Emese Ibolya:

Improving medical school curricula and Roma access to health care in Hungary

1. Abstract
My research aims at exploiting barriers to access of Roma people to health care and examining and analyzing medical school curricula for better cooperation of medical personnel with the Roma minority. To begin, I will give an overview of present Hungarian health care policy and its special measures to improve the health situation of the Roma.
I will also give an account what elements are missing from the present legislation concerning Roma health issues and analyze the underlying reasons why government initiatives are doomed to failure in case they lack wide-ranging public acceptance. I also intend to explore the curricula of medical schools in the interest of tracking contents specially included for sensitizing future health-care providers towards social issues, such as poverty or minority existence.
The underlying attitudes behind the formation of these curricula is also of great importance for my topic, moreover the exploration of these attitudes being passed in education from the old to new generation. To examine these issues, I will analyze the curricula of different medical schools both on intermediate level and in higher education with special emphasis on their ethnical content and their capability of developing significant amount of tolerance in medical students towards the Roma. The study will also focus on current practices of health care institutions considering Roma patients, moreover the communication between healthcare providers and their patients of minority groups; and to reveal the possible barriers of satisfactory access to health care for the Roma. Subsequently, I will investigate how medical schools’ curricula could be improved in the light of the conclusions of the situation of the Roma in health care. Additionally, after reviewing such curricula in other countries, I wish to design one appropriate for teaching professionals to deal sensitively with ethnic minorities in general.
    Based on the results of my research I intend to formulate recommendations for future improvement in my policy paper.

2. Introduction
Health should not be considered as a condition of absence of diseases. One definition of health includes the following: “the capacity for each human being to identify and achieve his/her ambitions, satisfy his/her needs and be able to adapt to his/her environment, which should include decent housing, normal access to education, adequate food, stable job with regular income and sufficient social protections”.  The Roma peoples of Hungary and the whole Central and Eastern Europe are in the position of suffering the worst health conditions of these societies.    As a result, it can be concluded that the morbidity and mortality indicators of this minority are generally worse than the majority population’s in Hungary. However, the Roma as a significant minority, consisting of 5-6% of the whole population of Hungary are often forced to face the negative discrimination from majority members of society due to their unique culture besides their existing economical, social and regional disadvantages.
According to a report by the Regional Office of the World Health Organization, the health problems of the Roma are not of cultural but more of social origin. Therefore, in their case, the real danger is not ethnicity, but poverty. However, a study made by Neményi  with nurses working in the Hungarian health care system reveals that the ethnical background of the patients strongly affects the healthcare providers’ perception and their treatment of them. As a consequence, the gaps in health status between the Roma and majority population reflect official discrimination and marginalization of this minority. In other words, the problems affecting the health of the Roma population are of both social and cultural origin, which areas often overlap.
    The method employed in my research includes an analytical overview of relevant research and expert studies, analysis of statistical data on the health situation of the Roma from different aspects, examination of the legislative situation, completed by the interviewing of people involved in Roma health; health and Roma experts, policy makers, NGO representatives, lobbyists, teachers and students of  medical schools, Roma patients and health care providers to generate relevant information on the issue in question.
3. Health Policy in Hungary and the health status of the Roma minority
Hungary has already passed the most difficult phases of political transition and has accumulated enormous experience in the course of preparing for fulfilling Community obligations and requirements. The current social protection system in Hungary is a result of the historical development and most recent responses to the challenges of the economic and social transition. The "Decade of Health" Government program aims at improving the health status of the whole Hungarian population. To enhance this process, the Government is committed not only to consolidate and modernize the current health care system but to carry on the financing reform of the health system. The Government implements a health-centered governmental strategy, which mobilizes all economic means and entire mental capacity of society in the interest of each individual.
The most important objective is to improve the health status of the population, the increase of life expectancy at birth and to facilitate the quality of life determined by health The health system is reorganized to become a service provider, which provides accountable, effective services with controlled quality can be financed as a result of modernized and consolidated organization and its effective functioning provides decent livelihood for those providing the care The program was adopted by the entire consensus of Parliament and its implementation started in April 2003. However, there are still unsolved areas remaining, which require urgent treatment.
As for the health situation of the Roma, in 2002 the Government launched a wide-ranging program, containing measures to provide equal rights for the Roma, improve their quality of life and their living conditions, develop their physical and mental health, besides providing equal education chances and marketable job opportunities to promote their social integration. However, the policy-making process does not seem very effective in terms of considering the real needs of this minority, as most of these problems are still unsolved and a large proportion of Roma often do not have proper access to public health services, therefore do not meet the most basic health and safety requirements.
From the factors affecting health education, economical status, economical activity, living conditions have a dominant role. These determinants influence the appearance of both the physical and mental illnesses. Risk factors affecting health appear in a joint manner, strengthening each other resulting in and maintaining a health status very difficult to handle. From the risk factors smoking, insufficient nourishment and the lack of preventive activities are issues affecting health status with high appearance among the Roma. Mortality rates are double among the Roma than the average population, while the most frequent illnesses causing death are cardio-vascular diseases and illnesses of liver.     
The current health care financing system is not in relation to the actual needs of society. Moreover, besides regional inequalities there is a severe lack of access to public health care from the side of the Roma population. As a result, recent health surveys confirmed a life expectancy for Roma of 15 years below the Hungarian average.  

4. Barriers of Roma access to health care

4.1 The Roma in Hungary after the Change of the Political Regime
The transition from the communist political system to market economy, economic regression and the enacted restrictive measures had a major impact on social and health conditions in Hungary as well as on our ability to tackle them. After the break-down of the communist system a huge proportion of unskilled Roma people became unemployed working previously as manual laborers in the manufacturing industry. The unemployment rate was considerably higher among the Roma (35,8%) than among the non-Roma (11,2%) .
With appropriate qualifications Roma people could not enter the work force again, therefore a social tendency took place resulting in Roma families’ ending up on the margins of society in large numbers. These indicators have slightly changed during the past 15 years, as a thin, educated layer in the Roma population appeared.
This new generation of Roma people consider education as a tool for social mobility and have entered or finished medium or higher education as a result of extensive government action in education for the integration of the Roma launched in the past few years. The appearance of this new ‘social elit’ in the Roma minority should have a motivating effect on future generations as well, however, research data shows that the representation of Roma students in high schools still does not exceed 20% . Therefore, the Roma population still struggles with social disadvantages arising from low education.

4.2 Geographical isolation
 There is a severe lack of access to public health care from the side of the Roma population, not only because of the negative, often discriminatory attitude of medical personnel of health care institutions towards them, but due to regional inequalities as well. Roma communities are usually situated in segregated settlements at the most deprived areas of the socially disadvantaged regions of Hungary. As a consequence, Roma people often lack proper medical treatment due to geographical reasons based in segregated settlements with significant distance not only from local hospitals, but often the office of the closest GP in their area.
Data show that settlements with multiple disadvantages do not offer local practitioner services directly. They also tend to lack other basic institutional services. In settlements, where there is no GP, the number of Roma among the general population tends to be significantly higher, therefore, the inhabitants of these communities suffer multiple disadvantages with the lack of local and assessable healthcare .
The size and other characteristics of the settlement indicates the access of its members to health services. As a significant amount of Roma people try to integrate into mainstream society by leaving these Roma settlements and try move to neighboring villages with better infrastructure, while others tend to see these communities as places where their culture and identity is relatively remains preserved, which is a guarantee for a strong Roma identity for the future generations aswell.      

4.3 Stereotypes of health-care providers on the Roma
Geographical inequalities, the Roma need to face, are often supplemented with negative, biased attitude of medical personnel of public health institutions. These notions originate from different stereotypes on Roma people, due to insufficient information and lack of objective data on poverty and related issues, including ethnicity.
Different drawbacks present in the state of health are deepened by the intolerant and often discriminatory approach of professionals working in health care towards this minority, which can be well demonstrated by the following case; according to a 2004 report of Amnesty International, a Hungarian hospital provided separate accommodation for Romani women in the maternity ward, which is one of the widespread forms of discriminatory cases in health care affecting the Roma. However, this is only one case of the numerous scandals emerging from discriminatory treatment of the Roma in health care in present-day Hungarian society.
We can make a clear distinction between 2 types of discrimination: when a person, due to their Roma origin, does not have access to a certain health service; and the other type is when a Roma person experiences concrete discrimination during receiving health service. As a result, a number of cases can be identified, when some type of discrimination takes place in health care:
- insufficient access to GPs or medical specialists,
- the supposition of health care providers that a Roma patient cannot afford to pay gratuity money for the medical service,
- negative discrimination in antenatal care
- improper access to preventive treatments.  
Although, there are numerous reports of racism on the part of health care providers towards the Roma, remedy is usually available neither in the courts, in the training framework for healthcare providers, nor through any other mechanism. In fact, there is an almost-complete lack of structures for protecting and promoting health-related rights, such as codes of ethics for health professionals, patients’ rights charters, complaints mechanisms of any kind, or ombudsman offices concerned with health rights. Therefore, besides the improvement of the institutional background of the health care system, specific steps are needed to guarantee equal rights in health care and the development of Roma peoples’ health status.

5. Medical Education as a Key for Roma Access to Health Care  

5.1 The ‘Culture’ of Medical Education

5.1.1 The Education of Doctors
The present state of educating doctors at medical universities require extensive reform . There are no selective mechanisms built in the system, which means anyone, who was accepted at the university can become a doctor regardless of their social sensitivity. The implementation of selective mechanisms in medical education are doomed to failure until normative government support of universities depend on the number of students they have. Moreover, there are no practical-oriented elements of medical courses for doctors at Hungarian universities to sensitize future doctors towards social issues.

5.1.2 The Education of Nurses
To be added later

5. 2. Possible Improvements in the Education of Health-care Providers
National health policies relevant to minority inclusion include increasing the tolerance level and conflict handling abilities of healthcare providers, due to the high number of conflicts between Roma patients and healthcare personnel. This tendency, according to the Roma Integration Directorate of the Government Office for Equal Opportunities in Hungary, requires a thorough overview of medical schools’ curricula and cross-cultural training in the educational programs of medical schools. Therefore, it is of utmost importance to clearly emphasize the complexity of social disadvantages in medical education. Moreover, future health service providers need to be faced with the realities of poverty and social problems through direct, first-hand experiences as part of their education in order to be sensitive enough towards, and understand problems with social origin in their work.

5.2.1 Attitude of Teachers at Medical Universities
The underlying attitude of teachers towards contents of the curriculum is of crucial importance in the teaching process. The negative or biased attitude of university professors can be a reason for not including social or ethnic related contents in medical curricula, and can prevent students’ attitudes being formulated in a positive way towards social disadvantages. Attitudes towards different social groups in society are inherited, passed on to the next generation at medical schools, which is a basic determinant of the ‘culture of doctors’. This value system, which is most of the time has certain elitist elements, most future doctors originating from upper or middle class families, is a complex code of values and norms of behavior, which is very difficult to detect. Therefore, the perception on society need to be changed by perceiving doctors as service providers. Moreover, it is of utmost importance that representatives of disadvantaged social groups, such as the Roma enter medical schools and become health care providers and teachers of medical schools receiving the social prestige of this profession in order to change the perception of society on the Roma; moreover, the attitude of medical students.    

5.2.2 Changes in the Curriculum of Medical Schools
Neményi (1998) emphasizes the integration of ethnical contents into medical schools’ syllabuses and state that certain initiatives should be taken for the improvement of communication between healthcare providers and the Roma . Moreover, different courses should be developed and introduced that provide information on the health status and social problems of the Roma population. As a consequence, the curricula of medical schools need to be filled with both theoretical-factual and practical features of social contents.

6. Conclusion
to be added later

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