Background

Roma population have been present in France for decades; they migrated mainly from Eastern countries for economic reasons (e.g. large differences of living conditions between Eastern and Western countries). Romania and Bulgaria’s accession to the European Union in 2007 further facilitated Roma population migration towards European countries including France, increasing their number.

The total number of Roma migrants present in France cannot be currently assessed as the available data does not allow the distinction between Roma migrants, other migrants or French nationals living in precarious conditions such as squats or slums. However, the latest census from the DIHAL (the Inter-ministerial Delegation for Accommodation and Access to Housing) estimates that there are nearly 17,500 people living in these conditions.

At the present time, it is still difficult to establish an accurate diagnosis of the health status of these Roma migrants in France; data is scarce or even absent on this matter, mostly due to fact that data collection according to ethnicity is not allowed in France. This situation also reflects the limited presence of health institutions addressing needs of this particularly hard to reach populations.

Difficulty of access to healthcare of Roma migrants in France is mainly due to: poor access to health insurance, lack of information among migrants about the functioning of the health system, the language barrier, the general lack of health education, the living conditions and also the lack of information among healthcare professionals about these living conditions.

The aggravated health status and the difficulty of access to health services of Roma migrants in France was objectified firstly by data from the Medecins du Monde’ intervention in several migrant groups in different countries; a report was published in 1999 called "Project Romeurope, access to care and health of Roma / Gypsy migrant populations in extreme exclusion in three European countries. Spain, France, Greece". Secondly, data collected in the observatory annual reports of access to rights and care from the intervention in France.

Project description

Since its creation in 2000, the National Human Rights Romeurope alerted the authorities to the need to take better account of difficulties of access to care of foreign Roma people living in France. Following extensive discussions and in order to verify the relevance of these recommendations for access to rights and health, the Directorate General of Health supported in 2008-2009 an action of  project engineering intended to present plans of development of mediation pilot projects. At the end of the project in 2009, the Romeurope published a report presenting the National Program of Health Mediation, which was initiated in 2011 with a pilot phase program of two years (2011-2012).

During this phase, initiatives were set up by 3 associations in 4 departments in France. The aims of this pilot project were to improve health access, especially prevention health for women and children and also to facilitate contact between professionals and the Roma population. The evaluation of this pilot phase showed very positive results in terms of health access of Roma women and vaccination rates in Roma children (e.g. DT polio vaccine: went from 20% to 80% - See Table 1).

Therefore, the health mediation program was prolonged for 2013-2016, while extending geographically and also in terms of target population; in this phase, all the Roma population was concerned. A secondary aim of this extended program was to adapt to other hard to reach populations such as Les gens du voyage, who encounter similar barriers in accessing health services.

Locally, a health mediator aims to:

• Develop knowledge and abilities of Roma population for autonomous access to care and prevention in the ordinary health services
• Mobilize health actors and promote a better understanding of this public (migrants)
• Report sanitary risks observed in living areas to project managers in order to attempt reducing those risks 

Nationally, the program of health mediation aims to:

• Develop actions of health mediation towards Roma population living in squats and slums and also, since more recently (2016), for other hard to reach populations such as  the “Travellers” (Gens du voyage”) 
• Promote health mediation towards all kinds of vulnerable or hard to reach population
• Professionalise health mediators and promote the recognition of this profession

In 2015, 11 mediators working with migrants living in slums were able to keep track of a total of 2,574 people, corresponding to an increase of 62% of the population, compared to 2013; this is mostly due to the development of the program. In 2015, the mediators were able to cover a radius of 35 slums and squats at the same time. Each mediator kept track of an average of 230 people and generally, women and children among the population (41% of total beneficiaries were children, 547 were under 6 years).  

In 2016, 14 mediators were working for 12 local associations all over France.  An interactive map of these 12 local projects is available here: http://www.mediation-sanitaire.org/les-acteurs/carte-interactive-des-12-projets-de-mediation-sanitaire-membres-du-programme/. A large part of health mediators’ actions concern infectious diseases, and their prevention in Roma populations, either through behavioural prevention or through vaccination prevention. Since the beginning of the program but mostly in 2015 and 2016, prevention tools have been co-created in collaboration with several health partners and also with the target populations; their aim was to be tailored to specific condition of health prevention in order to reach populations. These prevention tools included:

• The Pregnancy Book (Le carnet de grossesse Car’Mat' ), a bilingual document aiming to familiarize pregnant women with all pregnancy-related challenges and necessary appointments
• The pedagogic movie “The mother and the Infant” (“La mère et l’infant”), a film for the awareness on subjects as on maternity, pregnancy care, contraception, sexually transmitted diseases and children vaccination
•  Illustrative communication supports («Mon corps aussi » and « Le cycle de la femme et la grossesse »), conceived in 3 languages (Romanian, Hungarian, French), on topics such as sexual education or human body anatomy
• Movie on the hepatitis B prevention
• Education tool on tuberculosis (« Mythes ou réalités»), informing about tuberculosis transmission, symptoms, severity and treatment and aiming to change preconceived ideas on this disease
• The family card ( “la carte famille”), a tool helping mediators explain the role of GPs and the health monitoring system in France

Lessons learned and challenges

Life in the slums and squats remains marked by strong insalubrity, insecurity, a relatively poor access to health facilities and living conditions unfavourable to health, in terms of access to water, electricity, sanitation and general welfare. Territorial differences between conditions of reception of people living in slums/squats reflect the necessity of involvement of local communities and the need for health mediation promoters to put forward replicable practices for provision of sanitary facilities, access to water or servicing and relocation projects. If local health mediation initiatives put a lot of energy in access to housing, health coverage and response to health emergencies, it is important to also attempt to lift barriers to health access in these populations on the long term.

Status of the project

The project of health mediation in Roma populations in France is still ongoing. The final report evaluating the national mediation project is expected to be published at the end of 2016.