European level

Priorities and approach:

• the elimination of the health inequities aff ecting the Roma population ought to be considered as a priority of all the institutions constituting the EU. The European Com- mission, Council and Parliament in cooperation with the Council of Europe must therefore show strong will and persistence to push the issue of equity in health onto the political agenda of national governments.

On the one hand, the

• European Commission must respond to the mandate – of social inclusion and socio-economic cohesion, particularly with regard to the Roma population – assigned to it by the Council of the European Union¹⁰ and the European Parliament.¹¹

On the other hand, the EU ought to consider the development of actions aimed at the promotion of

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Roma and other vulnerable groups’ health as a priority within the framework of programmes of social inclusion and cohesion (European Social Fund [ESF], PROGRESS),¹² and of transnational cooperation (EU- Roma, European Grouping for Territorial Cooperation, Platform). The overwhelming preponderance of employment and professional training in these programmes potentially overshadows the implementa- tion of integrated and inter-sectorial policies, and thereby hinders their eff ectiveness by overlooking the social conditions that underpin the development of a qualifi ed and healthy workforce.

In that sense and because the health situation of Roma persons is a structural issue, member states

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should be able to access Structural Funds to support national eff orts to universalise and normalise healthcare provision (see below), in part by expanding the reach and quality of health resources in those areas that need it most, for instance by opening maternity and other primary care centres in areas with signifi cant Roma populations.

The 2008-2013 EU Health Programme and the Roma population

With regards to the fi nancing and actions aimed at the promotion of Roma health, the 2008-2013 Health Programme of the EU is considered as a particularly relevant instrument.¹³ The main objectives of the EU Health Programme are:

To improve citizens’ health security;

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To promote the reduction of health inequalities;

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To generate and disseminate health information and knowledge.

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These objectives are particularly relevant to Roma health. In order to achieve these aims, it is of fundamen- tal importance that the 2008-2013 EU Health Programme includes Roma health issues, and accordingly support actions that target specifi cally the Roma population.

In its second phase (2010-2013), the Programme should take into consideration the health situation of the Roma population and emphasise those aspects in which a greater inequality is detected. We suggest the incorporation of a pilot project aimed at Roma health in the Programme from 2010, and evaluated in 2012, in order for it to be scaled up in the following Health Programme (2014-2019). The pilot project would con- sist in the creation of a team of experts on health inequality, incorporated in the European Observatory on the Social Situation and Demography,¹⁴ with a particular focus on the situation of the Roma population.

This team would be in charge of:

10 Council of the European Union, Council Conclusions on Inclusion of the Roma. 2947^th Employment, Social Policy, Health and Consumer Aff airs Council meeting. Luxemburg, 8^th of June 2009.

11 European Parliament resolution on a European strategy on the Roma. P6_TA(2008)0035. 31 January 2008. Available at: http://www.

europarl.europa.eu/sides/getDoc.do?type=TA&reference=P6-TA-2008-0035&language=EN. Accessed 2 October 2009.

12 For information on the European Social Fund, see http://ec.europa.eu/employment_social/esf/. For information on the programme PROGRESS, see http://ec.europa.eu/social/main.jsp?catId=327&langId=en. Both accessed 18 August 2009.

13 European Parliament and Council, Decision No. 1350/2007/EC of the European Parliament and of the Council establishing a second programme of Community action in the fi eld of health (2008-2013). 23^rd of October 2007.

14 Information on the European Observatory of independent experts, established for the European Commission in 2005, is available at: http://ec.europa.eu/employment_social/spsi/european_observatory_en.htm. Accessed 10 September 2009.

Longitudinal, comparative analysis

• : the expert team would replicate the present survey in time and if possible expand it to other member states. By undertaking long term data collection and analysis, the team would improve the accuracy and reliability of the present study’s indicators, consolidate policy action paths and measure policy eff ects on the health situation of the most vulnerable popu- lations, in particular the Roma population. This would be consistent with the EU Health Programme’s aim of achieving the systematic collection, processing and analysis of comparable data for an eff ec- tive monitoring of the state of health in the EU.

Maps of inequality and warning system

• : the creation of a European map of health inequality between

member states, built on the maps of inequality and warning systems developed by national health systems and to which we will return.

Good practice and information-sharing

• : Identifi cation and exchange of examples of good practice

in the reduction of health inequalities, in collaboration with other European initiatives such as EU- Roma, the Decade of Roma Inclusion and the European Platform for Roma Inclusion.

By integrating Roma health as one of its priorities, the EU Health Programme 2008-2013 would contribute more fully to increased solidarity and prosperity in the EU.

Integrated policies

Intersectoriality and the social determinants of health: As previously emphasised, whenever reference is made to the health situation of the Roma population, it is necessary to bear in mind the social determinants of health, because a signifi cant proportion of the Roma population lives in a precarious socio-economic situation, which directly aff ects their health. In this sense, the EU will have to promote the implementation by its member states of integrated housing, education, employment and other policies aimed specifi cally at the Roma population, with a view to achieving equity in health.

Intersectoriality within the EU: the 2008-2013 EU Health Programme ought to be coordinated with other programmes aimed at the social inclusion of the Roma population, in order to achieve the implementation of integrated policies. The need for integrated policies is a priority of the EU’s Integrated Platform for Roma inclusion, as emphasised at its second meeting in September 2009 in Brussels.¹⁵

In order to achieve integrated and intersectorial policies, we propose that the use of the ESF for Roma health promotion be made through a more systematic coordination between the Directorate-General (DG) for Education and Culture, the Health and Consumers DG (DG SANCO), and the DG for Employ- ment, Social Aff airs and Equal Opportunities. Although joint projects exist, and meetings between staff in the DG take place to discuss Roma-related issues, they should be systematised through the elaboration of joint projects and actions. The EU also ought to be a model of intersectoriality not merely by exchanging knowledge but by working together regularly and on a variety of projects. However, coordinative mecha- nisms should always be matched with the Commission’s technical support of local administrations, because the latter play a fundamental role in the implementation and success of social inclusion policies.

For example, the DG SANCO and the DG for Education and Culture should jointly use the ESF to:

Articulate a European-wide scheme that fi nances, through Structural Funds, health education pro-

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grammes targeting schools and community organisations in impoverished and segregated areas, where disadvantaged groups such as the Roma are concentrated.

15 See EU Press Release, ‘EU Platform for Roma Inclusion (Brussels, 28 September 2009)’. MEMO/09/419. Available at: http://europa.

eu/rapid/pressReleasesAction.do?reference=MEMO/09/419&format=HTML&aged=0&language=EN&guiLanguage=en. Accessed

Provide fi nancial and logistical support to local administrations for health information campaigns

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adapted to the needs of Roma persons in order to achieve the transmission and acceptance of prin- ciples of preventive medicine, focusing for example on prenatal screening and the health behaviour and care of pregnant women. Women and children in particular should be targeted by campaigns, considering respectively their caretaker role and the more eff ective impact of information campaigns and education on youth. The promotion of a healthy lifestyle and a culture of prevention among Roma would be facilitated by developing attractive audio-visual materials for information campaigns.

Positive training measures for Roma mediators and professionals in the socio-sanitary fi eld, through

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bursaries and sustained training programmes.

Coordination between the DG SANCO and DG Employment, Social Aff airs and Equality of Opportunity could take the form of:

European intercultural training programmes for healthcare professionals, in order to improve their

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communicational abilities and to adapt their services to the needs of Roma patients.

The two actions constituting the aforementioned pilot project, the creation of a European Health

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Ombudsman and of a team of Experts on Inequality in Healthcare within the Observatory of the Social Situation.

Multilateralism

In order to buttress the implementation of integrated policies, and with regard to our recommendation that the EU should assume a leadership role in the resolution of transnational issues – including the health inequalities lived by the Roma – , we also suggest that the EU should intensify its eff orts to promote the development of a multilateral approach to health-related issues. Multilateralism, in contrast to unilateral or bilateral initiatives, refers to the principle that cooperative regimes based on sustainable consensus, joint answers to common problems, are more eff ective and legitimate ways of organising the resolution of inter- national and transnational social problems.

The EU should strive to coordinate its health-related activities with relevant multilateral organisations such as the World Health Organisation, the Council of Europe and the Organisation for Economic Cooperation and Development (ODIHR), the United Nations Development Programme, as well as specialised agencies and ini- tiatives such as the Decade of Roma Inclusion. The Decade in particular has acquired signifi cant know-how related to health and the EU should take advantage of its expertise to the fullest extent possible.

We propose a coordinative mechanism between the EU and aforementioned organisations, similar to the EU’s Open Method of Coordination, which already defi nes the relationships between EU member states.¹⁶ It would be based on the following principles:

Alignment: common objectives.

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Harmonisation: common quantifi able indicators.

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Coordination: identifi cation of specifi c competencies of each institution. In this sense a clear division

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of labour between diff erent organisations should be established, taking into account their respec- tive capacities and roles, in order to implement eff ective and effi cient health-related policies and to avoid the duplication of programmes. All organisations should coordinate their activities with na-

16 The Open Method of Coordination, defi ned as an instrument of the Lisbon strategy, is a framework of coordination allowing member states to elaborate a common strategy, based on common objectives, measurements and benchmarking (comparison of member states’ performance and exchange of best practice, monitored by the Commission). More information is available at:

http://europa.eu/scadplus/glossary/open_method_coordination_en.htm

17 This is consistent with Article 21 of the European Parliament’s Resolution on a European strategy on the Roma, which “Urges the Commission and Council to align EU Roma policy with the Decade of Roma Inclusion and to make use of existing initiatives such as the Roma Education Fund, the OSCE Action Plan and the recommendations of the Council of Europe to heighten the effi cacy of their eff orts in this area”. European Parliament resolution on a European strategy on the Roma. P6_TA(2008)0035. 31 January 2008. Available at:

http://www.europarl.europa.eu/sides/getDoc.do?type=TA&reference=P6-TA-2008-0035&language=EN . Accessed 5 September 2009.

tional and local authorities, while respecting the principle of subsidiarity. An example would be the coordination between the Observatory of the Social Situation (DG Employment) and the Observa- tory of National Health Systems (WHO).

Exchange of information between aforementioned agencies should be transparent and systematic.

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Promotion of transnational networks

In previous sections, we referred primarily to the relationships between multilateral organisations and be- tween EU institutions. At this point, we should stress the need for transnational networks founded on the principle of an active participation of civil society stakeholders, governments and the EU, working together and jointly planning policies to improve the health situation of the Roma. Initiatives along that line already exist – including the planned Platform for Roma Inclusion –yet they remain embryonic and must be further developed and structured.¹⁸ The point is to avoid the creation of phantom projects which marginalise civil society actors from the decision-making process and undermine the legitimacy of policy actions.

Such transnational networks will help the construction of a public service-civil society partnership that will achieve a greater degree of accountability, while ensuring that actions launched are fairer. In this sense, public institutions should reach out to Roma organisations and individuals, as well as other vulnerable col- lectives of all member states, for the elaboration, implementation and monitoring of healthcare policies.

The leadership of the EU, referred to earlier, should facilitate such public-civil partnerships, via three exist- ing networks of monitoring and exchange of best practices set up at the European level: the EURoma network, the Open Method of Coordination and the Platform for Roma Inclusion.

In order to ensure the input and feedback of Roma civil society actors, as well as the transparency of the ac- tions aff ecting the health situation of the Roma population, we recommend the creation of an independent mechanism of supervision of Roma inclusion in the national health systems as well as in the institutions of the EU, via the Platform for the Inclusion of the Roma.