A nonprofit in Sofia provides medical checkups for mothers and children who face many obstacles to accessing the Bulgarian health system.

A group of mothers and their children line up outside a community center in Fakulteta, one of the largest Roma neighborhoods in Bulgaria. They patiently queue, while their kids run around in the yard, waiting for their turn to be examined by pediatrician Krasimira Bainova.

Those monthly checkups are part of an initiative run by the Health and Social Development Foundation, or HESED, a Sofia-based non-profit that has been working with the Bulgarian Roma community for more than two decades.

Many Roma children do not have regular access to health care.

“We went to several hospitals but could not find a pediatrician,” said 20-year-old Violeta Ivanova, a mother of two. “I don’t know if it is because we are Roma, but doctors kept saying that they could not enroll my children as patients.”

Maternal and child mortality also remains high in the community and the country in general. While Bulgaria saw a significant drop in infant mortality between 2011 and 2021, its rate is still far above the EU average. According to some estimates, the infant mortality rate in some Roma settlements could be up to twice the national average, according to the Romani Early Years Network (REYN), a Europe-wide nonprofit that promotes access to early childhood services for Roma kids. 

HESED offers a tailored approach as an alternative to that grim reality.

“Many people do not understand how important it is for the Roma community to have access to healthcare, education, and social services. Many people still see them as a burden,” said Emilia Mikova, the director of one of the two HESED centers in Fakulteta, where a gynecologist and a pediatrician regularly see patients from the neighborhood.

Beyond medical screenings, HESED offers courses for parents, preschool care, and a range of educational programs to residents of Sofia’s Fakulteta neighborhood.

Fakulteta, home to tens of thousands of Roma – up to 50,000 by some estimates – is serviced by a handful of doctors and one run-down clinic. HESED, which operates three community centers in Sofia and also works with Roma communities in two other Bulgarian towns, is trying to address this issue by bringing doctors closer to the community.

Bulgaria’s Roma community is one of Europe’s largest. Activists believe the real figure may reach 10 percent of the population of 6.8 million, much higher than the 4.4 percent recorded at the 2021 national census.

The lack of proper care for mothers and children has plagued the residents of Roma quarters and settlements in the Balkan country for years. With the state turning a blind eye to one of the largest minority groups, HESED has long identified a gap between the needs of the Roma and the health services provided by the authorities. Based on a large body of research and their own experience in the field, the organization identified pregnant women and mothers, and children, as two of the most vulnerable groups. According to HESED, investing in maternal and early childhood care could have a big impact on the lives of Roma, helping forestall future health problems and empowering them to break the cycle of poverty.

Delivering Care Where It Is Needed Most

Close to 10 percent of all women in Bulgaria give birth without having their pregnancy monitored by a health professional, according to a 2021 report on prenatal care prepared by Largo, an association serving the Roma in the city of Kyustendil. Most of these women are Roma. The report also states that almost half of Roma women of childbearing age live in families earning less than around 100 euros a month per family member. 

Instead of relying on individual doctors and hospitals outside Fakulteta, HESED designated a space in its center where the medical checkups could take place. Three years ago, HESED opened a consultation room equipped with an ultrasound machine and basic equipment for OB-GYN checkups, funded by another non-profit, the Trust for Social Achievement, which continues to fund medical supplies for the day-to-day running of the room. In addition to pregnancy consultations, the gynecologist who sees patients one day a week also offers contraception measures and family-planning advice. After Romania, Bulgaria has the highest number of teenage pregnancies in the European Union, mostly due to a tradition for Roma girls to marry early.

For the last three years, hundreds of women and children have received access to healthcare, many of whom might not have received medical care otherwise. The center has offered medical checkups for around245 female patients, or a total of 470 checkups.

With just two doctors and two nurses, HESED can reach only a fraction of Fakulteta’s population, yet it is one of the few, if not the only, organization of its kind in the quarter. Residents can choose to visit hospitals in other parts of Sofia, if they can afford it, or go to emergency rooms.

Unlike general hospitals, HESED offers OB-GYN consultations to all Roma women, regardless of their insurance status. Universal care pays for the examinations of insured women, while those who are not insured pay as little as 20 lev (10 euros) per consultation, significantly lower than the average fee in Sofia.

Until recently the state covered only one examination and one test for uninsured women in Bulgaria during the entire nine months of their pregnancy, far below the minimum of eight checkups recommended by the World Health Organization. The rules were recently changed to provide equal coverage for uninsured women, permitting them up to 12 checkups during their pregnancies, the same number insured women enjoy. However, activists say there have been delays as the new rules roll out.

In addition to the hundreds of pregnant women, so far close to 200 children have been examined by a pediatrician who comes to the center once a month.

Roma in Bulgaria, especially children, are susceptible to outbreaks of measles, hepatitis, and tuberculosis, given the low vaccination rate among kids. Other health issues include lice, worms, and even cases of rickets, a disease linked to vitamin D deficiency, which is considered to have been nearly eradicated in Europe.

Pediatrician Krasimira Bainova examining a patient in Fakulteta.

“Parents usually do not have enough means to commute to another neighborhood or a hospital,” Bainova says. “Some of them cannot afford to buy the medicines I prescribe, so I try to prescribe the cheapest, generic brands.”

Malnourishment is also a widespread problem in Roma neighborhoods. Close to half of Roma children live in families that cannot afford to serve at least one meal with meat or fish a day, according to official statistics.

Beyond Health Screenings

HESED is not the first organization to provide medical care to the most vulnerable. Doctors Without Borders and other organizations send medical specialists directly into communities where they are most needed, and a number of states around the world provide mobile vans in poor and vulnerable communities. What the maternal care initiative in Sofia might offer is valuable insights both for other organizations working with disadvantaged groups or state authorities who are looking for solutions outside of the box and ways to spend healthcare money more effectively.

HESED’s objectives are broader than providing medical checkups to people in Fakulteta. Its staff has long tried to raise awareness about the importance of healthcare, encouraging families to get regular checkups and seek timely medical help when needed. Fear and stigma along with the discrimination that Roma patients face often discourage patients from seeking medical aid, which might lead to delayed diagnosis and complications of even treatable conditions.

The HESED team recruited doctors carefully and tried to find medical professionals who are committed to their work with the Roma community. Bainova, for example, flies to Bulgaria every month to see her Roma patients, even though she lives in Spain.

“We could not ask for more devoted doctors,” said Elena Kabakchieva, the director and co-founder of HESED.

“One key element in our success is the multidisciplinary team of experts we put together – we work with medical professionals, social workers, educators, psychologists,” Kabakchieva said.

Another important factor is that the organization stays away from a top-down approach. Its horizontal structure allows everyone to weigh in and offer their expertise when decisions are being made.

HESED also invests a lot in providing continuous and proper training for staff, some of whom live in Fakulteta.

“They go through not only health education but also how to deliver the right social services – they are trained to do community mapping, to identify people’s needs, who are the most vulnerable, and adapt our screening programs accordingly,” Kabakchieva said.

“We train them how to approach people and how to talk to them and explain the value of prevention when it comes to sensitive topics like diseases and their personal health and the well-being of their children,” she added.

The combination of offering different services – in addition to medical screenings, the center also offers courses for parents, preschool care, and a range of educational programs – aids the organization’s efforts to change deeply rooted stereotypes toward healthcare, child-rearing, and education.

For example, breastfeeding is also an issue within the community.

“Some mothers just think that they have no milk, when in reality no one explained to them how breastfeeding works,” Mikova said. “Some women stop breastfeeding and introduce solids to the babies’ diet too early because they are concerned that the baby is not eating enough and is hungry.”

Knowing the culture of the people the organization serves helps immensely. “We have developed close interactions with the grandmothers in the community – they are the ones who usually teach young mothers how to take care of their babies and sometimes even take care of the firstborn baby in the family themselves,” Mikova said. 

A decade ago, it was mostly the elderly women – mothers and mothers-in-law of pregnant women – who came to HESED’s courses, she added. Slowly, the young women started to take their place. The non-profit offers workshops for young mothers on a range of topics, from basic nutrition to cooking healthy dishes at home and to how to shop on a budget.

Some Challenges Remain

Despite the best efforts of the HESED team, sometimes patients skip appointments or need extra motivation to come in for check ups.

“Our main goal is to monitor the pregnancy from the beginning until the birth. But some patients do not come in for months, and that makes this task difficult,” said Nikola Poptodorov, the center’s gynecologist.

But Poptodorov reports that the ones who become regular patients usually bring their relatives and friends along.

An English class for children at the center.

Gender roles in the Fakulteta community can complicate providing health care to pregnant women.

“Some women do not see a doctor because the burden of childcare and household chores falls almost entirely on them,” said Poptodorov. “Some patients tell me, ‘Who is going to take care of the children and the house if I’m hospitalized?’ ”

Such women probably know that HESED can offer only a limited range of medical treatment. If the patients require further medical treatment or consultations, the doctors refer them to other hospitals and medical specialists outside of the neighborhood.

Funding is another problem. From the start, the project has been financed through donations and grants. For now, these are enough to keep the examination room running, but funding is the main reason why HESED hasn’t replicated the initiative in its other branches across the country.

Since, as Kabakchieva stresses, the state has not really shown any interest in scaling such successful practices to a national level, the efforts of the staff are destined to reach only a limited number of patients.

“Bulgaria should introduce a program that could provide equal access to healthcare for everyone, including a healthy menu for children at school and kindergarten,” Bainova said.

For now, though, hopes for a state-sponsored health program remain just wishful thinking. For some of the most vulnerable people in Fakulteta and other deprived communities, initiatives driven by a small number of dedicated civil society workers and health professionals are still the only route to receive access to healthcare.

Boryana Dzhambazova is a freelance journalist based in Sofia, Bulgaria. Her reporting on topics from economics and politics to social affairs and human rights has appeared in The New York Times, The Economist, Politico Europe, and other publications.

Research for this article was supported by a global fellowship with the Early Childhood Journalism Initiative of the Dart Center for Journalism and Trauma at Columbia Journalism School.

Photos by Dobrin Kashavelov.