Fighting inequities: the health mediator’s program in Bulgaria

For a country, being ready to face an infectious disease outbreak requires, among other things, the capability to reach and involve all the components of the society. Especially those that are more exposed to health threats due to low quality housing, poor nutrition, lack of parental education and weak links to health services, as it happened in the 2010 measles epidemic in Bulgaria, where 90% of recorded cases occurred within the so-called Roma community.

And Bulgaria itself offers a proper example – embodied by the health mediator model – of how these inequity-based issues may be tackled by the government.

The health mediator is an intermediary who facilitates the access of people and groups in disadvantaged position to health and social services. In Bulgaria, the health mediator model was launched in 2001 by the team of Ethnic Minorities Health Problems Foundation, and the first five health mediators were trained and employed by project Introduction of a system of Roma mediators – an efficient model for the improvement of the access of Roma to health and social services. Aim of this pilot program was to address the negative health tendencies among Roma groups in the country – low life expectancy, high share of chronical diseases, exclusion from the health and social system, poor living conditions – revealed by different researches. The program was also aiming to contribute for overcoming the cultural barriers in the communications between the Roma communities and the local medical staff; to overcome the existing discrimination attitudes in the field of health services for the Roma locally; to optimize the implementation of prevention programmes and the vaccination coverage among the Roma population; health education of the Roma and active social work in the community. 

The Bulgarian health mediator model was developed based on the Romanian model presented by Romani Christ Foundation and Romanian Ministry of Health and on the experience of the Dutch Institute of Public Health.

Programs for health mediation exist in many other European countries as well: in Spain and France they exist since decades, while mediation is also practiced in the Netherlands, Moldova, Slovakia, Serbia, FYROM, Hungary, Belgium, Italy.

In Bulgaria, since 2001, many health mediators were trained and hired in different projects. Then, in September 2005, the Bulgarian Government adopted the Health Strategy for Disadvantaged Persons Belonging to Ethnic Minorities, which involved several members of this new profession. In late 2005, the Ministry of Labour and Social Policy showed interest in the health mediator position and, as a result, the health mediators trained in the Bulgarian towns of Dobrich and Dupnitsa were appointed under the Programme “From social allowance towards employment”.  

In 2007, thanks to the efforts of the Ministry of Health, the Ministry of Labour and Social Policy, the Ethnic and Demographic Issues Directorate at the Council of Ministers and, last but not least, the non-government organizations working in this field, fifty-seven health mediators were appointed at work in thirty municipalities with budget provided by the state. The institutionalization of the new profession became a clearly defined national policy. The health mediator was included in the National Classification of Professions, and the job description of the health mediator has been adopted as well. 

In the same year, the National Network of Health Mediators (NNHM) was founded. The Network developed and successfully implemented the health mediator’s model in Bulgaria. It has reached national coverage and become 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 the access and the quality of health services for the people belonging to vulnerable communities. Members of the Network are more than 170 people – health mediators, medical specialists, sociologists, psychologists, public figures.

Since then, the number of Health mediators in the country raised from 55 to 170 (in 2015) thanks to the funds provided by the state. Each year the National Network of Health Mediators prepares a list with the municipalities that should receive financing by the state and sends it to Ministry of Finance and Ministry of Health. Nowadays, health mediators work in 26 out of 28 districts, in 99 municipalities throughout the country.

In Bulgaria, all candidates for a health mediator position must have secondary education grade and are selected though public competition. The candidates are interviewed by a commission whose members are representatives of the municipality, the Regional Health Inspectorate, the National Network of Health Mediators, the GPs and the members of the local vulnerable communities. 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, keeping in mind that, depending on the community, in some neighbourhoods men are in better position to pass health messages. They are of different age, originate from the communities in which they work and speak the community language (Romani, Turkish, Wallachian).

The professional training of the health mediators takes place in the Medical University of Sofia with academic lecturers and experts from the National Network of Health Mediators. After successfully taking their final exam, health mediators receive certificates for professional qualification that allow them to be employed by the municipalities.

Health mediators are expected to communicate with all local health and social institutions, to organize health-information meetings in the community, and to help increasing the health culture of local vulnerable groups through explanation and consultation. They also assist and accompany (when needed) people to institutions, help them to fill in documents, interact with GPs to enhance vaccination coverage and implement programs for sexual and reproductive health.

Health mediators work mainly with population living in segregated neighbourhoods, which is called Roma by the majority. However, not all of the 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.

For many years, several health mediators have been working in local hospitals too. They were invited by hospital directors to facilitate the communication between patients and hospital staff, mainly in maternity and paediatric ward. The main problem there was the tension arising between patients and staff because of some cultural differences, together with low level of health awareness and (in some cases) the impossibility of the patients to understand doctor’s prescriptions. The practice of employing health mediators in hospitals proved to be very successful also in economic terms and its popularity is increasing.

The successful development and institutionalization of the Bulgarian health mediator’s model throughout the years served as an example for developing similar programs in other countries as well, like Slovakia, Serbia and FYROM. The National Network of Health Mediators works in partnership with organizations and institutions developing mediation programs in Europe in different projects. Some of the main aims of these partnerships are the strengthening of European mediation programs, and the exchange of experience and good practices between mediators and coordinators of mediation programs from different countries.


Dilyana Dilkova

Member of the Managing team of the NNHM

MMLAP and other EU Projects

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