Belak andrej health_system_limitations_of_roma_health_in_slovakia_isbn9788097147525

ANDREJ BELÁK

Health-system
limitations of Roma health
in Slovakia
A qualitative study

Publication details
Author:

Andrej Belák, MSc.

ISBN:

978-80-971475-2-5

Consultants:

Chris Brown, PhD.
Tereza Stöckelová, PhD.

Reviewers:
Tomáš Hrustič, PhD.

Doc. Andrea Madarasová Gecková, PhD.
Language proof: David L. McLean
Design and Layout: René Říha
Photo:

©CandyBox-Images/Fotky&Foto, René Říha

Press:

EQUILIBRIA, s.r.o., Košice

For circulation please contact PaedDr. Marek Kmeť – EDUCON info@educon.sk

Health-system limitations of Roma health in Slovakia: A qualitative study

Acknowledgments
This work was supported by the WHO Country Office in Slovakia; Charles University
in Prague, Faculty of Humanities; the Slovak Research and Development Agency
under the contract no. APVV-0032-11; and the Agency of the Slovak Ministry of Education for the Structural Funds of the EU under project ITMS: 26220120058 (30%).
The author would like to cordially thank all anonymous health-system employees,
clients and owners who participated in the study. Should anything below help anyone in any way, it is mainly due to the study consultants’ brave willingness to share
personal space and experiences with a complete stranger. Hopefully, they will be
able to forgive eventual unfortunate misinterpretations, given that there were no
intentional ones and given that this report might present the initial input for a broader and welcoming discussion of their everyday issues. In addition, Dr. Darina Sedláková from the WHO Country Office in Bratislava and Dr. Andrea Madarasová Gecková from P. J. Šafárik University in Košice need to be thanked in person for taking
on board a socio-cultural anthropologist.

Acronyms
ACEC

Association for Culture Education and Communication

CSDH

WHO Commission on Social Determinants of Health

SES

Socioeconomic Status

WHO

World Health Organization

Andrej Belák

1

Table of contents
Acknowledgments ............................................................................................. 1
Acronyms ........................................................................................................... 1
Foreword ........................................................................................................... 3
Summary ........................................................................................................... 5
Introduction ...................................................................................................... 7
Part 1. Design .................................................................................................... 13
Basic specifications ........................................................................................... 15
Limitations ........................................................................................................ 17
Advantages ....................................................................................................... 18
Part 2. Findings ................................................................................................. 19
Types of limitations experienced ...................................................................... 21
Sources of limitations experienced ................................................................... 32
Part 3. Recommendations ................................................................................. 41
General strategy proposed for application of the findings ............................... 43
Overreaching dilemmas for consideration with respect to Roma health ......... 44
References ........................................................................................................ 49
Zhrnutie ............................................................................................................ 53

2


Foreword
According to the WHO Constitution, the enjoyment of the highest attainable standard of health is one of the basic rights of every human being regardless of race,
religion, political beliefs or economic and social condition. This does not mean the
right to be healthy, nor does it mean that poor governments must put in place
expensive health services for which they have no resources. It does require governments and public authorities to put in place policies and action plans which will lead
to available and accessible health care for all in the shortest possible time. The right
to health in all its forms and at all levels contains five interrelated and essential
elements: availability, accessibility, affordability, acceptability and quality. States
are under the obligation to respect the right to health and they should refrain from
limiting any of the five elements. And yet it seems that in many countries, including
Slovakia, there are problems regarding the right to health as described above. This
leads to health disparities and a health divide between countries but also has implications on the in-country situation.
Slovakia has one of the largest Roma minorities in Europe, estimated to be nearly
a half-million people. Despite the universal knowledge that the health condition
of Roma is lagging behind in practically all parameters compared with the majority
population, only scarce evidence-based work proving this was available in the past.
And it was only recently that researchers started to be interested in the “causes
of causes” of this situation. In this publication, the author and his colleagues assess
and analyse the limitations in the Slovak health system to respond to needs and
expectations for improving the health status of Roma – individuals, families and communities – how it defends them against health threats or provides access to people-centred care, with a specific focus on primary and specialised outpatient care. The
interviewed health care professionals, mostly physicians, provided a lot of information, experience and attitudes towards their work and their “clients”; this information was then processed into a set of general problems (“limitations”) arising from
the everyday work of health care professionals either in their offices or in the field, as
well as into a set of Roma-specific problems. The fact that they were ready to identify different problems when talking about health services for Roma indicated that
they needed to approach them differently. Unfortunately, the health system has not
always allowed this due to various limitations on various levels. Unfortunately, the
health system has not always allowed this due to various limitations on various levels.
These comprise not only the traditionally mentioned shortage or under-financing
of the health workforce, but also a lack of understanding of the needs and expectations of Roma, public health subordination to politico-economic regimes and escalated political connotations of Roma-related work.

Andrej Belák

3

The study calls for both professional and public consideration in reviewing the identified principal dilemmas related to Roma health-status disparities and offers health-system owners and administrators a strategy for verification and application of the
findings. These are in line with the conclusions and recommendations of the most
important documents adopted by the member states in the WHO European Region,
namely the Review of social determinants and the health divide – final report, and
Health 2020 – European policy framework supporting action across government
and society for health and well-being.
At the same time we have to point out that a health system alone cannot ensure
good health unless there is a high-level political support to mobilize the involvement of other sectors and social and policy environment support for reducing
inequities and changing individual behaviour. Health equity cannot be seen in isolation; rather, it must come to grips with the larger issue of fairness and justice
in social arrangements, including economic allocations and paying appropriate
attention to the role of health in human life and freedom. Without a whole-of-society and whole-of-government approach, success will never be complete.
Darina Sedláková

Head of WHO Country Office in Slovakia

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Summary
The relatively poor health status of the Roma population in Slovakia ranks among the
widest, steepest and most enduring intra-state health disparities in Central and Eastern Europe. The presented qualitative study examined how and why, paradoxically,
this and analogous inequities might be systematically supported by the respective
countries’ own health systems, too. Aimed primarily at researchers pursuing analogous
questions, the first part of the publication reviews the basic specifications, limitations
and advantages of the study design. In the second part, the main study findings are
summarised, offering types, sources and differential negative effects of limitations in
everyday health-system practice, as experienced from within by consulted Roma-serving practitioners. The publication closes with recommendations for various groups the
study has identified as being involved or being advisable for future involvement.
In particular, the Findings include descriptions, sources and possible negative differential health effects of the following types of limitations (respecting consulted practitioners’ language):
General limitations in emergency-rescue and clinical practices
»» Lack of appreciation
»» orkload beyond the scope of the profession
W
»» nsufficient capacities
I
»» ack of solidarity among practitioners
L
»» rowing general public ignorance regarding health
G
»» Crisis of confidence in own expertise

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Roma-specific limitations in emergency-rescue and clinical practices
»» oor functionality of clinical standards
P
»» ggressive Roma behaviour
A
»» ounselling and welfare workload beyond scope of the profession
C
»» ow hygienic standards within segregated Roma settlements
L
»» ruly racist practices
T
General limitations in population health research, surveillance and intervention
»» ack of experience in research
L
»» tate public health subordination to politico-economic regimes
S
Roma-specific limitations in population health research, surveillance and intervention
»» oor functionality of population standards
P
»» scalated political connotations of Roma-related work
E
The study Recommendations offer a 5-step strategy for verification and application
of the above findings to owners of health-system operations and close with a review
of 5 overreaching principal dilemmas identified with respect to health-status disparities involving Roma for both professional and public consideration:
»» A generalised or a varied understanding of health equity?
»» Generalised or varied sets of standards for health-system practices?
»» Adjusting emergency-rescue and clinical practices to professional education and
training or vice versa?
»» Fighting or healing racism?
»» Expert or politico-economic control of public health issues?

6


Introduction
“The fact that individuals have unique and
incommensurable views of the world does not
mean they cannot become friends, or lovers,
or work on common projects.”
David Graeber (2004)

Andrej Belák

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Introduction
Drawing from fragmentary historical indices (Crowe 2007; Fraser 1995; Horváthová 1964),
intra-state health disparities involving Central and East European Roma are likely to present the steepest, widest and most enduring health gradients in the region ever. Reviews
of the health status of contemporary Roma (EUC 2004; Hajioff and McKee 2000; Ringold,
et al. 2005; Sepkowitz 2006; Zeman, et al. 2003) as well as lately amassing social epidemiological resumes (Cook, et al. 2013; FRAEU and UNDP 2012; FSG 2009; Kosa, et al. 2007;
Masseria, et al. 2010) support such a proposition. Across countries, despite centuries
of intense sporadic campaigns targeting various aspects of Roma otherness, the majority
of Roma continue to live much shorter lives and to exhibit higher morbidity in comparison
with non-Roma citizens. For approximately 400 000 Roma living in Slovakia today, the situation appears to be identical (Cook, et al. 2013; Kolarcik, et al. 2009; Koupilova, et al. 2001;
Popper, et al. 2009; Rosicova, et al. 2009). What do we know about what maintains these
disparities? How might this knowledge be used to support authentic Roma health needs?
For answering such questions, the World Health Organization’s (WHO) multilevel
framework on reducing health inequities, developed by the Commission on Social
Determinants of Health (CSDH) (CSDH 2008) and endorsed by Member States in the
World Health Resolution of 2009 (WHA62/2009/REC/1), provides an indispensable
tool to start with. Summing up correlations accumulated by social epidemiologists
over the last 50+ years, it lets us know what (levels of) health outcomes have so far
typically occurred based on what (levels of) ‘social conditions’. It thus presents
an unprecedented guideline for empirically based hypothesising and analysing
of social inequities in further particular settings.
Yet, as routinely acknowledged by most prominent social epidemiologists (Berkman
and Kawachi 2000; Kaplan 2004; Krieger 2011; Marmot and Wilkinson 2006; McMichael 1999; Susser and Stein 2009), including the CSDH framework’s very convenors
themselves (Solar and Irwin 2007), from analogous reviews of common proxies there
is still a long way to answering what these might mean for particular groups of people both practically and morally. Admitting with its many reverse causation pathways
(Figure 1), the framework does not pretend to pose an unambiguous causal model – all
of its suggestions of causality might not hold true everywhere. Moreover, where anticipated causal relations get confirmed through statistical observations, these alone do
not indicate how which of them could (in terms of technical means) and should (according to the preferences of the people involved) be intervened upon.

8


These limits are nowhere as salient as when approaching exactly ‘ethnic’ health
disparities. Here, even methodologically rigorous designs examining correlations
thus far found almost universally – such as the relationship between socioeconomic
status (SES) and health outcomes – do not provide answers in the above respects
(Dressler, et al. 2005; Smith 2000). First of all, in the cases of many socially excluded and/or marginalized ethnic groups, there might not be enough unassimilated
members to compare with at the higher end of the SES spectrum. Second, where
such comparisons are being made, SES usually proves unable to explain differences
in all the measures of health outcomes employed (and sometimes none). Third,
for the remaining proxies, where there seems to be a strong statistical relationship
between SES and health outcomes, it still leaves us with clues neither regarding
why the SES of the given ethnic group is systematically lower than that of majority
compared with, nor how exactly does low SES in the case of the ethnic group examined damage its members’ very bodies. Last but not least, interventions against
the examined disparities usually evoked in the conclusions are not being outlined
in practical terms and within the targeted people’s known preferences.

Figure 1 Location of the study’s object within the CSDH Framework
Considering the country’s whole health system rather than just health care (the cross-out), the study focused on its relations with all: Roma differential health status (typical
object of analogous studies in the traditional quantitative approach; first red circle
from the right), Roma themselves including with respect to their specifics (the second
and the third circle), as well as with its own social determinants directly (the added
arrow and the last circle) (CSDH 2008)
Andrej Belák

9

Recent Roma-related SES epidemiological research (accounting for the vast majority of epidemiological research approaching Roma currently undertaken) matches this picture, too. There are too few segregated Roma with an SES comparable to that of the respective majorities above the lowest segment of the SES
spectrums. Standard SES hypotheses usually do not hold true for all proxies examined as anticipated. The question of why many more Roma live at the lower
end of the chosen SES spectrums is being missed, as is the question of how low
SES specifically affects Roma health. Consequently, even the most rigorous SES
studies contemplating Roma-involving health disparities typically conclude either
with their results being ‘inconclusive’, or with claims that are both exaggerated
(e.g. ethnicity effects are mediated by SES – as if the two proxies were separable
in reality) and uninstructive (e.g. socioeconomic situation of Roma needs to be
improved in order for their health status to increase). Or, at their best, vaguely
quoting possible ‘cultural influences.’ Simultaneously, no Roma views regarding
anything of the above are being taken into account at any stage (Kolarcik, et al.
2009; Voko, et al. 2009).
To move beyond the above illustrated limits of the traditional social epidemiological approach, empirical investigation is needed into additional questions such
as: Are particular causal suggestions from the framework feasible considering
the actual settings of the group of people in question? Are they present? If so,
what and who makes the identified patterns of ‘underlying social determinants’
the way they are patterned (the causes of ‘distal causes’)? How do they actually damage human bodies (the ‘mechanisms’ of ‘distal causes’ effects’)? Who
holds the means for shaping and changing these causes and effects? What are
the possibilities for improvement that are both practically possible and morally
acceptable to all people involved?
As a strategy for addressing such questions, the CSDH itself suggests putting
an additional accent on examining ‘context’. While the very notion of context has
so far not been fully elaborated directly within CSDH materials (CSDH 2008; Solar
and Irwin 2007; WHO 2013), its uses therein appear compatible with recent interdisciplinary accounts of the same domain of problems (Dressler 2005; Frohlich,
et al. 2001; Krieger 1999; Popay, et al. 1998). In these, ‘context’ is an acronym
for all specific contingencies of local histories, including the shared circumstances and understandings of involved actors (or what is commonly termed ‘cultural
influence’ in the traditional biomedical literature). In other words, to account for
questions critical for efficient and non-paternalistic assistance regarding health
inequities, apart from examining whether and to what extent which CSDH framework suggestions hold true statistically, for particular health disparities there
is also a need to examine empirically what is such relations’ place in both local
history and local understandings.

10


How can such a complex task be achieved in practice? One well established route
is the generation of related empirically testable hypotheses via qualitative research.
In the words of CSDH: “Understanding the impact that context has on health inequities and the effectiveness of interventions requires a rich evidence base that includes
both qualitative and quantitative data” (CSDH 2008). The basic idea behind qualitative research strategies is simple: to surface feasible possibilities within particular
settings by getting to know and talking to their inhabitants and stakeholders. Such
was the approach of the study presented here. An amended version of the CSDH
framework has been taken as a starting point (Figure 1) and a generation of complex and empirically testable hypotheses has been attempted on both the actual and
possible roles of one of the framework’s particular agents – the health system – regarding Roma-involving health disparity in contemporary Slovakia. In-depth interviews
were undertaken with Roma-serving health system professionals in their everyday
settings after a period of the researcher’s personal familiarization with the selected
operations’ routines. The professions included were: employees of state public health
authorities, epidemiologists in research, hospital nurses and specialists, general practitioners and health-workers in various emergency-rescue positions.
The focus of the study was picked neither at random nor does it suggest that the
health system is the most important agent contributing to the enduring Roma
health disparity in the country. With reference to the CSDH framework, a wide
range of other people and institutions are likely to be relevant: from politicians and
business owners, through various local authorities, to Roma themselves. Rather, the
choice presents but one particular step in the author’s broader qualitative approach to the topic: a multi-sited research (Fassin 2013; Marcus 1995) beginning within
the segregated Roma communities themselves (ethnographic research 2004-2010:
Belák 2005; Belák 2013) and following outwards to visit, observe and interrogate
regarding their contributions all other agents indicated as potentially involved.

Andrej Belák

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In conclusion, it might be worth summing up this introduction by briefly comparing the study approach described above (and in Part I in more detail) with
another recent study examining similar topic in a more traditional way. According to a general trend in quantitative social epidemiological research compatible with the CSDH framework (Solar and Irwin 2007), in their attempt to examine the contribution of health-system operations to Roma involving health
disparity in Slovakia, Jarcuska, et al. (2013) have chosen to concentrate on Roma
health-care access. As a result, they have confirmed – importantly – a generally
well established hypothesis that people with poorer access to health care tend
to have poorer health status. All that their study has asked and answered thus
is, whether and how strongly does one of the causal pathways set out in the
CSDH framework also hold true for segregated Roma in Slovakia. In contrast,
the research presented here has attempted to generate additional hypotheses
about why (because of what and whom) and how (in terms of effect pathways)
might this association be contributing to the disparity, as well as what could and
should be done about it, how and by whom, according to the country’s involved
health-system practitioners. The two studies are not in contradiction with each
other rather they are complimentary pieces of a quest for a more complex picture. Within CSDH’s framework itself, the comparison of the studies’ objects can
be seen schematically in Figure 1.

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1

Part 1.
Design

“We may transform social science into an activity done
in public for the public, sometimes to clarify, sometimes
to intervene, sometimes to generate new perspectives,
and always to serve as eyes and ears in our ongoing
efforts at understanding the present and deliberating
about the future.”
Bent Flyvbjerg (2001)

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Part 1. Design
THE PRESENTED STUDY WAS DESIGNED AND CARRIED OUT AS PART OF
A BROADER MULTI-SITED QUALITATIVE RESEARCH FOLLOWING ALL CONTRIBUTORS TO HEALTH DISPARITIES INVOLVING ROMA IN SLOVAKIA SUGGESTED BY THE CSDH FRAMEWORK ON HEALTH INEQUITIES. AS SUCH, IT
CAN BE UNDERSTOOD AS A RESPONSE TO THE CSDH’S CALL FOR BETTER
CONTEXTUALISATION OF PUBLIC HEALTH AGENDAS TARGETING PARTICULAR HEALTH INEQUITIES VIA MORE SUBSTANTIAL INVOLVEMENT OF QUALITATIVE METHODS (CSDH 2008; see also Introduction).
METHODOLOGICALLY SPEAKING, THE RESEARCH AIMED AT GENERATING
BOTH PRACTICALLY AND MORALLY SENSITIVE HYPOTHESES REGARDING THE
EXISTING CONTRIBUTIONS OF AND AVAILABLE OPTIONS WITHIN HEALTH-SYSTEM PROCESSES AND PRACTICES WITH RESPECT TO THE TARGETED
HEALTH DISPARITY. TO ACHIEVE THIS, IT EMPLOYED A STANDARD QUALITATIVE RESEARCH STRATEGY, COMBINING FEATURES OF QUALITATIVE SURVEYS
AND OF THE ETHNOGRAPHIC GENRE. SYSTEMIC LIMITATIONS AS EXPERIENCED IN EVERYDAY PRACTICE WERE DISCUSSED WITH DIRECTLY INVOLVED
HEALTH-SYSTEM PRACTITIONERS ACROSS PLACES AND PROFESSIONS IN THE
COUNTRY.
IN LINE WITH THE CSDH’S RECENT EMPHASIS ON “RESPECT”, ESPECIALLY
WHEN APPROACHING ”VULNERABLE GROUPS” (WHO 2013), IN ADDITION TO GENERATING NEW HYPOTHESES THE STUDY SIMULTANEOUSLY
AIMED AT INSPIRING AND FACILITATING WELCOMING COOPERATION OF
ALL ACTORS IDENTIFIED AS BEING INVOLVED OR AS BEING ADVISABLE
FOR INVOLVEMENT. THIS WAS ATTEMPTED BY SUBORDINATION OF THE
RESEARCH DESIGN AND OUTPUTS TO A SPECIFIC RELATIONAL AND PRAGMATICALLY OPEN-ENDED SOCIAL RESEARCH APPROACH. TERMED “PHRONETIC” BY ITS CONVENOR AND PROPONENT, THE APPROACH SUBSCRIBES
TO ”PRODUCING INPUT TO THE ONGOING SOCIAL DIALOGUE AND PRAXIS
IN SOCIETY, RATHER THAN GENERATING ULTIMATE, UNEQUIVOCALLY VERIFIED KNOWLEDGE” (Flyvbjerg 2001).

14


Basic specifications
Epistemology
Following relational sociological assumptions, for purposes of the study the examined
health-system processes and practices were understood as being patterned by historical
accumulations susceptible to both contingencies and the involved actors’ interpretations,
i.e. not as processes strictly following any deterministic laws. Therefore, the generation
of hypotheses was intentionally conceived of so as not to be based on filling in any preconceived causal models (such as top-down critical, or bottom-up individualist rational
action social theories). Instead, while imagining the involved actors as both contributing to
and familiar with the existing patterns in their everyday lives primarily at an unconscious
level (Bourdieu 2000), for the hypothetical reconstruction of their systemic on-the-job
limitations and options (both ‘structural’ and ‘behavioural’) the design took as a point of
departure the actors’ assumed ability to reflect on both in a practically and morally well-informed manner (Frohlich, et al. 2001; Popay, et al. 1998; Sen 1985; Williams 1995).
Such epistemological openness, indiscriminate of the nature or logic of the consultants’
descriptions or reasoning, was at the same time expected to encourage authentic interest
from the people involved in entering the eventual future composition and negotiation
of related health-system organisational adjustments (Flyvbjerg 2001; Latour 2010).

Methods
The traditional qualitative tool of in-depth interviews was used as a main method of data
construction (Baker 1999), but in most cases these were only carried out following previous personal familiarisation of the interviewing author with the everyday routines of the
interviewees’ operations, consisting in job-shadowing and informal discussions with other
staff (some owners did not allow for this to take place on their premises). Such mimicking
of the ethnographic approach was supposed to enhance the level of practical detail and
intimacy of the closing in-depth interviews (Hammersley and Atkinson 2007; Reeves, et
al. 2008). While in-depth, the closing interviews revolved around a few generic questions
suggested by the interviewer (here in their informal phrasing):
»» Why do you work in the profession?
»» Generally, what do you consider to be the main limitations of your everyday practice on the job, i.e. limitations preventing the work in your operation from being
done the way it could and should be done?
»» How would you characterise the specifics of Roma clients, if there are any?
»» What do you consider to be the main limitations of your everyday practice on the
job with respect to Roma clients specifically?
»» Do you know of any racist practices in your operations?
During the in-depth discussions pursuing these topics, the interviewing author concentrated on reconstruction of the consultants’ practical reasoning through additional questions, such as:
»» Why don’t you like this? Why do you think this is inappropriate?
»» Why do you think this is so? Who do you think is responsible for it?
»» What do you think could and should be done about this? By whom? Why?
Andrej Belák

15

Seeking most pressing issues rather than representativeness, sampling was carried out
on a fit-for-purpose basis: selected operations and professionals were invited to join the
study based on their practice serving in or targeting geographic areas with the highest
proportion of Roma residency and based on their specialisation areas being casually
reported as experiencing the most practical difficulties (most of the consultants were
approached randomly, some based on recommendations of their operations’ owners).
Hoping to generate as many different hypotheses and insights as possible, the particular
closing interviewees were selected following the highest possible variability in terms
of their age, gender, length of practice and specialisation.
Recursive abstraction, consisting in the repeated reading and non-exclusive summarizing of field notes and closing interviews, was used for data analysis (LeCompte
and Schensul 2013). Thus, types, sources and differential negative health-effects
of limitations constraining particular health-system operations on a daily basis were
constructed. These are presented in the report’s Findings. Based on these findings
and on additional facts from related literature, tentative recommendations were
proposed for the particular actors found involved or found advisable for future
involvement (Recommendations). This inviting way of formulating and presenting
findings was thought of as an encouragement for broader than usual scrutiny and
cooperation with respect to eventual problems confirmed following Bent Flyvbjerg’s concept of pragmatic relational social research: “In this scenario, the purpose
of social science is not to develop theory, but to contribute to society’s practical
rationality in elucidating where we are, where we want to go and what is desirable
according to diverse sets of values and interests.” (Flyvbjerg 2001).

Execution
From August to October 2013, the author spent 3 months visiting, observing and
interviewing health-system practitioners in the two Slovak counties with the most
Roma inhabitants (Prešov VÚC and Košice VÚC). After becoming familiar with the
daily routines of approximately 40 professionals (ranging from spending night
shifts accompanying emergency-rescue teams to interventions through spending
days observing clinical encounters of a hospital paediatrician) and a great number
of informal discussions, he recorded 20 closing in-depth interviews.
Recorded interviewees’ specifications:
»» Emergency-rescue physicians (3) and an emergency-rescue assistant (1)
»» urses (4) and specialist clinicians (8) in hospital wards (obstetrics, paediatric,
N
internal medicine)
»» eneral practitioners (2)
G
»» pidemiologist researcher (1)
E
»» ublic health officer (1)
P
»» ounties of practice: Prešov VÚC (12), Košice VÚC (8)
C
»» ender: 7 men, 13 women
G
»» ge span: 26 - 63 years
A
»» ength of practice span: 1 – 38 years
L
»» upervising positions: 10 of 20 (2 directors of whole institutions)
S
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Limitations
Some of the design’s limitations are inherent to the particular qualitative methods
employed:
»» he accuracy of the consultants’ assertions is questionable (perhaps especially
T
regarding racist practices, given the high public contentiousness of the issue)
»» he generalization potential of the findings is questionable as well (although this
T
usualy is not a problem with case-studies of sufficient depth: Flyvbjerg 2006)
Additional limitations of the study were specific to this particular realisation:
»» ue to time and budgetary constraints, the scope of the research was too
D
narrow given the breadth of the topic (in particular, more direct observation
and more discussions with the visited operations’ managements and owners
would probably be of extra benefit; saturation in terms of types of limitations
pertinent for particular specialisations remains questionable)
»» hile the response rate among the practicing employees was high (only 2
W
of 22 approached practitioners refused to be recorded, and none refused to
discuss the proposed themes in full), most operation owners were hesitant
to approve involvement in the study despite assurances that their institutions
and participating individuals would remain anonymous (one large central
hospital refused to cooperate whatsoever)

Andrej Belák

17

Advantages
Some of the design’s advantages are inherent to the particular qualitative methods
employed:
»» n most cases, the nature of the recorded in-depth interviews was informal
I
(preventing excessive performativity in responses and allowing for greater
depth based on greater intimacy) and the interviewer was previously familiarised with the operations’ routines (allowing for identification and easier
resolution of numerous neglected or seeming contradictions in the consultants’ statements) – both thanks to the employment of ethnographic features
(observant familiarisation and personal rapport building)
»» ecorded consultants’ rationales were indiscriminate in terms of the nature
R
of causal agents (sources of limitations ranged from political and historical
through individual to material and technological) and complex – both thanks
to the employment of relational sociological assumptions and of in-depth
interviews
Additional advantages of the study were specific to this particular realisation:
»» ost of the consultants were very open about all of the themes and expressed
M
appreciation for being talked to about their experience in the performed manner, probably thanks to a combination of their long-term on-the-job frustration and lack of feedback (many suggested spontaneously that there was no
need to make their contribution anonymous, some considered the discussions
therapeutic)
»» he consultants’ interpretations of segregated Roma specifics could have been
T
discussed in great detail (of revealing depth according to many) given the
author’s previous personal familiarity with both the related social scientific
literature as well as with particular instance of segregated Roma everyday
settings and life

18


Part 2.
Findings
“One thus has to acknowledge that practice has
a logic which is not that of logic, if one is to avoid
asking of it more logic than it can give, thereby
condemning oneself either to wring incoherencies
out of it or to thrust upon it a forced coherence.”

2

Pierre Bourdieu (1977)

Andrej Belák

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Part 2. Findings
AS STUDY RESULTS, THE CONSULTED HEALTH-SYSTEM PRACTITIONERS’
EXPERIENCES OF SYSTEMIC LIMITATIONS TO THEIR EVERYDAY OPERATIONS
ARE OFFERED FIRST, SUMMARISED INTO TYPES. ALL THESE TYPES PRESENT
PARTICULAR TESTABLE HYPOTHESES ABOUT WHAT EXISTING ASPECTS OF
HEALTH-SYSTEM OPERATIONS’ PROCESSES AND PRACTICES MIGHT BE CONTRIBUTING TO THE EXISTING HEALTH DISPARITIES INVOLVING ROMA IN
SLOVAKIA. UPON CONSTRUCTION OF THE TYPES, NO EXPERIENCES SHARED
WERE LEFT OUT BASED ON THEIR SCARCITY (THEY REMAIN QUOTED SPECIFICALLY). RECURRENT AND ANALOGOUS EXPERIENCES WERE MERGED INTO
A COMMON TYPE WITH STRESSING AN ESTIMATE OF THEIR PARTICULAR
FREQUENCIES WHERE POSSIBLE. THE TYPES OF LIMITATION EXPERIENCES
WHICH THE PRACTITIONERS FOUND HAD NO RELATION TO THE FACT THAT
MOST OF THEIR CLIENTS WERE ROMA ARE GROUPED UNDER “GENERAL
LIMITATIONS”. LIMITATIONS CONSIDERED SPECIFIC TO A ROMA-INVOLVING
PRACTICE FOLLOW BELOW, GROUPED AS ”ROMA-SPECIFIC”. FOR EACH
OF THESE GROUPS OF LIMITATION TYPES, A LIST OF THE THEORETICALLY
POSSIBLE (ACCORDING TO THE CSDH FRAMEWORK) OR ALREADY OBVIOUS
(ACCORDING TO THE PRACTITIONERS) NEGATIVE INFLUENCES THEY HAVE
SPECIFICALLY ON ROMA HEALTH STATUS ARE PROVIDED. THESE PRESENT
TESTABLE HYPOTHESES REGARDING HOW EXACTLY THE ABOVE LIMITATIONS
MIGHT BE AFFECTING THE HEALTH OF THE ROMA SPECIFICALLY.
NEXT, FOR ALL OF THE PARTICULAR EXPERIENCES OF THE LIMITATIONS
DOCUMENTED, ALL OF THEIR POSSIBLE SOURCES ARE LISTED INDISCRIMINATELY (REGARDLESS OF THEIR MATERIAL, SOCIAL, POLITICAL, HISTORICAL OR OTHER NATURES). THESE PRESENT TESTABLE HYPOTHESES ABOUT
WHY – AS A RESULT OF WHAT AND BECAUSE OF WHOM – THE LIMITATIONS
MIGHT BE IN PLACE. THEY ARE RECURRENTLY SORTED ACCORDING TO EACH
OF THE EXPERIENCE TYPES THEY WERE SUPPOSED TO MAINTAIN (MANY OF
THE SOURCES QUOTED WERE CONSIDERED TO MAINTAIN MORE THAN ONE
TYPE OF LIMITATION EXPERIENCE).
THE DESCRIPTIONS AND LANGUAGE OF BOTH THE EXPERIENCED LIMITATION
TYPES AND THEIR ALLEGED SOURCES WERE CAREFULLY PICKED IN ORDER
FOR THEM TO REMAIN CONSISTENT WITH THE ORIGINAL FIELD NOTES AND
RECORDINGS. DUE TO THIS DEVOTION TO AUTHENTICITY, SOME OF THE
PRESENTED DATA MIGHT DISTURB SOME READERS AS BEING TOO DISTANT
FROM VARIOUS POLITICALLY OR SCIENTIFICALLY ENDORSED DISCOURSES.
SHOULD THIS INDEED BE THE CASE, THOSE OFFENDED ARE ADVISED NOT
TO JUDGE TOO HASTILY AND TO RECALL THAT THE PRACTITIONERS WERE
KIND ENOUGH TO SHARE THEIR ACTUAL VIEWS IN ORDER TO HELP EVERYBODY INVOLVED.

20


Types of limitations
experienced
General limitations in emergency-rescue
and clinical practices
Lack of appreciation
Generally, appreciation of emergency-rescue and clinical practitioners’ work is too
low and radically weakening. In the communication of patients and their families
with practitioners, signs of sincere gratitude for received assistance are becoming
rare, while overt arrogance is becoming ever more common (e.g. a rude stressing of
the personnel’s public duties or threatening where the clinical itinerary differs from
the receiver’s projections; see also Aggressive Roma behaviour). In contrast to some
private and especially to most state-owned companies, treatment and appreciation
of less qualified personnel by their superior colleagues and management is supportive only in selected private ones (e.g. nurses in peripheral state-owned hospitals
are commonly treated with blunt disrespect). Salaries of lower qualification professions, such as nurses or emergency-rescue drivers, do not provide a decent living,
pressuring the personnel into accepting unbearable amounts of overtime and/or
into working additional jobs.

Appreciation of clinical
practitioners’ work is too
low and radically weakening

Workload beyond the scope of the profession
A substantial and growing proportion of emergency-rescue and clinical practitioners’ work – majorities in the case of emergency-rescue teams and nurses in
selected wards – deals with issues beyond the scope of the profession. Emergency-rescue teams carry out too much work beyond the treatment of urgencies, hospital
nurses beyond assistance with patients’ needs related to clinical treatment, internal
medicine wards beyond the treatment of undiagnosed conditions with unassigned
therapies, etc. The character of inadequate workloads approximates psychological
counselling or welfare services: taking care of anxieties, recurring psychosomatic
states, crises of neglected chronic conditions (typically of non-Roma elderly people)
and/or taking care of patients’ varied socioeconomic issues such as the unaffordability of medications, clothes or sanitary accessories, lack of transportation means,
demands for medical documentation supporting welfare allowance claims (mostly
on behalf of segregated Roma of productive age groups, see also Counselling and
welfare workload beyond scope of profession).

Andrej Belák

A substantial and growing
proportion of emergency-rescue and clinical practitioners’ work deals with
issues beyond the scope of
the profession

21

Insufficient capacities
Clinical practices are
chronically and increasingly
understaffed and underfinanced at all levels

Clinical practices are chronically and increasingly understaffed and underfinanced at all levels. Unless intrinsically lucrative, departments in peripheral hospitals
lack physicians (especially experienced ones), while their assistants typically serve
a great many patients and work hours far above the quotas permitted by law (e.g.
nurses in obstetrics- and paediatric wards). The low and ever decreasing number of
personnel is still usually combined with insufficient quality and capacities of clinical
premises, ranging from physicians sharing worn out and barely functional surgery
accessories to acute unavailability of patient beds in hospital wards. Older generations of physicians are experiencing a steadily decreasing trend in amount of effort
performed on the jobs per capita by their younger colleagues (see also Lack of solidarity among practitioners).

Lack of solidarity among clinical practitioners
Standards of interpersonal communication and
cooperation among clinical
practitioners remain very
low and are worsening

With the exception of selected instances (e.g. smaller privately owned practices
in lucrative locations and in specialised areas), the standards of interpersonal communication and cooperation among various clinical professions and departments
typically continue to remain very low and keep worsening. Hostility (ignorance, patronizing, verbal abuse, etc.) and lack of loyalty (from calumny to avoidance of colleagues’ patients in need) continue to be typical for the working ambience in most
clinical practices. In addition, older generations of practitioners consider the understanding and attitudes of their younger colleagues regarding clinical occupations
as increasingly opportunistic.

Growing general public ignorance regarding health
Patients’ confidence
is growing, while their
knowledge of health-related issues becomes more
fragmentary and confused

22

While most patients’ confidence in and demand for particular clinical treatments
continually grows, by biomedical standards their actual knowledge of health-related issues is becoming ever more fragmentary and confused. Emergency-rescue
and clinical practitioners are being increasingly pushed (see also Lack of appreciation) toward procedures without clinical indications, such as the prescription
of antibiotics for children or mood altering drugs. At the same time, their recommendations are not being followed where serious clinical indications exist. The latter is especially the case with chronic diseases. Here, patients’ compliance ends
with the intake of medicaments and the undergoing of surgical procedures, while
preventative measures (e.g. dietary or physical activity recommendations) are only
adhered to highly selectively or get ignored completely.


Crisis of confidence in own expertise
Many clinical practitioners are experiencing growing doubts about the validity
of their own expertise. Facing intensifying opposition from their patients (see also
Growing general public ignorance), increasing direct pressures from marketing (e.g.
incentives from pharmaceutical companies) and amassing expert opinion retractions and clashes (e.g. in medical journals), general practitioners and paediatricians especially are finding it ever more difficult to decide about particular matters
of clinical concern (e.g. regarding dietary recommendations in general practitioner
practices), to weigh their own clinical experience adequately (e.g. where their own
experience does not match general descriptions), and/or to not question the validity of all of biomedical knowledge as such (e.g. when compared with the pragmatic
common sense holism of various alternative or folk medicines).

Clinical practitioners
experience growing doubts
about the validity of their
own expertise

Differential negative effects of general limitations
in emergency-rescue and clinical practices on Roma health
»» he low quality of emergency-rescue and clinical services – especially at the
T
level of practitioners’ communication with patients – might be contributing
to existing Roma prejudices about non-Roma, supporting and deepening
existing Roma self-segregation practices (including aspects of existing Roma
non-participation in the health system; see Roma-specific limitations).

The low quality of emergency-rescue and clinical
services might be deepening existing Roma self-segregation practices

»» ue to their partial confounding with related Roma-specific limitations (e.g.
D
Lack of appreciation, Workload beyond scopes of profession), the above limitations identified here as general are likely to be more serious and apply with
more effect in areas with a higher proportion of segregated Roma patients.

General limitations are
likely to be more serious
in areas with a higher
proportion of segregated
Roma

Andrej Belák

23

Roma-specific limitations in emergency-rescue
Poor functionality of emergency-rescue and clinical standards
Standard clinical procedures prove to be significantly
less functional with respect
to the majority of segregated Roma

Both written and implicit standard emergency-rescue and clinical procedures working
for both non-Roma and non-segregated Roma patients consistently prove to be significantly less functional with respect to the majority of segregated Roma. Facing almost
exclusively patients from this Roma subgroup (understood loosely as Roma living
in variously segregated rural or urban enclaves), upon adhering but to such standard
procedures (more frequently on the part of practitioners with short-term experience,
high level of prejudices or those simply less willing to violate any official rules for other
personal reasons), emergency-rescue and clinical practitioners often find themselves
incapable of eliciting useful anamneses or securing even the most basic necessary
patient cooperation in particular diagnostic, therapeutic and/or administrative tasks of
their respective jobs. The clinical significance of such difficulties ranges from constant
rather formal complications (e.g. the incapacity to understand and sign an informed consent) to frequent unnecessary chronic damage to health, including preliminary deaths
(such as in cases of sudden patient withdrawals from life-saving therapeutic plans or
of nameless new-borns being left behind in hospitals by their adolescent mothers and
absent fathers). Emergency-rescue and clinical practitioners partially transcending such
difficulties (most practitioners at least in some respects on a daily basis) are only able
to do so based on a combination of long-term personal experience with this group of
patients and the willingness to systematically assign extra time and make the extra
effort on their behalf (such as undergoing an officially unacknowledged, unassisted
and uncompensated extra trial and error learning process; switching between various
modes of feeling, thinking and communication, including different moral priorities, formal rules, body and spoken languages, genres of humour; assisting patients with their
basic hygienic, socioeconomic, administrative and time-management incapacities; etc.).

Aggressive Roma-specific behaviour
A routine of Roma-specific
aggressive behaviour
is steadily intensifying

24

A routine (daily in obstetrics and paediatric hospital wards) of Roma-specific aggressive
behaviour, typically involving middle-aged and teen-aged segregated Roma of mid- to
high socioeconomic milieus (as estimated by supposed Roma preferences), is steadily
intensifying. Apart from hardly ever involving non-Roma, compared with the growing
arrogance experienced from non-Roma patients (see Lack of appreciation), such behaviour is both much more common and specific in its forms. The specific forms include:
extreme verbal abuse (including allusions to sexual perversity and/or to relatives); provocative allegations mimicking and mocking idealist evocations and practices regarding
social justice (unfair allegations of racism, claiming misuse of peoples’ taxes, inappropriate stressing of professional duties of the personnel, unjustified threatening with
legal authorities or media, etc.); blackmailing via demonstrative self-harm (e.g. mothers
banging their heads onto walls in order to achieve personnel violations of ward-rules),
direct physical attacks (shouting, slaps, pushing, spitting, equipment damage); etc. Following asymmetries in authority and physical involvement, most Roma-specific arrogance is aimed at and dealt with by professionals of lower qualifications rather than
physicians (i.e. clinical assistants, nurses, etc.). In the experience of emergency-rescue

personnel, most cases of such behaviour concentrate around regular peaks of Roma
collective conflicts related to welfare payment dates and usually involve alcohol intoxication. In the experience of nursing staff in obstetrics and paediatric wards, such
behaviour also escalates through collective hysteria, yet occurs constantly and does not
involve intoxication as often.

Counselling and welfare workload beyond the scope
of the profession
In most emergency-rescue and some clinical operations (e.g. in paediatric and obstetrics
hospital wards), a disproportionately large share of a substantial and growing workload
beyond the scope of the concerned professions involves Roma (see Workload beyond
scope of profession for primary explication). Work of this kind performed by emergency-rescue teams most often deals with social and economic issues of teenage and productive-age segregated Roma, such as the resolution of escalating fights within settlements
(usually assisted by police), the prestige deficits of individuals (increasing via recruitment of non-Roma), the lack of affordability of medications, lack of transportation
means, demand for medical documentation supporting welfare allowance claims, etc.
Most emergency-rescue teams also pay ridiculously regular visits (e.g. hundreds per
year) to elderly Roma individuals (here often not segregated) suffering from anxieties,
recurring psychosomatic states, crises of neglected chronic conditions, etc. Within hospital wards, in addition to all of the above-mentioned issues, practitioners constantly
deal with the consequences of recurrent child neglect (e.g. malnutrition, dehydration,
bedsores, infant injuries, etc.); of recurrent neglect of personal hygiene (e.g. parasites,
skin conditions); of the unaffordability of food, clothes and/or sanitary accessories; and
similar (all usually on behalf of the poorest segregated Roma and/or their children).
Apart from the high disproportion of Roma among the beneficiaries of such a workload,
its specificity as experienced consists mainly in an inappropriately active and implied
subscription to it by Roma patients: non-Roma patients in analogous situations typically
exhibit much less related practical knowledge and self-confidence, better fitting the
”helping-the-victim” character of the situation.

A disproportionately large
share of workload beyond
the scope of the concerned
professions involves Roma

Low hygienic standards within segregated Roma settlements
Both personal and communal hygienic standards within segregated Roma settlements
are too low. Compared with absolute majorities of non-Roma, non-segregated Roma
and better-off segregated Roma patients, worse-off segregated Roma patients and
their families approaching emergency-rescues and clinics often exhibit the consequences of long-term neglect of personal hygiene too appalling for the personnel to deal
with (parasites, filthy clothing and bodies, unbearable scents). Sanitary equipment in
hospital wards often suffer on one hand from patients’ and patient family members’
ignorance regarding its proper use (e.g. frequent damage, unnecessary contamination,
etc.) and on the other from excessive use of it by others (e.g. whole families often try to
take the rare opportunity for taking shower upon visiting their relatives, frequent thefts
of accessories, etc.). Missing and/or contaminated roads and shelters without any sanitary infrastructure within the segregated settlements themselves increase the risk of
contamination in clinical operations (e.g. emergency-rescue vehicles are contaminated
with faeces, emergency-rescue clinical procedures often need to be carried out within
filthy households).
Andrej Belák

Hygienic standards within
segregated Roma settlements are too low

25

Truly racist practices
Cases of intentional harm
to patients based purely
on them being identified
as Roma do occur

26

Cases of intentional harm being done to patients by emergency-rescue and clinical personnel based purely on the former being identified as Roma (i.e. without taking into
account their actual behaviour) do occur. Such truly racist behaviour (e. g. the unwillingness to treat Roma patients of some general practitioners, the unwillingness of some
clinical personnel to enter Roma households, derogatory communication with Roma
patients, etc.), however, typically comes from psychologically troubled practitioners and
is nowadays considered as unacceptable and opposed by both their colleagues and the
Roma involved themselves. The exact range of these kinds of racist practices is thus
hard to assess. Except for possible rare extremes (such as consistent harm being carried
out covertly), it most likely amounts at most to particular clinical practitioners and operations being consistently avoided by Roma. Much more common or constant (more
frequent on the part of practitioners with short-term experience, a high level of prejudices and/or paradoxically of those less willing to violate official rules for other personal reasons) are cases of lowering the quality of service specifically towards segregated
Roma patients based on previous frustrating experience with them or other Roma (not
necessarily personal). The existing tendency to such lowering of quality is inappropriate,
yet it is forced by constant failures in resolving clinical situations through standard fair
means (see Poor functionality of clinical standards), typically restricted to the quality of
the personnel’s communication (verbal abuse, shouting, threatening) and is not exclusive to only Roma patients under analogous circumstances. As such, it should be understood as a defensive (defensively racist at most) rather than a truly racist practice (e.g.
as poor attempts at resolving situations by other means or a poor way of letting out
one’s frustration for the moment).


Differential negative effects of Roma-specific limitations
in emergency-rescue and clinical practices on Roma health
»» The lower quality and efficacy of emergency-rescue and clinical services specifically toward particular Roma subgroups are disproportionately harming
their health directly. Such direct negative effects range from imminent psychosomatic harm from the substandard quality of the communication from
personnel to unnecessary chronic conditions, including preliminary deaths,
resulting from particular non-functionalities of clinical standards; see Truly
racist practices, Poor functionality of clinical standards.
»» Likely Roma awareness of the lower quality of emergency-rescue and clinical
services specifically against them might contribute to existing Roma prejudices about non-Roma, supporting and deepening existing Roma self-segregation practices (including aspects of existing Roma non-participation in the
health system).
»» on-Roma awareness of existing Roma incompatibility with emergencyN
-rescue and clinical standards (e.g. non-Roma patients’ complaints about
most of the above specifics of Roma patients are common; see also Aggressive Roma behaviour, Low hygienic standards, Counselling and welfare workload) contributes to existing non-Roma prejudices about Roma, supporting and
deepening existing non-Roma marginalisation of Roma (including aspects
of existing non-inclusion of Roma within the health system).
»» he presence of an officially unacknowledged and unresolved split of
T
emergency-rescue and clinical practices (see Poor functionality of clinical
standards), is the basis for additional unnecessary conflicts among emergency-rescue and clinical practitioners, further lowering the quality of their
service (see Lack of solidarity among practitioners).
»» here present, Roma-specific limitations might be enhancing the serioW
usness of particular general limitations and their effects (see Differential
negative effects of general limitations in clinical practices).

Andrej Belák

The lower quality and efficacy of clinical services specifically toward Roma are
disproportionately harming
their health directly
Roma awareness of the
lower quality of clinical
services specifically against
them might be deepening
existing Roma self-segregation practices
Non-Roma awareness
of Roma incompatibility
with emergency-rescue and
clinical standards supports
the existing non-Roma marginalisation of Roma
The presence of an unresolved split in emergency-rescue and clinical practices is the basis for conflicts
among practitioners,
further lowering the quality
of their service
The presence of Roma-specific limitations might
be enhancing some general
limitations and their effects

27

General limitations in population health
research, surveillance and intervention
Lack of experience in research
Population health researchers are too inexperienced
and isolated to make beneficial use of available funds
and talents

In the country, too many population health researchers are too inexperienced and
isolated to make beneficial use of available funds and talents. When compared with
scientific production in the West – especially in areas concerning the social aspects
of health – low ethical, efficacy, methodological, and utility standards prevent most
local research networks from sensitively and efficiently producing reliable and
usable outcomes (local studies still typically do not account for pitfalls long-known
of abroad), from successfully competing for necessary international resources
(given that domestic funding is continually diminishing), as well as from training
new scientists with such abilities for the future (deficiencies keep being reproduced
where young scientists do not enter international programmes).

State public health subordination to politico-economic
regimes
Excessive subordination
of state public health
to politico-economical
regimes compromises its
organisational stability and
expert content

28

State public health practice is subordinated to alternating politico-economical regimes to such a substantial extent that both its organisational stability and its very
expert content are compromised. Ever since the end of the Communist era, operations of the Slovak public health authority have suffered from constant economically, politically and ideologically reasoned organisational adjustments, including
reductions in funding, capacities and competencies. As a result, state public health
experts operate more and more as mere executive officers rather than as authorities responsible for proposals and protection of the setup of the state public health
practice. They lose on one hand control over organisational security of their operations (e.g. externally imposed headcounts, administration principles and budget
cuts), and on the other the means for updating their practice with state-of-the-art
expert knowledge (i.e. especially where recommendations are apparently incompatible with the state politico-economical ideology of the day). For example, an
absolute majority of related state resources and effort are focused on monitoring
of and intervention in only the physically most proximate factors (such as the quality of drinking water), while more distal determinants of health (such as structural
inequalities) remain untouched and unapproachable – despite their being more
recently pinpointed as being at least equally important by international public
health experts. Continuing substitution of state public health authorities by spontaneous private efforts (such as entrepreneur or NGO activities) has so far proven
favourable only in relatively limited respects (e.g. overall improvement of sanitary
conditions in hospitality industry or local trials of community health fieldwork
within segregated Roma settlements). Spontaneous and more substantial involvement of private investors does not seem likely in public health areas where there
are no profits to be made (i.e. especially where the final recipients are poor). The
budgets, expertise and legal status of the involved NGOs do not provide for the
necessary long-term management of such complex areas either.


Differential negative effects of general limitations
in population health research, surveillance and intervention
on Roma health
»» nderdeveloped population research on the social determinants of health
U
makes it impossible to understand and appropriately address the makeup
and sources of steep and enduring Roma health disparities (thus contributing
further to the differential deterioration of Roma health).
»» hrough the absence of social determinants of health from its practice, the
T
present organisational setup of state public health authorities makes it impossible to monitor, intervene or supervise specifically on behalf of Roma
groups as such – Roma health disparities are kept officially invisible and
unapproachable as a public health issue. The lack of potential profits makes
more substantial involvement of private investors unlikely.
»» nappropriate outcomes of poor research and the absence of appropriate
I
monitoring, intervention and supervision regarding Roma population health
might support existing Roma prejudices about non-Roma and existing non-Roma prejudices about Roma, as well as enlarge the existing political burden
of similar and other Roma-related agendas (see Escalated political connotations of Roma-related work).

Andrej Belák

Underdeveloped population research on the social
determinants of health
makes it impossible
to address Roma health
disparity appropriately
The present organisational
setup of state public health
authorities maintains
Roma health disparities
as officially invisible and
unapproachable as a public
health issue
Poor Roma-related population research, monitoring,
intervention and supervision
outcomes might deepen
both Roma self-segregation
and non-Roma marginalisation of Roma

29

Roma-specific limitations in population
health research, surveillance and intervention
Poor functionality of population standards
Standard notions and
methods of population
health research, surveillance and intervention
prove to be less functional
with respect to segregated
Roma

When applied to segregated Central and East-European Roma, standard notions
and methods used within population health research, surveillance and intervention
– such as ”ethnic minority”, “nation” or “marginalisation”, and self-reported health
surveys, life-statistics or monitoring via clinical databases – often prove significantly
less functional. Attempts at addressing arbitrary Roma subpopulations anticipating
homogeneity, accessibility, cooperativeness and historical orientations common for
other sedentary populations in the region typically fail in all aspects: by underestimating their greater internal variability (e.g. underestimating the extent of isolation
among Roma), endorsing naïve data-acquisition plans (e.g. underestimating local
social desirability of bluffing), constructing invalid primary data (e.g. overestimating
the local ability to understand questionnaires), reifying and relying on reified statistical artefacts (e.g. correlations confounding distinct specific causal pathways and
preferences within places), etc.

Escalated political connotations of Roma-related work
Extreme public polarisation
regarding Roma makes
addressing Roma-related
issues exceptionally difficult

30

Regarding Roma in general, the country’s public is extremely polarised; this makes
addressing any Roma-related issues – including health-status themes – exceptionally difficult. Turmoil and devoted opposition groups exist in and among various
parts of the public, activist groups, political representation, the media, scientific
communities, the Roma themselves, etc., and they are ready to pose and endorse
an overwhelming array of arguments both for and against all: the use of public
resources for affirmative action, approaching Roma as a cultural rather than a mere
socio-economically marginalised group, designing activities with or without participation of Roma political representatives, the moral and political right to live off
of Roma-related issues being or not being Roma, the intrinsic danger of ethnically
classified data collection and publication, feasibility of any progress in Roma affairs
given the long history of failures, etc.


Differential negative effects of Roma-specific limitations
in population health research, surveillance and intervention
on Roma health
»» The use of inappropriate notions and methods within population health
research, surveillance and intervention designs might be harming the health
specifically of Roma directly, e.g. by introducing systematic bias into estimates
of clinical significance in their case.
»» Inappropriate outcomes of poor research and the absence of appropriate
monitoring, intervention and supervision regarding Roma population health
might support existing Roma prejudices about non-Roma, existing non-Roma
prejudices about Roma and further enlarge the existing political overload
of similar and other Roma-related agendas
»» The political overload of Roma-related issues might demotivate experts from
entering or continuing efforts addressing Roma health disparities (thus contributing further to the differential deterioration of Roma health).

Andrej Belák

The use of inappropriate
notions and methods might
be harming the health
of Roma directly
Poor Roma-related population research, monitoring,
intervention and supervision outcomes might be
deepening both Roma self-segregation and non-Roma
marginalisation of Roma
The political overload
of Roma-related issues
demotivates expert efforts
addressing Roma health
disparities

31

Sources of limitations
experienced
General limitations in emergency-rescue
Lack of appreciation
»» istorical patient emancipation and/or retaliation (During the Communist era,
H
behaviour of clinical practitioners toward patients was traditionally rather
arrogant and/because it used to be hard for patients to hold them accountable. With subsequent gain in their agency within clinical settings, many
patients began actively to resist such treatment – or even retaliate for it – in
an analogous style.)
»» eneral loss of solidarity and an increase in competitiveness among people
G
»» ormal education is generally over-valued; informal experience, manual labour
F
and lower qualification efforts are devalued
»» tradition of arrogance among physicians (exercised toward less qualified
A
personnel)
»» mployees do not oppose inappropriate treatment by their superiors directly
E
»» mployees do not report inappropriate treatment by their superiors to higher
E
management
»» ack of interest of the state in peripheral hospitals
L
»» he region is poor historically
T
»» ealth care as a whole is underfinanced by the government
H
»» he financial crisis requires owners, employers and/or the government to save
T
money
»» nion strikes are not a viable pay negotiation option for nurses as mothers
U
»» onfidentiality of salaries enhances speculation, envy, and discontent among
C
personnel
»» ommercial media focus on clinical failures and cover them superficially and
C
unfairly (e.g. supposed victim-centred reporting and no recalls of false accusations)
»» High concentration of Roma in the area

32


Workload beyond the scope of the profession
»» he emergency-rescue network is too dense (since 2006, following implemenT
tation of EU requirements)
»» mergency-rescue intervention is free
E
»» o (applicable) charges or fines are in place for cases of emergency-rescue
N
being used for non-urgent cases or intended misuses
»» mergency-rescue dispatchers’ options have been narrowed (There are fewer
E
types of transportation available, more personal responsibility and missing
guidelines for differential diagnostics, loss of direct knowledge of patients’
medical histories in the area due to centralization of dispatching, etc.)
»» eneral public ignorance regarding urgent health issues has grown (also
G
thanks to media campaigns following implementation of EU requirements
in 2006)
»» ncreasing medicalization of life
I
»» People are able to call an clinics from anywhere since the introduction of mobile phones
»» o options available for clinic owners and management with respect to chronic
N
overuse other than organising psychological counselling for their employees
»» Insurance companies do not care about the absolute economic loss from chronic over-use of emergency-rescue services, because it is the cheapest option
relatively (The only other available option of hospitalising the same patients
is much more expensive and emergency-rescue operations have to be paid
a flat-rate, except for negligible extra distance top-ups.)
»» o legislature in place enabling insurance and/or emergency-rescue compaN
nies to prevent chronic overuse of emergency-rescue services legally
»» tatistics regarding inadequate use of clinical services are missing and not
S
required by owners / the state (e.g. statistical evidence of efficacy of service is
not required in state run public competitions for emergency-rescue licenses);
supports corruption suspicions
»» oo little time for communication with the patients in hospitals and general
T
practitioner’s operations (e.g. radically shortened in-patient periods leave
no room for educating the patients with respect to their conditions)
»» sychological counselling, social welfare and/or social medicine services are
P
underdeveloped, redirecting too many people toward clinical practice
»» he social and economic situation in the region has worsened
T
»» he traditional family is disintegrating (e.g. ever more elderly people live aloT
ne, abandoned by their descendants)
»» he workload content (shift) is appropriate, but clinical practitioners are not
T
being (re)educated and (re)trained appropriately for what their jobs actually
require (e. g. in psychological counselling or about social welfare options)
»» igh concentration of (segregated) Roma in the area
H

Andrej Belák

33

Insufficient capacities
»» he region is poor historically
T
»» he financial crisis requires owners, employers and/or the government to save
T
money
»» nion strikes are not a viable pay negotiation option for nurses as mothers
U
»» ealth care as a whole is underfinanced by the government
H
»» wners and managers lack interest in and/or under existing the clinical signifiO
cance of their decisions; nowadays, most of them lack any clinical experience;
supports suspicions of corruption
»» eedback regarding organisational issues from practitioners to management
F
is not being taken seriously
»» wners and management place short-term profit above long-term stability
O
and/or people’s health; supports suspicions of corruption
»» wners and their management are not being held accountable for long-term
O
planning by the state; supports suspicions of corruption
»» pecialisation is disappearing from nursing education
S
»» edical degrees and/or licenses are being granted to individuals incapable
M
of-/unwilling to take up the vocational aspects of their respective professions
»» eneral loss of solidarity and increase in competitiveness among people
G
»» ncentive-based organisation of clinical practice supports inappropriate motiI
vations

34


Lack of solidarity among practitioners
»» eneral loss of solidarity and increase in competitiveness among people
G
»» tradition of arrogance among physicians
A
»» ractitioners do not oppose inappropriate behaviour directly
P
»» ractitioners do not report inappropriate behaviour to management
P
»» anagement of state-owned operations lack the skills and/or interest in getM
ting rid of unprofessional behaviour among their employees
»» anagement of state-owned operations lack the means for getting rid of unM
professional behaviour among their employees, given the latter are under-paid
»» edical degrees and/or licenses are being granted to individuals incapable
M
of-/unwilling to take up the vocational aspects of their respective professions
»» ncentive-based organisation of clinical practice supports inappropriate motiI
vations

Growing general public ignorance regarding health
»» oor public health education
P
»» Too little time for communication with the patients (e.g. radically shortened in-patient periods leave no room for educating the patients with respect to their
conditions)
»» ncreasing self-confidence of patients regarding their knowledge of health
I
issues as well as in communication with professionals
»» ncreasing medicalization of life
I
»» ncreasing commodification of health-status parameters
I
»» ooming alternative approaches to health
B
»» ncreasing consumerism
I
»» rowing pressures on public from food and pharmaceutical marketing
G
»» nfluence of the Internet
I
»» massing of controversies regarding clinical expertise
A

Crisis of confidence in own expertise
»» ncreasing opposition and pressures from patients and marketing (especially
I
pharmaceutical companies and makers of medical devices)
»» ack of guidance and practical knowledge regarding evidence-based medicine
L
(from medical training and/or respective professional associations)
»» ack of guidance and practical knowledge regarding proper evaluation of own
L
clinical experience (from medical training and/or respective professional associations)
»» massing of controversies regarding clinical expertise
A

Andrej Belák

35

Roma-specific limitations in emergency-rescue
Poor functionality of clinical standards
»» ereditary / acquired (mostly conflated) Roma mental incapacities to achieve
H
and maintain non-Roma standards (e.g. low intelligence, chronic impatience,
hysterical tendencies, touchiness, etc.)
»» oma disinterest in achieving or contempt for the non-Roma way of life (valuR
ing of rational order and security based on long-term planning including with
respect to health)
»» pportunist Roma culture / Roma survival strategy
O
»» oma fear of non-Roma outside of Roma settlements
R
»» oma lack opportunities (infrastructural, educational, subsistence, etc.) to
R
achieve non-Roma standards due to marginalisation by non-Roma and/or
due to Roma self-exclusion and/or due to usury flourishing within segregated
settlements
»» ack of fieldwork and edification being done in segregated Roma settlements
L
»» on-Roma lack knowledge regarding / under existing Roma life
N
»» issing / weak repression in place against Roma norms within segregated
M
settlements
»» ocial welfare is too generous, supporting Roma passivity
S
»» oma lack purpose in life without the opportunity to work / to own land
R
»» linical education, training and practice do not reflect the practical need for
C
additional / more specific working standards
»» etter functioning standards widely in use are not being officially acknowledB
ged and appropriately compensated (Superiors tend to turn a blind eye, while
colleagues who are themselves not involved tend rather to discourage on-going extra efforts.)
»» esting and practicing of better functioning standards is not controlled legally
T
and thus is risky (Superiors turn a blind eye and self-made behavioural models
of Roma specifics are being tested and imposed wilfully outside any formal
records.)

36


Aggressive Roma behaviour
»» oma opportunist culture / Roma survival strategy
R
»» oma disinterest in achieving or contempt for the non-Roma way of life (valuR
ing of rational order and security based on long-term planning)
»» oma fear of non-Roma outside Roma settlements
R
»» ereditary / acquired (mostly conflated) Roma mental incapacities (e.g. low
H
intelligence, chronic impatience, hysterical tendencies, touchiness, etc.)
»» ncreasing isolation of younger Roma teenagers from non-Roma due to
I
growing lack of opportunities; diminishing Roma knowledge of non-Roma
means and manners
»» rowing confidence of younger Roma (e.g. based on experiences from visiting
G
Western countries or following role models such as emerging Roma rappers)
»» oma retaliation for a history of racism on the part of younger Roma (e.g.
R
based on experiences from visiting Western countries or following role models
such as emerging Roma rappers)
»» eaction to lower qualification personnel decreasing the quality of service
R

Counselling and welfare workload beyond scope of profession
»» n addition to sources for Workload beyond the scope of the profession:
I
H
»» Roma disinterest in achieving or contempt for the non-Roma way of life (valuing of rational order and security based on long-term planning including with
respect to health)
O
R
settlements
L
M
settlements
»» ocial welfare is too generous, supporting Roma passivity
S
»» oma lack a purpose in life without the opportunity to work / to own land
R
»» ooperation with / work of social welfare authorities is unsatisfactory (e.g.
C
social welfare officers refuse to remove constantly neglected children from
families)

Andrej Belák

37

Low hygienic standards within segregated Roma settlements
H
»» oma disinterest in achieving- or contempt for the non-Roma way of life (valuR
ing of rational order and security based on long-term planning including with
respect to health)
O
R
settlements
L
M
settlements
»» ack of non-Roma fieldwork and edification in segregated Roma settlements
L
»» tate / municipal / public health / social welfare authorities’ neglect of Roma
S
settlements

Truly racist practices
»» mployment / non-reporting of psychologically troubled individuals or collectiE
ves by superiors / colleagues, respectively
»» oor functionality of clinical standards with respect to segregated Roma
P
»» alaries of lower qualification personnel approximate social welfare
S
allowances
»» navailability of psychological counselling for (lower qualification) personnel
U
»» nfair activist interpretations / media coverage of defensive racist practices
U
increases practitioners’ loyalty with truly racist perpetrators
»» bundance of public prejudices regarding Roma
A

38


General limitations in population health
Lack of experience in research
»» Political history of Slovak science under Communist rule (Science incompatible
with Marxist historical materialism used to be programmatically curbed by
state authorities.)
»» nertial loyalty within low quality research networks
I
»» oo few scientists with experience from abroad, yet
T

Public health’s subordination to politico-economical regimes
»» ack of understanding, both among the public and among specific decisionL
-makers, regarding the inherent incapability of public health to demonstrate
short-term effects (presenting a preventative approach)
»» ecreasing understanding, both among the public and among specific deciD
sion-makers, regarding the key role public health has played in achieving and
continues to play in maintaining the existing population health-status
»» ack of understanding, both among the public and among specific decisionL
-makers, regarding the key role of social determinants of health for improving
health status and health-status justice.
»» verestimation, both among the public and among specific decision-makers,
O
of the abilities of the market and of spontaneous civic activities (such as NGOs)
regarding public health
»» oyalty of many state public health experts regarding the diminishing of their
L
roles within state public health practice
»» bundance of prejudices regarding Roma among state public health experts
A
and practitioners

Andrej Belák

39

Roma specific limitations in population health
Poor functionality of population standards
»» n comparison to all other sedentary groups in the region, Roma populations
I
have always been occupying and adapting to niches avoided by the former –
hence, the tools made by the former for their own purposes are likely to lack
both uses in and understanding of the history of the latter
»» ystematic evaluation of failures missing from practice
S
»» iomedical population research has traditionally been conducted on behalf
B
of non-Roma (considering Roma isolation a threat to public health) and/or on
Roma (as an isolated population posing promising discoveries) rather than for
Roma (incorporating target population needs)
»» iomedical research ignores social scientific accounts of Roma specifics
B
»» onclusions from social scientific accounts of Roma specifics are not being
C
presented in a generally understandable language (e.g. excessive use of technical terminology and references to social scientific theories) and/or in forms
accessible from within the existing capacities of biomedical professions (e.g.
no time to read lengthy, thick descriptions)
»» egregated Roma present an unattractive population for private health-system
S
services and investors (given their poverty)

Escalated political connotations of Roma-related work
»» here has been a long history of failing attempts to level average segregated
T
Roma standards with those of non-Roma populations
»» ith Roma typically remaining mostly external to both such levelling attempts
W
as well as to discussions about their failures, the latter present arenas where
any positions (including those most extreme) are easily maintained by participants without suffering any of the real consequences such positions might
imply (e.g. various repressive or assimilative measures)
»» bundance of prejudices regarding Roma
A
»» he involved parties ignore existing social scientific accounts of Roma specifics
T
»» onclusions from social scientific accounts of Roma specifics are not being
C
presented in generally understandable language (e.g. excessive use of technical terminology and references to social scientific theories) and/or in forms
accessible from within most professions (e.g. no time to read lengthy, thick
descriptions)

40


Part 3.
Recommendations
“Our notions of ‘culture’, of ‘ethnic group’ or ‘people’
are so utterly rooted in the schemas derived from
practices of nation states (which are, or at least strive
to be, homogenous, neatly bounded entities) that
Romany communities appear as an anomaly.”

Andrej Belák

3

Michael Stewart (2011)

41

Part 3. Recommendations
HOW MIGHT WHO MAKE USE OF THIS PUBLICATION WITHIN THEIR ACTUAL
ASSIGNED COMPETENCIES?
FIRST, THE INACCURATE NATURE OF BOTH THE STUDY METHODS AND THE
EXPERIENCES IT HAS ATTEMPTED TO RECONSTRUCT NEED TO BE ACCOUNTED FOR. THE FOLLOWING RECOMMENDATIONS THUS BEGIN BY ADDRESSING ALL OWNERS OF HEALTH-SYSTEM OPERATIONS, PROPOSING TO THEM
A GENERAL STRATEGY FOR LOCAL VERIFICATION AND IMPLEMENTATION OF
WHAT THE STUDY CONSULTANTS WERE WILLING TO SHARE AND WHAT THIS
STUDY MADE FROM IT.
THEN, FOR BOTH PROFESSIONAL CONSIDERATION AND PUBLIC DISCUSSION, A NUMBER OF PRINCIPAL DILEMMAS ARE DESCRIBED THAT APPEAR
TO BE HINDERING PARTICULAR HEALTH-SYSTEM ACTORS FROM RESOLVING
SEVERAL OF THE IDENTIFIED LIMITATIONS THROUGH JOINT EFFORT BOTH
WITHIN AND ACROSS THEIR OPERATIONS AND AREAS OF PRACTICE. REFERENCES TO RELATED SCIENTIFIC LITERATURE ARE INCLUDED WHERE PARTICULAR INTERPRETATIVE ASSERTIONS MIGHT NOT BE GENERALLY KNOWN
OR ACCEPTED. WHERE ILLUSTRATIONS MIGHT HELP, SOME ADDITIONAL
DETAILS ARE SHARED FROM THE STUDY FIELD DATA WHICH DID NOT MAKE
IT INTO THE REPORT’S Findings.
THESE RECOMMENDATIONS SHOULD CERTAINLY NOT BE FOLLOWED BLINDLY. THEY ARE INTENDED RATHER AS AN INSPIRATION FOR CONSTRUCTION
OF RESOLUTIONS THAT MIGHT BETTER FIT PARTICULAR SETTINGS.

42


General strategy proposed for application
of the findings
1) Assess the presence of the limitation experiences
Owners of all health-system institutions are encouraged to review the types of limitations experienced listed in the study Findings. Then, the range to which particular types
of limitation experiences occur within their particular operations should be assessed.

For the attention of:
Owners and managements
of all health-system operations

Do your employees really think they are facing such or similar limitations? What proportions of which employees think they face which limitations and to what negative
effects?

2) Assess the presence of the limitations
The presence of the actual particular limitations confirmed as experienced within
particular operations needs to be assessed next.
Do your employees really face the limitations they think they face? What proportions of which employees do face which limitations and to what negative effects?

3) Explain aspects of the limitations not confirmed
Should some of the listed types of experienced limitations or some of their aspects not
be found significant within particular operations, such findings – including their possible
explanations – should be shared with both the general public and professional colleagues.
Which of your employees only think they face which (aspects of) limitations that do not
really exist and why? Which of the limitations do not exist within your operations and
why?

4) Discuss options regarding remaining limitations with
involved practitioners
Available options regarding remaining limitations confirmed as real within particular operations need to be reviewed and discussed with involved practitioners.
At this stage, the overreaching dilemmas identified by this study are advised for
review and inclusion into the discussions (Overreaching dilemmas for consideration).
Who can do what to help remove, shift or compensate for which of the limitations
employees face within your operations?

5) Decide upon, implement and evaluate options against
existing limitations
Options identified in the discussions should be decided upon, implemented
and evaluated. Outcomes of the evaluations carried out need to be shared with
both the general public and professional colleagues.
Who is going to make sure which remedial steps will be taken, including an evaluation of their effects?
Andrej Belák

43

Overreaching dilemmas for consideration
with respect to Roma health
For the attention of:
Owners and management
of all health-system operations, the general public,
state ministries, political
representatives, health
insurance companies,
universities, NGOs, donors,
patients’ advocate groups,
and the media

44

A generalised or varied understanding of health equity?
Health-status related circumstances in both urban and rural segregated Roma settlements in Slovakia are radically distant from those typical for other Roma and non-Roma
inhabitants. According to fragmentary authentic indices (Belák 2005; Belák 2013), people
living in such circumstances are likely to agree that the existing expert understandings of
health are generally reasonable and worth following in both their broad formal and more
constricted practiced versions (Beaglehole and Bonita 2004). They too, seem to value their
own ”complete well-being”, and they, too, seem to consider increased bodily capacities
to be a meaningful goal for everyone. Along with obvious deliberate Roma utilisations of
health care, such and similar findings thus conform to the common impression (e.g. among
NGO activists) that these people would also do everything just as everybody else to increase their health status – if they only had equal opportunities. Yet, drawing from identical
ethnographic data, the very same segregated Roma simultaneously seem to consider
and to refuse many such exactly equal opportunities as being principally too conflicting
with their own understanding of a life worth living (Belák 2005; Belák 2013). This eventuality is congruent not only with most other methodologically analogous accounts of
non-assimilated Roma from across Europe (Dion 2008; Gay Y Blasco 1999; Gmelch 1986;
Okely 2011; Stewart 1997; Stewart 2004; Stewart 2011; Tesăr 2012; Van Cleemput, et al.
2007; Vivian and Dundes 2004; Williams 2003), but now – thanks to the presented study
– it also seems to be reflected in the understanding of many health-system practitioners.


In their experience, despite a full understanding of the consequences and the direct availability of equal options, segregated Roma often choose preservation of their everyday
life circumstances over improvements in their health. In other words, equal opportunities might not be understood and availed of equally by segregated Roma based on
radical differences in their identities (Dressler, et al. 2005; Frohlich, et al. 2001; Popay,
et al. 1998; Whyte 2009). If this were indeed the case for substantial proportions of
segregated Roma, the project of curbing Roma health-status disparities might eventually start facing the same seeming paradox faced by the interviewed practitioners. How
should particular professionals in the health-system position themselves regarding such
an eventuality? Should the endorsement of health-status improvements also continue
via pressure on segregated Roma’s very understanding of the place of diseases within
their lives (e.g. through ”nudging” them toward education, as most consultants within
this research were prone to suggest)? In what respects? Based on what rights? Or should
the project limit itself to searching for ways of helping all Roma improve their health
status solely under the specific conditions some of them might prefer (as the latest WHO
and CSDH recommendations suggest in stressing ”respect” toward vulnerable groups)
(CSDH 2008; WHO 2013)? Even if the latter might mean a long-term or total acceptance
of a more heterogeneous health-status reality (depending solely on availability of acceptable means)? If so, what tools are there for detection and reconstruction of eventual
authentic Roma conditions (in contrast, e.g., to conditions imposed on them by previous
marginalisation or other forms of violence)(Bourdieu 2000)? Should such tools become
part of public health expertise (if so, then how?), or should individual consultation of
existing social science research remain the way to go (even though this does not seem to
be a practical enough option according to most consulted health-system practitioners)?

Generalised or varied sets of standards for health-system
practices?
Regardless of exactly what health-equity projects will ultimately decide to aim at, it
seems obvious that health-related circumstances in both rural and urban segregated
Roma settlements will remain radically distant from what the existing health system is
capable of efficiently supporting for at least another great number of years (e.g. guesses
of the consulted practitioners ranged from decades to forever). Given the documented
difficulties of the officially acknowledged, trained and valued generalised standards,
and the documented lack of expert, legal and economic support for better functioning
unofficial standards already in wide use, the question of whether the health system
should not systematically acknowledge and incorporate the latter, too, might become
legitimate. Should institutions comprising the health system start looking into ways of
equipping its personnel and processes with additional tools, ones better capable of dealing with present specifics of segregated Roma? If so, what tools for what specifics? Plus,
what about the possibility of such varied standards themselves preserving differences
that are opposed in the long-term? What measures might prevent such inadvertent
fixation of health inequities (Betancourt, et al. 2005; Kleinman and Benson 2006)?
Should these issues become part of the public health agenda (if so, then how?), or
should individual consultation of existing social science research remain the way to go
(even though this does not seem to be a practical enough option according to most
consulted health-system practitioners)?

Andrej Belák

45

A project titled “Healthy communities” involving community health fieldworkers
assigned specifically to segregated Roma settlements might present a great live
example for the above-described dilemma (ACEC; http://www.acec.sk/). As part of
the project, lay individuals directly from within segregated Roma settlements are
being trained and financially compensated variously to assist the health system
(including its underdeveloped health-equity agendas) directly in such places. Within
this study, to a direct question regarding variegation of available services on behalf
of segregated Roma (sometimes asked at the very end of the interviews), every one
of all consulted health-system practitioners across professions offered a positive
reply. When additionally asked about what kind of specific variegation of services
might be appropriate, the majority of interviewees either recalled an analogous
community health fieldwork service once operating during the Communist era or
came up with an identical idea themselves. Most of the visited practitioners expressed spontaneous interest in obtaining contacts for community health fieldworkers
being trained in the area of their service. As the project, now operating under governance of Platform for support of disadvantaged groups (http://www.ppzzs.sk/), has
lately gained official support and funding directly from the Slovak government, perhaps a well-suited opportunity opens up to evaluate within its operations all of the
above and further similar questions.

46


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