Facts beyond Figures Communi-care for Migrants and Ethnic Minorities
The Health Situation of the Roma in Europe
Whom are we talking about? 1
• The term Roma refers to Roma, Sinti, Kale and related groups in Europe, including Travellers and the Eastern groups (Dom and Lom) and covers the wide diversity of the groups concerned, including persons who identify themselves as « Gypsies » • There are 10 to 12 million in Europe, the larger part in Central and Eastern Europe.
1 Geographical distribution 2
• Roma – in Central and Eastern Europe • Kale and Gitanos - in Spain • Sinti – in Italy, Germany and Switzerland • Jenisch – in Switzerland • Manouches (Gens du voyage) – in France • Irish and English Travellers – In Ireland and England
Common myths 3
• Nomadism has practically disappeared All sedentary in Central and Eastern Europe Slightly nomadic in Western Europe – Italy, France, Greece, Ireland, UK – with strong tendency to sedentarisation
2 Common myths 4
• Not all Roma are poor and live in miserable settlements. Many live in ordinary housing and are integrated • Not all Roma are illiterate. Many have University degrees. • The Roma do not spend their time singing and dancing
Health Situation 5
• Short life expectancy
Irish Travellers – 10-12 years less than majority population The Lancet, 2006
Irish Travellers – 15 years less than majority population Promoting the Social Inclusion of Roma – EU Network of Independent Experts on social Inclusion – December 2011
3 Life expectancy 6
• In Romania 3.3% of Roma reach 65 In FYROM 3.7% of Roma reach 65 UNICEF Report 2007
• Portugal, Slovak Republic – 15 years less than the majority population Italy – 20 years less than the majority population Promoting the Social Inclusion of Roma -EU Network of Independent Experts on Social Inclusion- December, 2011
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Life expectancy 7
• In Slovakia the life expectancy of Roma women is 17 years shorter than that of the female majority population Ina Zoon « On the Margins » 2001
• In Serbia, life expectancy is 16 years shorter than that of the majority population Roma Early Childhood Inclusion Report, 2011
4 Infant mortality 8
• Infant mortality amongst Irish Travellers- 14/1000 Promoting the Social Inclusion of Roma - EU Network of Independent Experts on social Inclusion, December, 2011
• Bulgaria - infant mortality is 25/1000 amongst the Roma and 9.9/1000 for the majority population Health and the Roma community :Analysis of the Situation in Europe, Dec. 2009
Infant mortality 9
• Greece – infant mortality is 11.6% Promoting the Social Inclusion of Roma -EU Network of Independent Experts on Social Inclusion –December, 2011
• Czech Republic, Slovakia, Hungary- infant mortality double that of majority population UNDP Report, 2003
5 Infant Mortality 10
• In Serbia, infant mortality is double that of the majority population • In Romania, infant mortality is six times higher than in Sweden • Roma Early Childhood Inclusion Report, 2011
Health Conditions 11
• Shift in emphasis in research from contagious to chronic illness and analysis of risk factors • Research on Roma health access to health care: state of the art and future challenges, Oct.2011 • By 2000 there were 32 papers on infectious diseases and 5 on chronic diseases Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
6 Health conditions –general 12
• In Eastern and SE Europe – higher rates of diabetes, coronary artery diseases, obesity, vitamin deficiencies, malnutrition, anaemia, dystrophy, rickets M. Schaaf:Confronting a hidden disease:TB in Roma communities, 2007
• Travellers in Ireland: high rates of heart disease, lung disease and cancer • Irish Times, 2010
Health conditions –general 13
• English travellers – 5 times more chronic bronchitis and two times more asthma Journal of Epidemiology and Community Health, 2009
• Between 2000 and 2010, 16 countries affected by measles – almost all were Roma Dr Muscat – Department of Epidemiology, Denmark, 2011
• High levels of measles, hypertension and obesity in Bulgaria, Hungary and Romania Socio-economic determinants of health status of Roma in Bulgaria, Hungary and Romania – 2010
7 Health conditions – general 14
• Roma suffering from a disability Bulgaria - 12.6% Czech Republic - 16.6% Greece - 16.1% Portugal - 19.5% Romania - 14.5% Slovak Republic - 18.8% Spain - 12.6%
Health conditions – general 15
• Portugal - 22% of minors have asthma • For all the countries under study (Bulgaria, Czech Republic, Greece, Portugal, Romania, Slovak Republic, Spain): - 1 in 4 has hearing problems - 19% had a limitation of daily activity in the previous 2 weeks - frequent ailments –migraine, headaches, hypertension
Health and the Roma community :Analysis of the Situation in Europe, Dec. 2009
8 Health situation – general 16
• English Travellers Two times more asthma and five times more chronic bronchitis
Journal of Epidemiology and community Health -2009
Health situation – children 17
• In Hungary, premature births are twice higher than in the majority population UNDP Report 2010
• In Serbia 20% of Roma children are stunted – the percentage is three times higher in urban areas Risk factors for childhood malnutrition in Roma settlements in Serbia, 2010
9 Health situation – children 18
• In S.E. Europe 30% of children suffer from diarrhoea UNICEF CEE/CIS -Report on Romani children in S.E. Europe, 2007 In Serbia - high rate of respiratory infection under 5 years of age Access to primary health care for Roma in Serbia – BioMed Central - August, 2011
Causes of ill-health 19
1. Poverty and malnourishment - in Kosovo 31% live in extreme poverty - in Romania 12% live in extreme poverty - in Montenegro half the Roma population lives in poverty - in Bulgaria 46% of the country’s poor are Roma World Bank Poverty Assessment ,2003
10 Causes of ill-health 20
• In S.E. Europe poverty rate is four times higher than that of the majority – in some countries ten times higher
• 40% live in poverty and 40% of Roma children are permanently hungry
UNICEF CEE/CIS - Report on Romani children in S.E. Europe, 2007
Causes of ill-health 21
• In Serbia 51% of women between 16 and 50 are undernourished UNICEF:Balkan Roma:shunned, illiterate and hungry, May 2007
• In the Balkans 53% of Roma are regularly hungry Surdu, L. and M. Surdu. Broadening the Agenda: The Status of Romani Women in Romania (Open Society Institute, 2006) • There are high levels of inadequate nutrition in the Czech and Slovak Republics Socio-economic determinants of health status of Roma, 2010
11 Causes of ill-health 22
2.Living conditions – Housing • Three types of habitation - integrated - concentrated in part of town - segregated in remote settlement
Causes of ill-health 23
• Czech Republic – 45% no water, 20% have electricity • Greece – 265,000 Roma live in 52 shanty towns without services • Hungary – 70% live in segregated housing 26% in settlements • Lithuania - 65% live in conventional dwellings; 41% have water; 37% connected to sewer
12 Causes of ill-health 24
• Portugal – rehoused in marginalised, polluted areas without infrastructure • Slovakia - 120,000 reside in rural settlements and urban slums • Italy – unauthorised camps – isolated, no services, no transport
Promoting the Social Inclusion of Roma- EU network of Independent Experts, Dec. 2011
Causes of ill-health 25
• In SE Europe - 47% have a bed for each family member - 66% have no bathroom - 61% have no toilet - 55% no sewerage - 41% no kitchen UNICEF CEE/CIS - Report on Romani children in S.E. Europe, 2007
13 Causes of ill-health 26
3. Lack of Education Lack of education of the mother is predictor of malnutrition and an indirect cause of stunting BioMed Central -Risk factors of childhood malnutrition in Roma settlements in Serbia – 2010 In Hungary twice as many infants are born prematurely - link between birth weight and mother’s education Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
Causes of ill- health 27
4.Habits and Practices linked to health
4.1 Early marriages leading to:
- lack of education - numerous successive pregnancies -frequentabortions
14 Causes of Ill-Health 28
In Bulgaria, the rate of abortion amongst Roma women is 2.4% Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
In Albania 56% of Roma women had one or more abortions At risk – the social vulnerability of Roma in Albania, 2004
Causes of ill-Health 29
4.2 Marrying within the family In Spain consanguinity is 12 times higher amongst the Roma population
The Health of the Roma people – a review of literature – Steve Hajioff, 2009
15 Causes of ill-health 30
4.3 Lack of family planning Lack of information on birth control In Albania, 46% know about birth control; 10% use it At Risk: the social vulnerability of the Roma in Albania, 2004 In Bulgaria 61% use contraception Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
Causes of ill-Health 31
• In Central and Eastern Europe many Roma women are unaware of HIV transmission. In Romania four times as many Roma women did not know that HIV/AIDS can be transmitted by unprotected heterosexual intercourse. • Roma men use condoms for birth control but not as an HIV protection UNDP–Romania. Social assessment of Roma and HIV/AIDS in Central and Eastern Europe. 31
16 Causes of ill-Health 32
4.4 Smoking Heavy smoking has been found in -Spain (Promoting the Social Inclusion of Roma- EU network of Independent Experts, Dec. 2011)
-Slovak Republic (Socio-economic determinants of health status of the Roma , 2010)
-Czech Republic – 44% of both sexes smoke (Health and the Roma community :Analysis of the Situation in Europe, Dec. 2009)
Causes of ill-Health 33
• Gypsies and Travellers in England –smoke heavier than the majority population (Journal of Epidemiology and Community Health, 2009) • Serbia:almost all women in Roma settlements around Belgrade smoke, many beginning at age 11. • Surdu, L. and M. Surdu. Broadening the Agenda: The Status of Romani Women in Romania (Open Society Institute, 2006)
17 Causes of ill-Health 34
4.5. Bad diet and lack of exercise Deficient eating habits and excessive consumption of coffee and animal fats Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
Perception of Health 35
• Subjective perception of health is relatively good due to the fact that the Roma have a young population 12% consider their health to be perfect 41% - good 45% - bad 57% claim child’s health is good; this is due to low parental awareness UNDP/ILO Study, 2009
18 Concept of Health 36
• Hospitalisation is associated with death • Concern is shown when symptoms become serious • Action and cure is expected to be immediate • Once the symptoms disappear all therapy is stopped • Decisions on health and therapy are taken by the extended family
Health Care Deficiency 37
1. Lack of preventive care - There is an underuse of preventive services Socio-economic determinants of health status of Roma in Bulgaria,Hungary and Romania, 2010 - Disbelief in the effectiveness of preventive care Living conditions of the Roma in Europe, 13 December, 2011
19 Health care deficiency 38
2. Lack of vaccination - In SE Europe 13% not vaccinated Romani children in SE Europe, UNICEF CEE/CIS, 2007
- In Romania 45.7% have not been vaccinated Promoting the Social Inclusion of Roma- EU network of Independent Experts, Dec. 2011
Health Care Deficiency 39
• In Slovenia vaccination of pre-school Roma significantly lower than in the majority Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
• In the Czech Republic only 3% not vaccinated Health of the Roma Community –analysis of the situation in Europe, 2007
20 Health Care Deficiency 40
3. Medical visits
• Romania – 48% registered with a doctor Schaaf, Confronting a Hidden Disease
Serbia – 40% have a family doctor Access to primary health care for Roma in Serbia – BioMed Central - August, 2011
Greece – 6% have never been to a doctor Health and the Roma Community –analysis of the situation in Europe, 2007
Health Care Deficiency 41
• Albania - 40% have a family doctor At risk – the social vulnerability of the Roma in Albania, 2004 • Spain – only 58% of children taken for check- ups Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
21 Health Care Deficiency 42
• Romania – - 43% never gone to a dentist - 89.3% of Roma women never had a mammography -84% of Roma women never had a screening for cervical cancer Promoting the Social Inclusion of Roma- EU network of Independent Experts, Dec. 2011
Health Care Deficiency 43
• In an analysis in Belgium, Greece, Czech Republic, Portugal, Romania, Slovakia -16% of women have never been to a gynaecologist - 22%% only have had a mammography • In the Czech Republic 83%- in the Slovak Republic 76% have been to a gynaecologist for reasons other than pregnancy Health of the Roma community – analysis of the situation in Europe, 2007
22 Obstacles to Health Care 44
1.Distrust - Distrust of the medical services – linked to forced sterilisation Research Note on the health of Roma, Philippa Mladovsky, LSE, 2007
- Example of distrust: In Serbia in 2000 the Commissioner for Refugees and the UNHCR organised registration of 19000 IDPs – by end 2001 39% were still without documents UNICEF Report – Breaking the Cycle of Exclusion, 2002
Obstacles to health care 45
• General disbelief in the effectiveness of preventative treatment and a belief that medical consultations reduces resilience by bringing bad news EU Roma Health Survey (2006-9) in Greece, Portugal, Czech Republic, Slovak Republic, Romania, Bulgaria and
23 Obstacles to health care 46
2. Lack of documentation Romania – 10% have no identity documents – 2.4% no birth certificate Montenegro – one-third have no birth certificate Romani children in SE Europe, UNICEF CEE/CIS, 2007 Serbia – 18% have no insurance card; 23.7% in rural areas Access to primary health care for Roma in Serbia – BioMedCentral - August, 2011
Obstacles to health care 47
• Serbia -39% have no identity card and one third no health card ERRC – Ambulance not on the way • Bulgaria – over 50% have no health insurance Socio-economic determinants of health status of Roma in Bulgaria, Hungary, Romania, 2010
24 Obstacles to Health care 48
• In Bosnia-Herzegovina a child cannot be registered at birth if the father does not have a medical record Romani children in SE Europe, UNICEF CEE/CIS, 2007 • Romania – permanent residence required to accede to social services UNDP/ILO Study, 2009 • UK Travellers refused treatment for lack of permanent address • Living conditions of the Roma, 2011
Obstacles to Health Care 49
3. Discrimination A prime reason for avoiding consultation is experienced hostility and prejudice in healthcare services EU Roma Health Survey (2006-9) in Greece, Portugal, the Czech Republic, the Slovak Republic, Romania, Bulgaria and Spain
25 Obstacles to Health Care 50
• Hungary – 25% faced discrimination in hospitals - 44.5% faced discrimination by practitioners Delphio Consulting, Budapest, 2004 Lack of cultural consideration on the part of health professionals Health and the Roma Community-Ministry of Health and Fundacion Gitano, 2004
Obstacles to Health Care 51
4. Cost A 2005 UNDP study found that one of the main causes of not accessing health is lack of money
A 2009 UNDP/ILO study finds that the financial contributions in the new insurance systems are too high for the Roma.
Health needs unattended to because too expensive Health and the Roma Community: analysis of the situation in Belgium, Czech Republic, Greece, Portugal, Romania, Slovak Republic, Spain, 2007
26 Obstacles to Health Care 52
• In Serbia obtaining documents is complicated and costly for Roma UNICEF Report – Breaking the Cycle of Exclusion, 2002 • In Serbia 56% did not use needed healthcare mainly because it was too expensive BioMed Central – International Health and Human rights, August 2011 • In Albania the cost of medical services and medicines are an obstacle At Risk:the social vulnerability of Roma in Albania
Bringing a change 53
• Limited governmental action
• Lack of political commitment
• Widespread prejudice and stereotypes
• Distrust between Roma and non-Roma and the authorities
27 Bringing a change 54
• Role of international organisations – - OSCE, UNHCR, UNICEF, WHO, IOM, EU • Role of the Council of Europe - active since the 50s - set up standards for health care for Roma - monitoring bodies – ECRI, European Social Charter, Convention Protection of Minorities - ECHR, European Committee on Social Rights
Bringing a change 55
• Latest developments – 2010 -2012 1.European Framework Strategy for Roma Inclusion (EC) - Development of national strategies - Evaluation of the strategies 2. High-level meeting on Roma (C of E) - appeal for non-discrimination and social inclusion - setting up of a Mediators Training Programme
28 Bringing a change 56
• Mediators Training Programme, jointly with European Commission - establish link with authorities - empower Roma to take responsibility - provide health education -build up trust between roma, non Roma and the auThorities
Bringing a change 57
• Evaluation of strategies by the European Commission - « only a few member states have defined a comprehensive approach to improve the health of the Roma » - several member states are involving mediators e.g. Hungary, Ireland, Romania
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