ASSESSMENT OF THE ACCESS OF THE
UNPRIVILEGED POPULATION, INCLUDING THE RROMA ETHNY OF THE COUNTY OF ILFOV TO THE
PUBLIC HEALTH SERVICES
L. VULCU
1, MINERVA GHINESCU
21The “Lucian Blaga ”University of Sibiu, 2Ph. D. Candidate The “Lucian Blaga” University of Sibiu
Abstract: I accomplished a study which aimed at knowing the opinions of the representatives of the health system regarding the reduced access of the Rroma ethny to the public health services on one hand and of the Rroma representatives on the other hand, at community level.
Keywords: qualitative analysis, semi-structured interview, Rroma leaders, focus group, health state, access to health services.
Rezumat: Am conceput un studiu în care s-a urmărit cunoaşterea opiniilor reprezentanţilor din sistemul de sănătate cu privire la accesul redus la servicii publice de sănătate a populaţiei rrome, pe de o parte şi reprezentanţii ( liderii rromi) etniei la nivel comunitar Cuvinte cheie: analiza calitativă , interviu semistructurat, lideri rromi, focus grup, stare de sănătate, acces la serviciile de sănătate
CONTEXT - MOTIVATION
The socio-economic situation of Rroma people is appreciated as being poverty marked (reduced income, improper living conditions, precarious nutrition and hygiene, lack of a permanent income, difficult access to the health services, lack of education) and poverty culture marked (values, attitudes, knowledge and practices, behavioural patterns and lifestyle); all these increase poverty.
There is a difference regarding the identification of the causes. The Rroma representatives see these causes as being related to discriminatory attitudes involving the existent society, while the representatives of the health institutions charge the unprivileged communities, including the Rroma ethny, with the responsibility for the conditions they are living in.
Starting with these two working hypotheses, we accomplished a study which aimed at knowing the opinions of the health system representatives, regarding the reduced access to the public health services of the Rroma population on one hand and on the other, the opinions of the ethny’s representatives (Rroma leaders) at community level.
METHODOLOGY
For the assessment, we used a qualitative analysis based on a methodology and instruments pretested within a pilot evaluation in the town of Buftea.
QUALITATIVE ANALYSIS
Within the qualitative analysis, we elaborated a set of instruments – interview guides for the category of people included in the assessment, containing questions correspondent to the purposes of the evaluation. The instruments were used on 150 persons included in the assessment:
Guide for the group interview (focus groups) for the members of the less-favoured population, including the Rroma ethny of 4 communities (Ştefanestii de Jos, Buciumeni, Găneasa, Vidra). Within each 4 communities included in the study, we organized a focus group of 10-12 persons coming from the unprivileged community, including the Rroma population. The results were used both for the elaboration of the research regarding the health services addressed to the Rroma population and for the formulation of the final recommendations.
Guide for the individual structured interview aiming at the decision authorities within the Public Health Authority of the county of Ilfov, House for Health Insurance of the county of Ilfov; a guide for the semistructured interview, family doctors of the communities included in the study and counsellor of the City Hall within the County Office for Rroma population.
Guide for the individual semistructured interview aiming at the mayors within 4 municipalities of the unprivileged communities, including the Rroma ethny ( Buftea- Buciumeni, Stefăneştii de Jos, Vidra and Jilava ).
The focus groups were established within a week, regarding a comfortable and controlled environment. The sessions were led by an investigator and a nurse and were tape recorded. At the end of each session, minutes were also taken with the observed non verbal language.
Interviews: on average, 30 minutes were awarded for each interview with an adjustment of 35-40 minutes. The discussions were taped recorded and the interviewer used notes in order to add information regarding the non verbal language of the respondents; at the end of the interview transcripts were made and then, the methods of the specific qualitative analysis were applied, in order to identify the common opinions of the respondents, as well as the specific particularities.
RESULTS
The assessment aimed first of all at gathering the opinions of the persons, members of the unprivileged communities, including the Rroma ethny regarding the population health state and access to the medical services within the communities included in our research. The questions aiming at gathering these opinions were addressed to all the categories of the interviewed persons.
A. SITUATION OF THE RROMA POPULATION IN RELATION WITH THE INSTITUTIONAL SYSTEM OF THE HEALTH SOCIAL INSURANCE.
All the interviewed subjects appreciate that the Rroma population is living in precarious socio-economic conditions with implications in health state.
Two directions of the probable evolution of the socio- economic conditions they live in were also developed:
1. a positive evolution – in the case in which the State issues coherent policies and strategies with a view to solve the problems the Rroma population confronts with; this supposes staying within the public field of social and health services.
2. on the contrary, the privatization of the public services – health, social protection, public safety – of the guidance of the activity taking into account the efficiency and not the efficacy, that is the centralization of the efforts on relation, means, objectives and not on objectives accomplishment.
Regarding the decision authorities interview, we came to the conclusion that the exact number of the insured persons of the county of Ilfov is not known. Out of a population of 300100 inhabitants, 70% is insured; the rest of 30% is not (House of Health Insurance of the county of Ilfov). The persons who are not insured are classified into two categories: “one segment is not preoccupied of being insured, who benefit from an income and who is entitled to health insurances, and another segment which is entitled to health insurances only if they go to the mayor in order to apply for the social aid.
The Rroma situation –as a result of interviewing both the Rroma leader of the City Hall, as well as the representatives of the House of Health Insurances of the county of Ilfov suggests the fact that a large part of the Rroma population is not paying their contribution to the health insurances fond; the majority of them does not have a stable employment and in this case, this is the only modality to benefit from social assistance.
One of the difficulties occurring in the registration of the Rroma population as insured people – in the opinion of the representatives of the House for Health Insurances of the county of Ilfov is the lack of the identity cards; for this reason, they cannot be employed legally and cannot gain the quality of insured person.
- At beneficiary’s level, other problems are identified, such as: problems regarding the information of the insured persons’ rights and duties. The interviewed local authorities’ representatives (the mayors) accuse the Rroma population under this situation, of ignorance and lack of seriousness regarding the community service as a modality to benefit from the
guaranteed minimum income and implicitly from health insurances. On the other hand, the Rroma representatives claim the situations in which they provide community service.
- In the majority of the municipalities, the doctors are commuting and the effective time for consultation is reduced. Many time, doctors concentrate on the municipality which serves more villages (In Găneasa, there is a medical office which serves 5 villages; the family doctor commutes to Bucharest every day; the medical office has only one nurse. In Buciumeni - Buftea the distance between the Rroma community and the nearest medical office is at 6 km away.
- The reduced number of medical assistants – one of the problems identified by the family doctors is the small number of nurses in the medical offices, making difficult the development of the medical activity.
- Within the communities of the county of Ilfov there is no infrastructure and logistics necessary for the services of family planning.
- The absence of the drug stores at community level is perceived more seriously than the absence of the family doctor, due to the tendency of the self administration treatment... “we get along with the pharmacist better than with the doctor or the nurse;
the pharmacist of the village gives us medicines on credit, she is more understandable. (villager of Ştefăneştii de Jos).
TABLE1. ATTITUDE OF PATIENTS OF RROMA ETHNY REGARDING DOCTORS, IN GENERAL
POSITIVE ATTITUDES NEGATIVE ATTITUDES She speaks nicely. She speaks rudely.
She makes no difference regarding people.
She throws me away from the office, she says she has a headache.
She observes her schedule, sometimes she stays until she finished all consultations.
She told me to look for another family doctor
She gives me treatment and advice on what to do, speaking my language.
She is never coming into the village.
She offers me consultation. She did not give me the treatment I asked her.
She gives me treatment for my children and powdered milk.
When I claimed an exemption, she told that we, the Rroma people, do not like to work.
She also called the ambulance for me.
She refused to see my child saying that she was going to hand in the reports.
She drove me to the hospital by her car.
She does not give me powdered milk, invoking breast feeding.
She understands our family problems.
She gives us better treatment than in hospital.
She speaks so that we could understand her.
Any time I needed, she gave me treatment and advice.
She offered me
consultation even if neither I nor my husband is working
B. THE MAIN HEALTH PROBLEMS THE UNPRIVILEGED POPULATION, INCLUDING THE RROMA ETHNY IS CONFRONTING WITH.
The accomplished interviews suggest that the Rroma population of the county of Ilfov is not confronting with health problems essentially different as against those of the majority population. There are certain specific elements resulted from the research.
The specialists of the health domain who were interviewed indicated certain health specific problems which derived from poverty and poverty culture:
“...I think that the most important health problems arise from the general social problems of the Rroma population, that is, many of them are not insured or are nomads who do not have a permanent family doctor and are not submitted to periodical check ups...”(
representative of the Public Health Authority of the county of Ilfov).
In this respect, Dr. C.D, pediatrist, shows that “…starting from early ages until they become an adult…..first, there is the respiratory pathology, following the digestive pathology, especially the infectious diarrhoea disease in children, parasitosis and afterwards the sexually transmitted diseases”. The TBC pathology is also mentioned, noting that it may not be invoked by a preponderance of this. The dental affections were also mentioned by the respondents. The majority of these affections derive from the living conditions and the precarious hygiene.
A series of problems are brought about the lack of organizing life from the point of view of the family planning. Within the traditional Roma communities, fertility is not controlled; the high birth rate in certain communities is associated to a high rate of abortion, after 1990.
“...I believe that this is due to the fact that they live their specific life, as they get married at early ages and implicitly they count many births or abortions. There are the same problems with smoking, too. They mention gynaecological problems, menopause, so, we can say there are not specific problems... (medical assistant – Găneasa)
The increased rate of morbidity within the marginal communities makes very difficult the intervention of the social and medical services. Belonging to marginalized, poor communities means on one hand the lack of opportunities and on the other hand, the assimilation of a lifestyle adapted to poverty and to social exclusion.
“...Poverty forms a culture or a subculture – values, norms, thinking and feeling ways which modulate the individual behaviour. Poverty does not occur only because of the living means but also, by cultural transmission regarding the socialization progress…”(quoted by V.O from Social Policies – Romania in the European context, E. Zamfir , C. Zamfir).
The living conditions of the Rroma communities are determined not only by the affiliation to a marginal social category (the lack of access to the public utilities) but also to the way of using the resources they have “...precarious hygiene, households agglomeration are factors that depend on the individual effort….” (P.I – hygienist, ASPJ Ilfov).
At the level of the county of Ilfov, especially within the marginalized communities, tuberculosis is the disease with the largest incidence (occupying the first place at national level). The interviewed subjects appreciate that we cannot speak about major differences between Rroma patients and the patients of other ethnies only if the risk, poor communities are populated by Rroma, in majority...”....The precarious living conditions, the improper hygiene, the precarious nutrition are the common factors which break the ethnic barriers…”
(M.O. pneumophysiologist)
“...A sick person of TBC is a source of illness for the other members of the family in the conditions in which the living space for 8-10 persons of 2 or 3 generations is reduced to one room… (M.M Social assistant Buftea).
Also, in the case of TBC patients, although the medical system provides free specific medicines they hardly access these services because of the distance and of the long term treatment.
Causes of the specific pathology incidence within the unprivileged communities, including the Rroma ethny.
Causes related to poverty culture.
Causes related to poverty as such.
The poverty manifested mainly by the precarious hygiene conditions, the lack of the elementary facilities: drinking water, light, gas, precarious nutrition, endangers the health state even during the prenatal period of time.
The interviewed public health specialists appreciate that the precarious nutrition of the mother negatively influences the harmonious development of the child and the different infections existing in the organism because of the unhygienic life conditions have the same impact. In the same conditions, the child is exposed to the risk of being born with a series of deficiencies. (Dr. L.M epidemiologist, ASPJ Ilfov). Specialists consider that smoking during pregnancy and the traditional care methods, the lack of the periodical check ups may lead to a series of disfunctionalities in the mother’s organism, some of them endangering her life. (Dr. V.I.
gynaecologist). If the baby is born healthy, he/she benefits from a relative healthy period during nursery. At the same time with the end of this period of time, the harsh impact of the improper food is following, aiming at the child’s health state, bringing about the digestive
diseases, subnutrition, dystrophy, rickets. (Dr. S.D Pediatric).
The precarious hygiene conditions allow the occurrence of parasites and of the respiratory infectious diseases. The poverty culture acts as a source of multiple causes of different diseases.
“...The lack of education, the ignorance towards the improper living conditions and nutrition, reticence in accessing the health services, deviant behavioural patterns and the lifestyle unadapted to the contemporary society represent causes of morbidity within the Rroma communities....” (Dr. D.C specialist doctor, public health ASPJ Ilfov).
The cultural and educational element has severe repercussions starting with the first years of life: “...the parents’ ignorance and indifference regarding the compulsory vaccination endangers the children’s health on long term” (Dr. S.D. family doctor)
The interviewed Rroma leaders include within poverty culture, the practice of involving the children in work, starting with the age of 9 or 10, bringing about the analphabetism and the school abandon, projecting “...an insufficient education for future, reducing the chances of Rroma people of coming out of misery and poverty…V.O.
– BJR Ilfov)
In the opinion of the Rroma leader, their non registration in the official evidences causes the deterioration of the public health of these people, especially along with the implementation of the health social insurances system.
“...The Rroma people without identity cards are not legally employed, they do not benefit from the guaranteed minimum income and from the medical services ...” (P.M.
leader Vidra).
C. HEALTH PROBLEMS OF THE CHILDREN WITHIN THE UNPRIVILEGED COMMUNITIES, INCLUDING THE RROMA ETHNY.
The interviewed subjects emphasized the fact that in case of the Rroma children, there are not specific diseases, different from those encountered in the children of the majority group.
The interviewed Rroma leaders consider that certain affections may however occur, referring to the prenatal period of time where the mothers do not benefit from proper food or they are smoking“…many mothers give birth at the age of 17, 18; this has a negative impact on pregnancy and the living conditions and the food make
that the Rroma children’s health be precarious”
(M.P. Vidra)
Causes of the health problems specific to Rroma children.
The main causes of illness regarding the Rroma children refer to the socio-economic conditions and to the parents’
ignorance - symptom of poverty culture. The food and care conditions are considered by the specialists as being inadequate.
“Parents do not take into consideration the indications of the family doctor, regarding their care or the baby’s hygiene; they run away from the hospital, do not obey the
prevention part; all these result in iron deficit or in rickets…” (Dr. P.O. Jilava).
The socio-economic conditions are considered both by the specialists and by the Rroma leaders responsible for the accentuated incidence of certain diseases.
The lack of food hygiene, the precarious nutrition, the lack of the subsistence means have a direct impact on the Rroma children’s health.
Many times, the Rroma people say that they are discriminated and they have adverse reactions against the doctors, and the medical staff invokes a chronic negligence of the Rroma people regarding the elementary hygiene conditions, as against the prescribed prevention conditions and against the advice received. These were reported by the foreign specialists and by the interviewed Rroma leader, as well
By the reduced level of education and traditional lifestyle, the Rroma ethny represents a vulnerable segment of the society and the Rroma children are the most fragile segment of it.
D. HEALTH PROBLEMS OF THE RROMA POPULATION IN COMPARISON WITH THE HEALTH PROBLEMS OF THE GENERAL POPULATION.
Both the interviewed Rroma leaders and the specialists in public health problems consider that is not correct to speak about the health problems specific to Rroma population.
It may be about the large frequency of certain diseases within the Rroma communities, but this is caused by poverty and poverty culture and not by the ethnic affiliation…”If the Romanian population is very poor, they would be in the same socio-economic situation as the Rroma population and they would have the same health problems…” (G.G, family doctor - Buftea).
“...The Rroma population is very careful with their health state…” (Dr. O.R., family doctor- Buftea)
There are differences of opinion between the Rroma ethny within the county of Ilfov, due to the reference area:
The counsellor B. J. R. (D-l V.O.) sustains that there are problems at county level. The fact that a large part of the Rroma population goes to the doctor only in case of affection leads to the worsening of their health state. The Rroma people have affections which require expensive treatments, for example: diabetes or the cardio-vascular diseases. They do not treat these affections, so they become chronic and require more money or this could have been avoided. Another example: many of the Rroma population do not treat their diseases, they become chronic or turn into handicaps so, they are entitled to a companion who earns the guaranteed minimum income.
The interviews taken on the medical staff suggest that within certain communities, there is a more serious incidence of diseases caused as a result of the children’s abandon or of the unvaccinated children.
The phenomenon of children’s abandon, taking into account the specialists’ opinion, requires large costs for society: the institutionalisation of the children without having a direct impact on the Rroma population’s health
state. Regarding the situation of unvaccinated Rroma children, this has direct repercussions on their health state or even on the community health. “... Many women understand very clearly the importance of vaccines on the child. There are women who do not understand this or they simply do not want to go. But I do not think this is something specific for the Rroma population...” (L. O. – Buftea).
The causes of these specific health problems are identified by the interviewed subjects as being the same precarious socio-economic conditions and poverty culture which maintain them. The opinion of the specialists in the field is that the reduced education of the Rroma women limits their access to information and makes them become reticent towards vaccination, precarious food, improper houses, hygiene: all these are attitudes based on ignorance and on a traditionalist culture.
E. CAUSES OF THE REDUCED ACCESS OF THE RROMA POPULATION TO THE HEALTH SERVICES.
Regarding the general causes which make difficult the access to the medical assistance, a central part is played by the attitude problems.
On one hand, doctors consider that “society has provided them with all the necessary conditions for having access to the medical assistance; now, it’s up to them…” (Dr. G.
O. MF- Buftea) and on the other hand, there are others who share the opinion of Dr. M. C. who says that “They are very reticent. They do not obey the treatment schedule. They do not observe the doctor appointment schedule for the annual examination….”
The accomplished interviews show that some of the doctors consider that they have communication problems with the Rroma people, accusing hygiene lacking clothing and an attitude they consider disrespectful and demanding.
The interviewed Rroma leaders state: “Generally, the Rroma people are very poor and at the same time they are very negativist. The typical situation is the following: my family go to the doctor’s once, twice and they aren’t accepted, the third time, they went, they argue and here is the conflict”. They smell “differently” when they go to the doctor...” (V. O. – Jilava).
Causes deriving from the law 95/2006.
Within the interview accomplished by Dr. G. E. (CJAS Ilfov), he appreciates that “For a large part of the Rroma population, the current law does not apply, 20% of the Rroma population does not benefit from health insurance either because of the lack of identity cards or because they have no job.”…
The lack of information regarding the legal framework which regulates the health social insurances within the Rroma communities is identified by the Rroma leaders as one of the causes which make difficult the access to the medical assistance: “...There are many who do not know:
if, a long time ago the Rroma people did not benefit from health services in normal conditions, today, they do not benefit from these at all, because of political reasons....”
(V. O. – Jilava).
The doctors’ perspective brings new arguments regarding the fact that the Rroma population is less favoured within the current system. “...Patients are very reticent and the doctors have the right not to register them on their list...”
(Dr. B. N. – Vidra).
The framework agreement and the norms of implementation specify very clearly that if the doctor’s directions are not obeyed, he is entitled to renounce to that patient.
Causes deriving from the educational and socio- economic status of the Rroma population.
The legal regulations connect the quality of being insured with gaining the guaranteed minimum income. The unemployment within the Rroma communities brings about its reduced access to the health system. The service community solution (Law no. 416/2002) helps those who have no income in order to gain the guaranteed minimum income.
The lack of the identity cards and the increased poverty maintained by the poverty culture accompany the causes which grew heavier the access to the medical assistance.
The lacking education within the Rroma population leads to the difficult access to information and the lack of information makes difficult the access of the Rroma people to the health system.
Dr. B. C. (ASPJ Ilfov) mentions the main problems of the health insurance system with incidence on the Rroma population“...The lack of information regarding the access to the health insurances system, the lack of resources for accessing this system and the problem of attitudes and behaviours generated by poverty culture...”.
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