Policy brief

Dotcho Mihailov

This brief is based on a broader analysis of Roma health issues, developed as a UNDP Roma inclusion working paper. In addition to health, this series includes thematic reports on employment, education, poverty, gender, migration, and civil society. These papers, which are being released during December 2012 – February 2013, are available at The brief and the paper behind it analyze health data from the 2011 UNDP/World Bank/EC regional Roma survey, which compared the living standards of Roma and Non-Roma communities living in close proximity in 12 Central and East European countries. The survey was conducted in Romania, Slovakia, Croatia, Bosnia and Herzegovina, Serbia, Montenegro, the Former Yugoslav Republic of Macedonia,1 Albania, Bulgaria, the Czech Republic, Hungary, and Moldova. It was based on representative samples of 750 Roma households in each country, as well as control samples of 350 non-Roma households living in close proximity. The survey generated data concerning Roma in three main public health areas: perception of health status, access to health services, and maternity and child health (which is a particularly sensitive Roma issue). As the survey data reflect respondents’ personal perceptions, they cannot be directly compared with epidemiological or other data collected by public health services or health care providers. Also, while the survey data are representative for the Roma population in the sampled countries, the data for non-Roma populations are only indicative (samples of non-Roma living nearby the Roma sample are not representative), and are not strictly comparable with national averages.2

There is general agreement (Doyle, 2004) among health and policy experts that Roma suffer from poorer health than the general populations in the Central and Southeast European countries in which they are most numerous. Various studies since the mid-1990s have shown that Roma display greater incidence of vitamin deficiencies, malnutrition, anaemia, dystrophy, and infectious diseases than majority populations (Save the Children, 1998). Ginter et al (2001) found that Roma mortality rates at the turn of the millennium were three times national averages in Slovakia. Combinations of socio-economic deprivation and unhealthy lifestyles in Roma communities are usually blamed for these outcomes. While Roma health indicators deteriorated in all countries of the region in the early 1990s, this trend to some extent mirrored general declines in life expectancy and health conditions during the first years of transition. Fortunately, the health situation in Central and Southeast Europe underwent subsequent improvement—particularly when compared to some former Soviet republics. Still, general improvements during the past 15 years can mask differentiated health outcomes even within successful countries—and Roma are usually among the groups not (fully) benefiting from these improvements. Coverage and “disparities in equity of access” remain an issue for Roma and other ethnic minorities (Figueras, McKee, Cain, Lessof, 2004). The health data from the 2011 UNDP/World Bank/EC regional Roma survey provide an important opportunity to update this picture. While some improvements are apparent compared with the health data produced by UNDP’s 2004

1/ Hereafter: “Macedonia” or “MK”. 2/ They would only be comparable with national averages if official surveys had been carried out in the in the same period, applying the same methodology.



Figure 1: Shares of adults (age 16 and above) reporting coverage by medical insurance (in %, 2011)


95 90


98 91


97 89 83

99 92

97 93 93 85

97 98

80 70 60 57 54 40 32





0 AL BA BG CZ H HR Roma MD non-Roma ME MK RO RS SK

regional Roma survey, the 2011 survey findings continue to demonstrate higher vulnerability for Roma households in terms of reduced access to health insurance, lower child vaccinations rates, physical access to medical services, and affordability concerns. They also indicate that Roma are more likely to only recognize health problems as such once they reach acute forms later in life—resulting in higher incidence of disabilities, long-standing illnesses, and greater numbers of in-patient visits. These problems seem to be particularly severe in Albania, Moldova, Romania, and Bulgaria. The survey data suggest that Roma isolation from the social mainstream—particularly the educational system and formal labour markets—is a key driver of these outcomes. Support for Roma should therefore focus on making official health, education, and employment systems more inclusive, rather than creating parallel health structures and instruments for the Roma. However, some particular health issues—especially concerning education, child vaccinations, and reproductive health—do need to be addressed separately and urgently.

cial constraints (income poverty) likewise continue to limit Roma households’ access to medical services. For example: „ Whereas 90% of non-Roma survey respondents in the region living in close proximity to interviewed Roma reported having access to medical insurance, this share fell to 74% for Roma respondents.3 Only in the Czech Republic, Slovakia, and Serbia did 90% (or more) of Roma respondents report access to insurance (Figure 1). By contrast, this share dropped to 32% in Albania and 40% in Moldova (although non-Roma living in close proximity in these countries also reported relatively low insurance coverage). „ Whereas only 25% of non-Roma survey respondents in the region living in close proximity to interviewed Roma reported being unable to afford to purchase prescription medications during the past year, this share rose to 55% for Roma respondents (Figure 2). „ Whereas only 26% of adult (age 16 and above) non-Roma survey respondents in the region living in close proximity to Roma reported not having physical access to a doctor during the past year, this share rose to 42% for adult Roma respondents. The survey data also show that health care affordability (for the household) decreases with the age of the respondent (household head); and is lower among female-headed households. Additional affordability concerns are raised by data on access to medical services classified as “optional” by health insurance companies, such as dental check-ups.

Main findings
Access to health services. The survey data indicate that— compared to non-Roma living in close proximity—Roma continue to have inferior access to health insurance, and to access to specialized health services. Physical access (i.e., long distances to health services providers) and finan-

3/ The question was asked to household heads, who reported for all household members.



Figure 2: Shares of households unable to afford purchases of prescription medication during the past year (in %, 2011)
80 73 70 60 50 44 40 30 20 10 0 10 29 22 20 14 8 37 32 31 31 57 47 45 50 45 66 67 66 71 65








HR Roma

MD non-Roma






Whereas 44% of non-Roma surveyed reported benefitting from dental check-ups during the past 12 months, the share dropped to only 26% for Roma respondents. Other relatively large differences were found for heart check-ups (40% versus 30% for Roma), and blood sugar tests (77% compared to 61% for Roma). Perceptions of health status. The survey data indicate that Roma generally have positive perceptions of their health status. However, they report larger numbers of inpatient and emergency medical visits, and are more likely to suffer from disabilities and addictions. These apparently contradictory findings can be explained by Roma households’ relatively low access to health services—which is aggravated by relatively weak awareness of health issues. When more specific and concrete the health issue are surveyed, difference between Roma and non-Roma survey respondents increase—indicating higher “real” Roma vulnerability. Larger numbers of inpatient stays and higher frequency of disabilities also point to higher objective Roma health vulnerability. Many health problems are therefore only perceived as such by Roma respondents once they reach acute form, and are recognized as disabilities or long-standing illnesses that require in-patient visits. This is apparent in the data shown in Figure 3, which indicate that—for the region as a whole—17% of insured Roma respondents had visited hospitals during the last 12 months, compared to 12% for non-Roma living in close proximity. The highest frequencies of inpatient stays reported by insured Roma respondents were registered in Romania (21%) and Bosnia and Herzegovina (20%). The lowest were reported in Montenegro (11%), Slovakia (13%), and Hungary (13%).

Once health services are accessed and poor health is diagnosed, reported health status can be expected to drastically decrease. This revelation effect is confirmed by a Probit analysis showing that Roma respondents with health insurance were 7% more likely to report a chronic disease than Roma respondents without insurance. Thus, lack of access to health care keeps the vulnerable health status of the Roma population hidden; health problems are more likely to be recognized (both by survey respondents and the health authorities) only when they reach a stage requiring an emergency or inpatient intervention. Fortunately, there are some indications of a general improvement in Roma perceptions of their health status since 2004. While the “health status” questions from the 2004 and 2011 regional Roma surveys are not fully identical, indicative comparisons reveal that, in eight out of nine countries surveyed in both years (Croatia is the exception), fewer numbers of Roma respondents reported chronic/long standing illnesses in 2011, compared to 2004. However, these shifts are most probably due to overall improvements in the socioeconomic environment in the countries surveyed since the improvements are observed also for the non-Roma sample. Maternal and child health. The frequency of unassisted births outside of hospitals—for both Roma and non-Roma living in close proximity—were particularly high in Serbia, Macedonia, and Bosnia and Herzegovina. For example, only 78% of non-Roma women respondents in Macedonia and 79% of non-Roma women respondents in Bosnia and Herzegovina reported giving attended birth in hospitals, compared to 97% for Roma women in Slovakia and 91% for Roma women in Hungary. The importance of access to

15 3


Figure 3: Share of adults (age 16 and above) reporting inpatient stays (%)
25 21 20 17 15 11 10 11 15 14 10 8 13 15 14 13 11 11 9 9 14 20 19 19 18 16 13 11


0 AL BA BG CZ H HR Roma MD non-Roma ME MK RO RS SK

Based on answers to the question: “During the past 12 months, how many separate overnight stays did you have to obtain inpatient care at a health facility?” medical insurance is further underscored by the fact that, in general, Roma women covered by insurance are 11% more likely to benefit from a pap smear test than those not covered. By contrast, Roma women in Albania are 39% less like to benefit from cervical cancer testing than Roma women from other countries surveyed. The survey data (Figure 4) also highlight significant differences in child vaccination rates—a key indicator of health vulnerability—across Roma and non-Roma respondents. However, in contrast to some other health indicators, differences across countries are less evident. Therefore, vaccination rates among non-Roma respondents—particularly those for IPV, MMR, and DTaP4 —are relatively high and uniform across the region. In contrast to other health indicators, the relatively low vaccination rates for Roma children would seem to reflect Roma-specific vulnerabilities rather than the specifics of national health care systems. In line with pattern apparent in other indicators, Roma respondents in Bosnia and Herzegovina and Romania reported particularly low child vaccination rates. By contrast, Roma child vaccination rates in Albania and Bulgaria were relatively high—making this one of the few Roma health indicators on which these countries performed comparatively well. The survey data (Figure 4) indicate that the frequency of BCG vaccinations (against tuberculosis) for Roma children does not differ significantly from their non-Roma neighbours (95% in both samples). However, three other routine vaccinations are administered significantly frequently among the Roma. This disparity is particularly high for vaccinations against the measles, mumps, and rubella (MMR): only 81% of Roma children were reported as vaccinated, compared to 90% for non-Roma children. Gaps are also observed for DTaP (86% against 95%) and IPV (87% versus 95%) vaccinations. The data also suggest that Roma in all countries surveyed are less aware of the importance of child vaccinations, and are less likely to be informed about vaccination schedules. Drivers of Roma health vulnerability. The 2011 survey support the hypothesis that socio-economic determinants— especially official employment and education status—have a large impact on Roma health conditions. In addition to providing opportunities for higher incomes, official employment and better educational attainment integrate Roma into the social mainstream, in which access to health insurance is accompanied by greater health awareness and better lifestyle choices. Ironically, however, the survey data indicate that, for many Roma families, unemployment is a better guarantee of access to health insurance than employment. This is because large numbers of Roma in the region are officially classified as unemployed—and because official unemployment status is a precondition for access to state-provided health insurance. Thus, the survey data indicate that, whereas Roma who are employed (formally or informally) are 4% more likely to have access to health insurance than Roma who are unemployed, Roma who are formally registered as unemployed are 13% more likely to have health insurance than Roma who are not registered as unemployed.

4/ The BCG vaccine immunizes against tuberculosis. The IPV (polio vaccine) immunizes against child paralysis. The DTaP vaccine immunizes against diphtheria, tetanus and perthussis; and the MMR vaccine immunizes against measles, mumps, and rubella.

15 4


Figure 4: Child (aged 0-6) vaccination rates in the countries of Central and Southeast Europe (in %, 2011)


81 90


86 95


87 95


95 95



80 Roma

85 non-Roma




These data show positive responses to the question: “Have you ever received a[n] [_____] vaccination] against [_____, that is ___]?” The question was asked about children age 0-6; respondents were their primary care givers.

Fortunately, health-related incentives for educational attainment seem stronger: the survey data indicate that Roma who have attained a secondary (or higher) education are 12.5% more likely to have medical insurance than those with lower (or no) educational attainment. However, the strongest predictor of not holding medical insurance is income poverty: a Roma living on less than $2.15 per day (in purchasing-power-parity terms) is 15% less likely to have health insurance than a Roma with higher income. This reflects the facts that many poor Roma are not officially classified as unemployed; and that (largely informal) employment for Roma is no guarantee of either escaping poverty or of access to health care. The 2004 and 2011 data indicate that affordability barriers to health services have declined in most of the countries surveyed, for both Roma and non-Roma respondents. For example, in seven of the nine countries surveyed, the number of Roma households who reported being unable to afford prescribed medication significantly decreased during 2004-2011. The most positive trends were reported in Montenegro, where the share of respondents who reported being unable to afford prescription medicines fell from 66% in 2004 to only 19% in 2011. On the other hand, these improvements seem to have resulted from generally favourable socio-economic trends, which raised incomes in Roma (and non-Roma) households and reduced income poverty. Much of this improvement may have occurred during 2004-2008, before the impact of the global and European financial crises took hold. Since

2008, household incomes and spending in many of these countries have stagnated, and jobless rates have risen. This raises questions about the future ability of favourable socioeconomic trends to generate continued improvements in Roma health conditions.

Conclusions and recommendations
The 2011 survey results show that, despite some improvements since 2004, the principle of universal access to reproductive and child health—as articulated in the Millennium Development Goals—continues to be honoured in the breach. Moreover, for many of the indicators studied here, differences between countries are larger than differences between Roma and non-Roma living in close proximity. Comparisons (where possible) with the 2004 survey data also indicate that the shifts in health outcomes that have occurred during 2004-2011 are likewise common for both Roma and non-Roma samples. That is: the most important longer-term determinants of Roma health vulnerability— access to health insurance, employment, education—reflect national, rather than ethnic (Roma), specifics. Towards more inclusive national health systems. This result strongly suggests that support for Roma health initiatives should be refocused on integrating Roma into national health, educational, and employment systems. Roma employment and participation in the official labour market,



which provides access to medical insurance and other forms of social protection, are absolutely essential. The priority addressees of this support should include not just the Roma and health-related NGOs, but also the educational, employment, and health institutions whose behaviour determines whether Roma have access to formal, mainstream services and opportunities. However, there are some health issues of particular concern to Roma communities—educational needs, child vaccinations, and reproductive health—that should be separately addressed. Efforts need to focus on integrating the Roma into official, formal health, educational, and employment systems—rather than taking creating parallel instruments and structures. Within the health sector, improving Roma families’ access to general practitioners, and to mainstream suppliers of child vaccinations, reproductive health, and specialized test services should be key priorities. This general emphasis on inclusion should be supported by specific instruments needed to include Roma into the social mainstream.

These include, for example, “health mediators” and other community-based approaches (OSI Roma Health Project, 2011) that strengthen the interface between formal health institutions and Roma communities—rather than creating parallel health structures and services, or supporting new health service providers that are external to national health systems. Sub-regional differences and needs. The 2011 survey data indicate that Roma health concerns are particularly pressing in Albania, Moldova, Romania, and Bulgaria. However, these countries face important challenges in improving access to health in general—not just for Roma. Moreover, the data also show that health discrepancies between Roma and non-Roma need to be addressed both in countries of lower and higher access to health. Finally, the survey data underscore the need for both paternal as well as maternal health education, as well as official employment as a screening variable to identify women and children at risk.

United Nations Development Programme Regional Bureau for Europe and CIS Grösslingova 35811 09 Bratislava, Slovak Republic Phone: (421–2) 593 37-111 Fax: (421-2) 593 37-450 The views expressed in this publication are those of the author and do not necessarily represent those of the United Nations, including UNDP, or their Member States.


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