Emese Ibolya:

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

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. This statement can be supported by numerous studies carried out in relation to this minority. As a result of these, we can conclude that the morbidity and mortality indicators of this minority are generally worse than the majority population’s in Hungary (Puporka & Zádori, 1999). 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, the real danger is not ethnicity, but poverty in their case (Vadászi, 1999). However, a study made by Neményi (2001) 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 each other.

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 as well as on our ability to tackle them. Hungary has already passed the most difficult phases of transition and has accumulated enormous experience in the course of preparing for fulfilling Community obligations and requirements. 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 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. As a result, recent health surveys confirmed a life expectancy for Roma of 15 years below the Hungarian average (Commission Report 2002).
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.
Even though there are numerous reports of racism on the part of health 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.
According to Holló (2004), 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. Neményi (1998) and Krémer (1998) both emphasize 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. Therefore, 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.

Research questions
The following research questions will be explored during the period of the fellowship:

How much medical schools’ curricula prepare medical personnel for the challenges of dealing with the Roma minority?
How could these curricula be filled with certain ethnical contents to develop a more tolerant approach in medical students towards the Roma?
How do communication and cooperation could be improved between healthcare providers and the Roma?

Design and methodological approach
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 begin with a narrative of the current situation in the involvement of ethnical elements into these schools’ curricula. It will then move on to analyze attitudes of professors of medical studies to Roma health problems, moreover I intend to explore what kind of effect their views have on their students’ attitudes 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. I will also analyze how cooperation could be improved between health care institutions and the Roma minority. Subsequently, I will investigate how medical schools’ curricula could be improved in the light of the conclusions of the Roma situation 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.
The method employed includes a profound analytical overview of medical school curricula, health care policies, expert studies and research, completed with the interviewing of and collecting data from health care experts, medical professors and students, doctors and nurses working with Roma patients in public health care. Data will be obtained from predominantly written sources such as scholarly publications, official documents from governmental and supranational organizations. I will produce recommendations to eliminate existing disadvantages and the short-comings of the public health care system, as well as the barriers of the system that inhibit equity in access to health care.
In this research, data and relevant information will be collected for different regions of Hungary. Textual analysis and quantitative analysis of statistical data will be employed to precede this data and to generate relevant information.

Work Program
I plan to finish this research within a year. Firstly, I will collect data and do required fieldwork. In the last phase, I will perform the analytical section of the project and write up the conclusions and policy recommendations for Hungarian policy makers, relevant NGOs and public health care institutions.

Anticipated outcomes and outputs
Having understood the present practices in healthcare education considering ethnical content and different ways of developing skills in medical students to promote tolerance towards the Roma and their current situation in the pubic health care system, I will produce practical policy recommendations and an ethnic-sensitive model curriculum to medical schools based on foreign resources. I also wish to provide some recommendations to improve the health status and life expectancy of the Roma population in Hungary, moreover to create a well-functioning public health care system with even distribution of resources based on equity and tolerance.

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