From the macro- to the micro-level in healthcare provision
4. Roma community
low patients and professionals to observe the geographical areas and populations that are most aff ected by health inequalities. These maps should be used as a basis to redirect resources and investment towards the most disadvantaged areas and groups, in accordance with the principle of equity and with the aim of systematically emulating areas where excellence prevails.
Whenever situations of inequality become manifest, healthcare systems must contemplate a number of responses:
Active engagement of patients and street intervention.
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Adapted information strategies.
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Targeted subsidies for activities and habits having a positive impact on health – for example sports.
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Inter-sectorial coordination with social and educational centres, NGOs and Roma organisations for
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fl exible, rapid and adequate investments.
Aforementioned maps and warning systems ought to be elaborated at both micro- and macro- levels, in coordination with the expert research team on health inequalities incorporated in the European Observa- tory on the Social Situation and Demography referred to previously.
Summary and conclusions
The health situation of the Roma requires urgent responses, which must be defi ned by a holistic approach translated into sustainability and mainstreaming. In order to eff ectively reduce the health inequalities ex- perienced by the Roma, inter-sectorial policies in education, training, labour market inclusion, housing and health must be implemented; the Roma population must actively participate in all processes of interven- tion; health programmes targeting the Roma population must be normalised and strengthened they must adopt a gender perspective and prioritise Roma youth. Crucially, all actions must rely on well-defi ned in- dicators, which in turn require longitudinal and periodic research to understand the specifi c needs of the Roma population regarding healthcare, and to identify any changes of those variables conditioning the health situation of the Roma. As such comparative data gathering must be pursued and, if possible, ex- panded to other EU member states and accession countries.
Universal and high quality health coverage, founded on inter-cultural exchange and the guarantee of the right to equitable access to health services
The economic crisis cannot be used as an argument to avoid investing in measures that correct inequali- ties and protect the rights of persons. We must take on the challenge of increasing social protection and guarantee public services through four key elements:
Universal healthcare.
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Active social inclusion relies on the following prerequisites:
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Suffi cient services for all.
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Services adapted to persons with specifi c characteristics and needs.
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Effi cient and eff ective services.
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It is an obligation of public authorities to remove any obstacle to an equitable access to services.
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Indubitably, the Roma population must also change many practices and habits but this does not
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exempts public authorities from fulfi lling their obligations.
Tackling the three dimensions of the health cycle and acting on the social determinants of health The three dimension of the health cycle (prevention – care – risk reduction) are complementary and must therefore be tackled concurrently.
Prevention
• : emphasis must be placed on habits, on lifestyles, on behaviours, on the perception of the health system, and on supposedly ‘cultural’ factors. What is detrimental to health is detrimental to culture.27
Care
• : healthcare must be universalised, i.e. it must reach all and be adapted to specifi c needs (media- tors, information campaigns, sensitisation of health professionals, solutions to transport problems).
Risk reduction
• : in the case of determined situations that cannot be resolved in the short-term, all stakeholders should focus on reducing risks.
Although substantial improvements may be obtained by acting in those three dimensions of the health situation without undertaking structural transformations, this is not a suffi cient condition to address the health inequities experienced by the Roma: the social determinants of health ought to be tackled through an integrated approach and inter-sectorial coordination.
27 José Manuel Fresno, Concluding speech of the Summit on Health and the Roma community, Madrid 1-2 October 2009.
Breaking the targeted VS mainstreaming dichotomy
The debate targeted VS mainstreaming approaches as alternative, mutually exclusive options is misguided, because it opposes actions which should be regarded as complementary. The second principle of the EU’s Platform for Roma inclusion refers to the need for explicit but not exclusive targeting of the Roma: “Explicit but not exclusive targeting of the Roma is essential for inclusion policy initiatives. It implies focusing on Roma people as a target group but not to the exclusion of other people who share similar socio-economic circumstances. This approach does not separate Roma-focused interventions from broader policy initia- tives. In addition, where relevant, consideration must be given to the likely impact of broader policies and decisions on the social inclusion of Roma people”.28 In some cases, targeted actions are necessary, but they should always lead to normalisation.
Roma health as a transnational challenge requiring EU leadership
The study has demonstrated that the issue of Roma health is transnational. It is common to all member states and is accentuated by large-scale migratory processes. For this reason, The EU must assume a posi- tion of leadership in the coordination of actions aimed at the promotion of health by member states and multilateral organisations.
All stakeholders must, with systematic EU support, undertake a qualitative shift from mutual knowledge to mutual exchange and learning must be undertaken (by sharing tools, platforms, working methods), while the issue of Roma health must be systematically incorporated into the Open Method of Coordination and the Platform for Roma inclusion.
Considering the fact that the Spanish Presidency of the EU (fi rst semester of 2010) aims at placing the issue of Roma inclusion among the key priorities of the EU’s social agenda, and at advancing the monitoring of health inequalities, there is an unprecedented opportunity and use the present study’s results to involve all stakeholders involved in the health - Roma community nexus in order to achieve an eff ective impact on the health situation of the Roma.
This chapter has been elaborated by Dr. Andreas Tsolakis (Department of International Relations of FSG) based on the recommendation made by health experts participating in the project and compiled in the national reports.