Content uploaded by Doncho Donev
Author content
All content in this area was uploaded by Doncho Donev
Content may be subject to copyright.
13
th
World Congress on Public Health (April 23-27, 2012, Addis Ababa, Ethiopia)
Strategy and Decade for Roma Inclusion in the Republic of
Macedonia 2005-2015
Donev D
1
, Cicevalieva S
2
, Kosevska E
3
, Kendrovski V
3
1
Institute of Social Medicine, Faculty of Medicine "Ss Cyril and Methodius" University,
Skopje, Republic of Macedonia
2
Ministry of Health of the Republic of Macedonia
3
Institute of Public Health, Skopje, Republic of Macedonia
E-mails: dmdonev@gmail.com
, scicevalieva@gmail.com, kosevska@yahoo.com,
kendrovski@yahoo.com
Summary
There were 53.879 Roma living in R. Macedonia (Census, 2002), representing 2,66% of the total
population. Government of Macedonia took an active part in the initiative known as the Decade of Roma
Inclusion 2005-2015. The general aim of the Decade and the National Strategy for Roma in Macedonia, adopted
in January 2005, is greater integration of Roma in the mainstream of Macedonian society and reduction of
poverty, as well as long-term development of every aspect of the Roma community. Macedonian state is devoted
for implementation of the priorities set forth in the Strategy and for establishment of normative and institutional
prerequisites for reaching the European Union standards. Remarkable progress has been achieved in the
implementation of the policies, strategy and outcomes related to the Strategy and the Decade for Roma inclusion
in R. Macedonia.
Key words: Roma, Strategy for Roma, Decade of Roma inclusion, health status, health needs, health
care
Introduction: Total number of the Roma people in R. Macedonia in 2002 was 53.879
(Census, 2002) or 2,66% of the population in the country. Macedonia is rare, maybe
exceptional, multiethnic and multicultural country allowing to Roma to have freely expressed
their ethnic affiliation in all censuses, continuously from the 1948 Census, as well as to
mention the Roma in the Constitution of the country and to recognize them as a constituent
people. Roma are often socio-economically deprived and especially burdened by transition
problems in many countries, as well as in R. Macedonia. Social and economic status places
them in the category of the poorest citizens and the most marginalized and vulnerable ethnic
group in Macedonia as illustrated by certain indicators in Box 1.
Poverty in Roma is associated with specific culture, tradition and lifestyle, low level of
education, access to public services, employment and continuous social exclusion, poor
housing and nutrition, lack of proper sanitation, poor health status and low level of
immunization, health education primary health care (PHC) services. The consequences of that
are higher morbidity and mortality, especially infant mortality, high birth rate and population
growth, underweight of Roma children and lower life expectancy. Communicable diseases,
especially tuberculosis and hepatitis B, are serious problem in Roma. Invalidity rate is much
higher, too (1, 2). Physical accessibility of health care to Roma is generally good. But,
economic accessibility was much lower because of reduced coverage by health insurance till
2009 (3). Some indicators and statements about the health status and accessibility of
healthcare services for the Roma population in R. Macedonia are presented in Box 2.
Disparities in access to healthcare services are result of: 1) lack of personal identification
documents; 2) lack of health insurance coverage; 3) inability to pay official and unofficial
costs associated with health care; 4) poor health literacy; 5) discrimination.
© Medimond .
P423C0207
139
13
th
World Congress on Public Health (April 23-27, 2012, Addis Ababa, Ethiopia)
It was necessary to promote an inclusive policy that shall enable a way out of the vicious
circle of dependence and discrimination that determine the long-term perpetuation of poverty.
The aim of the paper is to evaluate the contents and progress in implementation of the
policies, strategy and outcomes related to the Strategy and the Decade for Roma inclusion in
R. Macedonia with special attention to the health needs and health care.
Methods: A retrospective study based on analysis of the aims, contents and implementation
of the strategy documents and reports for activities and the results achieved in the first half of
implementation of the Decade for Roma Inclusion in R. Macedonia 2005-2015, and a review
of the relevant literature.
Results: Republic of Macedonia has made significant steps forward regarding improvement
the status of the Roma as an ethnic community. Macedonia became a member of the OSCE
Action Plan for development of Roma policies in 2003, and joined the preparatory activities
in 2004 and the official start of the Decade of Roma Inclusion on February 2, 2005 (3). Main
stakeholders responsible for coordination and implementation the activities set forth in the
Decade and Strategy for Roma Action Plans were the Government of Macedonia, Minister
and Ministry for Labor and Social Policy, Vice Prime Minister as National Coordinator, and
the National Coordination Body, established in 2004, comprising of representatives from the
related ministries and Roma NGOs. The main objective to the Decade is to accelerate the
progress towards an improved wellbeing through the inclusion of the Roma in the decision-
making processes, and to monitor the progress in a transparent and measurable way. The
objectives of the Decade for Roma inclusion in Macedonia are closely related to the European
Platform for Roma Inclusion establishing priorities in four sectoral areas: housing, education,
health and employment (1, 3-5).
National Strategy for Roma was adopted by the Government of Macedonia in January 2005.
The adoption of the Roma Strategy coincides in time with start of the Decade for Roma
Inclusion 2005-2015 and it is an expression of will and determination of the Government to
reduce the existing gap between the Roma community and the majority population and to
promote a truly multiethnic society. The general aim of the Strategy is empowerment and
greater integration of Roma in the main social and economic trends of the Macedonian society
and reduction of poverty, as well as long-term development of every aspect of the Roma
community (1). The National Action Plans and the Operational Plans were adopted in 2005
for the priority areas of the Decade, namely education, employment, health and housing, all of
them closely related to the Millennium Development Goals (1, 2-4, 6).
Minister without Portfolio in charge of Roma issues was appointed by the Government of
Macedonia in 2008, assisted by a four-member Cabinet. The Minister, who is of Roma ethnic
origin, thus fulfilling one of the most important postulates of the Decade: “from the Roma to
the Roma”, is responsible for implementation of the Roma Decade and Strategy and for
constantly bringing the Roma issues to the government’s attention (3, 4).
In order to improve the access to health care services some amendments to the Law on Health
Care were adopted in April 2009 and primary health care (PHC) coverage is now granted to
all citizens of R. Macedonia. All Roma citizens, if registered and in possession of personal
documentation, can access PHC structures free of charge. However, it is estimated that
between 3000-5000 Roma people do not have access to health insurance due to lack of
personal documents (3).
The Presidency of the Decade of Roma Inclusion of R. Macedonia lasted from July 1, 2011 to
June 30, 2012. The Presidency Program offered a matrix-like and multi-dimensional system
of priority areas (Tab. 1).
© Medimond .
P423C0207
140
13
th
World Congress on Public Health (April 23-27, 2012, Addis Ababa, Ethiopia)
The Ministry of Health, in collaboration with other ministries and governmental bodies,
university institutions, NGOs and international organizations, was coordinator of broad
spectrum of measures and activities for improvement of the Roma health status and access to
health care. Special programs for Roma were developed for peri-natal and paediatric care,
vaccination, reproductive health of women and girls, supply of medicines, equipment and
staffing of health units in the Roma settlements, health education related to risk factors
reduction, domestic violence, nutrition etc. (3, 4, 7-10). In addition, some measures were
undertaken for prevention and punishing incidents of direct and indirect discrimination in
healthcare system experienced by Roma, as well as for training health care workers to
understand relevant aspects of Roma culture. Program for Roma Health Mediators was
introduced in the health sector as a means of support for an improved access to health
institutions and an increased utilization of the quality services in the health system (3, 4, 6).
Roma Health Mediators Program has multi-sectoral approach. The Program is financed from
the State budget and the Foundation Open Society Institute Macedonia. Roma Health
Mediator became an official profession by an ordinance adopted by the Ministry of Education
and Science in January 2011, as well as the curriculum for the training of mediators. Program
for Roma Health Mediators was adopted by the Government of Macedonia in February 2011,
which consists of three main components: 1) Development and adoption of criteria for
educational background documents for the Roma health mediators training course
(curriculum); 2) Training of the Roma health mediators regarding how to mobilize local
community and civil society; and 3) Hiring of 16 Roma health mediators for 2011/2012 and
another 16 for 2013. The general and specific aims of the Roma Health Mediators Program
are presented in the Box 3.
In broader context, since the introduction of political pluralism in Macedonia in 1991, Roma
established their own political parties and more than 40 Roma NGOs in Macedonia, which are
active in the fields of human rights, culture, education, health, environmental issues and
infrastructure projects. There are a number of periodicals printed in Roma, as well as several
television and radio stations. In 2012 about 180 Roma are employed in the public
administration.
Discussion: Roma people are recognized as constitutional people in R. Macedonia. From the
very beginning, Macedonia joined the initiative of many countries in Europe and the
European Commission known as the Decade of Roma Inclusion 2005-2015, with commitment
to work towards uprooting discrimination and overcoming the unacceptable gap between the
Roma and the rest of society. Macedonian state is devoted for implementation of the priorities
set forth in the Decade and Strategy for Roma and for establishment of normative and
institutional prerequisites for reaching the European Union standards. Significant steps were
taken in the Decade and Strategy implementation through legislation and institutions creation
complying with the international commitments and approaching issues related to the Roma
community. Such efforts in R. Macedonia should continue in the coming years in accordance
with the Millennium Development Goals and the EU Framework for National Roma
Integration Strategies up to 2020, adopted by the European Commission on April 5, 2011, for
calling on Member States to prepare or revise National Roma Integration Strategies in order
to address more effectively the challenges of Roma inclusion to tangibly improve the situation
by the end of the current decade. The healthcare goal of the EU Framework is to reduce the
gap in the health status between the Roma and the rest of the population (11).
Conclusion: R. Macedonia has made remarkable progress in standardizing legislation within
the framework of the EU for improvement of the status of ethnic minorities, with subsequent
implementation of broad scope of measures and activities included in the National Strategy
© Medimond .
P423C0207
141
13
th
World Congress on Public Health (April 23-27, 2012, Addis Ababa, Ethiopia)
and Decade Action Plans for Roma inclusion. However, beside strengths some weaknesses
have been identified and gaps remain between commitments and practice due to insufficient
coordination and communication between stakeholders, weakness of the monitoring and
evaluation mechanisms, limited capacity of institutions and actors, and inadequate funding.
Enhanced efforts are needed for further strengthening of the country-specific policies and
approaches tailored to the needs of the Roma. Capacity building is needed for grass-root
activities and bottom-up approaches for rising awareness among the Roma community and
empowering it to contribute to positive and sustainable change for improving the situation of
the Roma community in the country and to take active part in the social and economic life for
overall inclusion in the society.
Box 1. Demographic characteristics and social and economic status of the Roma population in the
Republic of Macedonia
Macedonia is placed in the SEE part of Europe, land area: 25,713 sq km
Population (2002 Census): 2,022,577 (urban population 60%)
Roma (2002 Census): 53.800 people or 2.66% of the total population
Actual Roma (OSI, UNICEF & OSCE surveys): 135.000 – 260.000
43% of Roma live in Skopje, a half of them live in Municipality Shuto Orizari
Social and economic status - Roma are the poorest citizens and the most marginalised group in
Macedonia
Low level of education, especially health education
Poor nutrition
Continuous stress
Bad housing conditions (limited space for large families)
Lack of proper sanitation
Higher rate of unemployment
Source: State Statistical Office of R. Macedonia
Box 2. Health Status and health care of the Roma population in R. Macedonia
Data regarding the health status of Roma are not collected systematically
Existing data from NGOs and international agencies show disparities between Roma and the rest of
population regarding health status and access to health care
The State Statistical Office of Macedonia, survey from 2006 showed:
- 5.4% of ethnic Macedonian newborns were born below 2500 grams, while 6.9% of the Roma children
were born below this threshold;
- 2.3% of the overall population between the age from 0-59 months is at least two standard deviations
below the average weight for age, while 5.8% of the Roma children fit this criteria
- 88% of ethnic Macedonian children were reported as fully vaccinated, as compared to 66% of Roma
children
Higher morbidity and mortality in Roma, in general
Higher infant mortality (2 times more than national average)
High birth rate and population growth
Underweight of Roma children
Lower life expectancy
Higher morbidity rates of TBC, hepatitis B, diarrhoal, parasitic and skin diseases
Higher morbidity rates of CVD, diabetes, respiratory diseases, mental disorders
High rates with upward trend of dependencies, especially drug abuse
Invalidity rate in Roma is much higher
Physical accessibility of health care to Roma is generally good
Economic accessibility is lower because of reduced coverage by health insurance
Source: State Statistical Office of R. Macedonia
© Medimond .
P423C0207
142
13
th
World Congress on Public Health (April 23-27, 2012, Addis Ababa, Ethiopia)
Table 1. Priority areas for the Presidency of the Decade of Roma Inclusion (2)
Level of
intervention
Sectorial Inter-sectorial Advocacy, Coordination and
Partnerships
Employment
Roma women’s
rights
Improving information of the
administration about the
Decade’s objectives and
priorities
Primary
Housing Discrimination Public awareness raising
about the Decade
Health care Institutionalization
Persons without
documents
Data and indicators
Secondary
Early child
development
Cooperation with
EU
Instruments and needs for
funding of the Decade
Box 3. General and specific aims of the Roma Health Mediators Program in R.
Macedonia (2)
- Promote social and health status of Roma in Macedonia;
- Improve access to health services which are culturally and socially adapted to Roma
needs and requirements;
- Increase awareness and health promotion among the Roma;
- Improve information of the Roma for opportunities and access to health care;
- Make easier access to health care, social and civil rights protection of Roma;
- Increase sensitivity of the health institutions to the specific health needs of Roma;
- Increase trust by the Roma in the health care and social institutions;
- Introduce into the healthcare system persons without personal documentation, children
who do not receive regular immunization obligatory under the law;
- Facilitate the referral to the adequate point in the health system.
References
1. Ministry of Labor and Social Policy of the Republic of Macedonia. Strategy for Roma in the Republic of
Macedonia. Skopje, Dec 2004:97. Available from:
www.mtsp.gov.mk/?ItemID=FF5ABCD0FB50E44BACE7E5044640B7C6
Accessed: Jun 30, 2012.
2. Jandrijeska Jovanova K, Zefik P. European Social Watch Report 2009 - National Report of the Republic of
Macedonia. Helsinki Committee for Human Rights of the Republic of Macedonia. Available from:
http://www.socialwatch.eu/2009/Macedonia.html
Accessed: Jul 10, 2012.
3. Demarchi G. Status Report on Implementation of the Action Plan on Improving the Situation of Roma and
Sinti within the OSCE Area. OSCE Spillover Monitor Mission to Skopje and Ministry of Labor and Social
Policy of Macedonia. Skopje, Dec 2010:70.
4. Government of the Republic of Macedonia. Decade of Roma Inclusion 2005-2015 - 20
th
ISC Meeting
Presidency Plan. Available from: http://www.romadecade.org/20th_isc_m
acedonian_presidency_plan
Accessed: Jul 10, 2012.
5. European Commission. Manual for the ten common basic principles for Roma inclusion. European
Commission Roma Portal. Available from: http://ec.europa.eu/roma
Accessed: Jul 14, 2012.
6. Government of the Republic of Macedonia. Decade of Roma Inclusion 2005-2015 - Action Plans. Available
from:
http://www.romadecade.org/
files/downloads/Decade%20Documents/macedonia%20Decade%20action%2
0plan.pdf Accessed: Jul 20, 2012.
7. Association for emancipation, solidarity and equity of the women in R. Macedonia (ESE). Report of activities
of ESE for the period from Jan 2010 to Dec 2010 - Improvement of the Roma health. [In Macedonian].
ESE, 2011:20. Available from: http://www.esem.org.mk/Root/mak/default_mak.asp
Accessed: Aug 15,
2012.
8. Pavlovski B. Health, health care and factors affecting the health of the Roma in R. Macedonia. [In
Macedonian]. Association for emancipation, solidarity and equity of the women in R. Macedonia (ESE),
Skopje, 2008:81.
© Medimond .
P423C0207
143
13
th
World Congress on Public Health (April 23-27, 2012, Addis Ababa, Ethiopia)
© Medimond . P423C0207
144
9. Donev D, Cicevalieva S, Berat B, Hadziabduli S. Social status, health needs and health and social protetion of
the Roma population in R. Macedonia. [In Macedonian]. IOM Humanitarian and Social Program Project
Workshop "Better Health of Roma through Education". Institute of Social Medicine at the Faculty of
Medicine-Skopje, IOM Office, Skopje, 2005.
10. Donev D, Hadziabduli S, Cicevalieva S, Zerajic S, Taleska T. Information Manual for the rights of health
insurers and patients in R. Macedonia. [In Macedonian]. IOM Humanitarian and Social Program Project
Workshop "Better Health of Roma through Education". Institute of Social Medicine at the Faculty of
Medicine-Skopje, IOM Office, Skopje 2005:38.
11. European Commission. National Roma Integration Strategies - a first step in the implementation of the EU
Framework. European Commission Directorate-General for Justice, European Union, Brusselles, May
2012.