor health status, and a considerable ignorance of the degree to which general discrimination within healthcare may be to blame. The poor health status of a high proportion of Roma contributes to their raised poverty risk and compounds the effect of the other problems which they face. Alongside education, empowerment and vulnerability, health counts as a very significant non-income dimension of poverty: it 'interacts and reinforces these other factors, thus exacerbating the deprivation experienced by the poor2.' Despite being a very heterogeneous group, the Roma constitute both the largest ethnic minority in Europe and are subject to the highest degree of poverty risk in Central and Eastern Europe3.
Policy developments in the sphere of healthcare issues relating to the Roma in Slovakia and the Czech Republic appear to be predominantly determined by reactions to reporting from domestic and international NGOs, and subsequent international pressure and funding allocation. In theory, evidence of appropriate responses to these international pressures should be present in the national-level policies and it would be expected that measures (i.e. concrete projects or programs) are already in place in achieving these goals. Many NGOs, however, echo the sentiment that "a lot of the time there are many things written down on paper but the practice is often very different4" and that few measures actually have any effect on the average person.
This observation is reflected in the tone that governed the regular pre-accession reports issued by the European Commission on the state of each accession country with respect to their progress in the necessary reforms and policy5. In the case of Slovakia, the report issued in 2002 was in fact the first that expressed a positive evaluation of the country's fulfilment of the required political criteria6 and yet still noted that 'the situation of the Roma minority has remained difficult', that 'access [of Roma] to health care remains of particular concern', and that the 'majority of persons belonging to the Roma community continue to be exposed to social inequalities, and continue to experience widespread discrimination in education, employment, the criminal justice system, and access to public services.' The fact that discrimination within healthcare provision was not mentioned in the document is of particular significance since firstly, it has been typical of the stance of the Slovak Government to have paid little attention to this issue. Secondly, and more importantly, this went on to shape the making of subsequent Roma healthcare policy. The 2002 European Commission report on the Czech Republic has been far less critical and makes no remark about the Roma's access to healthcare, which may be a sign that as there is little information about the health situation of Czech Roma, it simply was not considered to present any particular problems.
In one of the final steps of preparation for accession, the Czech (winter 2003) and Slovak (spring 2004) governments both prepared a Joint Inclusion Memorandum together with the European Commission. The priorities identified in the Joint Inclusion Memoranda were, subsequent to accession, used to produce the Czech and Slovak National Action Plans on Social Inclusion 2004-2006 (NAP). These plans represent an attempt by the national governments to implement the EU common objectives relating to poverty and social exclusion into national objectives and programs.
Mounting pressure is also being exerted by other international organisations operating in the spheres of human rights, minority rights, health and justice. Both the Czech Republic and Slovakia are members of the World Health Organisation (WHO) and are thus signatories to its 'health for all' policy under the Health 21 program, developed in 1999. This program suggests policy recommendations for closing the health gaps within countries listed under a series of subheadings namely: the poor; the unemployed; gender inequity in health; ethnic minorities, migrants and refugees; the disabled. Owing to the social position of many Roma in Slovakia and the Czech Republic, the compound effect of many of these problems is potentially very high. The Health 21 report states that ethnic minorities' 'needs receive far less attention, and they cannot always be reached through the usual health and welfare channels7.' The report also focuses on the provision of outreach services for minority groups, which improve access to vulnerable groups by removing the barriers ordinarily presented to them.
Following the Millennium Summit held at United Nations in September 2000, Slovakia and the Czech Republic signed up to the Millennium Development Goals (MDG) program8. There are strong links between this program and the EU's social inclusion agenda, such that the focus is on solving problems of access and inequality. The goals themselves – as well as the time-bound targets and quantifiable indicators that their achievement requires – are intended to address global development challenges. Both countries were encouraged to draw on their own EU reporting frameworks and other national-level policies in order to set their respective targets, and worked with the UN in setting their own goals. Of the total of eight goals, three are of relevance here: the reduction of child mortality; the improvement of maternal health; and combating HIV/AIDS, malaria and other diseases. Since the majority populations of both the Czech and Slovak republics experience relatively high levels of health (compared to the Roma minority), many of the targets within these three goals – whether tacitly mentioned or not – are effectively aimed at improving the Roma health situation.
The Decade of Roma Inclusion developed as a result of the conference "Roma in an Expanding Europe: Challenges for the Future" held in June 20039. Representatives of both the Czech and Slovak republics attended this high-level conference, and made a political commitment to close the gap in welfare and living conditions between Roma and non-Roma. At the first meeting of the International Steering Committee of the Decade (ISC) in December 2003, four broad areas of priority were adopted: education, health, employment and housing. These priority areas were to serve as the basis around which national Governments would build action plans featuring goals, targets and indicators with which to monitor progress. It was clear that 'each participating country's action plan will identify goals and targets in these four areas10.'
Roma health issues have not initially been included in the plans of both the Czech and the Slovak governments for the Decade and it appeared that officials in the respective ministries were unprepared to meet their commitments made at the Budapest conference in 2003. The Slovak Ministry of Health (MZSR) coordinator of PHARE projects and structural funds, Jana Škublová, was sent as the Slovak delegate to the Budapest workshop on Roma health in June 2004 in order to speak on Slovak health policy regarding Roma. At that point in time, Slovakia had not included health amongst its priorities for the Decade. Ms Škublová reportedly enquired at the office of the Plenipotentiary for Roma communities as to why this priority had been left out of Slovakia's commitments, and was informed that the Slovak Government had the possibility of choosing only three of four priorities. Some time after the Roma health workshop in Budapest, she received a letter from Deputy Prime Minister for European Integration Pál Csaky which advised that health would be included as a priority and that this would have to be drafted in the following one month. In January 2005 the implementation of the Decade should begin, and according to Ms Škublová "this is a very short time away for the amount of work that needs to be done [at the MZSR]11."
While carrying out fieldwork in the Czech Republic, the authors were repeatedly referred to the Health Assistants Program Coordinator, Libuše Nesvadbová, a medical doctor and researcher, who was also sent as a delegate to the Budapest conference. In response to the question what she thought about health not being included among the Czech Republic's priorities, she commented, "… why health wasn't included into the Decade I really don't know. I was just told that I had to attend the conference, so I went12." Delegates representing the Czech Republic at the conference on Roma health – a key subject within the framework of the Decade – held in Budapest in June 2004 openly admitted that they had been selected at the last minute for the conference and knew very little about their expected roles as such. This is a very good example of poor communication between government, ministries and other offices of the administration. Czeslaw Walek, the head of the Office of the Council for Roma Affairs, claimed that the health priority was left out from the Czech Republic's Decade plans owing to lack of capacity to deal with it at the ministerial level and due to other, more pressing necessities such as education, unemployment, or housing. Such reasoning hints on a total misinterpretation of the aims and functioning of the Decade. The Decade is only meant to complement existing programs and projects and stimulate further developments in the Roma inclusion policy of all countries: if the Czech Republic does not yet have enough capacity to deal with the Roma health problem, then it is high time to address that problem. The Decade is in many ways the appropriate opportunity to instigate certain changes in the way that Roma health is dealt with at the Ministry, particularly in terms of reallocating funds within the Government's budgetary structures.
Czech Policy and Associated Programs/Projects
With respect to Roma health, the Czech National Action Plan on Social Inclusion 2004-2006 sets out objectives in accordance with international health programs of the EU, WHO and OECD13. A second, major written policy document is the Government 2004 Concept for Roma Integration14 which was adopted in June 2000 and has since been regularly updated.
In order to secure equal access to health care, the National Action Plan (NAP) establishes a strategic approach, within which it is necessary to combat poverty and social inclusion and 'support groups experiencing increased health care needs, among them people with disabilities and older people. Special attention must also be paid to groups which are disadvantaged in access to health care, such as the homeless and people from socially and culturally disadvantaging environments (for example the Roma)15.' Policy measures are also outlined as part of the WHO program Health for All for the 21st Century within the national-level document Long-term Programme for Improvement of the Population's State of Health - Health for All in the 21st Century; these measures are based on the Strategy to Promote Access to and Quality of Health Care in which 'basic public standards in the health area were specified to ensure minimum levels of care as to quantity and quality.' In this context, legislative measures have been taken to 'provide guarantees for an improved organisation of health services and strengthening of the roles of regions and municipalities16.'
The tasks for the Ministry of Health (MZČR) with regard to Roma health set forth in the first Czech government Concept for Roma Integration included the creation of conditions to prevent racial discrimination, legal provisions providing a basis for positive action to eliminate disadvantages experienced by members of the Romani community and research into the health of the Roma population. The subsequent, annually updated versions of the Concept contained few specific tasks for the MZČR, neither in terms of preventative, educational or anti-discriminatory measures, nor as concrete steps that would acknowledge the importance of quality, hygienic housing17. It is not surprising that in the course of interviewing various stakeholders in the Czech Republic, there was not only a lack of consensus as to what constituted 'government policy' on Roma healthcare, but also a general response that there is no coherent government policy that might be used as a coordinating material for regional or local activities.
The updated 2004 Concept for Roma Integration document is in many ways the first to present concrete steps forward in the consideration of health issues, essential for the development of the Romani community. This document draws attention towards the need to establish communication between the patients and the doctors by means of a program of health assistants for Romani communities. A second, less direct description of written preventative health policy details the state's establishment and support of 'half-way houses' for those young adults leaving state care institutions such as children's homes; such half-way houses are intended to prevent these young adults from succumbing to drug abuse or prostitution. However, this particular measure was not referred to by anyone during interviews relating to health policy which suggests there is no coherent understanding of the issues constituting health as such. As a final point, the 2004 Concept document reiterates the need to pursue sociological research.
Health Assistants as Part of the Social Field Workers Program
A proposed comprehensive program of field health assistants ties into the social field workers program, itself classified as an 'equalisation measure18'. Officially part of this social field work program, the pilot health project consisting of a single one health assistant co-operating with a paediatrician has been in operation for three years in the city of Ostrava.
The main role of health assistants will be to serve as a means of improving communication between patients and doctors. Given the problematic housing situation faced by many Roma – including the issue of people living in different places to those in which they are officially registered – the health assistant is to "keep track of families and make sure that reminders relating to infant vaccinations are delivered19" and inform Romani families about fundamental hygiene, nutritional and health issues. It also aims to establish trust between the doctor and the patient. At present, these tasks are performed by NGO workers.
Over the past few years, however, the Czech Ministry of Health had reportedly been unsupportive of any positive measures taken with respect to the Romani community. According to Czeslaw Walek, head of the Office of the Council for Roma Affairs, and confirmed by Lydie Polá20.
Currently, plans for enlarging the pilot scheme are being discussed as part of a major revision of the Concept for Roma Integration for the period 2005-2007. Implementation of the enlarged program will depend on the actions of regional and local government offices. There will be an open tender process for projects under the enlarged program. It is questionable whether this formalised framework of selection will function in the present vacuum surrounding Roma health issues. As one of the members of the Council for Roma Affairs said, "we seem to be unable to make the local council understand what the advantages of a social field worker are and I imagine that the attempt to establish a health assistant will meet with no less suspicion21." Many municipalities do not rank investment in social work as particularly important among their commitments, often because they have little information that might suggest otherwise; in many cases the chief problem is that they cannot see such a budgetary investment as being profitable – either financially or politically.
With respect to the problem of substance abuse, the Council for Roma Affairs in cooperation with the Council of the Government for Drug Policy Coordination22 supports and monitors a number of programs running under the auspices of a number of civil organisations. While these programs frequently have an educational basis, rather than a basis in general health – indeed they are not explicitly mentioned in the health section of the 2004 Concept although it is likely that they are implied in the need of establishing more 'half way houses' – they do constitute an important aspect of health. Civil organisations Sananim (Prague)23, HOST (Plzen) and Hvežda (Prague), are the major three cooperating bodies involved in programs reaching out to provide better training for Roma and non-Roma field workers in order to prepare them for team activities and direct work with clients and provide them with the means of carrying out preventative work and research24.
Further Needs to Extend Roma Health Policy
Mention of Romani women in the 2004 Concept for Roma integration is scant. Education on sexual and reproductive health currently depends on the capacities of NGOs and the good will of field workers. As one of the Regional Coordinators for Minorities noted, educational activities do not, however, solve the problem of exclusion, which Romani women encounter in under-equipped doctors' facilities and clinics. The revised Concept for Roma Inclusion for 2005 will apparently focus on women's health as a specific issue and will include a number of suggestions regarding reproductive and sexual health. Whether it will be possible to consistently formulate and implement the future policy on reproductive and sexual health is however highly questionable for 'owing to the lack of statistics no objective data are available on specific problems of Roma women25.' The question thus arises whether the policy-making body deems NGO's qualitative knowledge of the situation to be as valuable and relevant as the lacking quantitative data. According to a staff member of the Prague Open Society Foundation Gender programme, it is also believed that there can be little hope that this aspect of health will become a matter of direct concern unless, by means of a public discussion of problematic and alarming cases, the government is made responsive to this issue. A case in point is the recent debate in the Czech society on the issue of coercive sterilisations of Romani women26, which may bring reproductive health more into the forefront of policy-making.
While educational projects may be effective in partly improving the health situation of the Roma, NGO leaders point out that there is considerable need to invest directly into domestic infrastructural developments. Hygienic conditions are very closely connected to quality of housing. Lydie Pola Lydie Polačková, a member of the Council for Roma Affairsin Ostrava, herself having worked in health care, stated: “our priority is the building of social housing in Ostrava. One cannot only advocate for health when people don’t even have a suitable
place to live… We have even registered our own company in order to start solving the housing situation.” There is a general tendency to point out that the situation among the Czech and the Slovak Roma is different, since the former live in urban areas while a large proportion of the Slovak Roma live in isolated settlements. For both, however, the poor health situation presented by life in severely overcrowded housing can only really be solved through decreasing the level of overcrowding and providing necessary sanitary infrastructure. Access to clean and safe drinking water, infrastructure providing power for cooking, heating and lighting,
and functioning waste and sanitary facilities affect health and many other aspects of lifestyle. Domestic sanitary standards and overcrowding increase the risk of diseases like hepatitis. Genito-urinary problems affecting many women in areas with poor sanitary infrastructure (such as housing equipped with normal flushing toilets with no connection to water, or outside latrines) can be solved simply by developing the sanitary provisions available. Respiratory problems are caused by a number of factors, the majority of which relating to the domestic environment, particularly to poor ventilation and mould growth, both of which are common in poor quality housing.
According to the 2004 Concept for Roma Integration, in the field of housing, "the Government has only limited opportunities of influencing this situation because the issue lies mainly in the domain of local elected authorities". According to the Act on Municipalities, these are bound to create conditions that would satisfy the needs of inhabitants. While a Program of Supported Housing is seen by the government as a form of affirmative action in this context and is to include provisions of social services , it is striking that the impact of hygiene conditions on emerging health hazards for the Roma community should not be addressed as part of a housing policy.
The 2004 Concept states that a fundamental revision of the Concept is in process and will reflect the new possibilities and duties that arise from both the Czech Republic being an EU member and from the new framework created by the Czech reform of public administration. The 2004 Concept document points out that its primary deficiency is the 'absence of tools to influence the attitude of local Governments towards Roma communities.' In order to tackle this problem, one of the priorities for the revised Concept was to propose a draft of an implementation agency which will be a 'body of people who will approach the local Governments and will motivate them to taking positive action, with regard to financing as well as community planning. They will work together with mayors and other local partners and elaborate community plans and programs for Roma inclusion27.' Whether this agency will be successful in the future depends on the will and capacities of individual people. It also depends, however, on the formulation of a larger national policy capable of serving as a guideline for more specific local policies.
Slovak Policy and Associated Programs/Projects
Faced with the reported low level of Roma health, poor access to healthcare and mounting pressures from a number of both international organisations and Slovak NGOs in the mid- and late 1990s, the Slovak Government responded with a number of documents relating to Roma health issues. In 2002, the Strategy for the Solution of the Problems of the Roma National Minority and the Set of Measures for its Implementation – Stages I and II was drafted by the Government. The first stage outlined a set of general measures to be implemented, including the area of health. The second stage specifically listed tasks to be carried out in achieving specific goals. Well into 2002, a report issued by the Open Society Institute (OSI) criticised the Government for their lack of commitment to the Strategy and noted that 'in many cases, implementation either has not started or is still in progress and there has been little evaluation of results to date28.' The report continued to note that the Strategy does not effectively address serious healthcare problems associated with poor living conditions or limited access to healthcare. It also criticises the Strategy for not having responded to allegations of discrimination in the healthcare sector. The fact that the Strategy did not propose any strategic research or analysis is still fairly representative of the stance of the Government at the time of its publication.
Since the Strategy was ineffective in many areas, and reports of the low level of Roma health and poor access to healthcare continued to be reported by a number of international institutions (such the EU, World Bank, and the UNDP) and Slovak NGOs, the Slovak Government prepared a document entitled 'Basic Theses of the SR Government conceptual policy in the integration of Roma communities in 2003'. This document lists a number of specific tasks and the associated projects or programs designed to achieve them. Most of these projects are already supposed to be in progress, or completed, as indicated in an appraisal document issued by the Government;29 many of these projects are evaluated as their 'task currently being fulfilled' despite the fact that in a number of cases – the most significant being a PHARE funded project described below – certain tasks have ground to an absolute standstill. Thus, the Basic Theses are also a long way from being a representative written 'policy concerning healthcare of the Roma minority'. Other materials available to the public via the website of the Slovak Ministry of Health (MZSR) are very limited in scope and individual project documents make scant reference to their particular position within a larger policy concept.
The Slovak National Action Plan on Social Inclusion 2004-200630 (NAP), released on the 14th July 2004, is perhaps the document closest to being an up-to-date written policy for Slovakia. It is, therefore, very interesting that while this document includes a section on Roma communities, it does not list healthcare as one of its 'key challenges': instead the list comprises unemployment, educational disadvantage and integration. Under the section on health, the word 'Roma' is missing. The document lists one target relating directly to Roma health: '– to improve the access of the Roma living in segregated settlement to the provision of healthcare services31'. There is no target relating to fighting discrimination within the health service and this is a particularly important point, since this single issue alone is enough to hamper any other projects and policies aiming to improve the health status of Roma. The NAP document importantly concedes that although a Government strategy for solving the problems of Roma was written and a set of measures for its realisation passed in 1999, the implementation of these policies under the Comprehensive development programme of Roma settlements (2002) and the Basic theses of the SR Government conceptual policy in the integration of Roma communities (2003) is still insufficient. The Basic Theses still best represent the planned concrete actions of the Government at the present time. This is in spite of the fact that a new document 'Priorities of the Slovak Government on the integration of Roma communities 2004' has been formulated, since it does not make any mention of improving healthcare for the Roma.
Programs and Projects
The single largest program currently being implemented by the MZSR is the pilot project 'Improving the access of the Roma living in segregated settlements to the provision of healthcare services' which, if successful, is intended to be broadened out to a much larger scale. Funded primarily by PHARE, the project is supplemented by a financial contribution from the Slovak Government and it runs in conjunction with a program of field health assistants. The project includes providing educational materials to Roma, providing medical equipment and refurbishing ten health centres, purchasing of ten mobile health units with associated equipment, training field health assistants and their subsequent employment in the segregated communities, as well as training local doctors and other local healthcare representatives. The overall aims of the program have been to improve levels of hygiene and general health in the most isolated Romani communities and to reduce their exclusion from healthcare. Since beginning to select municipalities to be included in the project, the total number of these – and the number of field health assistants to facilitate in them – has been considerably increased: current plans suggest that 54 municipalities should be included in the program and these should be served by 38 assistants. The roles of these assistants are to provide education on issues of basic hygiene and health, to collect statistical data, provide basic healthcare, to help with visits to the doctor, and to communicate between the doctor and the patient – for instance, in issuing reminders about child vaccinations.
The project has been stalled at the point of selection of the villages due to financial management problems within the government. According to the MZSR representative responsible for its implementation, "the project was approved to start in November 2004, but the relevant Slovak institution ('implementation agencies') within the Ministry of Finance responsible for the implementation of PHARE funds was [...] found in an European Commission audit in June  to be incapable of carrying out its task32." This has totally disabled the project: the MZSR must now wait for reassessment of the relevant financial institutions before funding can be made available for this project. It is expected that this will be carried out in November 2004, although no official date has been set. Since the pilot project is set to run from January 2004 to December 2005, this setback presents serious organisational and timing problems to the MZSR.
An external adviser to the MZSR, Peter Tatar criticises the prevailing EU project-funding system, in which he sees responsibility for such programs lost. He makes the point that "the government has been forced into spending half of the project budget on what are unnecessary mobile health units33." In his opinion, these mobile units are useless because in bad weather they will not be able to reach the settlements and that they would only slightly improve inhabitants' health, which is mainly influenced by their surroundings34. Dr Eugen Nagy, an adviser at the MZSR, also voiced opposition to this aspect of the program. He claims that Slovak doctors are not in a position to carry out all kinds of health operations in the field. He stated that, for example, "if doctors are expected to work in the field vaccinating children and a child has an allergic response, the necessary equipment to deal with such an incident may not be available. The doctor concerned is then at risk of being blamed35." It is hard to imagine positive results from a project harbouring such a lack of consensus between donor organisations' decisions and those implementing the project.
According to both the NAP and the Basic Theses, the Ministry of Health shall support several minor educational projects for marginalised Roma communities focused on sexual health (education for reproductive health and family planning, prevention against sexually-transmitted diseases and other issues). It is noted that this education would be carried out in the official language (i.e. Slovak) 'and in case of need also in the languages of national minorities'. All funding for this program was awarded to the MZSR by the Slovak Government Office. Ms. Škublová from the MZSR explained that initial plans had been for a campaign project but funds awarded for the implementation of the tasks detailed in their application totalled 300,000 Slovak Crowns (approximately 7,500 Euro), herself referring to this amount as a "laughably small sum". It was then decided that the best use of this money would be designing a small grant scheme, for which NGOs and civil organisations could apply. Of 19 applications, three projects were selected in Detva, Chminianské Jakubovany and Kremnica. At the time of writing, a detailed budgetary summary was available for only one of these projects and, according to a representative of the MZSR, a lawsuit was soon to be filed against the other directors of the project who were apparently no longer replying to the Ministry's letters and email, nor answering their telephones. The authors were advised by the same representative not to attempt to make contact with the directors of this project and were only provided with contact information for the other two with the proviso that it would probably not be worthwhile36. In any case, attempts by the authors to speak to anyone working on these projects were not successful.
Two educational projects have been designed by the Ministry of Health: 'Intensive education of health workers', mainly GPs, focused on the cultural differences mainly in regions with raised concentrations of Roma communities, and a Complex program of systematic education on human rights for health workers and students preparing to work in this field. With respect to the former, the MZSR had no detailed information on the project design and referred the authors to the Faculty of Public Health (FPH) at the Slovak Health University, the responsible party for implementing the project. In response to the authors' request for information, the FPH stated that there are a number of postgraduate courses in which yearly about 1500 practicing healthworkers take part, and that the issue of Roma health is included in the material taught. Roma healthcare also constitutes a part of certain courses for graduate students of various disciplines. Neither numbers of participants, effectiveness of the courses, nor their content is monitored by the MZSR, which makes an evaluation of the courses impossible.
The second of the MZSR projects on human rights was designed by the FPH and was finally entitled 'Systematic education of healthworkers in the field of prevention of all forms of discrimination, racism, xenophobia, anti-Semitism and other expressions of intolerance.' The project was aimed at practicing healthworkers taking part in postgraduate courses, Roma assistants, students of public health and nursing, and Slovak citizens. The aims of the project are listed as achieving equality in health for all groups of citizens, elevating the level of knowledge of all categories of healthworkers such that they can inform patients of concepts of informed consent, providing health-related information, and information on the rights and obligations of patients, as well as on "disease-prevention among minority groups". Despite a detailed description of project aims, goals, target groups and indicators, the MZSR has not yet provided funding for the implementation of the project. In theory, the implementation of this action plan should begin in January 2005.
Another project proposed by the FPH aims to gather detailed information about the health situation and lifestyle and environmental conditions of inhabitants of selected Romani settlements in the central and eastern regions of Slovakia. On the basis of an analysis of the data, the FPH intends to elaborate a number of health educational activities and materials for Roma in these areas.
In 2004, as part of the Comprehensive Program for the Development of Roma Settlements, the Slovak Ministry for Work, Social Affairs and the Family (MPSVRSR) began both coordinating and financially supporting the project 'Establishing Personal Hygiene and Laundry Centres'. Financial support from the same Ministry was also provided for the Program of Social Field Workers. The project's duration is not fixed: for 2004 financial resources of 18.6 million Slovak crowns (466,000 Euro) have been allocated, of which 6.6 million Slovak crowns (165,000 Euro) was allocated to the social workers program37. As of March, municipalities were invited to apply for funds for setting up and equipping 'hygienic centres', up to a ceiling of 80% of purchase costs of the centre.
Although many municipalities applied for these funds and began the process of setting up the centres, the program has been fraught with problems. First of all, the decision to obtain the funds is the responsibility of the mayor and his delegates, and all subsequent decisions on financing and implementation also rely on their discretion. In cases where these centres have been built, financing has often been slowed down by municipal political process, by incapability or aversion of delegates and mayors, and by infrastructural problems in buildings concerned38.
No projects are currently running or planned with regards to the problem of substance abuse among Roma. The manager of the Centre for Treatment of Drug Dependency (CLDZ) was keen to point out that although the Centre "does not support any form of positive discrimination", individual Roma had been supported by the Centre in the past, and the Centre undertook work with Romani NGOs upon their own request39. These past projects were aimed solely at problems with hard drug abuse. The Centre has not worked specifically with toluene abusers for "there is no point in keeping volatile substance abusers in an institute for two months and sending them straight back home. Projects would have to be done 'in the field' long-term to have any effect." Surprisingly, the respondent also stated that "in the Romani settlements there are some problems with volatile substance abuse" but claimed that it is also a problem in general for the lower classes and not just among Roma. This seems to be at odds with informal reports from social workers in Romani settlements, who consider volatile substance abuse a serious problem. The fact that there is no government policy on this whatsoever (i.e. neither for Roma or more generally) is somewhat indicative of a general acceptance of the problem as being a 'lost cause'.
The one example of current research focused on Roma health, funded by the Slovak National Program for the Support of Health, is an investigation into nutritional habits of the Hungarian and Romani minorities in Slovakia. Despite being mentioned in various government documents, and its seemingly 'unofficial' availability to a number of people, this report is not available to the public. Attempts to contact its author, Dr Ginter, have not received a response. The state of provision of such information to the public is severely hampered by such organisational problems within and between the MZSR and research institutes.
A recent article in the Slovak newspaper SME discusses the problem of Roma access to healthcare and that according to a report written by the International Organisation for Migration (IOM), healthcare is simply not available for many Roma. The report claims that new social and health reforms in Slovakia have worsened the health status of Roma and that Romani children are frequently undernourished. Healthcare is inaccessible to many Roma as a result of the implementation of per visit payments and the health system reform. Mr Roman Krištof of the IOM stated, 'it has come to the point where a child has died due to an ear infection, although this is a banal illness'. According to him, the problem is due to a lack of both money and 'social inability to decide to go to the doctors on foot' and as such, Romani children remain without medical care40.
Access to health care is also obstructed by discriminatory attitudes of doctors. According to the MZSR coordinator of the PHARE project and structural funds, Jana Škublová, "There are currently some districts with high Roma populations where doctors are totally absent". This state of affairs results from doctors not being willing to work in areas where Roma live. Such problems are potentially much more complex and larger scale than can be fixed through direct provision of funding through PHARE or structural funds. Both she and Peter Tatár believe that health reform could solve both this problem and go some way towards solving the problem of discrimination. The reform should initiate a system within which the doctors will be paid according to the number of appointments held in their practices and the numbers of patients receiving healthcare, i.e. it would not be a case of just having names registered at their practices41. The new system would possibly offer higher pay for doctors working in certain conditions or places where currently no doctors want to work. In such a system, management of the healthcare providers (in this case, particularly GPs) would fall upon the insurance companies42. This ought to result in selective contracting which would encourage doctors to apply for jobs in those understaffed regions such as Rimavská Sobota and Banská Bystrica. It is difficult to know in advance whether financially rewarding doctors for working in Romani communities would truly encourage them to work in these areas, or whether anti-Romani aversion would prevail. The question remains whether or not a system of financial reward may enable individuals to overcome their negative attitudes towards Roma.
An additional factor compounding healthcare problems amongst the Roma is the way in which drugs are prescribed by doctors in both the Czech and Slovak republics. Acting under the pressure of large multinational drug companies, doctors frequently prescribe expensive versions of otherwise potentially common, inexpensive medicines. Under the current system, pharmacists are in no position to advise the patient on a less expensive version of the prescribed drug. While this impacts on society in general, it may have a greater impact on poor Roma, who as a result must either gather the money for the drugs or simply go without it. Additionally, a lack of information relating to these issues leads to Roma having a lower chance of asking the doctor for a cheaper medicine in the first instance. A paragraph in the Czech NAP reads, 'Health care in the CR is provided to all citizens irrespective of social, ethnical, religious, or other status of a patient. Access to health care is guaranteed to all by the fact that each health care unit has an obligation to provide urgent and life saving care. Access to medication is ensured by the existing arrangement whereby in each group of drugs and health appliances there are items which are fully covered by health insurance.' According to Kumar Vishwanathan of the non-governmental organisation 'Life Together', "Romani patients are not always informed about the cheapest alternative as to the prices of drugs which prevents them from following the course of treatment prescribed." This problem also affects Roma in the Slovak Republic. Reform of the health service here should specifically deal with this problem of 'favouritism' when prescribing drugs, such that pharmacists may offer cheaper alternatives.
Shortcomings of Policy-Making and Data Collection
One key problem that currently plagues most policies and programs targeting Roma, including issues relating to healthcare, is the dearth of information regarding their population size. Estimates vary both between and amongst official and external sources. The Czech Joint Inclusion Memorandum states the number of Roma being 12,000 according to the last census in 2001, but immediately makes it clear that the officially estimated number of Roma is 160,000 to 200,000 – these numbers being elaborated from 1972 and 1989 data43. The Slovak Government in its JIM document quotes population figures obtained from the UNDP, and offers no estimate of its own. In reviewing the literature on this matter of the Slovak republic, at least ten different Romani population estimates exist within an assortment of official Government papers, international donor organisations' materials and media sources. Estimates of Roma population vary between 84,000 and 550,000: this represents a difference by a factor of 6.5. While the authors were completing this report, the Slovak Plenipotentiary for the Roma Community, headed by Klara Orgovánová, held a press conference on the issue of Roma population size in Slovakia44. The Plenipotentiary announced the results of research that had been carried out across the country into the number of Slovak citizens considered by the Slovak white majority to belong to the Roma minority. Numbers were taken from municipal mayors and other representatives in all the municipalities considered to have a Roma population (more than 1,000). The estimates resulting from this research list the number of Roma in Slovakia to be about 320,000.
With respect to the healthcare provision, low levels of Roma identifying themselves as such through declaration of their ethnic status may result in potentially high levels of error in monitoring, epidemiological studies or any large scale healthcare plans arising from these45.
Problems with quantitative data also arise on a different scale: according to Kristína Magdolénová, Director of the Roma Press Agency46, a major problem common in Romani settlements is in establishing a figure for the number of Romani children not vaccinated. Experts within the Government do not agree on what the correct means of collecting data for such research should be.
Lack of Research on Health and Epidemiology
Recent information on the health status of the Roma is scarce, considerably limited in scope and quality and tends to focus on contagious diseases47. International research focusing on the health of Roma children has been at the expense of studies on the health of Roma adults, which has received little attention. In the case of Slovakia, although general information about the health of the Roma is more readily available than in many other European countries48, it is nevertheless scarce and outdated, with much of it published before 1989. Much of what little information is available has been gathered by general practitioners and NGOs in a non-systematic manner, and it focuses on contagious diseases. Most non-communicable diseases have not been studied at all.
The single largest Czech research project, Determinants of health of the Roma in the Czech Republic49, allegedly the basis for the formulation of a Roma health policy, lasted for three years and was completed in 2001. The research presents a number of problems. First of all, it was originally aimed at finding out a correlation between social status and ethnicity, but according to the researcher responsible for this work, the main problem in the Czech Republic is the lack of demographic data, and as such it is difficult to guarantee the representativeness of any of the results. Secondly, the final presentation of the research is largely criticised both in terms of the 'epidemiological' and sociological issues treated and in terms of its recommendations for future action. In a similar vein, this research has been criticised by those working in the sector as academic and unrelated to the immediate problems facing Roma with respect to health.
Additionally, it would appear that although this document is ostensibly the only concrete state-funded research on which health policy, outlined in the Czech 2004 Concept for Roma Integration, is based, there is in fact very little correlation between these two documents. It is possible that other sources may have been used in preparing the 2004 Concept, but the authors' experiences of being repeatedly referred to same person responsible for the research (who, incidentally, does not seem to be willing to be so much involved in the follow-up of this research and seems uncomfortable with the role of an advisor on Roma health issues) suggest that there is a lack of human capacity in the state structure and a communicative/coordinative problem between the various institutions.
The Czech National Plan on Social Inclusion 2004-2006 states that 'a lack of relevant and verified information' about the Roma communities is a major problem with respect to improving the national, regional, and local policies. In order to tackle this situation, the government was only recently provided with a long-term plan of comprehensive sociological field research directed at mapping situations in Roma communities. However, it is not clear whether this plan incorporates any research that would provide more comprehensive information on Roma health than the Determinants of the Health of Roma in the Czech Republic.
The continued lack of research on non-contagious disease among Romani populations is covering serious health problems within some communities. According to a social worker in eastern Slovakia, in one settlement near Prešov, Slovakia, even "…simple things like going to the toilet are painful. Everyone suffers from bladder and urinary infections… the Roma are not aware of its being curable since all of them have the same problems. Only if it really hurts do they take some tablets… And the doctors are not interested50."
Owing to the lack of hard data concerning health problems facing Romani communities, certain themes may gain significance in state policies, despite that they may not in fact be related to the situation in the field. For example, the final report to the Slovak government as part of the PHARE Twinning program comments that one of the risk factors dictating the poor health status of the Roma is 'sprawling drug dependence resulting in higher risk of HIV infection and B and/or C hepatitis51.' Another government document published the same year also refers to this spread of drug dependency and associated HIV risk52. In both reviewing the literature and carrying out interviews with social workers in several villages in eastern Slovakia, very little mention was made of injected drug dependence and, in one case, it was pointed out that anti-drug campaigns in high schools focus on injected drug dependency. In the case of Hermanovce, such a campaign was seen as having totally missed the point, since Romani children had no exposure to intravenous drugs. In this particular settlement, substance abuse problems among the youth were confined almost exclusively to volatile substance abuse, specifically toluene sniffing53. Extremely harmful, addictive and severely debilitating, volatile substance abuse particularly affects impoverished and isolated communities and yet does not feature in school anti-drug campaigns, any government materials, or programs on the state of health of the Roma.
Lack of Acknowledgement of Discrimination
Although outright racism towards the Roma is not disguised at all in certain Slovak hospitals (e.g. hospitals with segregated wards for Romani and non-Romani women; 'journalists who visited hospitals saw how Roma women were grabbed and physically coerced by a doctor into telling the journalists how 'well' she was looked after by him54'), in the Czech Republic, discrimination is much less openly visible and thus potentially operates at quite a different level.
A non-discriminatory approach to healthcare, which assumes equal treatment of all in its provision, constitutes a state obligation under international law. The Organization for Security and Co-operation in Europe High Commissioner on National Minorities noted in a report in 2000 that, despite the heterogeneous nature of the problems facing Roma, one problem that faces them is plainly warranted: discrimination and exclusion are fundamental features of the Roma experience55.' A publication prepared by the European Monitoring Centre on Racism and Xenophobia suggests that 'various Government strategies attribute the poor state of Romani health almost entirely on the Roma, appearing to ignore the cumulative significance of discrimination for limiting access for Roma to a wide range of goods and services56.' The report then uses as an example the 'Strategy of the Government of the Slovak Republic for the Solutions of the Problems of the Roma National Minority', which attributes the poor health status of the Roma to their lack of education, their dietary habits, and substance abuse. The strategy fails to acknowledge that discrimination may play a major part in the poor health of the Roma and, perhaps more importantly, does not address the fact that in not tackling discrimination, the effectiveness of any state implemented program or project is severely hampered. The document entitled 'Basic theses of the SR Government conceptual policy in the integration of Roma communities in 2003' also has a very limited scope for coming to terms with the role played in healthcare by discrimination against Roma. A list of 'major determinative factors contributing to a lower health status of the Roma population' includes lower educational level, low standards of personal and communal hygiene, unhealthy eating habits and substance abuse. Although a considerable portion of the same document highlights the fact that the Roma are – from human-rights and constitutional perspectives – being illegally prevented from experiencing equality in provision of healthcare, the document does not directly correlate this to the low health status of the Roma community.
This attitude is also extended to a lower level of the major health program in Slovakia: the Standard Summary Project Fiche issued for the project 'Improved Access to Health Care for the Roma Minority in the Slovak Republic57' claims to propose solutions that will 'improve the access of Roma in the target regions to health care' and 'enhance their knowledge and consciousness about healthy lifestyle.' In describing the causes of poor health amongst the Roma, the report cites 'lack of education, segregation, and poverty'. While this document recognises the existence of discrimination in the healthcare system, instead of conceding that such discrimination may represent one of the most important key barriers in establishing communication and improving the health situation of Roma, it considers the discriminatory approach of health workers as merely adding to the problems.
A number of problems relating to discrimination in healthcare provision are exacerbated due to the system by which individual hamlets in Slovakia are registered at hospitals of municipalities that may actually be further than a hospital of an alternative municipality. In Richnava, a settlement to which Roma complain ambulances often do not come when called, 'inhabitants are registered under the authority of Gelnica, but this is much further away than the hospital in Krompachy. Instead of going to the further hospital, they go to Krompachy. They are not turned away because the law prohibits that, but it is made clear to them by the negative attitude and behaviour of the staff that they are particularly not welcome there.'
Low health status among Roma is frequently ascribed by the state and the media to lifestyle and cultural factors. For example, a community of Roma might be described as having 'low levels of personal hygiene' instead of describing the lack of sanitary amenities available to them. This effectively serves as an attribution of blame onto the Roma themselves, and acts as a smokescreen for the discrimination and racism that may underlie poor provision of healthcare or lack of sanitary infrastructure in a Romani community. This approach serves to distract policy makers from the very real issue of discrimination within health services. The attribution of blame is compounded by a culture – amongst both Roma and majority alike – that very seldom criticizes its health professionals. For a number of historical and cultural reasons, doctors are frequently held to be incontestable in their decisions, and infallible in their deductions. Where health professionals hold racist motives for their poor provision of services to the Roma, it is very unlikely to be accepted by the majority that such an attitude might be wrong; it is also likely that Roma patients treated in such a way would seek to inform someone about the doctor's behaviour.
In Slovakia, expressions of blatant racism on the part of the doctors have often been described by Romani patients, human rights activists and NGOs. In the Czech Republic, the majority of the Czech respondents denied that open racism would be a crucial obstacle in communication between doctors and Romani patients, but as a member of the NGO Drom in Brno noted, "there is a certain ethical codex adopted by medical practitioners, yet certain people have more experience with how easily it can be forgotten58."
One particular point in case of discrimination and distrust is in children's healthcare. A number of the Czech respondents, mainly – though not exclusively – NGO workers, agreed that mothers are often unwilling to take their children to doctors or leave them in quarantine because they are afraid of having them taken away and put into state care. It may be this vicious circle that prevents some children from obtaining proper treatment. One NGO respondent highlighted a case in Krompachy, Slovakia, in which 'complaints circulated about the brutal treatment of Romani children by a certain medical practitioner. People started to avoid seeing him and began to prefer to address medical problems themselves59.'
Communication of Policy and Projects to the Public
There is a serious problem with information provision to the public. The Czech and Slovak populations receives all information on Roma issues via the majority press, which tends to portray the health problems of Roma as a problem for the majority only in terms of increased risk of communicable disease. The health ministries of both the Czech and Slovak Republic so far have made little attempts to present to the public results of research or the value of improving healthcare policy for ethnic minorities.
There is no central point of access to information or documents in the Slovak or Czech Republics relating to Roma and health, and very limited materials in the Romani language. The Slovak JIM states that: Public awareness of the Roma issue as a question that concerns society at large is still not very apparent. This results in deepened prejudice against the Roma people and in the separation of the Roma from the majority society. This in turn increases discrimination and makes the implementation of any programme more difficult. Future priorities include the development of programmes up to the point of implementation, and the extension of such programmes to include all members of the Roma ethnic minority who are at risk. At the same time, legal provision should be made for dealing with discrimination directed against the Roma in society60. In terms of healthcare issues relating to the Roma and programs or projects implemented in the effort of solving them, communication to the public appears to be extremely limited. Other than some documents relating to these programs having been made available on the Internet, no provision has been made to communicate these projects to the public at large.
Communication problems are not only visible in the way that information on policy and programs is not passed on to its potential recipients. Lack of communication is striking between the central decision taking bodies and local representatives; as is the case in many newly decentralizing states, information not always reaches local government representatives but also, as the head of the Office of the Council for Roma Affairs Czeslaw Walek himself stated, there is no feedback to the ministerial-level, or information provided on the effectiveness of programs and activities that are being decided by municipal-level Government.
As for communication between the doctor and the patient, a seemingly logical necessity, many NGO workers pointed out that a majority of Roma patients are unable to orient themselves in the ever-changing healthcare system and their confusion is hardly ever met with patience on the part of the doctor. While active NGOs in both of the countries have high hopes with respect to the future health assistants, it is questionable whether the situation will change in small municipalities with less emancipated Roma populations and no active NGO presence. Local authorities may be considerably discouraged from working on projects relating to the improvement of Roma health specifically for the reason that this area has such a low profile.
Monitoring of Roma access to health services must be improved in both Czech Republic and Slovakia. The state of affairs at the current time is seriously affecting both effectiveness and appropriateness of research and project proposals, it is obscuring the true importance of Roma health issues, and it encourages continued, poor majority-media representation of the Roma. In the current absence of high-quality quantitative data, research yielding quantitative information must be carried out by responsible parties and be focused on relevant topics. In both the Czech and Slovak republics, the transition to needs-led research within academia is still far from complete: the small degree of work carried out at the present time is poorly funded, and is supported by a culture of research for research's sake. Personal authorial responsibility for research that has been carried out is essential, particularly when work has been carried out with government funds or as a constituent part of a state project. The authors met with considerable difficulty on several occasions in obtaining reports summarising project findings, and those responsible for these reports were reticent to discuss their research, unavailable for comment completely, or had a very limited amount of interest in the way in which government had subsequently used their findings in future policy-making.
The means of communication between those managing projects and the field and those coordinating projects in the ministries needs to be reconsidered. As the coordinator of PHARE projects at the Slovak Ministry of Health pointed out, all official communication must be carried out by post, which takes a considerable amount of time. Streamlining of the communication process between field project managers and civil servants could lead to better timeliness in project implementation, greater efficiency in the use of financial resources and a clearer idea of any individual project's process relative to its goals.
Improved communication between the various ministries and governmental levels is essential in improving the effectiveness of healthcare policies on Roma. Projects and programs are all too often slowed down by a lack of appropriate planning and cooperation between different government bodies. As the current plight of Roma becomes clearer through appropriate research, efforts to support integration and lower levels of pov