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 – BULGARIA

Full Report available here

Over the last ten years, Bulgaria has adopted several strategic documents aiming to improve the Roma situation in areas such as housing, health, education and employment, including the National Roma Integration Strategy of the Republic of Bulgaria (NRIS) 2012-2020 and the Health Strategy for Disadvantaged Persons Belonging to Ethnic Minorities among others. Despite of the number of initiatives aiming to address the disadvantaged situation of the Roma community, several weaknesses of the Bulgarian Roma Integration Strategy, including lack of state funding, the privatisation measures of the health-care system, are downgrading the effectiveness of these initiatives.

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 Bulgaria.

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

The National Roma Inclusion Strategy, adopted in 2012, aims at creating the conditions for the integration of Roma and other vulnerable minorities into the social and economic life. The Strategy is accompanied by an Action Plan where priority fields are defined such as education, healthcare, employment and housing. In the field of healthcare, the NRIS highlights the importance of expanding the scope of health insured people and implement legislative measures at regional and local level.

Despite the high number of measures and activities to address Roma health risk factors, the NRIS in Bulgaria seems to suffer from several weaknesses, including the set of low targets to achieve, the low state funding of the planned activities, aggravated by the lack of political will, and non-inclusion of previously implemented local activities, considered as good practices.

On the other hand, the Action Plan contains some relevant monitoring indicators of implemented activities. However, monitoring indicators rely on current national statistical information, which does not collect data disaggregated by ethnicity. Furthermore, the monitory does not contain several relevant indicators, such as hospitalization of Roma, disability, life expectancy of different ethnic groups, etc. Consequently, evidence demonstrates that the indicators provided cannot give real information on the effectiveness of measures and activities implemented in the field of healthcare.


“The government has not introduced a monitoring system. Although there was a PHARE project and a monitoring system in the districts was developed and proposed, it was not implemented…There should be an operating implementation and monitoring system, which is absent. There is no real accountability. There might be something reported to the Ministries but in practice these Ministries do not report to the National Council (NCCEII).” (A physician representing an NGO)


Analyses on the healthcare system in Bulgaria suggest that unaffordability of health insurance represents the most significant obstacle to healthcare access. Vulnerable citizens, including Roma, have a high risk of being insured due to specific working and social conditions, such as self-employment, irregular and low income, etc. In this context, the Bulgarian state introduced a separate funding mechanism in 2008 to cover the costs of healthcare provided to socially vulnerable citizens without health insurance. However, the existing support mechanisms are inconsistent or insufficient and the actual use of health services remains on patients’ financial status.


“In practice, the fund for treatment of socially disadvantaged people does not work… If you go to Belgium, for example, you will be treated first and then the hospital will look for who is to pay. It is just the opposite here! If a Bulgarian Roma goes to Belgium, he will get better treatment than here! I constantly see patients who had been hospitalized 10 times already but are without a diagnosis and without adequate treatment. This is it – quality has rapidly declined. Because doctors no longer think about the diagnosis. They think about the clinical pathway and the financial result. Diagnosis is somewhere at the background. This is the reason why some hospitals have simply banned some types of tests. Not for a particular patient, but in general.” (А physician representing an NGO)


The National Network of Health Mediators, mentioned as another mechanism in the strategies and actions plans for providing healthcare to the Roma community, was launched in 2001. According to interviews conducted with Bulgarian experts, the health mediation programme has been praised as one of the most successful Roma targeting initiative. Health mediation has been officially recognized by the state as a profession occupation and the government provides continuous financial support for this programme. Nevertheless, the programme still faces challenges, including minimum wages for health mediators and an average low level of education within the Roma community, which lowers the employment opportunities for this community.

In this context, the Bulgarian NRIS requires further improvements, particularly in ensuring sufficient state funding for the activities and in widening the targets, including the adoption of previously implemented activities with successful results.

On the other hand, the lack of data on various vulnerable groups and the lack of consideration of several health related indicators are undermining the effectiveness of the monitoring activities of the Strategy. Therefore, further efforts should be made in developing meaningful indicators to monitor the effect of the NRIS and the Action Plan, and in improving data collection on ongoing Roma health-care projects and activities.
Finally, as health mediator programmes have been recognized as one of the most successful programmes in proving healthcare to the Roma community, further improvements should be applied, particularly in better pay for health mediators and in order to increase the number of employment opportunities for the Roma community.

The Progress Report was produced under IOM MHD, RO Brussels guidance by Ilona Tomova and Valentin Zhechev, and benefitted from peer review by Mariya Samuilova. Dj Krastev copy-edited, proofread, and assist with the general editing.

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