During and before the design phase of the project, project planners had misgivings about it reaching the goals set, due mainly to perceptions that Roma women could potentially lack interest in participation. Project planners speculated that Roma women would not respond to fi rst and subsequent examinations. The number of project benefi ciaries, however, exceeded the number anticipated, which in itself speaks for the success of the project. The successful project uptake was made possible by good organization and by the readiness of the staff at Primary Health Care Centre Obrenovac to engage in project implementation.
The staff enabled the use of Centre vehicles to transport women to and from examinations, provided full support of other services to the project, and recognized and responded to the need for the inclusion of a health professional of Roma origin in the project. Another, even more important, reason for the successful project uptake was cooperation with Roma NGOs, which worked to gain the confi dence of the project’s target group.
A basic prerequisite for implementing the Together for Health project in another place – other than fi nancial (which is not critical, considering the cost–benefi t) – is the existence of adequate human resources. The project team, including mediators, gained unique experience that resulted in positive programme outcomes. During the selection of human resources, the quality of experts was examined, as were their organizational and communication skills. As for the mediators, the status they had in the ethnic community was important, as were their level of cooperation and the interest they demonstrated in the project from the beginning. No special training sessions were held with the project team, but the level of organization, mutual planning, reporting and communication was exceptionally high.
Sustainability
The Government of Serbia provided funds for the project to the Ministry of Health, to promote Roma health within the Decade of Roma Inclusion 2005–2015. Funds deposited in the account created especially for this project were used according to the approved project budget, where every payment and expenditure was recorded. They were controlled by an analytical card for the account balance, which is available for inspection and was a compulsory and integral part of the fi nancial documentation of the project. This model is sustainable in the future, if fi nancing sources are available (where fi nanciers could be other institutions and donors, for example). Although the Ministry of Health launched a new public request for proposals following the end of the project in August 2007 – of which 39 were approved in 2008 – no proposal for the continuation of the Together for Health project was received. Thus, the desired sustainability of the project was not achieved, despite its evident success.
For this project or similar ones to continue, the support of local self-governing authorities is needed. It is recommended that such projects be linked to a strategy or policy, so that their existence will not be ad hoc, sporadic and unconnected. In addition, project funds should be allocated from the budget of the local self-governing authority, following an assessment of project needs.
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17. Slovakia: Healthy Communities
Ľubomíra Slušná Association for Culture, Education and Communication (ACEC)
In Slovakia, about half of the Roma population is integrated into the overall population, while the other half live in so-called Roma settlements. As in many countries in the Region, Roma settlements in Slovakia are often geographically isolated and characterized by a lack of infrastructure, hygienic amenities, and social and health services. Due to these and other factors, employment rates, educational attainment, and health literacy are especially low in Roma settlements.
Poor living conditions and socioeconomic exclusion infl uence the health status of the settlements’ inhabitants, and Roma living in these settlements are among the population groups most exposed to health-related risk factors. While isolated Roma communities are believed to generally experience poorer health status than the general population of the country, there are currently no ethnically disaggregated data in Slovakia to illustrate health disparities on a national level.
The Public Health Authority of the Slovak Republic has developed the Programme to Support the Health of Disadvantaged Communities from 2007 to 2015, to address the needs of Roma and other disadvantaged groups. It was endorsed by the government in April 2007.
Prior to this, in 2003, the Association for Culture, Education and Communication (ACEC), a NGO, had initiated the Healthy Communities programme, as a pilot programme, in 11 Roma settlements. As of January 2008, the programme has been active in 67 Roma settlements with a total population of more than 45 000 inhabitants. The aim of the programme is to improve the health status of the Roma population through increased human resource capacity, health literacy, health care access and assessments of Roma health. This turned out to correspond fully to the objectives of the new governmental programme.
Most programme staff are Roma women recruited from within Roma settlements. They complete a Ministry of Education accredited programme designed by the ACEC, which aims to build participant’s capacity to undertake community health work in Roma settlements. ACEC staff (including the programme manager, education manager, programme assistant and educational programme trainers), representatives from the Slovak Red Cross and the Operation Centre of Medical Emergency, and physicians contribute to the training.
The programme team includes 4 coordinators (workers from the target community), 88 health assistants (also from the target community) and 18 regular volunteers. The volunteers are inhabitants of the settlements and help health assistants carry out their work, mainly while organizing the inoculation of children. In addition to the 18 regular volunteers, there are several ad hoc volunteers. Also, local governments, elementary schools and about 100 physicians are involved, as needed.
The ACEC has noted the particularly low level of health literacy among settlement inhabitants. For this reason the presence and activities of health assistants are very important, because they share information with settlement inhabitants about various
Summary
Socioeconomic and policy context
After an initial downturn, the Slovak economy grew substantially between 1993 and 1998 and has grown more or less steadily since then (Hlavacka, Wagner & Riesberg, 2004). However, in parallel with economic growth, there is evidence that the Slovak population living on US$ 4.30 per day or less – the World Bank’s recommended benchmark for measuring absolute poverty in Europe – grew during that same period. The 1988 household survey identifi ed 0.2% of the population as living on US$ 4.30 per day or less. The last survey, in 1996, found the rate had jumped to 11.4% (World Bank, 2005). The percent of the population living in relative poverty – that is, below the risk-of-poverty threshold set at 60% of the national median equivalent disposable income (after social redistribution) – was 12% in 2006 (Eurostat, 2006).
As stated in the National Report on the Strategies for Social Protection and Social Inclusion 2006–2008, the 20% of the Slovak population with the highest income had 3.9 times more income than the 20% of the population with the lowest income, with a corresponding income inequality under the EU average (4.8). Children under 17 years of age (18.7% of the Slovak population) and young people aged 18–24 years (16.3% of the Slovak population) are much more endangered by impoverishment than people older than 65 years (7.1% of the Slovak population) (Ministry of Labour, Social Affairs and Family, 2006:7).
In 2007, the unemployment rate (11.1%) fell by 2.3 percentage points relative to the 2006 rate. The reported unemployment rate for 2007 was the lowest in seven years. Despite this, it is still above the EU average (7.1%). The regions of the country with the highest unemployment rates are the two eastern regions, Košice and Prešov, and the south-central region of Banská Bystrica, with unemployment rates of more than 20% (Ministry of Labour, Social Affairs and Family, 2008). The main causes of the high unemployment rate in the Slovakia are a lack of jobs for people with lower qualifi cations and the need for reform of the content of education to meet labour market demands (Ministry of Labour, Social Affairs and Family, 2006:6).
Social exclusion and adverse living conditions can result in children from vulnerable Roma communities leaving school early.
According to a UNDP report on the living conditions of Roma in Slovakia (Filadelfi ová, Gerbery & Škobla, 2007), as many as 35%
of Roma older than 25 years did not fi nish their basic education. About the same share (36.6%) fi nished basic education. Also, only 15.4% of the Roma population reached high school or higher education. (Ministry of Labour, Social Affairs and Family, 2006:6).
The current national life expectancy in Slovakia is 74.2 years (UNDP, 2008). Life expectancy among males, however, varies by as much as 5–6 years in different districts (Infostat, 2006), with socioeconomic and environmental determinants believed to be the main causes for these differences.
In 2002, the main noncommunicable diseases accounted for about 89% of all deaths in Slovakia; external causes accounted for about 6%; and communicable diseases accounted for less than 1%. In total, 54% of all deaths were caused by diseases of the circulatory system and 22% by cancer (WHO Regional Offi ce for Europe, 2006).
Slovakia, along with Bulgaria, Hungary and Romania, has one of the largest populations of Roma in Europe, relative to the total population of the country. In Slovakia, this represents an estimated 400 000 inhabitants – meaning 7% of the overall population (Vaňo & Mészáros, 2004). About two thirds of Slovakia’s Roma population live in eastern and south-central Slovakia.
forms of ill health, as well as the means required to treat them, information on health promotion and prevention, and approaches to improving access to health care.
A signifi cant and notably effective strategy is the employment of health assistants from the settlements in which the programme is being implemented. Health assistants selected in this manner have the advantage of being able to communicate with settlement inhabitants on sensitive issues. They are also the most effective connection between the community and local doctors, as well as the regional authorities. Moreover, training and empowering Roma from isolated settlements creates a cadre of advocates who can speak on behalf of their communities.
The Healthy Communities programme has also helped signifi cantly to include disadvantaged Roma in the new decentralized and privatized health system. The programme does this through the creation of sustainable links with other service providers and local governments. Moreover, the involvement of physicians ensures that they are more aware of Roma community health needs. In parallel with the creation of sustainable links to other service providers and local governments, Roma health assistants report that Roma communities are building trust in the health care system and that they have a better understanding of their health care rights and entitlements.
Slovakia The Offi ce of the Plenipotentiary for Roma Communities is a state advisory organ that focuses on solving problems in Roma communities and that implements systematic measures for the improvement of their position and integration into majority society. According to materials obtained from the Plenipotentiary, at the end of 2004, 1575 Roma communities had been identifi ed in Slovakia. In 772 villages or towns, Roma communities were integrated with the majority society. Of the remaining communities, 168 were identifi ed as Roma communities within a larger town or village, 338 were Roma settlements located on the outskirts of a town or village, and 281 were Roma settlements remote from any other town or village. Of all the Roma communities, 149 were classifi ed as segregated (Offi ce of the Plenipotentiary for Roma Communities, 2004).
Roma communities are divided into three categories, according to their spatial distribution. Settlements where Roma inhabitants live diffusedly among the majority of the population are considered integrated/diffused. Integrated/concentrated settlements refer to concentrations of Roma in villages and towns where, according to majority opinion/perception (on the part of the majority of the population), the Roma populous exceeds 80% and the locality is made up of at least three dwellings; if there are less than three, the locality is not considered a settlement (Radičová et al., 2004:200). Residential Roma communities that are physically separated from a village or town, but are physically located within their territories, are considered segregated settlements. A totally segregated settlement creates an individual urban unit, which is physically separated from the village or town (Mušinka, 2002:648). The Offi ce of the Plenipotentiary for Roma Communities defi nes a segregated settlement as a “residential system that is located on the edge, or away from the village/town, inside which there is no accessible running water and the share of illegal dwellings is higher than 20%” (Offi ce of the Plenipotentiary for Roma Communities, 2004).
The following data were collected from sociographic research on Roma settlements in Slovakia, conducted by the Social Policy Analysis Centre (SPACE) between 2003 and 2004. The data are available on the Offi ce of the Plenipotentiary for Roma Communities web site (Offi ce of the Plenipotentiary for Roma Communities, 2008).
About a third of the dwellings in Roma settlements are informal (legal property rights are unclear). These dwellings generally consist of shacks made of scavenged materials, prefabricated dwellings, non-residential buildings, and some houses. Of informal dwellings, 49% were in segregated Roma settlements. Of these, 16% were shacks. In Roma settlements, the infrastructure was insuffi cient. The following data describe the status of village and town concentrations, settlements located on the edge of a village/town, and settlements located further away or separated by natural or artifi cial barriers. While 91% of these settlements had electricity, 81% lacked sewerage, compromising hygiene and contributing to the spread of disease. Also, 59% lacked gas, and 37% lacked piped water. According to the Offi ce of the Plenipotentiary for Roma Communities, in total, 46 settlements had nearly no infrastructure (piped water, sewerage, gas and paved access road). The population of these especially deprived villages was 6355 people (Offi ce of the Plenipotentiary for Roma Communities, 2004).
In the most isolated settlements, secondary illiteracy – that is, even those that have completed primary school, and even secondary school, experience signifi cant diffi culty in reading and writing – is a problem.
The health status of Roma living in segregated settlements is related to their lower rates of employment, inadequate living conditions, lack of equitable access to public services, and lower educational attainment and health literacy. These inequities result in inadequate personal and communal hygiene, leading to infectious and parasitic diseases, such as respiratory tract infections, TB, scabies, pediculosis capitis, pyodermia, mycosis and hepatitis, and the occurrence of lice is also very frequent.
Lack of sexual education, in particular, leads to higher rates of venereal disease. Vulnerability to these and other diseases is heightened by the low rates of vaccination (Ministry of Health, 2007).
Lack of education and secondary illiteracy hinder access to health care. Offshoots of these shortcomings are poor health literacy and a poor ability to understand and navigate the health system, particularly the health insurance system. Also, high unemployment – often 100% in isolated settlements – decreases the ability of Roma to pay costs related to health care and contributes to their overall feelings of frustration and to their lack of motivation. These and other factors may contribute to drug abuse and family violence. Drug addiction among Roma creates a higher risk of infection by the HIV and hepatitis B and C viruses and by other sexually transmitted diseases. All these factors have a negative infl uence on the community (Šaško, 2002).
Currently, no study summarizes the health status of the Roma community as a whole in Slovakia. Given this, many of the indicators provided in this case study come from an analysis of data collected by the Association for Culture, Education and