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Guest article Borjan Pavlovski, Programme Coordinator Public Health and Women’s Health, Association for Emancipation, Solidarity and Equality of Women, North Macedonia

Since the start of the COVID-19 vaccine rollout at the beginning of 2021, major inequity issues have emerged. Insufficient number of available vaccine doses accompanied with the great demand, resulted in a situation where many countries still do not have sufficient vaccines to conduct massive vaccination. This situation is especially valid for smaller and developing countries, although many of the developed European countries face the same problem. Having in consideration the scarcity of the vaccines, most of the European countries introduced priority groups in their national COVID-19 vaccination plans. Usually among the prioritized groups are health workers, police, army and elderly people. Older persons over 77 years are the first priority group in the national plan of North Macedonia due to the greater risk they face from COVID-19.

According to the 2002 national census, 53,879 people identify themselves as Roma, which represent 2.7% of the two million North Macedonian population. However, the Council of Europe estimates that 134,000 – 260,000 Roma live in the country and they face many socio-economic challenges increasing their vulnerability to poor health, including chronic disease.

What are the barriers to vaccine equity for Roma?

Roma people due to their poor socio-economic status, life in poverty, living in dense settlements, inadequate housing conditions and other negative social determinants of health are not only at greater risk of contracting COVID-19 and developing more severe forms of the disease. Thus it is clear that Roma people, at least the most marginalized groups of Roma should be prioritized in the national COVID-19 vaccination process. Living in dense settings is recognized as a risk factor and such population groups have been prioritised in COVID-19 vaccination as has been recommended by the World Health Organization, but in North Macedonia Roma people are placed in the third priority group, which means they will receive the vaccines last. Choosing age as a key indicator in COVID-19 vaccination plans does not advance equity. According to a European Commission report, Roma people have at average 10 years shorter life expectancy than the general population, and that Roma people tend to develop chronic diseases 10 -15 years earlier than the rest of the population. Another issue is that due to the negative social determinants of health, many Roma do not properly manage their chronic diseases well.

Digital literacy becomes another obstacle for Roma to access COVID-19 vaccination as many countries, including North Macedonia, introduced web-based registration platforms to access vaccination. This represents another barrier for Roma people, since many of them do not have access to internet, or have lower digital skills and literacy.

The accessibility of where the vaccines are administered is another obstacle. Until now, In Skopje, the capital of North Macedonia, all the vaccines are administered in facilities in the centre of the city, although there is a health facility in the largest Roma municipality of Shuto Orizari. This might create financial hardship for Roma people, especially for the most vulnerable Roma, which need to travel more than 10 kilometers to access these vaccination facilities.

Another important issue is also vaccine hesitancy which is present among the population, due to false information widespread in the media. Considering the lower levels of health literacy among Roma, they might be more susceptible to this information and develop hesitancy towards the vaccines. Yet the Government in Macedonia didn’t develop a vaccination awareness raising campaign which could be easily accessed by the majority of the population, and especially by vulnerable groups.

In the mid and long term these important issues may result in lower COVID-19 vaccination coverage among Roma, which may result with residual outbreaks with Covid-19 in Roma settlements, even in cases when the majority of the population will be vaccinated. In order to avoid such a critical situation, the Government must place marginalized Roma higher on the vaccination priority list, taking into account co-morbidities experienced by vulnerable groups, which do not depend on age as a major social determinant of health. The Government must ensure that the vaccines are available in the settlements where Roma people live, or at least in vicinity to avoid further financial hardship for people at risk of poverty and exclusion. The national government must immediately establish cooperation with grassroots Roma civil society organisations, community leaders, religious leaders in order to ensure access to reliable information regarding the vaccines, to enroll Roma people in the vaccination lists and to increase vaccines uptake.