XXXI. Annual conference of Slovak GPs

Bojnice, Friday 22th October 2010

Annual conference of Slovak general practitioners organized in the city of Bojnice

Report of the contribution by:

Prof. J. De Maeseneer, MD, Ph.D.[1][2]

C. Leyns, MD.[3]

J. Lobbestael, MD.2

Meeting with the major of Bojnice:

Bojnice is a small city of 5000 inhabitants in central Slovakia. There are no Roma people living in Bojnice, only 2 Roma are working there.

The twin city of Bojnice is Kosice. Kosice is situated in the east of Slovakia and has a lot of Roma inhabitants. 5000 of them are placed in the ghetto named Lunik IX. Vtáckovce, a small village just outside Kosice, has 90% Roma as inhabitants.

The major of Bojnice would very much like to help us in exploring our contacts to Kosice and hoped it would be possible for the city of Kosice to work together with the cities of Ghent and Sint-Niklaas in the sharing of expertise on Roma People.

Keynote lecture:Primary Health Care as a strategy to achieve equitable care.By Prof. J. De Maeseneer, M.D., Ph.D., Head of Department of Family Medicine and Primary Health Care, Ghent University – Belgium.

"Health care for Roma people” by general practitioners Christine Leyns and Janique Lobbestael

Goal:using an interactive workshop based on clinical cases from GP’s in Ghent and Sint-Niklaas we tried to reach:

  • Exchange of experiences between GP’s in Belgium (Ghent and Sint-Niklaas) and in Slovakia. Exchange with Roma people or their representatives.
  • Identification of common care problems/ pitfalls
  • Discussion on possible solutions for these care problems

Our main findings:

  • Primary care organization in Slovakia: There is no specific training for GPs. General Physicians start working as GP after 7 year of education. They treat people from the age of 20 until the end of life. They don’t assist in the follow up of pregnant women, nor do they treat any children.
  • Overall the Slovakian GP’s had few positive experiences in the care for Roma people. Frustration and pessimism were reflected through their contributions.

Many GPs quoted: “They only want rights and no duties; "The Roma families have many children, because they earn the money for the family”. ” They only live today and are not interested in what tomorrow brings. They don’t buy or take the medication the GP prescribed.”

“They see no advantage in education so they don’t bother bringing their kids to school.”

One nurse expressed positive relations with Roma people. She thought that using role models within the Roma-community was an appropriate strategy to start change.

Another person participating in the discussion worked on a project for the promotion of Roma health. They started a training of field health workers. This training takes 4-6 years but the program was recently shut down due to lack of money.

  • We learned that GPs internationally can exchange experiences, because global problems ask for global answers and a global commitment.

In Belgium or Slovakia we share the same frame of reference as general practitioners, as primary health care providers. We share the commitment, the context and the focus on the patient and we share patient centeredness.

The problems with appointments and follow-up of Roma-patients, the problems to involve Roma-people in proactive care, to make a shared plan for the future, the problem of inappropriate behaviour in hospitals are common in the Belgium and Slovakian context and could benefit from exchange of experiences.

  • Also the problem of "interest in obtaining social benefits" should be addressed.

The difficulty in the position of general practitioners is that when it comes to social benefits for patients, general practitioners play an important role, because they have to fill in the documents

GPs are in a constant risk to "blame the victim": when we declare that Roma-people should behave otherwise, but often they are not able to do so and do not have the skills to behave as we expect them to do.

  • Roma-people do not always have easy access to jobs.

We have to start the dialogue on the problem of rights and duties: there is no right without a duty, but the translation of these concepts into the cultural framework of Roma-people, is not obvious.

  • The frustration and pessimism of health care providers is understandable. But on the other hand pessimism is not an option. We have no choice. "Optimism is a moral duty" and we think that we have to cooperate internationally in order to deal with these problems.
  • Change is made in very small steps and such a small step can diminish frustrations on both sides.As an example:home visits for chronically ill patients may avoid unneeded hospitalisations, due to missing appointments.

One thing is clear: we as health care providers are not in the position to solve the problem only from the medical context. We have to frame the problem in a broader context and to look for solutions, taking into account the upstream causes of the problem, what is behind.

Results:

Is there a way out and what could be the way out?

The first step is: we have to document the situation.

  • “Howmany Roma-people are at work”is an important question.

We have to document what is happening, not in order to condemn but in order to have a transparent starting point for discussion, not based on prejudices but on facts. Access to the labour market is dependent on educational level of the people.How many Roma at the age of 18, finish secondary school.Transparent information leads to a "diagnosis" of the problem. It is clear that GPs - from their medical perspective - cannot make this "diagnosis" on their own.

  • When it comes to social benefits, we probably have to change the paradigm.

An approach could be:"Ok, you can have access to social benefits, but there will be a contract. There will be an effort, a contribution from your side ". The benefits will be conditional. Let us try to do that in a synergetic way here, in East-Europe and in West-Europe, and let's harmonize our messages. We need an international cooperation to create synergies.

  • We will definitely need an anthropological perspective in order to understand what really happens, what the driving forces and the cultural and contextual determinants are.

We have to try to understand the complexity of the motivations that underpin the behaviour of people and very often we have difficulty to cope with diversity.

  • We need both economical approaches, andeducational approaches.

The school will be a place to act, education will be a sector to act, employment will be very important, and housing will be a problem to address.

So, as the problem is multi-axial, it requires a multi-axial strategy. There is no one-size-fits-all solution. The health care system is not able to provide answers: an intersectoral action is needed.

  • We will have to look at a de-centralised approach: e.g. the problem is different in Ghent (Roma from Kosice - Slovakia), in Sint-Niklaas (Roma from Kosovo),...We will need local plans that are comprehensive and multi-axial and a strategy to make change happen.
  • The idea of using role models from the Roma community is really inspiring. Role models work. If we can identify in the Roma-community, people who can act for their community as role models and if we support them, we can make a difference.
  • We urgently need a participatory sociological approach towards the Roma-community.Knowing and understanding their history and especially the moments in history that have been painful is important.

Leadership in the Roma-community should be identified and recognized. Also in Belgium, people within the Roma-community are standing up and saying: "This has to change. We have to take a different step, a different strategy, there are not only rights, there are duties as well". This linkage with leadership in the Roma-community is crucial.

  • When we are pessimistic that trust is disappearing, we should remember that building trust is a responsibility of all of us. Not only of the Roma-community, but also of the Flemish Community, of the care providers and of the politician. Trust building is an important strategical issue.

In conclusion:

  • There is a need for a comprehensive, multi-axial and international approach in Europe towards the situation of the Roma-Community.
  • Participation and involvement of the Roma-community is essential in developing an effective strategy. Leadership should be recognized and role-models identified.
  • Local authorities can play an important role in addressing the complexity and diversity of the problem, with the help of the European Union.
  • Human rights-approaches provide and important frame of reference, and should be complemented with social justice, solidarity and responsibility of European citizenship.

[1] Department of Family Medicine and Primary Health Care, GhentUniversity – Belgium.

[2] Family Physician,Gent

[3] Family Physician, St-Niklaas