The Hurdles Roma People Must Clear to Access Gynecological Care in North Macedonia

SKOPJE — Only one gynecologist serves the 8,000 to 13,000 people of reproductive age who need those services in the municipality of Shuto Orizari in North Macedonia’s capital city, the only municipality with a Roma majority in the country. And as of last month, he’s no longer on duty.

Before Dr. Bozidar Boskovski began working there (his tenure was initially slated for October 2020 but was pushed to late April 2021 for unknown reasons), Shuto Orizari had no gynecologist from 2012 to 2019 — when one finally agreed to that post, only to leave abruptly — according to Salija Bekir Halim, a Roma activist focused on Roma women’s reproductive and sexual rights. What’s certain, says Halim, is that consistent, reliable gynecological care has been chronically out of reach for this population for at least a decade.

“Roma” is a catchall term for the different sub-groups who are collectively believed to have descended from the Indian subcontinent 1,500 years ago, later migrating across Europe, where they have suffered centuries of discrimination and organized persecution. Roma people have been maligned by a racial slur that has been romanticized in fashion and pop culture as shorthand for thievery, free-spiritedness, and seductiveness (but is broadly rejected by Roma organizations and allies). Roma people were targeted under Nazi Germany as “racially inferior” (which resulted in the deaths of half a million Roma people during World War II), as well as by more recent eugenics studies that likely furthered causes to keep their communities segregated, isolated, and disadvantaged. And during pandemic-related lockdowns, Roma communities were again victimized by centuries-old racism to subject them to harsher restrictions, police violence, houselessness, and social segregation.

Today, Roma people live predominantly in Europe (but are present in different parts of the world as well), where they continue to face discrimination as one of the most oppressed populations in Europe, both in and outside of the European Union.

Given that Roma people already face many societal barriers, it is not surprising that Roma people in need of obstetric and gynecological services are underserved when it comes to access to reproductive and sexual health services in North Macedonia.

“Often, a non-Roma from North Macedonia [will] point out how Shuto Orizari is the only Roma municipality in the world that has a Roma mayor,” said Semran Sulejman, a Budapest-based Roma activist, who was himself a longtime resident of the municipality. “That’s true, but if you compare our municipality with other municipalities in Skopje, you will see that we are one of the least developed,” citing its many infrastructure problems, such as unrenovated roads and sewage issues, as well as a lack of primary health care physicians — especially gynecologists.

“There is indirect discrimination by the state [towards Shuto Orizari],” said Halim. “It has shown it many times through their lack of interest in our problems. That leads us, as a Roma community, to feel like second-class citizens.”

Halim is the spokesperson for the Initiative of the Women of Shuto Orizari, a group of women activists founded in 2012. The Initiative provides assistance in the fields of social and health protection, as well as paralegal and other kinds of support in cases of discrimination to the residents of Shuto Orizari — such as the issue of gynecology patients being illegally charged for services that are free.

“In an analysis that we did together with HERA (Health Education and Research Association — a larger Macedonian organization allied with the International Planned Parenthood Federation that advocates for reproductive and sexual rights), it became known that, in fact, the problem is not the lack of gynecologists in our country, but that they are not proportionally distributed,” said Halim. “In the municipality of Centar (in the central area of Skopje, which, according to the 2002 census, had around 45,000 residents), for example, there are about 20 gynecologists; in Shuto Orizari there is only one.”

But an equally significant factor that bars the Roma community in Shuto Orizari from access to proper sexual and reproductive health care is an economic one. Due to systemic racism, prevailing negative stereotypes and other social prejudices, the Roma population in North Macedonia faces high levels of poverty. According to a 2019 study, the employment rate among the Roma population in North Macedonia was around only 22 percent. And, according to North Macedonia’s last nationwide census, taken in 2002 (the results from the 2021 census are not yet available), the municipality is home to some 35,000 residents, 52 percent of whom live under the poverty line, according to a 2012 case study of the municipality.

And even though abortion care is legal in North Macedonia, the service isn’t free, making care cost-prohibitive for many — including Roma people.

“The co-payment [for an abortion] is really high and ranges from 4,000-6,000 denars (roughly $70-110),” said Halim, which, she says, is far too costly for the average Roma household, especially in Shuto Orizari. “Given that contraception is not free, there are also a lot of unwanted pregnancies, which, unfortunately, many decide to continue these pregnancies, creating a cycle of poverty.”

What’s more, Halim says, illegal abortions are flourishing, especially in recent years. “We have noticed that, in several clinics, illegal abortions are performed for a much lower price.”

The Initiative appealed to the country’s Ministry of Health several times to make abortions free, but to no avail, Halim said. As of writing, the Ministry of Health has not responded to our requests for comment.

Even with the financial means to access care, Roma people are also often subjected to discrimination and unfair treatment in their pursuit of health services. Halim noted that doctors lack sensitivity training to overcome negative assumptions and stereotypes about Roma people, such as misconceptions about the community being uneducated or having a prevalence of child marriages. Halim also stressed that those who are visibly of a lower economic class are even further mistreated and dismissed by health care establishments. In response, Halim and other activists from the Initiative frequently act as companions and advocates during gynecological appointments.

“We had a 20-year-old pregnant woman who looked quite young and was immediately approached with prejudice,” said Halim. “The personnel thought she was underage and immediately asked for her ID card. They used abusive words and commented on how young she was. Many Roma women approach health services with distrust because many times each of us has experienced that way of communication.”

In 2015, the Initiative advocated for a case of two Roma women who were discriminated against while trying to choose a primary gynecologist. They were given the misleading explanation that the office was not taking young patients, but advocates say they were likely rejected simply because they were Roma: At the same time as the Roma women’s attempted visits, two ethnically Macedonian women sought the same primary gynecologist and were admitted without issue.

The case was brought before the Macedonian courts by the two Roma women without success, so the Initiative, with the support of HERA and the Helsinki Committee of Human Rights, took the case to the United Nations’ Committee for the Elimination of All Forms of Discrimination Against Women (CEDAW). In December 2020, CEDAW “found a violation of the right to equal treatment” and provided a series of recommendations to North Macedonia to make structural changes and eliminate harmful practices.

“This is the first verdict in our country from the CEDAW,” said Halim. “And for this there are no mechanisms for implementation of the recommendations, especially regarding the financial compensation we are asking for the women.” After the CEDAW verdict, however, the case has entered a second proceeding in the Macedonian courts where financial compensation is being sought, said Halim.

Meanwhile, discrimination continues for Roma people seeking obstetric services — and with lethal consequences. Last year, two pregnant Roma women died within five months of one another; the second died during childbirth in November at the “Mother Teresa” Cair state hospital. “Are Roma women paying with their lives during childbirth in our country?” the Initiative wrote on their Facebook page. It also identified inconsistencies in a statement issued by the Ministry of Health — namely, that the deceased patient did not have enough check-ups during her pregnancy. According to Halim, the Initiative retrieved information from the hospital itself reporting that the patient had gone to seven appointments during her pregnancy. Halim and others from the Initiative have often accompanied women to that hospital, women who are uninsured but are still entitled to free examinations during pregnancy. They are calling for a thorough investigation into the hospital, as well as the gaps in that woman’s care.

But while the Initiative continues to apply pressure, without the political will to overhaul a system that appears to inherently discriminate against the Roma population, the barriers for Roma people to access responsible, quality reproductive and sexual health care will likely stay in place.

As for Shuto Orizari, Dr. Boskovski retired last month, leaving his practice on December 14, 2021, abandoning some patients mid-care, said Almira Fasljii Muarem, another activist from the Initiative, in a feature for PINA. A replacement stepped in for the period between the doctor’s last day and the end of the calendar year, but plans for his successor in 2022 are unknown — if there even are any.

The likeliest scenario is, unfortunately, the most grim: as of January 1, anyone in need of gynecological care in the municipality should count on being on their own.