Author
Article 27 of the Qualification Decree specifies that beneficiaries of international protection are entitled to equal treatment with Italian citizens in the area of health care and social security.
Like asylum seekers, beneficiaries of international protection have to register with the National Health Service.[1] They have equal treatment and full equality of rights and duties as Italian nationals concerning the obligation to pay contributions and the assistance provided in Italy by the National Health Service.
Registration is valid for the duration of the residence permit and it does not expire in the renewal phase of the residence permit.[2] Beneficiaries of international protection enjoy equal treatment with Italian citizens in the COVID-19 vaccination scheme.
Contribution to health spending
Beneficiaries of international protection and national protection (humanitarian/special), as applicants for international protection, are obliged to register with the National Health Service and are entitled to equal treatment and full equality of rights and duties compared to Italian citizens both with regard to the obligation to contribute and to the assistance provided in Italy by the NHS and its temporal validity (art. 34 of TUI). On the subject of exemption, of particular relevance is what is provided for by art. 17(4) of the Reception Conditions Directive, transposed in Italy by the Reception Decree, pursuant to which “member States may oblige applicants to bear or contribute to the costs of the material reception conditions and health care provided for in this Directive, if the applicants have sufficient resources, for example where they have been employed for a reasonable period of time.” Despite this, access to health care for beneficiaries of international protection varies greatly across regions. The main differences and difficulties are found with reference to the exemption from the cost-sharing of healthcare costs. Only some regions, including Friuli-Venezia Giulia and Puglia, currently extend the exemption until the beneficiaries of international and national protection actually find a job.[3]
On April 18, 2016, ASGI and other NGOs sent a letter to the Ministry of Health, asking it to implement Article 17(4) of the recast Reception Conditions Directive, according to which applicants for international protection may be required to contribute to health care costs only if they have sufficient resources, i.e., if they have worked for a reasonable period of time. ASGI also asked the Ministry to consider that, following the adoption of DL 150/2015 for the granting of the right to exemption from participation in health care costs, distinctions can no longer be made between the unemployed and the inactive. On May 9, 2016, the Ministry of Health responded that it had engaged the Ministry of the Economy and the Ministry of Labour and Social Policies in order to obtain a uniform interpretation of these regulations.[4]
While waiting for the Government to take an official position on the matter, the right to exemption from healthcare spending for unemployed refugees has also been recognized by the Court of Rome, which, on February 17, 2017, ruled on an appeal lodged by an ASGI lawyer for a refugee woman whose request for exemption was refused by the local health authorities because she was considered inactive and not unemployed”.[5]
In 2018, the Civil Court of Rome confirmed the previous decision and accepted the appeal lodged by a Sudanese citizen in subsidiary protection, reaffirming the right to exemption from the “health ticket” for people without work and without income.[6]
In a judgment of October 22, 2018, the Court of Appeal of Milan upheld the appeal, stating that for the law it is not possible to make any distinction between those who have already had a job and lost it (unemployed) and those who have never had it such as, for example, asylum seekers and refugees (inactive).[7] The Civil Court of Brescia ruled on July 31, 2018 in a similar manner.[8]
In 2019 and 2020, again in response to the illegitimate practice of the ASLs of refusing the exemption to beneficiaries of international and national protection, the jurisprudence unanimously reiterated that the distinction between inactive and unemployed is not applicable for purposes of accessing health care services.[9]
On 19 July 2022, the Council of State (the Upper administrative Court in Italy), replying to the request submitted by the Ministry of Health, expressed the opinion that, following the repeal of Legislative Decree 181/2000, the distinction between unemployed and inactive people for the purposes of exemption from participation in health care costs is to be considered obsolete.[10]
Moreover, on 12 January 2023, on a case brought by ASGI and Emergency, the Civil Court of Milan ascertained the discriminatory conduct of the Lombardy region which, like other regions, distinguishes, for the purposes of exemption, between the unemployed and the inactive. This particularly affects asylum seekers and refugees who, compared to other categories of foreigners, have been staying in the territory for less time and, in most cases, have not had previous working relationships before enrolling in the national health service. The Court acknowledged, with specific reference to the category of asylum seekers, how it is “obvious that an asylum seeker cannot claim a previous employment relationship in Italy, especially because, pursuant to art. 22 of Legislative Decree no. 142/2015, asylum seekers can carry out working activities only after 60 days from the request for the relevant residence permit”.[11]
Specialised treatment
To implement Article 27(1-bis) of the Qualification Decree, the Ministry of Health published on 22 March 2017 the Guidelines for the planning of assistance and rehabilitation as well as for treatment of psychological disorders of refugees and beneficiaries of international protection victims of torture, rape or other serious forms of psychological, physical or sexual violence.[12] The Guidelines explicitly specify that also applicants for international protection are entitled to specialised assistance and rehabilitation.
The Guidelines emphasise the importance of early identification of these vulnerable cases in order to provide probative support for the application for international protection, to direct the person to appropriate reception facilities and towards a path of protection even after that international protection has been granted, but also to provide for rehabilitation and assistance. According to the guidelines, the recognition of a traumatic experience is the first step towards rehabilitation. The work of multidisciplinary teams and the synergy of local health services with all those who, for various reasons, come in contact with beneficiaries of international protection or applicants for international protection – reception operators, educators, lawyers – is considered crucial in these cases.
The Guidelines highlight the importance of early detection of such vulnerable cases in order to provide probative support for the international protection application, to direct the person to appropriate reception facilities and to a path of protection even after the grant of protection, but also to provide for rehabilitation itself. According to the Guidelines, the recognition of a traumatic experience is the first step for rehabilitation. The work of multidisciplinary teams and the synergy of local health services with all those who in various ways come in contact with protection holders or asylum seekers – reception operators, educators, lawyers – is deemed decisive in these cases.
According to the Guidelines, the medical certification, to be understood not as a merely technical act but as the result of a network collaboration, must follow the standards set out by the Istanbul Protocol and maintain maximum impartiality, assessing the consistency of the person’s statements with the examination findings without expressing any judgment on the truthfulness of the individual’s narrative. The Guidelines also propose templates of health certificates to be adopted in cases of torture, trauma, psychiatric or psychological disorders and propose the use of the final formulas suggested by the Istanbul Protocol: evaluation of non-compatibility, compatibility, high compatibility, typicality, specificity.
Five years after the guidelines’ publication, the required activation by each local health authority of a multidisciplinary therapeutic and assistance program – the cornerstone of the assistance and rehabilitation of torture victims – has, however, remained a dead letter: the few services that already existed have barely managed to continue operating, and little to no new ones have been created.
[1] Article 34 TUI; Article 16 PD 21/2015; Article 21 Reception Decree.
[2] Article 42 PD 394/1999.
[3] SAI and ASGI, Legal Handbook for Workers – International protection and other forms of protection, July 2019, available at: https://bit.ly/3u0wRZA.
[4] Article 19 LD 150/2015 states that “unemployed” are workers who declare, in electronic form, their immediate availability to exercise work activities.
[5] Civil Court of Rome, Decision 33627/16, 17 February 2017, available at: http://bit.ly/2nIv0HF.
[6] Civil Court of Rome, Decision 5034/2018, 13 June 2018.
[7] Court of Appeal of Milan, Decision 1626/2018, 22 October 2018, available at: https://bit.ly/2uTd5kx.
[8] Civil Court of Brescia, Order 5185/2018, 31 July 2018, available in Italian at: https://bit.ly/2GdgbVJ.
[9] Court of Appeal of Venice, Decision 15/2020 of 27 April 2020; Civil Court of Milan, Decision 5688/2019, 18 July 2019, available in Italian at: https://bit.ly/34SqYFm; Civil Court of Milan, Decision 3568/2019, 21 May 2019, available in Italian at: https://bit.ly/3u4mcNA.
[10] Council of State, opinion published on 19 July 2022, available at: http://bit.ly/40byAK4.
[11] Civil Court of Milan, decision of 12 January 2023, available at: http://bit.ly/3LwUuDr.
[12] Ministry of Health, Linee guida per la programmazione degli interventi di assistenza e riabilitazione nonché per il trattamento dei disturbi psichici dei titolari dello status di rifugiato e dello status di protezione sussidiaria che hanno subito torture, stupri o altre forme gravi di violenza psicologica, fisica o sessuale, 22 March 2017, available in Italian at: http://bit.ly/2EaINAY.