The health mediation in Bulgaria
Read the interview to Dilyana Dilkova
By definition, a “health mediator” is an intermediary facilitating the access of disadvantaged people and groups to health and social services. In Bulgaria, the Health mediator model was launched in 2001 by the team of “Ethnic Minorities Health Problems Foundation” – the first five health mediators were trained and employed in the context of the “Introduction of a system of Roma mediators – an efficient model for the improvement of the access of Roma to health and social services” project. The main objective of this pilot program was to address established negative health tendencies among Roma groups in the country, such as low life expectancy, high prevalence of chronic diseases, exclusion from the health and social system, poor living conditions, etc. The program was also aiming to contribute to overcoming the cultural barriers in the communication between the Roma communities and local medical staff; to overcome possible discriminatory attitudes in the field of local health services against the Roma people; to optimize the implementation of prevention programmes and to improve the vaccination coverage among the Roma population; to provide health education and active social work in the Roma community.
As such, the area of prevention of epidemics is central in the experience of Health Mediators in Bulgaria. Moreover, this experience is fully in line with the central theme of adapting the communication and the interaction to the many local cultures that can constitute a community target of prevention and risk communication actions.
The Bulgarian health mediator model was developed based on the experience of the Dutch Institute of Public Health and on the Romanian model of health mediators, which was presented by the Romani CRISS Foundation and the Romanian Ministry of Health. Programs for (health) mediation exist in many other European countries as well; for instance in Spain and France such programs have existed for decades. Health mediation is also practiced in the Netherlands, Moldova, Slovakia, Serbia, FYROM, Hungary, Belgium, and Italy.
In Bulgaria, since 2001, many Health mediators were trained and hired as part of various projects. Then, in September 2005, the Bulgarian Government adopted the Health Strategy for Disadvantaged Persons Belonging to Ethnic Minorities. The new profession – Health mediator – had a significant place in the Strategy, and one of the indicators for its successful implementation was the number of Health mediators employed by the government. Late 2005, the Ministry of Labour and Social Policy also showed interest in the Health mediator profession – as a result the Health mediators trained in two Bulgarian towns (Dobrich and Dupnitsa) were appointed under the Programme “From social allowance towards employment”.
In 2007, through the efforts of the Ministry of Health, Ministry of Labour and Social Policy, Ethnic and Demographic Issues Directorate at the Council of Ministers and, last but not least, of the non-government organizations working in this sphere, fifty-seven health mediators were appointed to work in thirty municipalities, with budgets provided by the state. The intention of institutionalizing the new profession of Health mediator became a clearly defined national policy. The Health mediator was included in the National Classification of Professions, and its job description was also adopted.
In 2007, the National Network of Health Mediators was founded. It develops and implements successfully the Health mediators’ model at a national level in Bulgaria – it is the biggest public benefit organization in Bulgaria, whose members work daily on the field, helping the most vulnerable groups of the population.
The mission of the Network is to improve access and quality of health services for the people belonging to vulnerable communities. Members of the Network are numerous (more than 170 people) including Health mediators, medical specialists, sociologists, psychologists and public figures.
Since the state started to provide the municipalities with funds for employing Health mediators (2007), the number of the Health mediators in the country raised from 55 (in 2007) to 170 (in 2015). The Health mediators work in 26 out of 28 districts and in 99 municipalities throughout the country. Each year, a list of municipalities that should receive state financing is prepared by the National Network of Health Mediators, which is afterwards sent to the Ministries of Finance and Health.
All Health mediators in Bulgaria are selected through competitive examination, which is widely advertised by the municipality. The candidates are interviewed by a commission whose members are representatives of the municipality, of the Regional Health Inspectorate, of National Network of Health Mediators, GPs, and members of the local vulnerable community.
The Health mediators are women and men of different ages, coming from communities in which they work and speak the community language (Romani, Turkish, and Wallachian). Secondary education is the minimum requirement; also communication, dynamism and creativity are essential.
Thus, the experience of the Health Mediator project is a remarkable example of integration of Civil Society into Public Health service.
The professional training of the Health mediators takes place in the Medical University in Sofia. Trainers of the Health mediators are University lecturers and experts from the National Network of Health Mediators. After successfully taking their final exam, Health mediators receive certificates for professional qualification allowing them to be employed by the municipalities.
Some of the main tasks of Health mediators are: to communicate with all local health and social institutions; to assist and accompany (when needed) people to these institutions; to assist GPs in obtaining better vaccination coverage; to help people fill in documents; to organize health-information meetings in the community; to contribute to increasing the health culture of local vulnerable groups through explanation and consultation; to implement programs for sexual and reproductive health and to assist the organization of prophylactic check-ups with mobile units.
Health mediators work mainly with populations, called “Roma” by the majority, living in segregated neighbourhoods. However, not all inhabitants of these neighbourhoods call themselves Roma – some of them identify as Bulgarians, others as Turks or Romanians. They speak different languages and have different religions.
As previously mentioned, the position of health mediators is aimed at optimizing the implementation of prevention programmes and increasing vaccination coverage among the Roma population. Some of the prevention-related projects of the NNHM (National Network of Health Mediators) are listed below.
Projects involving Health Mediators in Bulgaria
Initiative for Health and Vaccination
The project was implemented under the patronage of the Parliamentary Committee on Health and the Council of Ministers (National Council for Cooperation on Ethnic and Integration Issues). It started in 2010, as the measles outbreak in Bulgaria affected mainly Roma communities – 92% of the reported cases were in the Roma population. During the epidemic, national and regional meetings were held. The main objectives of the project were:
- To improve health access to Roma communities by cooperation between health mediators, GPs, and Regional Health Inspectorate representatives
- To extend the vaccination coverage among hard to reach groups;
- To raise awareness of benefits and safety of vaccines.
Health mediators had an active role during the measles outbreak and its containment.
Health Promotion & Preventive Maternal and Child Health Care
The project was implemented by Open Society Institute – Sofia, ICON Institute (Germany), the Ethnic Minorities Health Problems Foundation and the Bulgarian Family Planning Association. The project aimed to improve access to preventive health services for women and children of ethnic minorities, with a focus on Roma. Several preventive clinical examinations with mobile units were undertaken in previously chosen locations. Meetings and discussions were conducted with families and youth, emphasizing the importance of preventive medical examinations. Both local communities and institutions (such as RHS, RIHPC, and NGOs) were involved, and families and youth underwent training (in two regions).
Let's talk about protection – a communication guide on childhood vaccination
In the period 2012 – 2014, the National Network of Health Mediators and the National Centre of Infectious and Parasitic Diseases started co-working on this project, financed by ECDC. The main goal of the project was to enhance the communication between health workers (GP’s, paediatric specialists, nurses and health mediators) and families who were reserved towards, or refused mandatory vaccination. A Handbook aimed at helping parents to understand vaccination and supporting their choice to get their children protected was prepared by ECDC and adapted in Bulgarian – it included materials about diseases, vaccines’ ingredients, their safety, answers to the most frequently asked questions related to the use of vaccines that parents had, etc. In addition, a study focusing on factors of vaccine refusal was conducted.
Personal Hygiene and Sanitation Education Campaign
In 2015, the National Network of Health Mediators started developing a Handbook focused on hygiene, as primary non-pharmacological step for prevention of epidemics and pandemics. A workshop was organized and the main discussed topics were: transmission of diseases, introducing hygiene topics and unsafe practices in Roma neighbourhoods. Participants proposed different materials for the educational Handbook. The campaign is continuing in 2016 and focusing on training of Health mediators for the usage of the developed materials.
In the past several years, many Health mediators started, among other activities, working in local hospitals. They were invited by hospital directors to facilitate the communication between patients and hospital staff, mainly in maternity and paediatric wards. The main problem was the tension arising between patients and staff because of some cultural differences. Additionally, the low level of health awareness and, in some cases, the difficulty encountered by patients to understand doctor’s prescriptions was problematic. Employing Health mediators in hospitals showed to be very successful, also in economic terms, and is becoming more and more popular in the country.
Lessons learned and challenges
The National Network of Health Mediators works in partnership with organizations and institutions developing mediation programs in Europe through different projects. Some of the main aims of these partnerships are the strengthening of mediation programs in Europe and the exchange of experience and good practices between mediators and coordinators of mediation programs from different countries.
One of the strengths of the Bulgarian Health mediation model is the requirement for obligatory secondary education for each of the candidates for Health mediator. Another strength of the program is that each Health mediator is selected through fair competition, by a commission with representative from the Network of Health Mediators. In this way, the transparency and the quality of the selection are ensured. The possibility for both women and men to become Health mediators is also an asset – depending on the community and in certain neighbourhoods, men are considered to be in a better position to communicate health-related messages.
However, there are still some challenges to overcome, such as the inconsistent financing and/or contracts e.g. health mediators can work sometimes without being paid up to 3 months, the time it takes for the contract to be finalized. Moreover, salaries remain low with an average of 165€/month, ranging from 153 to 200 euros and depending on each municipality (Schaaf, 2011). Furthermore, providing adequate supervision of Health Mediators is one of the most important component of the success of such a project. Even if providing this supervision by allocating supplementary funds requires a large financial investment, it is essential for the program. Adequate supervision may also improve Health Mediators’ effectiveness, as it is known that poor supervision can be associated with low motivation and decreased efficiency.
Status of the project
The Health Mediation project in Bulgaria is still ongoing, its model and successful development and institutionalization throughout the years served as example for developing mediation programs in other countries as well – Slovakia, Serbia, and FYROM.
Additional information on the program can be accessed via the following sources:
- Official website of NNHM: www.zdravenmediator.net
- Short video “Profession Health mediator” - https://youtu.be/PExp0pfH6nE
- Article, Vaccines Today: http://www.vaccinestoday.eu/vaccines/bridging-the-gap-health-mediators-help-reach-roma/ , 20 November 2013
Schaaf M. Roma Health Mediators: Successes and Challenges 2011.