Roma health report, health status of the Roma population : data collection in the Member States of the European Union : executive summary.
Date: 2015-09-08
Institutions: Directorate-General for Health and Consumers
Subjects: EU Member State, European Union, Roma, data collection, health policy, public health, report, right to health

Roma Health Report 

Health status of the Roma population. 

Data collection in the Member States 

of the European Union 

Executive Summary 

Written by  

    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

© European Union, 2014 
The information and views set out in this report are those of the author(s) and do 
not necessarily reflect the official opinion of the Commission. The Commission does 
not  guarantee  the  accuracy  of  the  data  included  in  this  study.  Neither  the 
Commission  nor  any  person  acting  on  the  Commission’s  behalf  may  be  held 
responsible for the use which may be made of the information contained therein. 

ISBN 978-92-79-37903-1 
DOI 10.2772/31384 

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Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

Part 1 

Health Status of the  

Roma Population 

Executive Summary 

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Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

Executive Summary 

Introduction 

This  study  was  carried  out  by  Matrix  Knowledge  in  collaboration  with  the  Centre  for 
the  Study  of  Democracy,  the  European  Public  Health  Alliance  and  individual  national 
researchers  on  behalf  of  the  Consumers,  Health  and  Food  Executive  Agency  and  the 
DG  SANCO.  The  purpose  of  this  report  is  to  provide  an  evidence-based  review  of 
literature on Roma health, covering 2008–13 and the following indicators:  

1. 
2. 
3. 
4. 
5. 
6. 
7. 

Mortality and life expectancy; 
The prevalence of major infectious diseases; 
Healthy lifestyles and related behaviours; 
Access and use of health services and prevention programmes; 
The prevalence of major chronic diseases; 
Health factors related to the role of women in the Roma community; 
Environmental and other socio-economic factors. 

The  methodology  used  was  based  on  two  steps:  (i)  Desk  Research  based  on  the 
review  of  secondary  data  (a  literature  review);  and  (ii)  Fieldwork  collecting  primary 
data through semi-structured interviews.  

Background and context 

There  has  long  been  a  consensus  that,  compared  with  the  non-Roma  population  in 
Europe, Roma have poorer health. The poor health of Roma is closely linked to social 
determinants of health. The social inclusion and integration of Roma communities is a 
joint  responsibility  of  Member  States  and  the  European  Union.  The  Commission 
monitors  progress  made  by  Member  States  through  the  EU  Framework  for  National 
Roma Integration  Strategies1. The EU has been also supporting international network 
initiatives  e.g.  Roma  Summits  and  the  Decade  of  Roma  Inclusion  (2005–15).  The 
Enlargement Countries have been encouraged to shape their strategies to support the 
integration of Roma (including health) based on Commission Communication of 2011. 
Results  for  better  inclusion  of  the  Roma  population  have  been  limited2.  In  particular, 
issues related to health have been only partly addressed.  

The first Commission assessment of the NRIS reported some limitations regarding the 
possibility  of  measuring  the  potential  impacts  of  the  stated  objectives3.  There  is  a 
need  to  establish  specific  targets,  attainable  goals  within  the  time  frame  set  and 
measureable deliverables through an effective system of monitoring and evaluation of 
the  implementation  of  the  national  policies4.  The  second  assessment  of  the 
Commission  in  June  2013  reiterated  that  Member  States  need  to  make  stronger 
efforts  to  set  up  sound  monitoring  and  evaluation  methods  to  assess  the  results  and 

1  COM/2012/0226  final  Communication  from  the  Commission  to  the  European  Parliament,  the 
Council,  the  European  Economic  and  Social  Committee  and  the  Committee  of  the  Regions 
National Roma Integration Strategies: a first step in the implementation of the EU Framework.  
2 Council Conclusions 10658/11: ‘An EU Framework for National Roma Integration Strategies up 
to  2020’.COM(2011)  173  ‘EU  Framework  for  National  Roma  Integration  Strategy’  and 
COM(2013) 454 final: ‘Steps forward in implementing a national Roma integration Strategy’. 
3 COM(2012) 226: ‘National Roma Strategy Integration and COM(2013) 454: ‘Steps forward in 
implementing a national Roma integration Strategy’. 
4 SEC(2009) 92 Impact Assessment Guidelines, European Commission (2009). 

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impacts  of  Roma  inclusion  measures,  including  health,  in  order  to  enable  policy 
adjustments when necessary5. 

Roma Health Status Findings  

Mortality and life expectancy 

There  is  consistent  evidence  demonstrating  that  the  Roma  population  has  a 
considerably shorter life expectancy compared to the non-Roma population. Indeed for 
many  years,  published  information  has  persistently  shown  that  the  Roma  population 
has  a  markedly  lower  life  expectancy  than  the  general  population6.  The  gap  in 
longevity  may  be  a  decade  or  more.  Data  is  less  able  to  explain  the  cause(s)  of  the 
difference  between  Roma  and  non-Roma  health  and  to  sufficiently  explore  issues 
around the impact of specific social determinants on particular health outcomes.  

In Austria regional estimates suggest that the mortality rate for Roma at regional level 
is  14 %  higher  than  for  the  rest  of  the  country7.  In  Slovakia  the  biggest  gap  in  life 
expectancy  is  present  in  segregated  and  secluded  areas  of  Roma  settlements  with 
poor living conditions and it is estimated  that mortality rates in such settlements  are 
twice or three-times higher compared to integrated Roma8. 

Across the countries data on life expectancy for Roma populations was available for 12 
of 31 countries with estimates ranging from 7–20 fewer years of life.  

Comparatively  higher  rates  of  infant  mortality  among  Roma  have  been  observed  in 
Bulgaria,  Slovakia,  Hungary  and  the  Czech  Republic.  High  infant  mortality  among 
Roma was also observed in Italy, however the data is outdated. In the Czech Republic, 
at least one study9 illustrates the relationship between higher infant mortality among 
Roma  and  socio-economic  conditions,  with  a  high  incidence  of  risk  factors  among 
pregnant  women,  especially  smoking  during  pregnancy  (57 %10),  and  poor 
environmental  conditions;  especially  housing.  These  socio-economic  conditions  and 
health  behaviours  increase  the  relative  risk  of  lower  birth  weight  and  other  non-
favourable outcomes11 12. In Hungary data also suggests a link between relatively high 
infant mortality rates and social determinants of health. 

Prevalence of major infectious diseases 

For more than half of the countries with a Roma population, the data on their health 
status  and  disease  prevalence  is  lacking,  and  in  the  remaining  countries  the  data  is 

5 COM(2013) 454: ‘Steps forward in implementing a national Roma integration Strategy’. 
6 e.g., The Council of Europe, The World Bank . 
7 Austria country profile. 
8 Zdravotná starostlivosť v sociálne vylúčených rómskych komunitách, 2007, p. 28. 
9 Rambouskova J. a kol. Stravovací zvyklosti romských těhotných žen, (Eating habits of Gypsy 
pregnant women), Hygiena, 48, 2003, No.4, p. 187-193. 
10 Rambouskova J. a kol. Stravovací zvyklosti romských těhotných žen, (Eating habits of Gypsy 
pregnant women), Hygiena, 48, 2003, No.4, p. 187-193. 
11 Bobak, M., et al, Unfavourable birth outcomes of the Roma women in the Czech Republic and 
the potential explanation: a population-based study, BMC Public health, 2005, 5, 106. 
12 Mihailov, D. The Health Situation of Roma Communities, Analysis of the UNDP/World Bank/EC 
Regional Roma Survey Data, UNDP, 2011. 

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often fragmented.  Quantitative data tend to be limited to specific localised outbreaks 
or  vaccination  uptake.  Available  studies  have  shown  a  higher  rate  of  infectious 
the  majority  population13  and  Roma  are 
diseases  amongst  Roma 
disproportionately  affected  by  communicable  diseases  (particularly  in  segregated 
communities).  This  is  linked  to  living  conditions,  health  perceptions  and  behaviour, 
limited  inclusion  in  prevention  programmes  such  as  vaccination  programmes,  and 
entrenched discrimination14. The problem is not confined to specific countries. 

than 

A  significant  amount  of  data  on  the  prevalence  of  measles  and  TB  within  Roma 
communities  relates  either  to  specific  outbreaks  or  to  regional  cohorts  and  may 
therefore  reflect  marginalised  Roma  health.  No  country  systematically  collects  and 
reports comprehensive data or evidence of Roma health status for the major infectious 
diseases  covered  in  this  study.  The  European  Centre  for  Disease  Prevention  and 
Control  has  up-to-date  data  on  (inter  alia)  measles  outbreaks  but  it  is  not  ethnically 
disaggregated. 

Roma in Bulgaria are especially vulnerable to outbreaks of measles and hepatitis A, B 
and  C,  while  rates  of  HIV  infection  have  been  evidenced  amongst  the  most  socially 
excluded  Roma,  such  as  prisoners,  drug  addicts  and  prostitutes.  An  outbreak  of 
measles in this country registered in 2009 found 89.3 % of the 24 047 people affected 
were  of  Roma  origin  and  22  out  of  the  24  deaths  were  Roma  patients15.  Interviews 
with  health  practitioners  have  uncovered  frequent  outbreaks  of  hepatitis  A  in 
geographically  isolated  Roma  communities  with  overpopulation  of  Roma  settlements 
and  households  making  it  more  difficult  to  isolate  hepatitis  A  virus  carriers,  and  as 
such infections frequently turn into epidemics16. 

A  study  of  five  Italian  cities  found  risk  factors  associated  with  diarrhoea,  cough  and 
respiratory  difficulties17.  Camp-related  risk  factors  included  water  stagnating,  size  of 
camp  (population  density),  the  presence  of  rats  and  prolonged  stays.  Household-
related  risk  factors  included  poor  housing  conditions,  overcrowding, no  indoor  access 
to sanitation and the use of wood-burning stoves. 

A  study  amongst  injecting  drug  users  (IDUs)  found  the  highest  prevalence  of  HIV 
infection and TB was within the Roma population18. The Roma population is the largest 
ethnic minority among HIV-infected patients registered in the Spanish VACH Cohort19. 
In this cohort, HIV disease progressed faster to Aids (and to death) in Roma than non-
Roma. 

13  Save the Children via Roma Inclusion  Working Papers  UNDP  Europe and  the  CIS,  Bratislava 
Regional  Centre,  The  health  situation  of  Roma  communities:  Analysis  of  the  data  from  the 
UNDP/World Bank/EC Regional Roma Survey, 2012. 
14  ECDC  Meeting  Report  Communicable  disease  prevention  among  Roma  Vienna,  27–29 
November 2011. 
15  Mira  Kojouharova,  NCIPD,  Bulgaria,  Measles  outbreak  in  Bulgaria,  2009–10,  2010,  National 
Centre of Infectious and Parasitic Diseases, Bulgaria. 
16  Ilona  Tomova,  The  Health  Status  of  Roma  in  Europe.  National  Report  on  Bulgaria,  2009, 
Foundation, The health of Romany people, Sliven, Bulgaria. 
17  Monasta,  L,  N.  Andersson,  R.  J.  Ledogar,  A.  Cockcroft,  Minority  Health  and  Small  Numbers 
Epidemiology: A Case Study of Living Conditions and the Health of Children in 5 Foreign Roma 
Camps in Italy, American Journal of Public Health, 2008 available at  
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636417/pdf/2035.pdf 
18  Roma  Inclusion  Working  Papers  UNDP  Europe  and  the  CIS,  Bratislava  Regional  Centre,  The 
health  situation  of  Roma  communities:  Analysis  of  the  data  from  the  UNDP/World  Bank/EC 
Regional Roma Survey, 2012. 
19  The  VACH  cohort  is  a  prospective-recruited  Spanish  cohort  currently  made  of  10  800  HIV-
infected adult patients from 19 hospitals across Spain. 

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Vaccination uptake is not consistent across Member States. In some countries levels of 
vaccinations  are  almost  comparable  to  the  general  population  (HR,  HU  and  CZ20). 
Other  country  findings  suggest  (anecdotally)  comparatively  low  levels  of  vaccination 
rates (BG, FR, EL, DE, IT, LU, PL, RO, SK and the UK). This group of countries includes 
the countries with the highest levels of migrant Roma.  

A  little  over  half  of  the  Roma  population  in  Slovakia  have  received  some  sort  of 
vaccination,  whereas  the  vaccination  rates  among  the  majority  population  is  up  to 
99 %.  They  find  it  more  difficult  to  access  general  health  services,  there  is  irregular 
contact with general practitioners and other health practitioners, and there is a lack of 
awareness  about  the  importance  of  vaccination  and  useful  information.  In  2007 
Slovakia  adopted  a  programme  focused  on  the  improvement  of  Roma  health21,  but 
this programme is currently on hold due to lack of financial resources. 

Romania suggests 45.7 %  of Roma  children did not receive all of the  mandatory and 
free-of-charge  vaccines  included  in  the  National  Immunisation  programme  and  more 
than  50 %  of  them  did  not  receive  even  one  vaccination22.  The  Bulgarian  National 
Health  Strategy  found  that  15 %  of  Roma  children  is  without  complete  mandatory 
vaccinations23 (likely to be much higher in isolated communities).  

French data strongly links Roma vaccinations and outbreaks to social conditions. Low 
vaccination rates (38.9 % in 2010 in under 30-year-olds24), poor living conditions and 
low  access  to  preventative  healthcare  all  contribute  to  an  easier  spread  of 
communicable  diseases  such  as  TB  amongst  Roma  in  France25,26.  Evictions  and 
deportation  mean  no  continuity  of  care  which  results  in  poor  compliance  with 
medication  and  lack  of  effective  monitoring  and  follow  up.  This  is  a  matter  of  great 
concern,  since  incomplete  treatment  can  lead  to  multi-resistant  TB27  and  worse 
outcomes.  

Healthy lifestyles and related behaviours 

Smoking  prevalence  levels  are  consistently  higher  in  Roma  than  non-Roma 
communities. Mixed findings indicate significantly lower illicit drug use amongst Roma 
communities,  although  overall  there  appear  to  be  a  number  of  cultural  factors  which 
have a negative impact on the lifestyles of Roma. 

20 UNDP: UNDP-WB-European Commission regional Roma survey 2011. 
21 Programme of health support of disadvantaged communities in Slovakia for years 2009–15 — 
Second phase. Available at 
http://www.uvzsr.sk/docs/info/podpora/romovia/romovia_2_etapa.pdf 
22  Wamsiedel,  M.  &  al.,  Health  and  Roma  community  –  analysis  of  the  situation  in  Romania, 
Fundacion Secretariado Gitano, Madrid, 2009. 
23  Council  of  Ministers  of  Republic  of  Bulgaria,  National  Health  Strategy  for  Disadvantaged 
Persons Belonging to Ethnic Minorities, 2005, Sofia, Bulgaria. 
24  Médecins  du  Monde  (2011),  Rapport  d’enquête  sur  la  couverture  vaccinale  des  populations 
Roms  rencontrées  par  les  équipes  de  Médecins  du  Monde  en  France,  Rapport  de  la  Direction 
des Missions France, 22p. 
25 Médecins du Monde (2012), Actions mobiles auprès des Roms, 2011, not published. 
26 Halfen, S. (2012) Situation sanitaire et sociale des 'Roms migrants' en Île-de-France, Rapport 
de l’Observatoire régional de santé d’Ile-de-France, 144p. 
27 Halfen, S. (2012) Situation sanitaire et sociale des 'Roms migrants' en Île-de-France, Rapport 
de l’Observatoire régional de santé d’Ile-de-France, 144p. 

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Roma  tend  to  have  illnesses  associated  with  poor  diet  and  stress28.  Depression  and 
psychosomatic  complaints  are  common  and  there  is  a  high  frequency  of  eye  and 
dental problems, which can be attributed to poor diet and malnutrition29. Poor health 
and an unhealthy lifestyle are significant problems associated with low income30. Some 
data  on  this  indicator  is  robust  and  illustrative;  for  example  from  the  UNDP  and  FRA 
surveys with a strong correlation between social exclusion and illicit drug use. 

A further study found only five countries (HR, FI, IE, LV and LT) included interventions 
targeted  specifically  at  Roma31.  All  countries  indicated  vulnerability  for  Roma  beyond 
non-Roma populations. A recent (but not representative) survey of adolescents (aged 
13–16) in Hungary who already used drugs found a large difference between the rate 
of drug use among Roma (22 %) and non-Roma (2 %)32. 

Small-scale  qualitative  studies  in  Ireland  based  on  interviews  and  focus  groups  show 
the Roma population is more likely to exhibit these risk behaviours and are less aware 
of  drug  side-effects  and  the  related  health  services  available33.  In  the  UK  there  are 
reports of rising numbers of young men from Central and Eastern Europe who require 
intervention for heroin and cocaine dependency. The Roma community and non-Roma 
from  Eastern  European  Countries  account  for  10 %  of  referrals  to  the  specialist  drug 
treatment centre for heroin dependency34. 

Tobacco use has a strong association with lower levels of education35. Our indications 
demonstrate  that  these  patterns  can  also  be  found  in  Roma  communities.  Higher 
smoking prevalence for Roma communities has been found in  nine countries (AT, HR, 
CZ, SK, BG, HU, IE, PT and RO)36. The UNDP/WB/EC Regional Roma Survey in Croatia 
observed 52 % more Roma smokers than non-Roma in Croatia37. Evidence from UNDP 
et  al  also  suggests  that  Roma  less  frequently  quit  smoking  (and  later  in  life)  than 

28  FRA  Country  thematic  studies  on  the  situation  of  Roma,  June  2013.  Available  at: 
http://fra.europa.eu/en/country-data/2013/country-thematic-studies-situation-roma 
29 FRA Country thematic studies on the situation of Roma, June 2013. Available at:  
http://fra.europa.eu/en/country-data/2013/country-thematic-studies-situation-roma 
30  M.  Benzeval,  et  al  Fiscal  Studies  (2000)  vol.  21,  no.  3,  pp.  375–399  ©  Institute  for  Fiscal 
Studies,  2000,  Evidence  on  the  Relationship  between  Low  Income  and  Poor  Health:  Is  the 
Government Doing Enough? 
31 Drug prevention interventions targeting minority ethnic populations: issues raised by 33 case 
studies EMCDDA, Lisbon, April 2013. 
32  Gerevich  J.,  Bácskai  E.,  Czobor  P.,  Szabó  J.  (2010),  Substance  use  in  Roma  and  non-Roma 
adolescents, The Journal of nervous and mental disease Volume: 198, Issue: 6, pp. 432–436 
33  Van  Hout,  M.  and  Connor,  S.  (2008),  The  Normalisation  of  Substance  Abuse  Among  Young 
Travellers in Ireland, Journal of Ethnicity in Substance Abuse, Vol. 7, No 1, pp. 5–21. 
Van  Hout,  M.  (2009),  Irish  travellers  and  drug  use  –  an  exploratory  study,  Ethnicities  and 
Inequalities in Health and Social Care, Vol. 2, No 1, pp. 42–49. 
Van Hout, M. (2010a), Alcohol use and the Traveller community in the west of Ireland, Drug and 
Alcohol Review, Vol. 29, No 1, pp. 59-63. 
Van  Hout,  M.  (2010b),  Traveller  health  and  primary  care  in  Ireland:  a  consultative  forum, 
Community Practitioner, Vol. 85, No 5, pp. 27–30. 
Van  Hout,  M.  (2011),  Assimilation,  habits  and  drug  use  among  Irish  Travellers,  Critical  Public 
Health, Vol. 21, No 2, pp. 203–-220. 
Van Hout, M. and Staniewicz, T. (2012), Roma and Irish Traveller housing and health — a public 
health concern, Critical Public Health, Vol. 22, No 2, pp. 193–207. 
34 Winyard and Felja 2010, Children of Roma Druglink Vol 25 Issue 6 November/December 2010 
35 Eurostat 
36  Yet  the  Czech  profile  also  suggests  that  self-reported  numbers  slightly  differ  in  different 
sources, which may well be the case in other countries too. 
37 UNDP: UNDP-WB-European Commission regional Roma survey 2011. 

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nearby communities38. Pregnant women admitted to smoking in pregnancy – 58 %, in 
comparison with 20 % of non-Roma pregnant women. 85 % of pregnant Roma women 
reported smoking before pregnancy39. In the UK, from a sample of 260, 64 % of 16–
35  year  old  Gypsy  Travellers  were  current  smokers  compared  to  26 %  of  the  control 
group40.  

The  UNDP  et  al  surveys  suggest  that  the  real  health  problems  of  Roma  are  only 
perceived  once  they  reach  acute  forms  and  are  strongly  linked  to  access  to  health 
services and the level of health knowledge and culture41. UK research attributes poor 
diet  amongst  Central  and  Eastern  European  Roma  in  Leeds  to  poverty  and  a  lack  of 
money to buy fresh fruit and vegetables42. 

Access and use of health services and prevention programmes 

The  data  collected  by  this  study  identify  multiple  barriers  which  impact  on  Roma 
access to health care and services. 

Language, literacy and health system knowledge 

These barriers have been widely reported and are likely to have the largest impact on 
migrant  Roma.  Small-scale  studies  from  multiple  sources  and  evaluations  in  the  UK 
illustrate many of these issues, which are likely to be applicable to other countries.  

The  London-based  Roma  Support  Group’s  evaluation  of  its  three  year  Mental  Health 
Advocacy  Project  (2012)43  found  recurring  themes  of  barriers  to  mental  health 
services  including  a  lack  of  knowledge  of  the  existence  of  mental  health  services, 
communication, language and literacy barriers and the stigma of mental health issues. 
In the UK issues such as a lack of a postal address, having to travel long distances to 
visit their GP and evictions due to a lack of authorised sites are all relevant44. 

Data collection in Finland indicates that Roma tend to use health services less than the 
general  population  due  to  linguistic  and  cultural  differences  as  well  as  lack  of 
knowledge  of  their  entitlements  concerning  welfare  issues  and  available  services45. 

38  Mihailov,  Dotcho,  The  health  situation  of  Roma  communities:  Analysis  of  the  data  from  the 
UNDP/World Bank/EC Regional Roma Survey 2011. Roma Inclusion Working Papers. Bratislava: 
United Nations Development Programme, 2012. 
39 Davidova E. a kol. Kvalita života a sociální determinanty zdraví u Romů v České a Slovenské 
republice (The Quality of Life from the Aspect of Health Determinants in the Roma in the Czech 
and Slovak Republics), TRITON, 2010. 
40  Glenys  Parry,  Patrice  Van  Cleemput,  Jean  Peters,  Stephen  Walters,  Kate  Thomas,  Cindy 
Cooper,  (2007),  Health  status  of  Gypsies  and  Travellers  in  England,  Journal  of  Epidemiologic 
Community Health 2007; 61:198–204. 
41  Mihailov,  Dotcho,  The  health  situation  of  Roma  communities:  Analysis  of  the  data  from  the 
UNDP/World Bank/EC Regional Roma Survey 2011. Roma Inclusion Working Papers. Bratislava: 
United Nations Development Programme, 2012. 
42  Cath  Mahoney  (2006),  Roma  Families  in  Leeds.  A  social  audit  of  their  situation  needs  and 
services, Traveller Health Partnership. 
43  Smolinska-Poffley, G., Ingmire, S.  (2012),  Roma Mental  Health Advocacy Project  Evaluation 
Report, Roma Support Group. 
44  Clark,  C.,  and  Greenfields,  M  (2006),  Here  to  Stay,  The  Gypsies  and  Travellers  of  Great 
Britain, University of Hertfordshire Press. 
45 Ministry of Social Affairs and Health, (2009), The proposal of the working group for a national 
policy on Roma — working group report. Available at: 
http://ec.europa.eu/justice/discrimination/files/roma_finland_strategy_en.pdf  

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German  literature  draws  attention  to  mistrust  of  health  providers  and  personnel, 
limiting access to health services by Roma and Sinti46.  

Discrimination and trust 

Reports  on  discrimination  or  fear  of  discrimination  (self-assessed)  or  cultural  barriers 
preventing access to health care are also found in France47, Sweden48, Slovakia49 and 
Poland50. In addition, access to social services requires residency registration, which in 
the  case  of  Roma  in  Poland  was  reported  to  potentially  represent  a  deterrent,  given 
their nomadic habits51.  

Identification and insurance 

Another  reported  barrier  is  a  lack  health  insurance  cards  or  ID  documents  for 
countries  without  universal  health  care  access.  Non-insured  Roma  may  have  access 
only to emergency care but cannot use other health services. Countries where health 
insurance  data  suggest  Roma  are  disadvantaged  include  Belgium52,  Bulgaria53, 
Croatia54,  France55  56  57  and  Germany58.  In  France  Romanian  and  Bulgarian  nationals 
are  only  allowed  to  stay  in  France  for  over  three  months  if  they  either  hold  a  valid 
work  permit  or  have  enough  funds  to  live  in  France  without  being  a  burden  to  the 

Available 

åtgärder. 

46  European  Parliament  (2011)  Measures  to  promote  the  situation  of  Roma  EU  citizens  in  the 
European Union — Study. Available at: 
http://www.europarl.europa.eu/committees/en/libe/studiesdownload.html?languageDocument=
EN&file=34328  
47  ASAV,  AREAS,  Médecins  du  Monde,  Romeurope,  (2012),  Projet  de  Médiation  santé  en 
direction de femmes et jeunes enfants Roms, Rapport final, 59p. 
48  Statens  Folkhälsoinstitut  (2010)  Hur  mår  Sveriges  nationella  minoriteter?  Kartläggning  av 
hälsosituationenen  bland  de  nationella  minoriteterna  samt  förslag  till  forebyggande  och 
hälsfråamjande 
at: 
http://www.fhi.se/Documents/Omoss/redovisadeuppdrag/2010/Aterrapportering_regeringsuppd
rag_nationella_minoriteters_halsa.pdf 
49 Popper, M., Szeghy, P., Šarkozy, S. (2009), Roma population and health: Analysis of situation 
in Slovakia, p. 70. 
50 Puckett, L.S., Barriers to access: Social services and the Roma of Poland, International Social 
Work 2005 48: 621. 
51 Puckett, L.S., Barriers to access: Social services and the Roma of Poland, International Social 
Work 2005 48: 621. 
52 Regional Integration Centre - Le Foyer (RIC-Le Foyer) (2004), Les Roma de Bruxelles, RIC-Le 
Foyer, Bruxelles. 
53 UNDP UNDP-WB-European Commission regional Roma survey 2011. 
54 UNDP UNDP-WB-European Commission regional Roma survey 2011. 
55  Romeurope (2012),  Les  Roms,  boucs-émissaires  d’une  politique  sécuritaire  qui  cible  les 
migrants  et 
l’Homme 
Romeurope,30p. 
56 Halfen, S. (2012) Situation sanitaire et sociale des 'Roms migrants' en Île-de-France, Rapport 
de l’Observatoire régional de santé d’Ile-de-France, 144p. 
57  JORF  (2012).  Arrêté  du  1er  octobre 2012  modifiant  l'annexe  de  l'arrêté  du  18  janvier  2008 
relatif  à  la  délivrance,  sans  opposition  de  la  situation  de  l'emploi,  des  autorisations  de  travail 
aux ressortissants des Etats de l'Union européenne soumis à des dispositions transitoires, JORF 
n°0240, 14 October 201, p. 16060,No 14. 
58  Bundesministerium  des  Innern  (2011)  An  EU  Framework  for  national  Roma  Integration 
Strategies  up  to  2020  –  Integrated  packages  of  measures  to  promote  the  integration  and 
participation 
from: 
http://ec.europa.eu/justice/discrimination/files/roma_germany_strategy_en.pdf  

les  pauvres,  Rapport  2010–11,  Collectif  National  Droits  de 

Germany. 

Available 

Roma 

Sinti 

and 

of 

in 

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Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

French social security system, which means subscribing to private health insurance59 60 
61 62 63. 

Physical barriers – mobility and distance 

Associated  evictions 
for  political  and  sanitary  reasons  have  major  negative 
consequences for Roma health, for their eligibility for social health protection and thus 
for  their  access  to  health  services  and  effective  use  of  health  care64  65.  The 
administrative  steps  required  for  social  health  protection  and  the  links  with  health 
professionals are interrupted and broken in these cases. 

In  the  Czech  Republic  Roma  reported  more  obstacles  to  access  health  care,  however 
care  utilisation  is  higher  (44 %)  than  non-Roma  (28 %),  34 %  at  least  once  a  year 
and 23 % less than once a year (number of visits does not differentiate among GPs or 
specialists66).  Some  studies  state  that  in-patient  ward  or  emergency  wards  are  more 
frequently  used  by  Roma  than  the  majority  population,  others  conclude  higher 
frequency doctors’ visits by Roma (only General Practitioners)67.  
– 
An  Irish  study68  found  the  Traveller  population  makes  greater  use  of  Accident  and 
Emergency  (Casualty)  services,  consistent  with  higher  rates  of  non-accidental  injury. 
FRA  also  confirms  a  high  utilisation  rate  of  Casualty  services,  paediatrics  and 
obstetrics69.  But  the  ‘All  Ireland  Travel  Health  Study’  reports  a  lower  level  of 
assistance  was  granted  to  Traveller  children  for  a  problem  needing  attention  (8.3 %) 
in  comparison  with  similar  situations  in  the  sedentary  population  (2.8 %)70.  The 
reason given is fear of lack of payment for care. 

Prevalence of major chronic diseases 

In  the  context  of  this  report,  major  chronic  diseases  include  heart  disease,  stroke, 
cancer, diabetes and arthritis. Taking into account the demography of Roma, the data 
indicates higher incidence of major chronic diseases in the Roma community compared 
to the general population. 

59  Romeurope (2012),  Les  Roms,  boucs-émissaires  d’une  politique  sécuritaire  qui  cible  les 
migrants  et  les  pauvres,  Rapport  2010–11  Collectif  National  Droits  de  l’Homme  Romeurope, 
30p. 
60  Amnesty  International  (2013),  Facts  of  shame.  Discrimination,  forced  evictions,  segregation 
and  violence  against  Roma  in  the  European  Union,  Public  Statement,  4.4.2013,  AI  Index: 
01/008/2013, 2p. 
61 Halfen, S. (2012) Situation sanitaire et sociale des 'Roms migrants' en Île-de-France, Rapport 
de l’Observatoire régional de santé d’Ile-de-France, 144p. 
62 Médecins du Monde (2011), Parias, les Roms en France, Dossier de Presse, 15p. 
63  Amnesty International (2013),  The  rhetoric and  reality of Roma  rights, OP-ED,  4.4.2013,  AI 
Index EUR 01/009/2013, 2p. 
64 Médecins du Monde (2011), Parias, les Roms en France, Dossier de Presse, 15p. 
65 Médecins du Monde (2007), Les Roms que l’Europe laisse à la porte, 30p. 
66  Nesvadbová,  L.,  Sandera,  J.,  Haberova,  V.:  Romská  populace  a  zdraví,  Česká  republika  - 
Národní zpráva 2009, (Roma population and health, the Czech Republic, National report 2009). 
67 Davidova E. a kol. Kvalita života a sociální determinanty zdraví u Romů v České a Slovenské 
republice (The Quality of Life from the Aspect of Health Determinants in the Roma in the Czech 
and Slovak Republics, TRITON, 2010. 
68  All  Ireland  Traveller  Health  Study  (2010),  Technical  Report  I.  Available  at:  http://www. 
dohc.ie/publications/aiths2010/TR1/AITHS2010_TechnicalReport1_LR_All.pdf?direct=1  
69  FRA  Country  thematic  studies  on  the  situation  of  Roma,  June  2013.  Available 
at:http://fra.europa.eu/en/country-data/2013/country-thematic-studies-situation-roma. 
70 National Longitudinal Study of Childhood. 

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The  Regional  Roma  Survey  data  found  Roma’s  perceived71  health  status72  is 
comparatively  close  to  non-Roma.  A  real  world  comparison  of  actual  health  found 
17 %  of  Roma  suffered  from  one  or  more  chronic  disease,  while  the  equivalent 
number was 18 % for non-Roma73 74. However, the UNDP findings indicate that Roma 
in  the  older  age  groups  (65+)  report  a  much  steeper  increase  in  chronic  disease-
related  problems  (70 %  compared  to  56 %  for  non-Roma75).  These  trends  were 
mirrored  in  a  Madrid  study  published  in  2006  for  cholesterol,  depression,  stomach 
ulcers  and  migraine  headaches.  It  found  Roma  over  the  age  of  35  suffer  from  these 
conditions in greater proportions than the general population. In some cases this was 
also true for younger age groups76.  

A report from Luxembourg found sub-standard housing conditions. Forty-five per cent 
of Roma lived in households lacking at least one basic housing amenity and 90 % lived 
in  households  with  an  income  below  national  poverty  lines.77  In  the  context  of  social 
determinants for health, poor diet and malnutrition can contribute to diseases such as 
obesity, hypertension, diabetes and chronic heart disease, while damp, cold and poor-
quality  housing  can  contribute  to  respiratory  diseases  such  as  asthma  and  bronchitis 
or  musculoskeletal  diseases,  such  as  rheumatoid  arthritis78.  Specific  health  problems 
suffered by Roma in Hamburg are heart disease, asthma and rheumatism. Obesity and 
associated  health  problems  such  as  metabolism  disorder  and  hypertension  are  of 
concern within the migrant Roma population79. According to the Polish NRIS, Roma are 
especially at risk of developing diabetes, cardiovascular and respiratory diseases such 
as asthma, bronchitis and pneumonia as a result of catastrophic social situations80. 

Slovak  Roma  in  the  UK  have  been  found  to  have  high  rates  of  type  two  diabetes 
mellitus, cardiovascular disease, premature myocardial infarction, obesity and asthma, 
and  it  is  common  for  Roma  to  have  undiagnosed  health  conditions81.  Nearly  half  of 
Roma respondents to a survey in Leeds reported someone in their house was suffering 

71 Perceived — i.e. replies to surveys are based on personal perception and attitudes. 
72 Covering EU countries the Bulgaria, Croatia, Czech Republic, Hungary, Romania and Slovakia. 
73  Asthma;  Chronic  bronchitis,  chronic  obstructive  pulmonary  disease  (COPD), or  emphysema; 
Hypertension  (high  blood  pressure);  Long-standing  problems  with  muscles,  bones  and  joints 
(rheumatism, arthritis); Chronic anxiety or depression; Diabetes. 
74  Roma  Inclusion  Working  Papers  UNDP  Europe  and  the  CIS,  Bratislava  Regional  Centre,  The 
health  situation  of  Roma  communities:  Analysis  of  the  data  from  the  UNDP/World  Bank/EC 
Regional Roma Survey, 2012. 
75  Roma  Inclusion  Working  Papers  UNDP  Europe  and  the  CIS,  Bratislava  Regional  Centre,  The 
health  situation  of  Roma  communities:  Analysis  of  the  data  from  the  UNDP/World  Bank/EC 
Regional Roma Survey, 2012. 
76 Hacia la Equidad en Salud. Disminuir las Desigualdades en una Generación en la Comunidad 
Gitana.  Estudio  comparativo  de  las  Encuestas  Nacionales  de  Salud  a  población  gitana  y 
población general de España. 
77 European Union Agency for Fundamental Rights, 2012 UNDP, 2012 The situation of Roma in 
11  EU  Member  States  Survey  results  at  a  glance.  Luxembourg:  Publications  Ofﬁce  of  the 
European Union, 2012, p. 12. 
78  Ministry  of  Social  Affairs  and  Health,  The  (2009)  The  proposal  of  the  working  group  for  a 
national policy on Roma – working group report. Available from: 
http://ec.europa.eu/justice/discrimination/files/roma_finland_strategy_en.pdf  

Poland 

79  FRA  Country  thematic  studies  on  the  situation  of  Roma,  June  2013.  Available  at: 
http://fra.europa.eu/en/country-data/2013/country-thematic-studies-situation-roma. 
80 
Integration 
http://ec.europa.eu/justice/discrimination/roma/national-strategies/ 
81  Lizzie  Moore  (2010).  A  Healthcare  Needs  Assessment  of  the  Slovak  Roma  Community  in 
Tinsley, Sheffield, University of Sheffield 

Strategy, 

Available 

National 

Annex 

Roma 

6. 

at 

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Roma health in the Member States  

from  a  long-term  health  condition82.  More  than  half  of  the  population  of  Romanian 
Roma in Madrid over the age of 45  were found to suffer from disabilities or a chronic 
disease83. 

The  2011  Census  reports  Irish  Travellers  had  higher  rates  of  disability  than  the 
general population. FRA confirms this finding, explaining that the Traveller population 
is  affected  by  nutrition-related  illnesses  such  as  higher  rates  of  diabetes  mellitus, 
hyperlipidaemia,  coronary  artery  disease  and  obesity84.  It  should  also  be  noted  that 
the  more  socially  excluded  Roma,  living  in  poor  conditions,  seem  to  use  health 
services  less  frequently,  hence  the  actual  number  of  people  suffering  from  chronic 
diseases could be higher than the number diagnosed (as it may go unrecorded). 

Roma  in  France  do  not  seem  to  have  access  to  tailored  prevention  programmes  for 
chronic diseases in their own language. With delays in follow-up care, chronic diseases 
are not managed effectively and flare ups are more frequent leading to a worsening of 
the global health status of patients85 86 87. 

Health factors related to the role of women in the Roma community 

There is a lack of research dedicated to understanding Roma women’s health. Recent 
(2013)  FRA  data  on  Roma  women’s  health  is  the  most  comprehensive  European 
source  and  underlines  that  Roma  women  are  generally  in  worse  health  and  more 
disadvantaged  than  Roma  men  and  non-Roma  alike.  Available  data  and  small-scale 
studies both highlight a range of additional barriers to improve health amongst Roma 
women. Poor maternal health is a particular risk for Roma women. 

Research  concludes  that  Roma  women  are  often  overlooked  in  health-related 
research,  partly  stemming  from  methodological  challenges88.  In  addition,  the  socially 
disadvantaged  position  of  Roma  women  compared  to  Roma  men  means  they  are 
disproportionately  affected89.  The  Open  Society  Institute,  which  works  across  Central 
and  Eastern  Europe,  maintains  that  many  Roma  women  have  limited  educational 
opportunities and live in inadequate housing and suffer poor health; they also take on 
traditional  gender  roles  domestically  and  can  potentially  become  socially  excluded 
from mainstream society as a result90.  

82  Cath  Mahoney  (2006),  Roma  Families  in  Leeds.  A  social  audit  of  their  situation  needs  and 
services, Travellers Health Partnership 
83  Wamsiedel,  M.  &  al.,  Health  and  Roma  community  –  analysis  of  the  situation  in  Romania, 
Fundacion Secretariado Gitano, Madrid, 2009 
84 FRA Country thematic studies on the situation of Roma, June 2013. Available at:  
http://fra.europa.eu/en/country-data/2013/country-thematic-studies-situation-roma. 
85 Halfen, S. (2012) Situation sanitaire et sociale des 'Roms migrants' en Île-de-France, Rapport 
de l’Observatoire régional de santé d’Ile-de-France 
86 Médecins du Monde (2012), Rapport 2011 de l’Observatoire de l’Accès aux Soins de la Mission 
France. 
87  Médecins  du  Monde  (2010),  Synthèse,  forum,  La  santé  des  Roms  en  France:  une  urgence 
sanitaire?, Médecins du Monde, 25 February 2010 
88 M.E Foldes and A. Covaci, Research on Roma health and access to healthcare: state of the art 
and future challenges Int J Public Health. 2012 February; 57(1): 37–39. Available at: 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282005/ 
89 http://www.osce.org/odihr/94320 
90  Open  Society 
http://www.opensocietyfoundations.org/sites/default/files/z_romani_women_0.pdf 

Institute’s  Network  Women’s  Program 

Initiative.  Available  at 

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According  to  the  2013  report  by  the  FRA91  in  Poland,  75 %  of  Roma  women  stated 
that  they  were  in  ‘bad’  or  ‘very  bad’  health  and  in  Italy  a  58 %  difference  exists 
between the self-declared health status of Roma and non-Roma women. Roma women 
also  encounter  greater  limitations  in  their  daily  activities  (23 %  compared  to  17 %). 
Regarding  medical  insurance,  18 %  of  Roma  women  declared  having  no  medical 
insurance (8 % non-Roma). Three countries in particular show large differences in this 
respect (25–37 % Bulgaria, Greece and Romania). However, within Roma communities 
women have slightly higher levels of medical insurance than men (82 % to 80 %).  

Two  UK  reports  make  general  statements  about  significant  pressure  within 
Gypsy/Roma  Traveller  communities  to  conform  to  traditional  gender  roles,  common 
occurrences  of domestic violence and the impact this has on mental health (low self-
esteem  and  depression)92.  FRA  studies  have  found  that  Roma  women  in  Slovenia 
experience stress, loneliness and depression as a result of their subordinate role in the 
Roma community93. 

In  Spain,  Roma  women  were  found  to  be  more  likely  to  suffer  from  obesity, 
depression and migraines, had significantly higher alcohol consumption, exercised less 
and  used  preventative  healthcare  (such  as  smear  tests  and  mammograms)  less 
frequently94.  The  only  direct  contradiction  between  this  study  and  similar  work 
concerned  smoking  prevalence.  It  was  believed  that  up  to  70 %  of  Roma  adults 
smoke;  however  in  practice  reports  found  smoking  levels  lower  than  non-Roma95. 
Spanish  data  also  identified  problems  associated  with  early  and  late  pregnancy  and 
health problems caused by work overload96. 

In  2011,  50 %  of  pregnant  women  who  came  to  MdM  Roma  Programmes  in  France 
were not being followed up throughout pregnancy. The study found that 70.8 % had a 
delay in the pregnancy follow-up as they had been pregnant for more than 12 weeks 
without any care when they presented97. There was an average of 1.88 miscarriages in 
the  12.7 %  of  Roma  women  who  had  already  had  at  least  one  miscarriage  in  2011. 
There was an average of 1.44 stillborn babies per Roma woman98 among the 6.3 % of 
Roma women who had had at least one stillborn baby. Among Roma women, only two 
out of four pregnancies resulted in a living infant on average99. The 8.3 % of pregnant 
women  who  benefit  from  being  treated  in  public  health  care  facilities  can  seldom 
complete  pre-natal  care  as  a  result  of  evictions  forcing  them  to  move  further  away 
from  the  health  care  facility  where  they  were  being  treated.  Stress  from  fear  of 
eviction,  identity  checks  and  the  experience  of  living  and  coping  in  informal 
settlements without water, electricity or sanitation also results in higher proportions of 

91 FRA for the European Parliament Analysis of FRA Roma survey results by gender, 2013. 
92 See the UK country report for full references. 
93 FRA Country thematic studies on the situation of Roma, June 2013. Available at: 
 http://fra.europa.eu/en/country-data/2013/country-thematic-studies-situation-roma 
94 Casals, M. Pila, P. Langohr, K. Millet, J.P. Caylà, J.A. Roma Population Working Group, (2011), 
Incidence  of  Infectious  Diseases  and  Survival  among  the  Roma  Population:  A  Longitudinal 
Cohort Study, European Journal of Public Health, Vol. 22, No. 2, pp. 262–6. 
95 Carrasco-Garrido, P. López de Andrés, A. Hernández Barrera, V. Jiménez-Trujillo, I. Jiménez-
García, R.  (2010), Health Status of  Roma  Women in  Spain,  European Journal of Public Health, 
Vol. 21, No. 6, pp. 793–8. 
96  García,  C.  (2005).  Guía  para  la  actuación  con  la  Comunidad  Gitana  en  los  Servicios 
Sanitarios. Madrid. Fundación Secretariado Gitano. 
97 Médecins du Monde (2012), Actions mobiles auprès des Roms, 2011, not published. 
98 Ibid. 
99  Médecins  du  Monde  (2010),  Synthèse  -  forum,  La  santé  des  Roms  en  France:  une  urgence 
sanitaire?, Médecins du Monde, 25 February 2010, 10p. 

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women unable to access prenatal care100  101. Many countries’ data indicate that Roma 
women start having children at a younger age than the majority population. 26.9 % of 
Irish  Traveller  women  had  given  birth  to  five  or  more  children  (compared  to  2.6 % 
overall)102. 

Among interventions to support Roma women’s health, mediation is reported to be an 
increasingly successful method of supporting Roma health. Roma health mediators are 
almost exclusively women and provide a key bridge between Roma women and health 
care  systems.  They  facilitate  access  to  services  such  as  antenatal  care  and 
vaccination. 

Environmental and other socio-economic factors 

In  most  Member  States  the  housing  situation  of  Roma  families  is  worse  than  non-
Roma.  Only  a  few  countries  found  (anecdotal)  evidence  of  Roma  housing  conditions 
comparable to the rest of the country, including access to social housing (Germany103, 
Lithuania104  and  Sweden105).  Roma  frequently  face  difficulties  in  accessing  social 
housing  either  as  migrants  where  they  lack  documentation  (France106)  or  due  to 
discrimination (Finland107, Lithuania108 and Luxembourg109).  

Data  from  2004  found  that  Roma  in  Bulgaria  live  in  0.76  rooms  per  household 
member, compared to 1.58 for non-Roma110. The average size of housing units was 34 
m2 in Bulgaria but only 15 m2  for Roma.  Overcrowding is a known  risk factor for the 
spread of infectious diseases111. 

100 Médecins du Monde (2007), Les Roms que l’Europe laisse à la porte, 30p. 
101  Romeurope  (2000),  Roms,  Sintés,  Kalés,  Tsiganes  en  Europe,  promouvoir  la  santé  et  les 
droits d’une minorité en détresse, Actes du colloque européen, Paris, 19 and 20 October 2000, 
129p. 
102 All Ireland Traveller Health Study (2010) of Technical Report I. Available at: 
http://www.dohc.ie/publications/aiths2010/TR1/AITHS2010_TechnicalReport1_LR_All.pdf?direct
=1  
103  Bundesministerium  des  Innern  (2011),  An  EU  Framework  for  national  Roma  Integration 
Strategies  up  to  2020  –  Integrated  packages  of  measures  to  promote  the  integration  and 
participation of Sinti and Roma in Germany. Available from: 
http://ec.europa.eu/justice/discrimination/files/roma_germany_strategy_en.pdf  
104  RAXEN  (2009),  Lithuania  National  Focal  Point  Thematic  Study  Housing  Conditions  of  Roma 
and Travellers. 
105  Sweden,  RAXEN  National  Focal  Point  Thematic  Study  Housing  Conditions  of  Roma  and 
Travellers. Centre for Equal Opportunities and Opposition to Racism, March 2009. 
106  BILAN  D’APPLICATION  DE  LA  CIRCULAIRE  INTERMINISTERIELLE  DU  26  AOÛT  2012 
RELATIVE A L’ANTICIPATION ET A L’ACCOMPAGNEMENT DES OPERATIONS D’EVACUATION DES 
CAMPEMENTS ILLICITES. AOUT 2012-MAI 2013. Available at 
http://www.defenseurdesdroits.fr/sites/default/files/upload/rapport-roms-2013-06-25.pdf 
107 FRA (2009) Housing conditions of Roma and Travellers – Finland RAXEN National Focal Point 
— Thematic Study. 
108 The Institute for Ethnic Studies (A division of the Lithuanian Social Research Centre). Please 
see http://ces.lt/en/ 
109 Council of Europe, ECRI Rapport (2012),  
http://www.coe.int/t/dghl/monitoring/ecri/country-by-country/luxembourg/LUX-CbC-IV-2012-
004-FRE.pdf 
110 UNDP (2004) Faces of Poverty, Faces of Hope, p. 16, in: FRA (2009), Housing conditions of 
Roma and travellers in the European Union, comparative report, p. 72. 
111 Removing obstacles to healthy development’, Report on Infectious Diseases WHO, 1999 

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The FRA found in 2012 that only 50 % of Roma children attend pre-school or nursery 
on  average112.  Although  90 %  of  Roma  children  between  7  and  15  years  old  are 
reported  to  be  in  school  (except  Bulgaria,  Greece  and  Romania),  poor  school 
attendance and high drop-out rates were reported113. A report from Germany stated in 
some  cases  almost  50 %  of  all  school  age  Roma  and  Sinti  children  do  not  finish 
primary school. Girls were more likely to drop out than boys, as they marry early and 
subsequently  family  obligations  take  precedence.  Education  is  less  frequently 
completed by girls with travelling parents than boys114. 

In Germany research highlights the lack of trust among Roma in formal institutions as 
a  barrier  to  engagement  in  education115.  Poor  educational  attainment  can  impact  on 
long-term  occupational  outcomes.  In  Bulgaria  40 %  of  Roma  are  unemployed 
compared to 20 % of non-Roma116. Roma unemployment has been recently estimated 
as high as 84 % in Ireland117 and 57 % in Lithuania118. In Croatia only 14 % of Roma 
are employed compared to 49 % of non-Roma119. In Hungary only 20 % of Roma are 
employed,  compared  to  55 %  of  non-Roma120.  In  some  countries  male  Roma  are 
unemployed  more  often  than  female  Roma  (AT121  and  IE122),  however  employment 
rates  for  Roma  women  are  typically  lower  than  men123.  As  a  consequence  of  high 
unemployment,  many  Roma  live  in  poverty124.  Reasons  reported  as  contributors  to 
high  unemployment  rates  include  language  difficulties,  poor  education  levels  and 
cultural differences.  

Conclusions  

In line with previous findings, the evidence currently available for the  comprehensive 
indicators included in this project continue to demonstrate that, notwithstanding some 
variation between countries, Roma populations in Europe generally: 

  Suffer greater exposure to wider determinants of ill health (e.g. socio-economic 

and environmental); 

– 

and 

centre 

report. 

report. 

shadow 

research 

Available 

Available 

Documentation 

112 FRA (2012), The situation of Roma in 11 EU Member States, survey results at a glance. 
113 FRA (2012), The situation of Roma in 11 EU Member States, survey results at a glance. 
114  Open  Society  Institute  (2004)  Joint  EU  Monitoring  and  advocacy  program/European  Roma 
from: 
rights 
http://www.opensocietyfoundations.org/sites/default/files/roma_shadow_20040121.pdf  
115  Daniel  Strauss  (Ed)  (2012)  Study  of  the  current  educational  situation  of  German  Sinti  and 
Roma 
from: 
http://www.stiftungevz.de/fileadmin/user_upload/VZ_Uploads/Handlungsfelder/Handeln_fuer_M
enschenrechte/Sinti_und_Roma/engl-studie.pdf  
116 UNDP UNDP-WB-European Commission regional Roma survey 2011. 
117  Central  Statistics  Office,  Information  Section,  Profile  Central  Statistics  Office,  Information 
Section (2011) Profile 7: Religion, Ethnicity and Irish Travellers. 
118 UNDP UNDP-WB-European Commission regional Roma survey 2011 
119 UNDP UNDP-WB-European Commission regional Roma survey 2011 
120 UNDP UNDP-WB-European Commission regional Roma survey 2011 
121  Austria,  Riesenfelder,  A.,  Schelepa,  S.  und  Wetzel,  P.  (2011),  Beschäftigungssituation  von 
Personen mit Migrationshintergrund in Wien – Endbericht, Study commissioned by the Chamber 
of  Labour,  NGO/social:  99  telephone  interviews  with  male  and  female  Roma.  Available  at: 
www.arbeiterkammer.at/bilder/d164/Studie_MigrantInnen_2012.pdf 
122  Central  Statistics  Office,  Information  Section,  Profile  Central  Statistics  Office,  Information 
Section (2011) Profile 7: Religion, Ethnicity and Irish Travellers. 
123  FRA  (2012),  The  situation  of  Roma  in  11  EU  Member  States,  Survey  results  at  a  glance, 
p. 16. 
124  FRA  (2012),  The  situation  of  Roma  in  11  EU  Member  States,  Survey  results  at  a  glance, 
p. 25. 

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  Live less healthy lifestyles; 
  Have  poorer  access  to  and  lower  uptake  of  primary  care  and  preventative 

health services; 

  Suffer poorer health outcomes, in terms of morbidity from both infectious and 

chronic diseases and shorter life expectancy. 

Furthermore  there  are  some  indications  that,  as  a  result  of  the  economic  crisis  and 
subsequent recessions in European countries, Roma health status and health access is 
deteriorating further in a number of places as a result of cut-backs.  

The key conclusions per indicator are summarised below. 

Mortality and Life Expectancy 

  The  Roma  population  is  demographically  different  from  the  majority  European 
populations  insofar  as  it  is  noticeably  younger  —  and  consistently  so  across 
Europe.  

  Life expectancy data is very limited on a national and regional level. Most data 
are based upon estimates. The most widely cited data stems from the Council 
of Europe.  

  Roma experience substantially lower (up to 20 years) life expectancy compared 

to non-Roma.  

  Some  evidence  exists  suggesting  that  shorter  life  expectancy  in  Roma  people 
occurs as a result of the broader environmental conditions they experience.  
  Higher rates of infant mortality are reported in some Roma populations (those 
living  in  poor  housing,  with  low  educational  levels,  and  migrant  Roma) 
compared  to  non-Roma  in  countries  including  Bulgaria,  the  Czech  Republic, 
Hungary, Italy and Slovakia.  

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Prevalence of major infectious disease and immunisation uptake 

  Recent  comprehensive  data  regarding  infectious  diseases  within  Roma 
communities  is  not  readily  available,  and  the  data  obtainable  are  often  old, 
small-scale or, in a few cases, collected during disease outbreaks.  

  Some of the available studies show higher rates of infectious diseases or risk of 
infectious  disease  outbreaks  amongst  Roma,  particularly  segregated  Roma, 
compared to the majority population (including measles and hepatitis A). 

  Evidence  relating  to  rates  of  HIV/Aids  is  more  mixed,  though  some  findings 

report faster disease progression. 

  There is a lack of data on vaccination uptake in the Roma population.  
  The available evidence  suggests that with some exceptions (Croatia, Hungary, 
and the Czech Republic) the Roma population, particularly migrant Roma, have 
lower or much lower rates of childhood vaccination uptake. 

Healthy lifestyles and behaviours 

  Roma  suffer  disproportionately  from  illnesses  that  are  associated  with  the 

social determinants of health.  

  While  data  on  health  lifestyles  and  behaviours  among  Roma  populations  are 
generally  limited,  the  available  evidence  from  a  large  majority  of  countries 
included  in  the  project  suggests  that  Roma  people  have  poorer  health-related 
lifestyles. 

  Available  data  on  diet  and  physical  activity  consistently  suggest  that  healthy 
diet and physical activities to stay healthy are less common in Roma people.  
  Available  data  on  smoking  prevalence  from  Austria,  Croatia,  the  Czech 
Republic,  Slovakia,  Bulgaria,  Hungary,  Ireland,  Portugal  and  Romania 
consistently show smoking is more common in the Roma population.  

  Available  evidence  on  alcohol  consumption  and  illicit  drug  use  amongst  Roma 

communities reports conflicting findings. 

  Very  few  interventions  were  reported  specifically  targeting  the  health 
behaviours of Roma, though exceptions include drug rehabilitation programmes 
in Croatia, Finland, Ireland, Latvia and Lithuania. 

  Small-scale  studies  have  identified  a  number  of  cultural  factors  which  have  a 

negative impact on the health lifestyles of Roma.  

Access to and utilisation of health services and prevention programmes 

  Patterns  of  access  and  use  of  health  services  is  not  homogenous  in  Roma 
populations across all 31 countries, implying different impacts on Roma health 
and  experiences  of  health  care.  The  level  of  marginalisation  or  integration  of 
Roma populations appears to be a crucial factor. 

  Where  data  is  available  it  provides  sufficient  evidence  that  numerous  barriers 

to health care exist across the majority of countries. 

  Evidence  consistently  suggests  that  barriers  to  access  are  closely  linked  to 

social exclusion factors, and specifically include the following factors:  

  Language and literacy barriers;  
  A lack of knowledge of available health care systems;  
  Discrimination by health care professionals;  
  A lack of trust in health professionals; 
  Physical barriers — mobility and distance; 
  A lack of identification and/or insurance. 

  Evidence also shows that patterns of health care utilisation among Roma differ 
from  the  general  population,  such  as  higher  levels  of  use  of  acute  hospital 

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services;  possibly  the  result  of  lower  levels  of  engagement  with  or  access  to 
preventative primary care. 

  There  is  evidence  that  the  economic  crisis  is  disproportionately  impacting  on 

the Roma populations’ access to health care.  

Prevalence of major chronic disease 

  Once  allowance  is  made  for  demographic  differences  with  the  general 
population, Roma communities appear to suffer higher rates of chronic disease 
(i.e.  asthma,  diabetes,  cardiovascular  disease  and  hypertension)  and  the 
associated disability and limitations on daily activities.  

  A range of small-scale studies highlight dramatically higher and more complex 
cases of chronic disease amongst Roma across a range  of  European  Countries 
— Germany, Finland, Poland, the UK (migrant Roma), Romania, Ireland, Italy, 
Spain and France. 

  Some evidence reports links between these higher rates of chronic disease, and 
higher prevalence of risk factors (e.g. diet, exercise and stress), poor access to 
and uptake of primary care and preventative health programmes among Roma.  
  A  number  of  studies  again  highlight  the  disproportionate  impact  of  the 
economic  crisis  on  Roma  populations  and  its  relevance  to  chronic  disease  risk 
factors.  

Health factors related to the role of women in the Roma community 

  The  recent  (2013)  FRA  data  on  Roma  women’s  health  is  the  most 
comprehensive  European  source  and  underlines  that  Roma  women  are 
generally  in  worse  health  and  more  disadvantaged  than  Roma  men  and  the 
general population.  

  Available  evidence  suggests  a  range  of  additional  barriers  to  improved  health 
amongst Roma women, including expectations to fulfil traditional gender roles, 
limited educational and employment opportunities, physical and social isolation 
and poor living conditions. 

  Maternal  health  risks  (i.e.  early  and  late  pregnancies,  large  families,  poor 
access  to  and  low  uptake  of  antenatal  care),  and  poor  outcomes  (i.e. 
miscarriage and still birth) are more common in Roma women. 

  Evidence  suggests  that  Roma  women  are  at  higher  risk  of  domestic  violence 

and the associated mental health risks. 

  A Spanish study suggests that the position of Roma women had improved as a 
result in  part  due  to lower  birth  rates,  however  it  was  also  reported  that  they 
suffered  more  from  obesity,  depression,  metabolic  diseases  and  sexual  health 
problems,  exercised  less  often  and  had  lower  uptake  of  breast  and  cervical 
cancer screening. 

  A  French  study  suggests  that  Mediation  Programmes  appear  to  offer  a 
potentially effective means to engage with Roma woman about health issues. 

Environmental and socio-economic determinants of health 

  European  institutions  —  the  FRA  and  Eurofound  —  publish  the  most 

comprehensive data on environmental and other socio-economic factors. 

  The  housing  situation  of  Roma  families  is  generally  worse  than  the  housing 
situation  of  non-Roma  citizens,  though  in  a  minority  of  countries  some 
evidence  suggested  that  access  to  social  housing  and  standards  were 
comparable to the general population (Germany, Lithuania and Sweden).  

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  The  Eurofound  study  reported  that  accommodation  overcrowding  is  most 
severe in Slovakia and Hungary, causing problems such as poor sanitation and 
segregation. 

  Roma  usually  have  a  lower  level  of  education  than  non-Roma.  Comparatively 
low  educational  attendance  (Bulgaria,  Greece  and  Romania)  and  segregation 
remain challenges (Estonia and Germany). 
In  all  Member  States  that  have  statistics  on  Roma  employment,  the 
unemployment rates  of Roma are higher than those of non-Roma. Particularly 
stark  unemployment  differences  between  Roma  and  non-Roma  have  been 
found in Bulgaria, Croatia, Ireland, Lithuania and Hungary.  

 

Although  the  main  conclusions  above  show  that  sufficient  data  on  Roma  exist  to 
evidence  poor  health  and  social  and  economic  exclusion,  there  are  still  vast  gaps  in 
Roma  health  data  which  impedes  our  full  understanding  of  the  situation.  Data  that 
allow  for  comparisons  between  populations  and  that  constitute  a  baseline  for 
measuring  health  improvements  are  systematically  collected  predominantly  on  an 
international level, and the data from national and regional level which are available is 
partly  old,  patchy  and  is  not  suitable  for  extrapolation.  Member  States  that  have 
implemented data collection systems should be encouraged to share  and help spread 
best practices to ameliorate the situation.   

Unfortunately little of the available evidence on Roma health adequately describes  or 
categorises  the  precise  ethnic  group  or  lifestyle  characteristics  of  the  Roma 
communities  concerned.  Consequently  it  has  not  been  possible  to  systematically 
review  health  across  the  heterogeneous  Roma  populations.  For  instance  there  are 
variations  such  as  being  settled,  travelling,  segregated  or  integrated,  remotely 
located, urban or rural, migrant or non-documented. 

There  are  also  indications  that  not  all  data  collected  is  fully  utilised  in  the  Member 
States  nor  used  extensively  as  a  basis  for  effective  policy-making  to  improve  the 
health  situation  of  Roma.  Past  research  efforts  have  largely  focused  on  infectious 
diseases among Roma, yet even here is there no identifiable comprehensive evidence 
base  and  baseline.  There  are  gaps  in  largely  every  indicator  covered  by  the  study, 
with  particularly  acute  gaps  concerning  Roma  women’s  health,  mental  health  issues 
and  migrant  health.  Methodologically,  there  is  a  dearth  of  longitudinal  and  in-depth 
studies  to  support  and  contextualise  the  findings  uncovered  by  the  international 
surveys. 

The  Roma  population  is  the  largest  minority  in  Europe,  living  in  principally  all  EU 
Member States. The poor health and data status of the Roma population is therefore a 
truly  European  issue  which  needs  to  be  tackled  through  pan-European  research  and 
engagement.  

The  European  Commission,  the  European  Union  Fundamental  Rights  Agency,  the 
United  Nations  Development  Programme  and  the  World  Bank  are  leading  this  work 
through their continued commitment to  research, community engagement and in the 
development of the National Roma Integration Strategies. This work is vital and needs 
to be  further  supported by the  Member States that, although improving, can step up 
their  activities.  As  discussed  in  the  accompanying  Report  on  Roma  health  data,  the 
Structural  Funds  make  funds  available  to  support  socio-economic  integration  of 
marginalised communities such as Roma. 

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Recommendations 

The  findings  of  this  project  suggest  that  comprehensive  programmes  of  initiatives 
across  the  full  range  of  potential  public  health  interventions  continue  to  be  required 
across Europe to improve the health of Roma.  

While variation exists between individual countries, in terms of the size, nature, health 
of  the  Roma  population  and  existing  initiatives,  it  seems  likely  that  all  the  actions 
above require consideration and review to varying degrees in all countries in order for 
proportionate responses to be made. 

Key areas for potential action are summarised below. 

Wider determinants of health 

  Access to and engagement with educational systems;  
 
Improvement of employment opportunities; 
  Reductions in segregation and marginalisation; 
 

Improvements in the provision of facilities with improved living conditions. 

Healthy lifestyles and behaviour 

  The provision of tailored health information materials; 
  Community initiatives to improve health engagement in Roma communities. 

Disease prevention 

 

Improved 
opportunities and services to Roma communities; 

information  provision  and  marketing  of  disease  prevention 

  Adequate  provision  of  tailored  disease  prevention  programmes  and  services 
acceptable  to  Roma  communities  and  meeting  their  particular  needs  (e.g. 
mobility and living circumstances). 

Accessibility to high-quality services that are acceptable to Roma communities 

  Adequate  provision  of  tailored  health  services  that  are  acceptable  to  Roma 
communities  and  meet  their  particular  needs  in  areas  of  large  Roma 
communities; 
Improvements 
(including 
discrimination) in the provision of health services to Roma  by universal health 
care providers and professionals. 

to  good  practice  standards 

in  adherence 

 

Knowledge 
The design of the above programmes and initiatives need to be informed by: 

1.  Improved  generation  of  consistent  information  on  the  health  risks  and 
outcomes experienced by Roma communities to monitor progress, tailor action 
and target resources. 

2.  Monitoring and evaluation of interventions to improve Roma health. 
3.  Review and dissemination of knowledge on interventions effective in improving 

the health of Roma communities. 

4.  Translation of knowledge on effective interventions into best practice guides for 

policy-makers and programme and service managers. 

5.  Primary research into key obstacles in improving Roma health, including: 

i. 
ii. 

iii. 

Approaches to improving health knowledge in Roma communities. 
Tailoring  of  health  knowledge, 
recognising the perspective of Roma communities. 
Tailoring  the  delivery  of  health  improvement,  disease  prevention  and 
primary care services targeting or serving Roma communities. 

lifestyle  and  behaviour  messages 

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iv. 

Empowerment of Roma girls and women. 

Investment 
Investment  in  Roma  health  issues  should  be  reviewed  through  systematic  processes 
examining  the  size  and  needs  of  Roma  communities,  and  knowledge  on  the 
effectiveness of alternative policies, programmes and services. 

These recommendations should be read in parallel with the recommendations included 
in Report II regarding action to improve data collection and monitoring of Roma health 
status.  

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Part 2 

Data Collection 

in the Member States 

Executive Summary 

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Executive Summary 

This  report  is  the  result  of  a  study  examining  the  EU  Member  States'  current  and 
future  activities  in  data  collection  and  development  of  specific  surveys  aiming  to 
monitor  the  progress  in  the  implementation  of  the  National  Roma  Integration 
Strategies (NRIS) in the area of health.  

It  was  carried  out  in  2013  by  Matrix  Knowledge  on  behalf  of  the  Consumers,  Health 
and  Food  Executive  Agency  (Chafea)  and  the  DG  Sanco.  The  study  reviewed  policy 
documents  and  evaluations  on  the  NRIS,  and  surveyed  and  interviewed  Member 
States,  policymakers,  data  experts  and  Roma  Non-Governmental  Organisations 
(NGOs) on issues on Roma health data collection and the monitoring thereof.  

Findings  

Roma Health Data Collection 

The  findings  of  the  study  show  that  in  the  Member  States  Roma  health-related  data 
collection  is  normally  organised  and  collected  through  a  bottom-up  system  with  a 
reliance on community-based data and surveys, and collection at national level is not 
comprehensive and systematic. 

There  are  practical  obstacles  to  data  collection,  including  a  lack  of  ethnically 
disaggregated  data  and  the  monitoring  of  a  partly  mobile  Roma  population.  Many  of 
the censuses in the European Union do not gather data on ethnicity125. Since national 
legislation  can  prevent  countries  from  taking  information  on  the  basis  of  ethnicity, 
quantitative information about Roma is fragmented at a local level. Data is also sparse 
and  data  collection  appears  to  have  shortcomings  in  terms  of  quality,  timeliness, 
collection methods and reporting. Our survey126 confirms this position, with 40.7 % of 
the respondents reported the lack of disaggregated data and 25.5 % reported relying 
mainly  on  administrative  registers  or  existing  international  surveys  able  to  provide 
partly disaggregated data. 

The lack of comparable, coherent data collection which can be disaggregated by ethnic 
origin  and  gender  makes  it  impossible  to  investigate  the  specific  morbidities  and 
health conditions for Roma populations as very few countries gather this type of data. 
In particular there are shortcomings in collecting comparable data on Roma health and 
the general population. The timeliness of the data it is also a major issue, with half of 
the study survey respondents unable to state how frequently the data that they have 
access to is collected127. The reasons for these data gaps relate to concerns about data 
protection as well as the cost and difficulty of collecting new datasets and the lack of 
political  interest  in  investigating  this  issue128.  In  practice,  the  country-level 
examination suggests that the impossibility of collecting data on the basis of ethnicity 

125

 CoE (2007), Ethnic" statistics and data protection in the Council of Europe countries, 2007 

.http://www.coe.int/t/dghl/monitoring/ecri/activities/Themes/Ethnic_statistics_and_data_protection.pdf 
126

 The survey was carried out in the period between 15 July and 8 September. It was directed to a sample 

of 150 respondents selected between national and regional health institutions, policy maker and 
representatives of civil society (i.e. NGOs advocacy for Roma). Survey respondents: 38 persons. 
127

 Survey Question No 16.  

128

 EU Data protection legislation establishes limits to the use of ethnically disaggregated data, but does not 
forbid it. On the other side, EU Discrimination legislation encourages the use of ethically disaggregated data. 
Directive (2000/43/EC) implementing the principle of equal treatment between persons irrespective of racial 
or ethnic origin. 

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has contributed to a problem of ‘lack of ownership’ regarding minorities and collection 
of data.  

Our  study  confirms  that  the  possibility  of  developing  data  coding  based  on  ethnicity 
within  national  censuses  is  limited129  but  that  there  are  possibilities  of  using  proxies 
for  ethnicity.  According  to  our  findings,  territorial  and  living  conditions  information, 
gathered  through  local  actors  are  judged  to  be  the  most  appropriate  proxies  to 
indirectly  obtain  data  on  Roma  health  status.  Other  options  suggested  are:  i) 
observing the status  of vulnerable groups  within which Roma are very often present, 
and; ii) gathering data from health bodies that operate close to Roma settlements. In 
practice, this is geographical data that can be used to obtain information on mortality 
and life expectancy and to plan health initiatives at local level.  

In 12 countries (DK, EE, EL, ES, HU, IE, LV, PL, PT, SK, SE and the UK) institutions at 
domestic  central  level  have  carried  out  quantitative  studies  to  monitor  Roma  health 
that  might  constitute  a  starting  point  to  evaluating  and  monitoring  the  national 
strategy  for  Roma  in  the  future.  Survey  data  has  to  some  extent  overcome  the 
deficiencies in disaggregated data by providing data on ethnic minorities. Surveys are 
also  a  solution  to  national  censes  failing  to  provide  a  good  reference  point  on  Roma 
health as they are generally conducted every ten years; which does not allow for the 
development of a dynamic assessment of changes in Roma health status. Surveys by 
comparison  are  able  to  be  reiterated  and  updated.  Another  relevant  observation  is 
that the role of local institutions and NGOs has been essential in implementing actions 
to  collect  data.  In  fact,  our  survey  suggests  that  surveys  supported  by  the  EU  and 
UNDP survey are considered best practice130.  

The central role exercised by local actors holds true also when looking at the other 14 
countries  (AT,  BE,  BG,  HR,  CY,  CZ,  DE,  FI,  FR,  IT,  NL,  SI,  LT  and  RO),  where  the 
actions  of  the  domestic  central  level  of  government  have  been  more  limited  in 
comparison  to  the  initiatives  of  local  and  supranational  organisations  in  collecting 
data. 

In the 31 countries subject contained in this study, when recent data and research are 
available  they  have  usually  been  generated  because  of  civil  and  academic  society 
initiatives  or  under  the  aegis  of  a  supranational  institution  commissioning  ad-hoc 
studies. 

Roma Health Monitoring 

Our  findings  conclude  that  the  majority  of  Member  States  do  not  have  a  monitoring 
system  in  place  to  measure  the  results  and  impacts  of  their  NRIS.  The  Commission 
has  already  observed  a  general  lack  of  impact  indicators  and  recommended  that 
Member States explore possible synergies with existing EU policy indicators131. 

According  to  this  report,  in  more  than  half  of  the  Member  States  no  plans  exist  to 
regularly report on or evaluate the NRIS at a national level. This assessment is in line 
with  the  evaluation  conducted  by  Open  Society  Foundations  (OSF)  of  the  NRIS 
submitted  by  the  governments  of  five  Member  States  (BG,  CZ132,  HU,  RO  and  SK) 

129

 Survey Question No 33.  

130

 First Round Survey Question No 32. 

131

 COM(2013) 454 final, Commission Communication, Steps forward in implementing Roma integration 

strategies, p. 8. 
132

 The 2010–13 Roma Integration Concept submitted by the Czech Government. 

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which pointed to weak monitoring practices and a lack of data from which to monitor 
the Member States reviewed133. According to the Commission’s 2013 progress report, 
examples  of  robust  monitoring  systems  are  Hungary  and  Estonia134.  The  Commission 
expressed its concerns regarding the extent of stakeholder involvement in monitoring, 
evaluation  and  policy  review,  as  recommended  under  the  Ten  Common  Basic 
Principles for Roma Inclusion135.  

Our survey findings were most likely to not agree with the statement that the existing 
data  collection  system  ensured  that  civil  society  organisations  working  with  Roma, 
Roma  NGOs  and  Roma  community  representatives  are  involved  in  the  design, 
implementation and assessment of data collection. Many respondents stated that they 
were  'not  sure'  of  the  extent  to  which  they  agreed  or  disagreed  with  the  four 
statements regarding data collection and monitoring provided. This lack of knowledge 
could be further evidence that stakeholders are not well informed on these issues. 

It may be that monitoring challenges are the result of constraints arising from a lack 
of funds allocated by Member States to develop and improve data collection systems. 
The  EU  Framework  invited  Member  States  to  allocate  sufficient  funding  for  Roma 
inclusion  measures  from  national  budgets,  to  be  complemented  by  international  and 
EU  funding  (such  as  the  European  Structural  and  Investment  Funds).  However, 
according  to  our  study,  more  than  a  third  of  the  respondents  did  not  believe  (totally 
disagreed)  that  the  funds  allocated  for  the  data  collection  system  are  enough  to 
monitor  NRIS  progress  on  Roma  integration.  These  findings  are  supported  by  the  EU 
2013 progress report, which observed that the financing of national strategies was not 
yet  adequate136.  One  third  of  our  survey  respondents  did  not  find  (completely 
disagreed)  that  the  existing  data  collection  system  was  able  to  detect  whether  the 
NRIS  is  improving  the  data  gap  between  the  general  population  and  Roma  (with 
respect to health), or that the data collection system is able to detect the impacts of 
the NRIS on disadvantaged micro-regions or segregated neighbourhoods. 

Our  in-depth  investigation137  on  a  country-by-country  basis  (see  Appendix  A) 
regarding  planned  monitoring  activities  and  studies  on  Roma  health,  suggests  that 
some initiatives within the NRIS framework will be put in place to improve the current 
scenario.  But  Member  States  have  not  presented  precise  sustainable  data  collection 
strategies with a long-term perspective.   

133

 OSF review of NRIS Foundation, Review of EU Framework National Roma Integration Strategies (NRIS) 

submitted by Bulgaria, the Czech Republic, Hungary, Romania and Slovakia (February 2012), p. 3. 
134

 COM(2013) 454 final, Commission Communication, Steps forward in implementing Roma integration 

strategies, p. 15. 
135

 COM(2013) 454 final, Commission Communication, Steps forward in implementing Roma integration 

strategies, p. 8. 
136

 COM(2013) 454 final, Commission Communication, Steps forward in implementing Roma integration 

strategies, p. 6. 
137

 Our analysis is based on the review of the national strategies documents and on the comments provided 

by the National Contact Points through the second round of our survey 

August, 2014 

26 

 
 
 
 
 
 
 
 
 
 
 
                                           
Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

Country Overview138 
Table 1 Overview of National Roma Integration Strategies 
NRIS 
NRIS 
Member 
(current 
priorities 
State 
or future) 
for Roma 
projects 
health 
on Roma 
that 
might 
produce 
data on 
health 

Roma health 
issues targeted 
through 
mainstreamed 
actions in the 
general 
domestic 
welfare and 
social inclusion 
policy 

NRIS 
Specific 
Indicators/ 
benchmarks 
to evaluate 
NRIS 
outcomes/ 
impacts on 
Roma Health 

NRIS 
(current or 
future) 
specific 
projects on 
monitoring 
Roma 
health 

Roma 
health 
issues 
subject 
to 
specific 
positive 
actions 

Allocation 
of NRIS 
funds for 
projects 
to 
monitor 
or to 
improve 
Roma 
health 

Use of 
structural 
funds for 
projects 
to 
monitor 
or to 
improve 
Roma 
health 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czech 
Republic 
Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Ireland 

Italy 

Latvia 
Lithuania 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

Luxembourg   

Malta139 

 

Netherlands   

Portugal  

Poland 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

UK  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

Not 
confirmed  
 

Not 
confirmed  
 

Not 
confirmed 
 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

n/a 

n/a 

n/a 

n/a 

n/a 

n/a 

n/a 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

138

 Our in-depth investigation on a country-by-country basis (see Appendix A) regarding planned 

monitoring activities and studies on Roma health, suggests that some initiatives within the NRIS framework 
will be put in place to improve the current scenario. Member States have not presented precise sustainable 
data collection strategies with a long term perspective. Our analysis is based on the review of the national 
strategies documents and on the comments provided by the National Contact Points through the second 
round of our survey. 
139

 Malta has no Roma population. 

August, 2014 

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Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

Conclusions  

Roma  populations  in  Europe  are  in  poorer  health  than  non-Roma  populations.  But 
while  sufficient  data  on  Roma  exists  to  evidence  social  and  economic  exclusion,  and 
poor health, there are still vast gaps in Roma health status data which impede any full 
understanding  of  the  situation.  Our  study  indicates  that  stakeholders  are  generally 
dissatisfied  with  the  quality  of  data  and  data  collection  systems  available  to  support 
efforts to improve Roma health. Some survey respondents feel strongly that a lack of 
funds available to support monitoring of NRIS is one of the main barriers to improving 
the quality of data collected.  

Roma  health-related  data  collection  is  normally  organised  and  collected  through  a 
bottom-up  system  with  a  reliance  on  community-based  data  and  surveys.  But  there 
are  significant  obstacles  to  data  collection,  including  Member  State  statutes  that 
prevent  the  collection  of  data  that  identifies  specific  ethnic  groups  and  the  practical 
challenges of collecting data relating to a sometimes highly mobile Roma population. 

The NRIS are moving forward, but there is a recognised need for stronger monitoring 
methods to support data collection specifically, as well as the overall evaluation of the 
aggregate impact of actions.  

The  findings  from  the  survey  of  Member  States  of  this  study,  when  taken  in 
conjunction with the reports from National Researchers, provide support for the policy 
recommendations set out by the Commission earlier in 2013140.   

The  study  provides  additional  detail  as  to  how  each  of  the  Council  recommendations 
could  be  most  purposively  focused.  The  need  to  establish  a  robust  and  consistent 
European  baseline  has  been  reinforced  by  this  study  and  the  means  to  do  this 
illustrated through examples provided by countries such as Hungary and Estonia. The 
setting  of  core  indicators  alongside  the  establishment  of  a  common  evaluative 
framework  remains  a  challenge  for  many  Member  States  and  the  study  findings 
suggest  that  further  concentrated  and  coordinated  effort  will  be  required  to  support 
the  NRIS  programme.  It  is  good  that  the  groundwork  for  this  next  developmental 
stage  has  been  undertaken.  However,  the  concern  remains  that  without  a  further 
concentrated  effort  to  support  Member  States,  the  limited  progress  that  has  been 
made  to  date  will  not  be  built  upon  and  that  delivery  of  the  NRIS  could  be 
fundamentally undermined.  

As  the  report  on  Member  States'  current  and  future  activities  in  data  collection  and 
development of specific surveys aiming to monitor the progress of the implementation 
of the National Roma Integration Strategies in the area of health, the NRIS can further 
strengthen  their  data  collection  and  monitoring  aspects  to  complement  international 
and regional activities.  

140 Recommendation on effective Roma Integration measures in the Member States. 

August, 2014 

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Report on the health status of the Roma population in the EU and monitoring data collection in the area of 
Roma health in the Member States  

Recommendations 

Recommendations for the European Commission 

  The  European  Commission  should  provide  leadership  in  setting  standards  and 
establishing  protocols  for  data  collection.  To  this  end  it  should  continue  to 
facilitate  cooperation  between  relevant  international  agencies,  so  as  to 
minimise  the  risk  of  duplication  and  to  maximise  the  potential  to  develop  a 
common platform for data collection and reporting. 

  Research commissioned by the European institutions should strongly encourage 
the  use  of  comparable  indicators  and  comparable  research  to  allow  for  a 
baseline from which the research can develop across Europe. The Commission 
could  support  the  Member  States  in  developing  suitable  and  sustainable  data 
the  European 
collection  and  monitoring  approaches.  Where  possible, 
institutions  should  encourage  data  collection  which  is  ethnically  disaggregated 
and collected in agreement with EU’s Roma communities.  

  Where  barriers  to  collect  ethnically  disaggregated  data  are  encountered,  the 
study recommends that the European Commission go beyond the debate about 
the  collection  of  data  on  ethnicity  and  the  respect  of  anti-discrimination  by 
considering  experimental  methods  such  as  the  World  Bank  poverty  mapping 
method  based  on  socio-economic  indicators.  The  European  Commission  could 
lead the work in the use of appropriate proxy indicators to ensure the highest 
level of compatibility across Europe.  

  The  Commission  should  support  the  Member  States  in  exchanging  best 
practices and ensure the compatibility and comparability of data collection and 
of  monitoring  and  evaluation  of  the  NRIS.  For  example,  some  regional 
vaccination  programmes  have  clearly  proved  successful,  and  lessons  from 
these interventions could potentially be applied to other programmes within the 
country,  or  other  vaccination  programmes  implemented  by  other  Member 
States. 

Recommendations for the Member States 

  Data  collection  and  monitoring  measures  should  be  designed  with  SMART141 
objectives  in  mind  and  have  sufficient  financial  resources  allocated.  Research 
methods should be tried and tested and best practices should be shared among 
stakeholders.  If  ethnically  disaggregated  data  are  not  available,  consideration 
should  be  given  to  begin  collection  of  this.  If  this  option  is  not  available, 
appropriate  proxy  indicators,  agreed  by  civil  society  actors  and  government 
agencies at a European level and endorsed by the Commission, should be used 
as a substitute. 

  This  study  recommends  that  Member  States  are  encouraged  to  collaborate  on 
data collection concerning migrant and undocumented Roma. This is an area in 
urgent  need  of  more  data  and  this  is  particularly  challenging  considering  the 
fluidity  of  the  population.  The  IOM’s  Roma  EQUINET  may  be  able  to  provide 
guidance. 

141

 Specific, Measureable, Attainable, Realistic and Timely. 

August, 2014 

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Roma health in the Member States  

  The  NRIS  should  ensure  the  participation  of  a  range  of  civil  society  and 
governmental  organisations,  including  local  government  research  bodies  to 
provide  methodological  support  to  grassroots  monitoring  efforts.  Data 
collection  is  often  a  bottom-up  exercise.  Monitoring  and  evaluation  capacities 
could  be  enhanced  by  using  the  European  Structural  Funds  Technical 
Assistance. 

  The NRIS should ensure the active participation and engagement of Roma and 
civil  society  organisations  representing  Roma.  The  strategies  should  moreover 
focus  on  Roma’s  real  needs  as  and  when  they  are  identified  by  the  evidence 
base  from  European  projects.  Regions,  local  authorities  and  local  civil  society 
should be involved in reviewing and monitoring their national strategies. 

N
D
-
0
4
-
1
4
-
4
4
8
-
E
N
-
N

  This  study  recommends  that  the  focus  of  data  monitoring  should  be  on 
indicators measuring Roma access to health care (including immunisation) as a 
lack of health care access hampers improvements in Roma health at large and 
contributes  to  the  social  exclusion  experienced  by  Roma.  A  focus  on 
administrative  data  rather  than  health  outcomes  data  may  prove  easier  to 
collect in a format that is comparable and can be aggregated into national and 
international  data  sets.  Indicators  of  health  access  are  useful  proxy  indicators 
for inequalities in health status.  

August, 2014 

30