Implementation of the National Roma Integration Strategy and Other National Commitments in the Field of Health SPAIN A multi-stakeholder perspective report on 2005–2014 developments The information and views set out in this report are those of the author and do not necessarily reflect an official opinion of the EC or IOM. Neither they nor any person acting on their behalf may be therefore held responsible for any use of the information contained therein. Reproduction is authorized provided the source is acknowledged. This Progress Report from a multi-stakeholder perspective on the implementation of the National Roma Integration Strategy (NRIS) and other national commitments in respect to Roma Health was undertaken by the International Organization for Migration (IOM) within the framework of the project “Fostering Health Provision for Migrants, the Roma, and Other Vulnerable Groups” (Equi- Health). The EQUI-HEALTH project is co-financed under the 2012 work plan, within the second programme of Community action in the field of health (2008–2013), by direct grant awarded to IOM from the European Commission’s Directorate General (DG) for Health and Consumers (SANTE), through the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The Equi-Health project is designed and managed by the International Organization for Migration (IOM) Regional Office Brussels, Migration Health Division (MHD). In addition, this report on the Implementation of the National Roma Integration Strategy and Other National Commitments in the Field of Health in Spain has benefited from a grant of the Ministry of Economy and Competitiveness, s of Spain (Ministerio de Economía y Competitividad; PSI2011- 25554). The Progress Report was produced under IOM MHD, RO Brussels guidance by Manuel García- Ramírez, Marta Escobar-Ballesta and Tona Lizana Alcazo and benefitted from peer-reviews and editing by Mariya Samuilova. We thank DJ Krastev for his copy-editing, proofreading, and general editing assistance. IOM would like to extend its thank to the research team and collaborators involved in this research, especially: Mª Jesús Albar Marín,1 Rocío Garrido Muñoz de Arenillas,1 Lluís Granero Giner,2 Pablo L. Pérez Montesinos,2 Mª Dolores López Gándara, Virginia Paloma Castro,1 Belén Aguilera Gómez del Castillo, Constanza Cardona Viroga, Alexandra Orgaz Camacho, Laura Rodríguez Candea, Emilia Sánchez López and Carmen Sánchez Ocaña A special note of thanks is due to Daniel La Parra for his thoughtful and valuable contributions to this report. IOM is also grateful to all the people who have contributed to make this study possible; especially Manuel Borrero Arias, Montserrat Bret Garriga, Carmen Cabezas Peña, Carolina Carmona Ruiz, Beatriz Carrillo de los Reyes, Alba Fernández, Tania García Espinel, Manuel Heredia Jiménez, Montserrat Jara Martín, Tincuta Leonte, Óscar López Catalán, Carmen Méndez López, Xavier Miranda, Anna Montoriol, Juan Carlos Navarro Zafra, Antonia Núñez García, Llorenç Olivé i Morros, Florinel Paun, Mercedes Pérez Dechent, Isabelle Peris, Joan Lluís Piqué i Sánchez, Francina Planas, Antonio Redondo Buzón, José Rodríguez, José Antonio Rodríguez Cuellar, Desiré Sánchez, Antonia Sánchez Franco, Ana Sancho, Lucía Sanjuan Núñez, Gerardo Tiradani and Conchita Vila Vila. 1 CESPYD Universidad de Sevilla. 2 ASPCAT Generalitat de Catalunya. 2 CONTENTS ACRONYMS .................................................................................................................................. 4 EXECUTIVE SUMMARY ................................................................................................................. 5 1. INTRODUCTION: BUILDING COLLABORATIVE CAPACITY AMONG STAKEHOLDERS TO DEVELOP TRANSFORMATIVE ROMA HEALTH POLICIES ............................................................................... 11 1.1. Background…….. ....................................................................................................................... 11 1.2. Failure of European responses .................................................................................................. 12 1.3. Roma health inequities as a “wicked” problem ........................................................................ 13 1.4. Transforming Roma health policy through stakeholder collaboration ..................................... 14 2. FRAMING THE PROBLEM ..................................................................................................... 17 2.1. National and foreign Roma in Spain.......................................................................................... 17 2.2. Roma health inequities and social determinants ..................................................................... 18 2.3. The EU response to Roma health inequities ............................................................................. 20 3. BUILDING COLLABORATIVE CAPACITY TO TRANSFORM ........................................................ 22 3.1. Evidence based approach: systematic review .......................................................................... 22 3.2. Discursive approach: key stakeholder involvement ................................................................. 22 3.3. RIPEX: an NRIS assessment tool ................................................................................................ 24 4. PROMOTING SHARED UNDERSTANDING TO TRANSFORM ROMA HEALTH POLICIES ............. 27 4.1. Entitlement to health care ........................................................................................................ 27 4.2. Access to the health-care system ............................................................................................. 30 4.3. Responsiveness of health-care services .................................................................................... 43 4.4. Achieving and sustaining change .............................................................................................. 60 5. PLANNING THE FUTURE ....................................................................................................... 78 5.1. Principles………… ........................................................................................................................ 78 5.2. Priorities…………. ........................................................................................................................ 81 5.3. Tools………………. ....................................................................................................................... 82 FINAL THOUGHTS ....................................................................................................................... 86 BIBLIOGRAPHY ........................................................................................................................... 87 ANNEX I. DESK REVIEW .............................................................................................................. 97 ANNEX II. EQUI-HEALTH STAKEHOLDERS IN SPANISH COALITION .............................................. 104 ANNEX III. SPANISH GUIDELINE FOR STAKEHOLDERS INTERVIEW .............................................. 108 ANNEX IV. TERMS OF REFERENCE OF THE EQUI-HEALTH PROJECT ............................................. 109 3 ACRONYMS ASPCAT Public Health Agency of Catalonia (Agència de Salut Pública de Catalunya) CatSalut Catalan Health-care Service (Servei Català de la Salut) AACC Autonomous Communities (Comunidades Autónomas) CESPYD Coalition for the Study of Power, Health and Diversity CSO Civil Society Organizations DG Directorate General DRI Decade of Roma Inclusion EC European Commission EU European Union IOM International Organization for Migration MIPEX Migrant Integration Policy Index NGO Non-Governmental Organizations NHS National Health System (Sistema Nacional de Salud) NRIS National Roma Integration Strategy PHC Primary Health-care Centres RDL Royal Decree-Law (Real Decreto Ley) RIPEX Roma Integration Policy Index SAS Andalusian Health-care Service (Servicio Andaluz de Salud) ToR Terms of Reference of the Equi-Health project TRHP Transformative Roma Health Policies WHO World Health Organization 4 EXECUTIVE SUMMARY Introduction: Building collaborative capacity among stakeholders in order to develop transformative Roma health policies In February 2013, the Migration Health Division of the Regional Office for Europe and Central Asia of the International Organization for Migration (IOM) launched the project “Equi-Health: Fostering Health Provision for Migrants, the Roma and Other Vulnerable Groups.” Equi-Health´s sub-action “Roma Health” seeks to improve the accessibility, adequacy, adaptability, satisfaction with and the quality of health assistance, preventive care, and health promotion services for Spanish and foreign (EU and third country nationals) Roma. The first stage of this project focuses on elaborating progress reports from a multi-stakeholder perspective on the implementation of the NRIS and other national commitments with respect to Roma Health. The Roma are one of the largest minorities in Europe and the main ethnic group in Spain. Roma health is a challenge that is extremely difficult for European society to tackle. The isolation, discrimination, and poverty in which many of them live are unacceptable sources of inequity that have been in place for hundreds of years. In order to tackle this problem, in 2005, the European governments committed to a Decade of Roma Inclusion (DRI, 2005–2015) to “combat discrimination, poverty, and exclusion against