State of the World's Minorities and Indigenous Peoples 2013 - Case study: Bulgaria: community monitoring improves access to health services for Roma

by Jack Denith

A campaign run by Roma NGO Amalipe has improved awareness of health issues and rights, and access to health services.

Roma in Bulgaria live, on average, 10 years less than ethnic Bulgarians. High rates of poverty among Roma communities combine with other socio-economic factors to adversely affect their health and their ability to access adequate health care. For example, a 2011 survey carried out by the United Nations Development Programme, the World Bank and the European Commission found that 48 per cent of Bulgarian Roma had medical insurance, compared to 85 per cent for non-Roma living in the same area.

National legislation has been drawn up to address these inequalities, but implementation of these policies has been 'close to zero' say Lyubomir Lazarov and Deyan Kolev of the Amalipe Center for Interethnic Dialogue and Tolerance, a Roma NGO. Although the legislation sounded good on paper, there was a lack of financial and administrative support for the proposals, and no mechanisms to allow participation by Roma communities.

In 2011, Amalipe decided to put Roma at the heart of assessing and monitoring health services in Bulgaria. Following a model first proposed by Abhijit Das of the Public Health Institute in India, Amalipe developed a system to enable communities to monitor health care services themselves, and carry out their own research into their own health needs and how local services met (or failed to meet) them.

Amalipe established local volunteer clubs that brought young people, women and informal leaders together with trained moderators (also from the community) to discuss health issues. Together with the Amalipe project team, these community organizations conducted surveys of the health of Roma women and their use and knowledge of health care services. They also developed a health information campaign using community theatre.

The challenges were substantial: not only in terms of Roma health, but also in terms of the barriers to improving access – from poor diet and an inability to afford medication, to facing discrimination from medical staff. High rates of poverty make health insurance a rare luxury for the majority of Roma, while the rural areas where many Roma live have only a few general medical practitioners working insufficient hours to cover the population.

The surveys found that these factors were compounded by a lack of awareness of health issues, such as what rights to health people have, or what services are available (half of the women surveyed by the communities did not have information on when doctors visited their village). These issues were influenced in turn by Bulgarian and Roma scepticism about the ability or willingness of civil institutions to create positive change.

Through the information campaign, advocacy activities of the project team and free gynaecological checks organized within the project, the Roma communities improved access to a number of health services, from primary health facilities to emergency and hospital care. From simple measures such as raising awareness about what services are available to communities and what they are entitled to receive, substantial improvements were made by the communities themselves.