Asylum seekers and beneficiaries of international protection must enrol in the National Health Service.1 They enjoy equal treatment and full equality of rights and obligations with Italian citizens regarding the mandatory contributory assistance provided by the National Health Service in Italy.
There is no distinction between asylum seekers benefitting from material reception conditions and those who are out of the reception system, since all asylum seekers benefit of the National Health System.
The right to medical assistance is acquired at the moment of the registration of the asylum request but very often the exercise of this fundamental right is hindered and severely delayed, depending upon the attribution of the tax code, assigned by Questuras when formalising the asylum application. This means that it reflects the delay in proceeding to “C3”, in some territories corresponding even to several months (see section on Registration).
Pending enrollment, asylum seekers only have access to sanitary treatments ensured by Article 35 of the Consolidated Act on Immigration (TUI) to irregular migrants: they have access to emergency care and essential treatments and they benefit from preventive medical treatment programmes aimed at safeguarding individual and collective health.2
During the 2016 the delay has been accentuated because of the attribution to asylum seekers of special tax codes other than the ones attributed to other people, consisting in numerical and not alphanumeric codes.3 Insufficient information provided for public offices and the failure to update the computer systems has effectively prevented access to this as to other fundamental rights.
Asylum seekers have to register with the national sanitary service in the offices of the health board (ASL) competent for the place they declare to have a domicile.4 Once registered, they are provided with the European Health Insurance Card, tessera sanitaria (TEAM), whose validity is related to the one of the permit of stay. Registration entitles the asylum seeker to the following health services:
Free choice of a general doctor from the list presented by the ASL and choice of a paediatrician for children (free medical visits, home visits, prescriptions, certification for access to nursery and maternal schools, obligatory primary, media and secondary schools);
Special medical assistance through a general doctor or paediatrician’s request and on presentation of the health card;
Midwifery and gynaecological visits at the “family counselling” (“consultorio familiare”) to which access is direct and does not require doctors’ request; and
Free hospitalisation in public hospitals and some private subsidised structures.
The right to medical assistance should not expire in the process of the renewal of the permit of stay,5 however in practice, asylum seekers with an expired permit of stay have no guarantee of access to non-urgent sanitary treatments for a significant length of time due to the bureaucratic delays in the renewal procedure. This also means that where asylum seekers do not have a domicile to renew their permit of stay, for example because their accommodation right has been revoked, they cannot renew the health card.
Medical assistance is extended to each regularly resident family member under the applicant’s care in Italy and is recognised for new-born babies of parents registered with the National Health System.6
Regarding the effective enjoyment of health services by asylum seekers and refugees, it is worth noting that there is a general misinformation and a lack of specific training on international protection among medical operators.7 In addition, medical operators are not specifically trained on the diseases typically affecting asylum seekers and refugees, which may be very different from the diseases affecting Italian population.8
One of the most relevant obstacles to access health services is the language barrier. Usually medical operators only speak Italian and there are no cultural mediators or interpreters who could facilitate the mutual understanding between operator and patient.9 Therefore asylum seekers and refugees often do not address their general doctor and go to the hospital only when their disease gets worse. These problems are worsening because of the severe conditions of the accommodation centres and, as highlighted by MSF in the report Fuoricampo published on March 2016 of the informal accommodation in the metropolitan areas.10
Contribution to health care costs
Asylum seekers benefit from free of charge health services on the basis of a self-declaration of destitution submitted to the competent ASL. The medical ticket exemption is due to the fact that asylum seekers are treated under the same rules as unemployed Italian citizens,11 but the practice is very different throughout the country.
In all regions, the exemption is valid for the period of time in which applicants are unable to work, corresponding by law to 2 months from the submission of the asylum application (see Access to the Labour Market). During this period they are assimilated to unemployed people and granted with the same exemption code.
For the next period, in some regions such as Lazio, Veneto and Toscana,12 asylum seekers are no longer exempted from the sanitary ticket because they are considered inactive and not unemployed. In other regions such as Piemonte and Lombardia, the exemption is extended until asylum seekers do not actually find a job. In order to maintain the ticket exemption, asylum seekers need to register in the registry of the job centres (“centri per l’impiego”) attesting their unemployment.
On 18 April 2016, ASGI together with other NGOs sent a letter to the Ministry of Health requesting that effect be given to to Article 17(4) of the recast Reception Conditions Directive, according to which asylum seekers may be required to contribute to the costs for health care only if they have sufficient resources, for example if they have been working for a reasonable period of time. ASGI also asked to consider that from the approval of LD 150/2015 on granting the right to the exemption from participation in health spending, there can no longer be a distinction between the unemployed and the inactive.13 As of 9 of May 2016, the Ministry of Health replied to have involved the Ministry of Economy and the Ministry of Labour and Social Policy in order to achieve a uniform interpretation of the aforementioned rules.
Specialised treatment for vulnerable groups
Asylum seekers suffering from mental health problems, including torture survivors, are entitled to the same right to access to health treatment as provided for nationals by Italian legislation. In practice, they may benefit from specialised services provided by the National Health System and by specialised NGOs or private entities.
In order to ensure the protection of the health of foreign citizens in Italy, ASGI has collaborated with the Italian Society of Migration Medicine (SIMM) since 2014, monitoring and reporting cases of violation of the constitutional right to health.
From 2015, ASGI also collaborates with MSF, providing legal support for migrants victims of violence. As of April 2016, the two organisations have started a project in Rome opening a centre specialising in the rehabilitation of victims of torture.14 The project is intended to protect but also to assist in the identification of victims of torture who, without proper legal support, are unlikely to be treated as vulnerable people.
- 1. Article 34 TUI; Article 16 PD 21/2015; Article 21 LD 142/2015.
- 2. Article 21 LD 142/2015; Article 16 PD 21/2015.
- 3. MoI Circular of 1 September 2016; Revenue Agency Circular n. 8/2016.
- 4. Article 21(1) LD 142/2015, citing Article 34(1) LD 286/1998; Accordo della Conferenza Stato-Regioni del 20 dicembre 2012 “Indicazioni per la corretta applicazione della normativa per l'assistenza sanitaria alla popolazione straniera da parte delle Regioni e Province Autonome italiane”.
- 5. Article 42 PD 394/1999.
- 6. Article 22 Qualification Decree.
- 7. See M Benvenuti, La protezione internazionale degli stranieri in Italia, Jovene Editore, Napoli 2011, 263.
- 8. See CIR, Le strade dell’integrazione – Ricerca sperimentale quali-quantitativa sul livello di integrazione dei titolari di protezione internazionale presenti in Italia da almeno tre anni (The streets of integration - Experimental research on the qualitative and quantitative level of integration of beneficiaries of international protection present in Italy for at least three years), June 2012.
- 9. Ibid.
- 10. MSF, Fuoricampo: Richiedenti asilo e rifugiati in Italia: insediamenti informali e marginalità sociale, March 2016, available in Italian at: http://bit.ly/1S5IHGh.
- 11. Ministry of Health Circular No. 5 of 24 March 2000.
- 12. Information provided to ASGI by the Italian Society of Migration Medicine (SIMM), In Lazio, the exemption is validi for 6 months, in Toscana for 2 months and another 6 in case of unemployment, and in Veneto for 2 months.
- 13. Article 19 LD 150/2015 states that “unemployed” are workers who declare, in electronic form, their immediate availability to exercise work activities.
- 14. See Redattore Sociale, ‘Migranti, apre a Roma il centro di riabilitazione per le vittime di tortura’, 4 April 2016, available in Italian at: http://bit.ly/1ShpCGG.