Example 4: Roma Health mediators in Romania
Project Type: Advocacy
Founded on April 4, 1993, Romani CRISS is a human rights NGO with a mission to “defend the rights of Roma in Romania” The organization focuses on issues of education, health, civic mobilization, legal assistance, promoting ethnic identity and other human-rights campaigns. Romani CRISS first pioneered Roma mediation in 1992 as a community conflict mitigation program.
The Public Health Program of Open Society Foundation created and manages a Roma Health Project which has supported the Roma health mediators since 2001.
Roma are disproportionately excluded from accessing health care services, and they encounter prevalent discrimination by providers. In a 2005 survey among 717 Romanian Roma women, 70% reported discrimination from health provides based on their race/ethnicity. Roma women face particular problems, including coerced sterilization and separate maternity wards. There is no administrative mechanism to address these abuses against the Roma and other vulnerable groups.
Romani CRISS developed a program in Romania whereby health mediators helped improve communication between the Roma community and health providers through the use of health mediators. Health mediation was designed to improve the Roma health status and access to health care services. The health mediators also refer cases of abuse and discrimination in health facilities to human rights monitors for documentation and legal advocacy.
The objectives of the program are to facilitate communication between medical personnel and Roma communities, and to increase the efficacy of public health interventions. Mediators are usually Roma women with an average level of education, recommended by local communities and agreed upon by medical practitioners, who have successfully completed a brief period of training. Their main responsibilities are to serve as liaisons between communities and health care practitioners; to collect data on the health situation in the community; to facilitate Roma access to health care; to provide health education; and to support public health interventions in Roma communities.
Romani CRISS negotiated an agreement with the Ministry of Health and the Organization for Security and Co-operation in Europe Office for Democratic Institutions and Human Rights. Romani CRISS trains Roman Health Mediators (RHM), who are employees of the public health system. Mediators are from Roma communities but are situated in health clinics to improve communication with providers. They educate communities on how to access health services and sensitize doctors on Roma health needs.
In 2007, Romani CRISS initiated a program to create a link between health mediators and the human rights monitors. Health mediators were trained in human rights, and human rights monitors were trained in health issues. This way, the mediators knew to refer cases of discrimination or abuse to the monitors for documentation, and they could sensitize communities on human rights issues. The monitors would then document cases of discrimination in health care settings and bring them for redress before the National Council to Combat Discrimination, the College of Physicians, and other institutions.
Recommendations for Health Mediator Programs for Minority Populations:
- Ensure the institutionalization of health mediator programs
- Include doctors, nurses, social workers, and other professionals in health mediator trainings and professional events
- Support the development of health mediator professional associations
- Ensure that program monitoring focuses on outcomes as much as possible
- Ensure supportive supervision
- Increase the number of mediators to meet the current needs of the population they serve
- Ensure continuing education
- Create opportunities for health and social policy officials to learn from health mediator experiences
- Ensure that health mediators have a secure contract and salary
- Ensure that health mediators earn a living wage
- Ensure that health mediators have the money and other tools required for the tasks
Larger Health Policy Recommendations:
- Ensure that health education materials that health mediators and health professionals distribute are adapted for the audience
- Ensure that mediation is part of a continuum of services available to excluded populations
- Better integrate minority health concerns into health policy
- Ensure that other steps are taken to reduce poverty among the minority population
- Ensure that laws relating to personal documentation and health insurance coverage are not too onerous for minority groups
- Take steps to increase routine vaccination coverage
- Engage minority men in sexual and reproductive health programs
- Design programs that take a community-building approach to minority health
- Increase the number of minority health and social service professionals
Challenges to Roma Health Mediation programs:
- Low salaries for RHMs
- Inadequate supervision
- Lack of professional development opportunities
- Governments fail to leverage RHM experience
- Persistence of focus on health care and not the social determinants of health
- Insufficient cooperation with other actors in the health care system
- Lack of support because of decentralization
- Contract and pay insecurity
- Physicians rely on RHMs to aid Roma clients, relieving themselves of this responsibility
Results and Lessons Learned
Evidence suggests that mediators both directly affect health and change the nature of the community in which programs occur. RHMs increase access to health care and other social services, and increase health literacy among Roma populations. The reporting system operates as a check on rights violations. RHMs do not address structure discrimination, poor health policies, or poverty levels.
The successes of the program include the collaboration between governmental and nongovernmental structures in the planning and implementation of health mediation; the number of women trained and hired as health mediators; the number of beneficiaries; and the geographical coverage, but also the transferability in other European countries that have a significant number of Roma, such as Bulgaria or Macedonia. Other strong points of the program are the focus on preventive instead of curative care; the contribution towards increasing knowledge pertaining to Roma health; and the assistance provided to some of the most vulnerable categories of Roma, particularly the persons lacking identity documents.
With the adoption of its new strategic plan in 2010, Open Society Foundation’s Roma Health Project (RHP) shifted focus from health education campaigns and service delivery to human rights-based advocacy. RHP’s key achievements since that time include:
Legal strategies. Jointly with the Open Society Foundation’s Law and Health Initiative (LAHI), RHP’s partners in Macedonia, Romania, and Serbia have piloted legal and paralegal services to remedy human rights abuses against Roma in health settings and to address systemic barriers to health care such as lack of identification documents and health insurance. In Romania, RHP is supporting the European Roma Rights Center to investigate the differential infant mortality rates between Roma and non-Roma communities, and to launch litigation aimed at establishing a government duty to collect ethnically disaggregated data as part of its obligation to promote non-discrimination in health care.
Innovations in accountability. Jointly with Open Society Foundation’s Accountability and Monitoring in Health Initiative (AMHI), RHP’s partners in Bulgaria, Macedonia, and Romania have successfully used community monitoring to press governments to implement and pay for health programs described in national policy documents. In Bulgaria, a series of “community inquiries” into local health services by over 500 Roma women resulted in a 12% increase in Roma accessing medical examinations free of charge over a period of four months. In Macedonia, a community investigation into measles outbreaks linked to differential immunization rates led to a targeted and long overdue government budget allocation for immunization services in Roma communities.
Advocacy and capacity-building. In Bulgaria, Romania, Macedonia, and Serbia, RHP has built a cohort of NGOs advancing Roma health using rights-based advocacy. In Bulgaria, RHP’s partner advocated in 2011 to include Roma as a distinct group in national health policies and guidelines for EU funds. In Romania, RHP’s partner contributed to a General Policy Recommendation on Roma Health, which was circulated to all relevant government agencies developing Romania’s national Roma strategy. In Macedonia, partners secured a government commitment to finance the salaries, training, and logistics for nine Roma Health Mediators—members of the Roma community who are trained to act as an interface between the Roma community and the health system. In Ukraine, RHP’s partner raised third-party funding that more than tripled the number of Roma health mediators in the country.
OSF/RHP and European Public Health Alliance (EPHA) Roma health fellows. In 2012, OSF’s Roma Health Project together with EPHA are launching a two-year fellowship to train and mentor two Roma health EU advocates. The fellowship aims to increase the capacity of the Roma community for leadership on Roma health at EU level by facilitating advocacy efforts for establishment of an EU Roma Health Strategy. More information is available at: www.epha.org/spip.php?article5017.
Roma health at the European Union. As members of the Roma Civil Society Contact Group on the Right to Health, established in 2012 by the World Health Organization and the Office of the High Commissioner for Human Rights, seven RHP partners have provided policy guidance on health-focused components of National Roma Integration Strategies (NRIS), the EU Platform for Roma Inclusion, the Decade of Roma Inclusion, and national health programs. In June 2012, one of these partners convened a European Commission hearing on strengthening monitoring and evaluation of NRIS recommendations that resulted after the hearing and the link with more information about the EU hearing: http://amalipe.com/index.php?nav=news&id=1234&lang=2. RHP is participating in an OSF-wide effort to leverage the European Cohesion Policy towards greater Roma integration by proposing ex ante conditionalities for Structural Funds for health.
Individual leadership. Together with the Roma Education Fund (REF), RHP spearheaded the Roma Health Scholarship Program (RHSP), which since 2008 has awarded a total of 676 scholarships for tertiary and vocational medical education in Romania, Bulgaria, Macedonia, and Serbia. In 2010, RHP/REF’s partners in Romania secured €4,800,000 in European Structural Funds to sustain RHSP over three years. RHSP’s combination of scholarships, preparatory courses, advocacy training, mentorship, and media outreach is creating a generation of Roma health professionals with the potential to challenge deep-rooted anti-Roma prejudice within health systems.