In light of the upcoming European Summit on Roma Inclusion, EPHA prepared a briefing paper and policy recommendations aimed at stimulating action to improve Roma health. EPHA will attend the Summit in the framework on its work on health inequalities in Europe.
It is well-recognised that differences in public health outcomes at a population level are closely linked to degrees of social disadvantage among different communities. Across Europe there are dramatic differences between and within countries in terms of health status. These differences result from the circumstances in which people grow, live, work and age. Furthermore the absence of and/or unequal access to systems put in place to deal with illness also result in increased inequities in health.
There is extended evidence available on the determinants of health and levels of inequalities within Europe- namely the ’Closing the Gap’ report from the WHO Commission on the Social Determinants of Health- including frameworks for action to tackle inequities in health.  Policy makers at all levels need to take on board such recommendations and commit to a cross-sectoral approach that ensures political, social and economic environments are health-enhancing for all.
One of the most universally disadvantaged communities living in Europe are the Roma. The great majority of the Roma population is found at the very bottom of the socio-economic spectrum. It is generally accepted that the Roma suffer worse health than the other populations in the countries where they live due to their higher exposure to the range of unfavourable factors that influence health.  Poverty, inadequate education and lower social integration result in poor health outcomes. Moreover, discrimination and unregulated civil status (including lack of personal documents, birth certificates, insurance) make it particularly difficult for Roma to access health services. Due to the multiplicity of their discrimination and social exclusion, the inequalities faced by the Roma population highlights the cause for combating the social determinants of health across the board.
This briefing paper will examine the framework for tackling inequities in health and apply it to the situation of many Roma communities across Europe. Recommendations to improve the health prospects for the Roma should be seen as a call for concerted action to reduce discrimination, social deprivation and exclusion in Europe. Government should put in place the necessary structures across all sectors to facilitate better health and its fair distribution for Europe’s vulnerable groups.
In the final report from the WHO Commission on the Social Determinants of Health, the authors outline three principal recommendations for governments to help reduce inequities in health:
1. Improve daily living conditions;
2. Tackle the inequitable distribution of power, money, and resources;
3. Measure and understand the problem and assess the impact of action 
The recommendations represent a call for a cooperative effort to modify the external factors that impact upon people’s lives and their health. The immediate environment in which people live affects their health and the opportunities to achieve their full potential. Priority areas include education, employment, social protection and housing. For Roma communities, many of the priority areas identified in the WHO report still remain to be addressed.
In order to reduce inequities in health among future generations, the WHO Commission recommends that children and young people be considered a priority. The provision of a comprehensive package of polices targeting children, mothers and caregivers is seen as instrumental in laying the foundations for health through the life course. Quality compulsory primary and secondary education for all children is also seen as crucial not only to improve employment prospects but also to provide people with sufficient information to make life choices that are right for them- including choices for healthy lifestyles. In many cases, there are extremely high rates of illiteracy among Roma communities, as families often cannot afford to cover the education costs and need to use their children as a source of income. Furthermore, cultural traditions such as early marriage results in a situation whereby children/adolescents leave formal education earlier than those in the non-Roma community. Subsequently, the Roma suffer from high levels of unemployment and are over-represented in low-skill jobs.
As regards the built environment, the daily conditions in which people live have a strong influence on health equity. Access to quality housing, clean water and sanitation are human rights. Many Roma live in conditions that do not support good health, such as informal settlements, and there is a high rate of ghettoisation, whereby Roma live in distinct neighbourhoods noted for their poor sanitary facilities. The impact of poor sanitation on levels of communicable diseases amongst these communities, such as tuberculosis, should not be underestimated. Furthermore levels of preventable injuries are much higher amongst deprived communities and this is also true among the Roma. Urban and rural housing renewal schemes should aim to ensure the greater availability of safe and affordable housing, invest in the upgrading of slum and sink estates and focus on the provision of water, sanitation and electricity.
Employment and working conditions also have a powerful effect on health outcomes. Secure employment can provide financial sustainability, social status, personal development and a strong social network. However, it is important that working conditions are reasonable, fair and safe- meeting international core labour standards and policies. Wages should meet the real and current cost of healthy living in a given location, so that safe housing is affordable and people can purchase safe and nutritious food. Roma populations experience disproportionally high levels of unemployment and many families have no fixed/secure income. This also has an impact when it comes to making out-of-pocket payments for health care, for example, or for pension claims in later years when it may be necessary to stop working.
Interlinked with employment is the need for social protection throughout the life course. People not only need social protection at all stages of life, they also need it in case of unforeseen circumstances such as illness, disability or loss of income. The WHO recommends establishing and strengthening universal comprehensive social protection policies, particularly for those in precarious and informal work (including household or care work). An important issue that has a major impact for Roma communities is the lack of documents and papers providing proof of eligibility for state-provided welfare. This is also an obstacle that has a major effect on the ability of the Roma to access health services.
Access to and utilisation of health care services is vital to good and equitable health. Without health care, many opportunities for health interventions (both prevention and treatment) are lost. The provision of equitable, universal access to health care services- regardless of the ability to pay- should be a priority to reduce health inequities among deprived communities. Groups working with Roma Communities have identified a number of barriers to accessing health service among the Roma, namely a lack of knowledge on disease prevention, a lack of knowledge about their health service rights and a lack of physical access to services. Many Roma are thought not to be registered with a general practitioner, which may result from a lack of documents, but also a reluctance on the part of health service providers to accept Roma patients. Furthermore, their access to health services may be influenced to a certain extent by their beliefs and cultural norms as it has been shown that Roma communities tend to access services for severe problems only, as hospitilisation is sometimes perceived as a sign of death . 
Disproportionately affected by poverty and discriminated against in access to employment, education, health care, administrative and other services, Roma communities face considerable obstacles to the full enjoyment of fundamental human rights and freedoms. Direct and indirect discrimination in access to health care and ill treatment by health care professionals is a serious issue that many Roma experience. One grave consequence of this discrimination is the abuse of sexual and reproductive health and rights. A lack of access to and use of contraceptives, health facilities and services results in teenage pregnancies and unwanted pregnancies. Illegal or unsafe abortions are common within Roma communities and levels of HIV/AIDS and other sexually transmitted infections (STIs) are also disproportionately high. Coercive sterilisation is a real threat that many Roma face, and it has life-long impact on the mental and physical integrity of the affected person. The multiple discrimination facing the Roma is clearly extensive.
Readdressing the social imbalances, in terms of inequitable distribution of power, money and resources, should be an overarching aim of any policy to reduce inequities in health. Practices that tolerate or promote unequal access to power and wealth result in a social environment that is systemically inequitable. The degree of marginalisation and discrimination experienced by Roma communities across Europe results in a situation whereby they are unable to adequately participate in society and therefore lose their voice. The continued failure to address these issues is due in part to the absence of an organised political voice at all levels. The multiplicity of the issues facing the Roma demands a comprehensive response to ensure improvements to the driving factors for health- education, employment, social policy, housing and more. The advancement of the Roma community depends on opportunities to increase participation and integration, and improve health outcomes through tackling the social determinants of health.
Roma communities are found across Europe, and there a particular health concerns relevant for each community. Nevertheless as a general point, it is important to note that it is difficult to find good quality information on the health status of the Roma. Several reviews of the published literature on the health of the Roma people have identified the serious lack of research into their distinctive health needs and patterns of disease.
As mentioned earlier in the briefing, it is generally accepted that the Roma suffer worse health than other groups in the countries where they live. The health of the Roma community at a population level is characterised by high levels of both communicable and non-communicable diseases. 
Studies conducted in Eastern Europe reported a higher prevalence of infant mortality, low birth weight and prematurity in Roma children, and a higher prevalence of type II diabetes and cardiovascular diseases among all age groups in comparison to the majority population. Rates of tuberculosis and hepatitis are disproportionately high among the Roma and is likely to result from the inadequate housing and sanitation facilities in the neighbourhoods and settlements. Immunisation coverage among Roma communities has also been found to be low.
Rates of sexually-transmitted infections (STI) and HIV are higher among the Roma, resulting from a range of unprotected practices and misconceptions about HIV and STI transmissions. Condoms are mainly perceived as a means of contraception and many Roma women have little knowledge about STIs and HIV. The high rate of unwanted pregnancies among Roma women is reflected in the high rates of abortion. So long as Roma communities do not have access to adequate health services, Roma women are placed at great risk, with many suffering unintended health consequences. Furthermore, given the extremely young average age of first pregnancy among Roma women (17 years on average in France, for example) strategic investment in pre-natal and early infant health is crucial.
Poverty and discrimination among the Roma community put them in precarious situations and drive them into high-risk behaviours, which impacts greatly on their health outcomes. There is a pressing need to raise awareness and provide life skills education in and out of school
A high proportion of Roma families have no health insurance and are generally unaware of their right to have it. A further obstacle to obtaining health insurance is the non-regulated citizenship status of many Roma. As a high number of Roma are unemployed or work on an informal basis they are not entitled to health insurance on the basis of employment. Furthermore stigma and language barriers also deter Roma communities from accessing health services. In some countries a system of Roma mediators has been introduced, where the mediators have been working in and for the Roma communities, acting as facilitators between Roma people and health professionals.
In many countries,the Roma have a life expectancy that is significantly lower than that of other ethnic groups living in the same territory. For example, UNDP/ILO data indicates that Roma have a life expectancy on average 5-6 years lower than that of ethnic Bulgarians.  Research from across Europe, including the United Kingdom, show that the health outcomes of the Roma people are significantly poorer than those of the lowest socio-economic population across a range of indicators.
EPHA reaffirms its support for the European Parliament Resolutions on the situation of the Roma in Europe (2005) and a European Strategy on the Roma (2008).
Work on Roma issues should be supported by a comprehensive policy at EU level to tackle health inequalities. This should address the social determinants of health that are of particular importance to all communities hit by poverty and social exclusion. This will create the foundation for more targeted work to address those issues specific to the Europe’s Roma communities.
The EU should adopt a multi-sectoral approach to addressing the wider problems of social disadvantage and exclusion, bringing together the necessary state and non-state actors including civil society and groups representing the interests of Europe’s Roma community.
A strategy on the Roma will ensure coherence at EU level as regards those drivers that impact on health outcomes among Roma communities. Action to reduce discrimination and social exclusion should be supported by work to tackle the social, environmental and employment risks that lead to poor health.
The European Commission should establish mechanisms to facilitate communication and joint action between the Commissioners responsible for social inclusion, through portfolios on employment, social affairs, equal opportunities, justice, freedom, education, culture and regional policy.
There should be sustained work at the EU level on the fight against discrimination, with a defined examination of discrimination against people from disadvantaged minorities. This should cover the systemic exclusion of Roma communities from health and also the human rights abuses targeting Roma in the health care system.
Sustained action is needed to improve the living conditions for Roma communities across Europe. There needs to be strong support for an improvement in hygiene and safety standards in both rural and urban Roma communities.
The EU should consider mechanisms, in collaboration with Member States, to ensure that all Roma have full access to state-sponsored health insurance as well as supplementary insurance to cover fees for medical services and medication as necessary.
The European Institutions should facilitate an exchange of information on national and local programmes to improve the health status of Roma communities. The EU should also provide financial support to such initiatives. The EU should explore mechanisms to support the ongoing development of Romani health mediators at the local level, making these positions formal within health institutions with adequate funding and other forms of necessary support
An improvement in access to education and opportunities for academic achievement should be promoted by all relevant EU actors.
With specific attention to sexual and reproductive health and rights, the EU should promote a rights- based approach and allocate adequate resources in order to provide redress and compensation for victims of coercive sterilisation and ensure that law and procedures are in place to avoid coercive sterilisation of Roma women. Furthermore the EU should support programmes to raise awareness and provide comprehensive sexuality/ life skills education in and out of school. Another priority for such programmes is to address alternative lifestyles and sexual orientation with regard to SRHR in Roma communities.
For Further Information
EPHA related EPHA
EU Action on Roma Integration
Guide launching for the social integration of Roma in Europe
Invoking an EU-strategy for Roma communities across Europe
Prevalence of TB and Inequalities in Health Care for Roma in Europe
 Closing the gap in a generation: Health equity through action on the social determinants of health
 Health and Economic Development in South Eastern Europe
 Closing the gap in a generation: Health equity through action on the social determinants of health
 Health and Economic Development in South-Eastern Europe.
 Health and Economic Development in South Eastern Europe
 UNDP (2003) Avoiding the dependency trap