To Build a Bridge

Training for Health Professionals and Law Enforcement Officers

Summary Report on the MIPEX Health Strand and Country Reports

EQUI HEALTH Public Report

Border Management and Detention Procedures: Health Perspective




Migration Health: Better Health for All in Europe


Assisting Migrants and Communities


Improving HIV data comparability


HIV-related data on migrant and ethnic minority populations in EU/EEA/EFTA


Mobility of Health Professionals

MHD RO Brussels Publications

Implementation of the National Roma Integration Strategy (NRIS) and Other National Commitments in the Field of Health – SPAIN

Full Report available here

The health of national Roma in Spain has improved in recent years thanks to developments in housing, the implementation of universal healthcare, the rehabilitation of marginal areas, and the expansion of compulsory schooling. Social discrimination and health inequalities between the general population and the Roma community (national and foreign) remain as a major problem to be addressed. To cope with Roma health inequalities, Spain has developed a National Roma Integration Strategy (NRIS), implemented through the Operational Plan (2014-2016) establishing the accessibility to the healthcare system as one of the strategic lines of action to improve Roma health. However, the current economic and political context in Spain is affecting negatively the implementation of the NRIS and other policies aiming to ensure the access to healthcare for the Roma communities, and entailing conflicts of interest among different levels of governmental administration.

The Progress Report, part of the EQUI-HEALTH project – Roma health sub-action, presents the results of the assessments on the relevant developments made in respect to Roma health in the Spain for the period 2005-2014.

Based on desk research, fieldwork and interviews with different stakeholders, including representatives from national authorities, professionals working with Roma, health providers, and civil society organizations, the report provides an analysis on the implementation of the Spain NRIS and other national commitments in the field of healthcare.

The Spanish NRIS is based on the concept that healthcare assistance in Spain is free and universal for everyone living in the country, regardless ethic origin and/or legal status. However, the current economic and political situation in Spain led to legislative changes in the healthcare system having negative consequences affecting national and foreign Roma populations in particularly, and creating additional barriers to the effective implementation of the NRIS.

The RDL 16/20121 strictly regulates free access to healthcare services through the Health Card (Law establishing new regulations on the Spanish Healthcare System)

As a response to these legislative changes, certain regional Governments such as Andalusia and Catalonia developed parallel strategies to ensure healthcare access to those excluded from the new law.


“I can order blood tests and other things, but I can’t prescribe them medicines because they are not in the system.” (Healthcare provider)


Regarding the access to the healthcare system, the Operational Plan of the Spanish NRIS aims at an equitable, accessible and quality healthcare system by removing existing barriers. In this way, several obstacles have been identified, many of them being related to lack of adaptation of healthcare services to culturally diverse health users, and the socio-economic situation of the Roma community (labour market segmentation, gender roles, and/or their concept of health). The NRIS has limitations as it focuses on the national Roma population and by not having its objectives interconnected and integrated with other policies and strategies of the Spanish National Health System.


“If the patriarch, (...), the venerable elder, is ill, it is normal for different Roma communities to want to go and visit him; but there is a system, certain visiting hours and so forth, and that’s when both cultures clash.” (Policymaker)


“Our NHS is not ready professionally to deal with exclusion, and it does not know how to manage diversity because neither at university nor anywhere else are providers trained to work in conflict areas.” (Mediator)


However, there has been a process of adaptation of protocols of some healthcare providers working in centres with high rates of Roma users. Contrary, the Roma community remains little engaged in policy planning and implementation. Furthermore, the fact that National Roma and their associations do not sympathize with, and even discriminate, foreign Roma constitutes an addition problem for the foreign community.

“Foreign Roma (...) are not integrated in our health culture, they are not aware of the services and resources to which they have right, because in most of the countries where they are from, mainly Central Europe, there are difficulties regarding access, so they think it’s the same here.” (Manager)

In terms of health mediation, actions are addressed through public institutions participating in policymaking, health centres, and programmes implemented and funded by social institutions. However, the most effective actions are conducted by healthcare providers and social workers from civil society organizations, often having a localized character and organized through a small number of workers or mediators. Regarding the impact of these processes, assessment is carried out in a participatory and observational way (familiarization with the community and their needs, etc.).

In this context, The NRIS and its Operational Plan intend to address the National Health System towards reducing specific Roma health inequities by establishing specific lines of action. However, limitations in the NRIS remain unaddressed, particularly regarding the fact that it is mostly focused on national Roma population and the lack of interconnection and integration of the objectives with existing policies and strategies, which highlights the need to improve coordination between different stakeholders and levels of government.

Regarding Roma access to healthcare services, the assessment suggests to simplify the administrative procedures that ensure medical assistance for this community. On the other hand, differentiated measures should be implemented concerning foreign Roma population as the national Roma community mainly faces socio-economic barriers (employment, education, etc.) rather than vulnerability based on ethnic belonging.

Finally, although health mediation processes play a central role in enhancing Roma’s accessibility to medical services, more training for health mediators should be provided, covering knowledge on health issues, cultural competences, and knowledge of the Roma community and their health.

The Progress Report was produced under IOM MHD, RO Brussels guidance by Manuel García-Ramírez, Marta Escobar-Ballesta and Tona Lizana Alcazo and benefitted from pre-reviews and editing by Mariya Samuilova. DJ Krastev copy-edited, proofread, and assist with the general editing.

1Real Decreto-ley 16/2012, de 20 de abril, de medidas urgentes para garantizar la sostenibilidad del Sistema Nacional de Salud y mejorar la calidad y seguridad de sus prestaciones. Available at 5403.pdf


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