We have identifi ed a series of transversal recommendations, which must be taken into consideration by all institutions and actors when addressing any of the specifi c areas of intervention in healthcare and are to a large extent consistent with the 10 Common Basic Principles on Roma Inclusion, promoted by the EU’s Integrated Platform for Roma Inclusion:1
Tackling the structural determinants of health: inter-sectorial intervention in education, training, la- 1.
bour market inclusion, housing and health;
Involvement and participation of the Roma population in all processes of intervention;
2.
Normalisation and strengthening of health programmes aimed at the Roma population: ‘explicit but 3.
not exclusive targeting’.
Inclusion of a gender perspective;
4.
Prioritising preventive healthcare by targeting Roma youth;
5.
Continuation of data gathering and analysis, in order to deepen our understanding of the specifi c 6.
needs of the Roma population regarding healthcare, and to identify any changes of those variables conditioning the health situation of the Roma.
1. Tackling the structural determinants of health: inter-sectorial intervention in education, training, labour market inclusion, housing and health.
The circumstances under which persons are born, grow, live, work and age determine to a large extent their health situation.2 These circumstances are conditioned by the distribution of resources and power, which are in turn shaped by policy choices. As pointed out by the WHO (2008: 1), the ‘structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries’.3 Moreover, If the health situation of any population infl u- ences and is infl uenced by other social areas (housing, education, employment), this inter-relationship is particularly acute in the case of the Roma population. Social welfare is not the sum of diff erent parts, but is rather conditional on integrated actions in all social fi elds, simultaneously and always with a consideration of the eff ects of a specifi c policy on other fi elds. A holistic approach, which seeks to redress geographical, national/ethnic and income inequalities EU-wide, should systematically and concurrently target education, professional training, employment, health and housing through eff ective and effi cient fi scal and organisa- tional instruments.4 Human health in particular should be a cross-cutting issue throughout the decision- making in diff erent sectors and at diff erent levels.
Holistic, inter-sectorial work should therefore entail a shared responsibility between all agents involved in welfare and employment, and the incorporation of health issues in all programmes aimed at the Roma population as well as other vulnerable populations. Inter-sectorial information sharing and coordination should be undertaken and sustained as a matter of principle.
1 10 Common Basic Principles on Roma Inclusion. 1st European Platform for Roma Inclusion (Prague, 24 April 2009): 10 Common Basic Principles on Roma Inclusion. Annexed to Council Conclusions, 8 June 2009. Available at: http://www.euromanet.eu/
upload/21/69/EU_Council_conclusions_on_Roma_inclusion_-_June_2009.pdf . Accessed 10 September 2009.
2 World Health Organisation (WHO), Sixty-second World Health Assembly, Resolution WHA62/R14. 22 May 2009. Available at http://
apps.who.int/gb/ebwha/pdf_fi les/A62/A62_R14-en.pdf. Accessed 10 September 2009.
3 Commission on Social Determinants of Health (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health (Geneva, WHO). Available at http://
whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf. Accessed 10 September 2009.
4 Vladimir Špidla’s speech at the Second European Platform for Roma Inclusion (Brussels, 28 September 2009), which is premised on the implementation of integrated policies, emphasised that: “... It is vital that policies for Roma education are not dealt with in isolation from those in employment and social aff airs, housing and public health.” Available at: http://europa.eu/rapid/
2. Normalisation and stabilisation of health programmes aimed at the Roma population: ‘explicit but not exclusive targeting’
Roma persons’ equal access to health services must, however, be facilitated by compensating for existing social inequalities through programmes targeting the specifi c needs of the Roma defi ned by adapted and non-discriminatory attention. Given the need for explicit but not exclusive targeting, health programmes and medical attention aimed at the Roma should always tend towards normalisation and sustainability, i.e.
the Roma population should be allowed and encouraged to be off ered medical care by the same profes- sionals and in the same resources as the rest of the citizenry.5 The central aim of these programmes should be to guarantee that the specifi c needs and peculiarities of the Roma population are included in the normal functioning of the resources and the actions of their professionals.
If interventions specifi cally targeting the Roma are implemented, they should be considered as temporary measures aimed at preparing the eventual incorporation of the Roma population into normalised resources.
The incorporation of the Roma population into normalised healthcare provision is a protracted and com- plex process involving the interaction between numerous social and individual factors, and can therefore not be achieved through ad hoc, temporary and intermittent programmes. Healthcare programmes aimed at the Roma should therefore be, whenever possible, strengthened and stabilised in the medium term.
However, the long-term objective of programmes directed exclusively at the Roma should always be their eventual disappearance, in order to achieve the aim of healthcare normalisation, and to eliminate the po- tential stigmatisation that such specifi c programmes might involve if they rigidify over the long-term.
3. Involvement and participation of the Roma population in all processes of intervention.
It is of fundamental importance that the EU, national and local administrations as well as the NGO sector steer clear of lapsing into a paternalistic approach of health intervention. Therefore, the participation and whenever possible, the leadership of the Roma in all processes of intervention aff ecting them is recom- mended. The point is to secure the involvement of the Roma population as agents of their own devel- opment. Roma involvement implies changes of attitudes and habits that are unhealthy. The participation must take place in the phases of planning, implementation and evaluation, at both macro- and micro-levels of intervention:6
Planning, implementation and evaluation:
•
diagnosis of Roma needs –
defi nition of objectives and methods –
implementation –
evaluation.
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Macro- and micro-levels of participation:
•
Macro: Identifi cation of strategic lines of action at the EU and national levels;
–
Micro: local implementation of these strategic lines of action.
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5 This refl ects principles 2 and 4, regarding ‘mainstreaming’ and ‘explicit but not exclusive targeting’, of the 10 Common Basic Principles on Roma Inclusion. 1st European Platform for Roma Inclusion (Prague, 24 April 2009): 10 Common Basic Principles on Roma Inclusion. Annexed to Council Conclusions, 8 June 2009. Available at: http://www.euromanet.eu/upload/21/69/EU_Council_
conclusions_on_Roma_inclusion_-_June_2009.pdf . Accessed 10 September 2009.
6 The principle of Roma participation has been reiterated in EU resolutions. Council Conclusions on inclusion of the Roma. 2914th General Aff airs Council meeting. Brussels, 8 December 2008. 16862/08 (Presse 359). Available at: http://register.consilium.europa.
eu/pdf/en/08/st15/st15976-re01.en08.pdf. See also principle 10 of 10 Common Basic Principles on Roma Inclusion. 1st European Platform for Roma Inclusion (Prague, 24 April 2009). Both accessed 10 September 2009.
Such participation must involve diversifi ed civil society interlocutors, in order to refl ect the heterogeneity of the Roma population and diverse realities lived by Roma men and women:
Associations that may represent one sector of the Roma population (but not others), and with which
•
alliances can be built to work on determined areas of intervention (but not others).
Roma mediators, who are in a position to provide valuable knowledge on the reality lived by Roma
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communities.
Members of the Roma population who are not affi liated to any association or church, but who, thanks
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to their experience, training and sensitivity, may provide valuable contributions to the elaboration and evaluation of health policies.
Users of the services, who through their relationship with healthcare staff or mediators may collabo-
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rate in all phases of planning and implementation.
Without the active participation of the Roma population in the planning, implementation and evaluation of policies, the legitimacy, transparency and eff ectiveness of policies are likely to be hindered.
4. Incorporating a gender perspective
Working towards a reduction of health inequalities requires the systematic integration of a gender per- spective by all stakeholders, which takes into account the fact that health problems are more acute among Roma women.7 Roma women suff er a triple discrimination; for being women in a patriarchal society, for belonging to an ethnic minority that is aff ected by the most negative social perception and for belonging to a culture whose gender values have been associated almost exclusively to the function of mother and spouse. The opportunities available to Roma women are therefore limited in relation to men in their com- munity and to society as a whole. In order to address this multiple discrimination, any policy aimed at re- ducing health inequities should focus particularly on the specifi c conditions and needs of Roma women.
It must be taken into account that the diff erent health situations of Roma women and men are defi ned primarily by the distinct lifestyles (nutrition, consumption of tobacco, physical activity, etc.), which in turn are conditioned by their diff erent social roles. The social norms that have traditionally governed the diff er- ent roles and positions of men and women in the Roma population have a clear impact on the signifi cant diff erences in the health situation of Roma men and women detected in the present study.
The roots of gender inequality, within the Roma population as in broader society, are socially constructed, and can therefore be modifi ed, by Roma men and women. For this reason, and as already mentioned, all interventions aimed at improving the health situation of Roma women ought to be particularly sensitive to their particular situation.
The inclusion of a gender perspective is not only justifi ed by the inequalities detected between men and women, but also by the multiplying eff ect of interventions aimed at women, for their pivotal role in the organisation of the family and the transmission of values and habits. Interventions should seek to promote a greater visibility (as mediators, educators) of and access to health resources by women. Furthermore, interventions cannot overlook younger Roma women and must bolster, through dialogue and refl ection, a growing participation in society, which contribute to the creation of new meanings to Roma identity and convert themselves in referents for other persons of their community. Nevertheless, if we exclusively reinforce the responsibility and implication of women, we run the risk of contributing to the consolidation of gender inequalities.
7 European Parliament resolution on the situation of Roma women in the European Union (2005/2164(INI). P6_TA(2006)0244. (1 June 2006). Available at: http://www.europarl.europa.eu/sides/getDoc.do?type=TA&language=EN&reference=P6-TA-2006-0244.
5. Prioritising preventive healthcare by targeting Roma youth
Any reference to the Roma is a reference to an extremely young population, with close to half of the popu- lation under 20 years old and a traditional population pyramid (high birth rate, low life expectancy). Con- sidering the determining eff ects of children’s living conditions on their adult health and life expectancy, the need to target Roma children therefore becomes a vital necessity. In particular, preventive healthcare, which involves changes in habits and behaviours, may generate profound transformative processes by tar- geting children. It is therefore considered that Roma children and adolescents should be prioritised for in- formation and education campaigns, in part because they are more permeable to any type of intervention.
Furthermore, taking into account the characteristics of Roma teenagers and youth – defi ned by relatively early adulthood –, we urge that interventions be targeted at Roma boys and girls, in order to integrate concepts of preventive medicine and, in the case of drug abuse, before the fi rst situations of consumption may occur.
Investing in sustained health programmes targeting Roma youth and adapted to their specifi cities will have the greatest probability of having a lasting positive impact on health equity and the health situation of the Roma population.
6. Continuation of data gathering and analysis, in order to identify any changes within or of key variables
We must emphasise the groundbreaking nature of the present report. The lack of studies and research on the health situation of the Roma population in the UE profoundly undermines the planning of specifi c pro- grammes adapted to the reality and needs of the Roma.
The present study should be replicated on a regular basis by using the same indicators and, if neces-
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sary, by adapting indicators to new empirical evidence, in order to establish a longitudinal analysis that allows for historical as well as geographical comparisons.
More specifi c and in-depth studies should be undertaken, in part to redefi ne and ‘funnel’ the indica-
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tors used in the present report. Thematic examples include drug abuse, the use of emergency serv- ices, obstacles to the access and use of health care services.
In order to take into account the territorial diversity of the Roma population, studies of specifi c lo-
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calities and regions within each of the case studies analysed at the state level in this report should also be carried out.
Healthcare provision to the Roma population would be signifi cantly improved by closer cooperation be- tween researchers, policymakers and social workers. Gaps between the elaboration of the studies, the plan- ning of policies and the development of intervention should be bridged in order to be more attuned and responsive to the needs of the Roma population.