Questions and answers: Health mediation in Bulgaria

Dilyana Dilkova – Member of the Managing Board, National Network of Health Mediators;

Description of the initiative

Q1: How did this initiative start?  What were the needs it addressed?

A: The introduction of the profession of the health mediator (HM) in Bulgaria started 23 years ago as a result of the work of a neurology professor – prof. Ivaylo Tournev. At that time, he travelled throughout Bulgaria in search of patients suffering neuromuscular diseases which led to serious invalidity. Entering in numerous Roma communities, prof. Tournev found out their dramatic social situation – poverty, poor living conditions, lack of access to healthcare and social workers; low health literacy; lack of identity cards in some cases. In order to help these people get diagnosed and receive proper medication, it turned out that their social problems needed to be addressed first. In that moment, the idea emerged that people from those communities who were more educated should be trained to help others reach health and social services. Then, in 2001, started the first project for HMs – the first five HMs were trained and started work in the Roma neighbourhood of the town of Kjustendil.

Q2: Can you describe how civil society was included in your project?

A: The project for introducing the position of the health mediator in Bulgaria was in itself a civil society initiative set up by the Ethnic Minorities Health Problems Foundation and its chairman prof. Ivaylo Tournev. Later, this mission was supported by other civil society organizations, such as the Bulgarian Family Planning Association. Many Roma NGOs also developed projects focused on health mediation in the first years of the introduction of the new profession. The institutionalization of the health mediators in 2007 was a direct result of years of advocacy with state institutions on behalf of the civil sector.

Q3: Why do you think it is important to include civil society in your project?

A: Civil society, when it functions well, performs several very important functions that could contribute to better state governance and better policies on state or local level. Among these functions is the possibility to represent the point of view of the weakest and most vulnerable members of society; to be a watchdog against violations on behalf of institutions; to increase the awareness of people with regard to their rights and responsibilities, etc. The National Network of Health Mediators (NNHM) has always counted on the voice of the local representatives of civil society. This is one of the reasons why our efforts with regards to the process of selection of new HMs have always been directed towards ensuring transparent procedure – for several years already all state-funded HMs are selected by commissions including representatives from the municipality, the Regional Health Inspection, NNHM representatives, local medical services provider and representative of local Roma NGO and/ or representative of the local Roma community.

Q4: What is the role of health mediators in your country, in the context of the Health Mediators project?

A: The HMs are women and men of different age, they originate from the communities in which they work and speak the community language (Romani, Turkish). They have graduated secondary education as a minimum and are communicative, dynamic and creative persons. They are trusted by the communities. The HMs act as intermediaries who facilitate the access of persons or groups in disadvantaged positions to healthcare and social services. In their daily work the HMs provide health or social information; organize and carry out health information gatherings; collaborate with GPs on issues like prophylaxis and vaccination; accompany clients to health or social institutions and help them fill in documentation or understand the prescriptions of the doctor; follow up families with chronically ill members; provide information on family planning and have a special focus on young mothers, health uninsured pregnant women, and children.

In 2007, the HMs were officially included in the Classificatory of Professions; their training started to take place in Medical Colleges and the state started to pay their salaries. The first 56 HMs were appointed in Bulgarian municipalities.  

Q5: How does this work? Can you give more details?

A: The profession “Health mediator” succeeded to make its reputation in Bulgaria because it addresses problems related to poor health information and culture, existing myths for certain diseases and their treatment in the isolated communities, the lack of or the irregular immunizations among vulnerable groups. One of the key factors for HM’s success is the fact that they belong to the community they work for. They help people overcome their prejudices and fears, gain their trust and contribute to community development.

Q6: How many Health mediators are working at the present?

A: In 2017 the State supports the salaries of 215 HMs; in 2018 their number will increase to reach 230 HMs working in 117 municipalities.

Q7: Can you give us some specific examples of initiatives / projects / campaigns Health mediators have worked on?

A: Within the peak of the European measles epidemic in 2010 (in Bulgaria about 24 000 people, mainly Roma, were affected and 24 children died) NNHM was one of the key drivers of the Initiative for Health and Vaccination that united the efforts of Parliamentary Health Commission, National Council for Integration on Ethnic and Integration Issues, Ministry of Health (MoH), Regional Health Inspectorates (regional structures of MoH), General practitioners. As a result, about 188 000 complementary measles vaccinations were administered with the assistance of the HMs who explained from door to door to parents the importance of child vaccinations.

The success of the initiative in 2010 lead to a second campaign in 2011, when NNHM was again invited by the MoH to cooperate with the Regional Health Inspectorates in a national campaign for vaccination against poliomyelitis with about 8400 children who received vaccine.

Throughout the last 10 years the HMs participated in different projects of the Network and its partners – HMs were interviewers of people from the communities in several surveys on health and social status of Roma; HMs organized information gatherings on the topics of discrimination and helped victims to address the institutions in charge; HMs carried out meetings in the communities for addressing the issues of early marriages and domestic violence; HMs were trained to work with children on personal hygiene; annually, HMs support the work of the mobile units providing prophylactic check-ups for health uninsured people, with health information campaigns and organization of check-ups; HMs are partners of all institutions on the territory of their municipalities and take part in local initiatives focused on Roma communities. In some small municipalities, the HM is the only Roma working in the municipality – in this way, all kinds of issues concerning local Roma are addressed to him/ her.  

Q8: In your opinion, what are the attitudes / beliefs of the Roma population towards vaccination? Do you think health mediators can help improve these attitudes / beliefs?

A: Many of the common concerns about vaccines in Roma populations echo those outside the community. In Bulgarian society the old-fashioned ideas that measles and rubella are diseases the child should just “pull through” still persist. In some cases healthy children are taken to meet infected ones because some still believe that the earlier the child “passes” through this, the better. In the Roma community these views are also present, plus the suspicion that vaccination could cause sterility. In general, the Roma community needs more health information about vaccines and how they work.

Roma parents are concerned that vaccination could make their child ill. They are not acquainted with the normal side-effects of vaccination such as redness etc; the GPs usually don’t have the time to explain to every parent what is normal and what is not and sometimes parents get concerned if the child feels discomfort. This is also a task of the HM – to explain all this – why this vaccine is important, why it should be administered within a given period, what are the possible complications if the child gets ill from a vaccine-preventable disease.

In the first months of their work, newly-trained health mediators have several important tasks, one of which is to establish contacts with all health and social institutions representatives working on the territory of the municipality. One of these important contacts is with the general practitioners that work with Roma patients. The GPs prepare lists with non-vaccinated children and give them to the HM. The HM finds the parents of these children and explains to them why it is important to vaccinate their children.

After explanation from GP or HM, Roma parents usually agree that vaccination is needed and important but still some of them don’t take their children to the GP’s consulting room. We have observed better results when the vaccination campaigns are organised in the field, within the community, at a place where Roma people could gather without leaving their locality. The other successful method is the health-informational work of a HM in the community and, in certain cases, having the HM accompany some of the children to the GP.

Q9: Can all these explain why vaccination coverage is lower among Roma population compared to national averages?

A: In addition to certain beliefs of fears among Roma, children may also miss out vaccinations either because their parents do not have health insurance and have fewer contacts with health services as a result, or because the children are not registered with GPs. There are families that travel to work abroad together with their children and sometimes the immunization status of these travelling children is also not clear, so the HMs are not able to find them when the time for immunization comes. Another problem is the unwillingness of some GPs to collaborate with HMs; there are many cases of GPs that report immunizations that haven’t been administered in practice – because the parents didn’t show up or weren’t found or because they missed an appointment.

Q10: How can this issue be addressed, in your opinion?

A: Our experience shows that, in the neighbourhoods where HMs work well with GPs, the cases of epidemic outbreaks are less or missing. For example, the GP working since 2005 in the town of Straldza together with the local HM has in her list 3000 patients (1000 of them children). She recently reported 1500 prophylactic check-ups carried out for one year; 900 immunizations (including on the field); and for the period 2012-2016 – 180 immunizations for HPV (recommended vaccination in Bulgarian Immunization Schedule covered by the state for girls of age 12 and 13 years).

In addition, control over the GP practices should be tightened – not only for GPs that report immunizations that weren’t actually administered but also for GPs that refuse to follow the obligatory Immunization Schedule and the recommended immunizations (HPV and rotavirus).

Q11: Was there an evaluation of the project conducted? If yes, what were the results?

A: Until now, no external evaluation of the National Health Mediation Program was conducted. NNHM makes efforts to carry out internal monitoring and evaluation of the work of the HMs. At the end of 2016, the Ministry of Health approved unified reporting forms for HMs developed by NNHM and made it obligatory for all HMs in the country to fill in the forms – the quantitative results gathered from these reports are summarized by the NNHM team on a 6-month basis. In addition, since the beginning of 2017 the team of the Network carries out monitoring visits to HMs and municipalities – however this internal monitoring is not able to cover all working HMs in a short time, since all monitoring activities are financed only by projects implemented by NNHM and not by operative funding.

Q12: Do you think your project could be implemented in other regions / countries / communities? Has this already been the case?

A: Before being introduced in Bulgaria, the health mediation model was already functioning in other European countries, the closest being Romania. Although the models differ from country to country, the health/ cultural mediation is known also in Spain, Holland, France, Finland, Italy, Belgium, Slovakia, Serbia, FYROM, and Moldova. With some of these countries we have ongoing exchange of experience and good practices, we have also partnerships with several organizations working for the sustainability of national mediation programs.

Q13: Please feel free to add any other comments you might have.

A: You could watch the video clip “Profession Health Mediator”; the short film “To Build a Bridge” presenting the work of Bulgarian HMs; the video clip Roma Health Mediators-Bulgaria. Also, you could visit our website

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