Author
Asylum seekers and beneficiaries of international protection are required to register with 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 from the National Health System.
Practical obstacles in accessing health care
The right to medical assistance is acquired at the moment of the lodging of the asylum application. However, very often the exercise of this fundamental right is hindered and severely delayed, depending upon the attribution of the tax code assigned by Questure when lodging the asylum application. This means that it reflects the delay in lodging the asylum claim, which corresponds to several months in certain regions (see Registration).
Pending enrolment, asylum seekers only have access to medical treatment ensured by Article 35 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 public health.[2]
Asylum seekers have to register with the national sanitary service in the offices of the Local Health Board (Azienda sanitaria locale, ASL) competent for the place they declare to have a domicile.[3] Once registered, they are provided with the European Health Insurance Card (Tessera europea di assicurazione malattia, TEAM), whose validity is related to the one of the permits 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 planning” (consultorio familiare) to which access is direct and does not require doctors’ request; and
- Free hospitalisation in public hospitals and some private subsidised structures.
Delays in the issuance of health cards were exacerbated in 2016 due to the attribution of special tax codes to asylum seekers other than the ones attributed to other people, consisting in numerical and not alphanumeric codes.[4] Such obstacles were reported with regard to access to health cards from 2019 until now. These problems persist also with regard to access to other social rights.
The right to medical assistance should not expire in the process of the renewal of the permit of stay.[5] In practice, however, 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 if reception conditions were withdrawn, 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 the Italian population.
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.[8] 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 due to the adverse conditions of some accommodation centres and of informal settlements (see conditions in makeshift camps).
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,[9] 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 lodging of the asylum application (see Access to the Labour Market). During this period, they are assimilated to unemployed people and granted the same exemption code.
For the next period, in some regions asylum seekers are no longer exempted from the sanitary ticket because they are considered inactive instead of unemployed. In other regions such as Piedmont and Lombardy, the exemption is extended until asylum seekers manage to access the labour market. 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 12 January 2023, regarding 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 unemployed and inactive people, a circumstance which particularly impacts 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”.[10]
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.
The Ministry of Interior has clarified that the Guidelines on assistance and rehabilitation of refugees and subsidiary protection beneficiaries, victims of torture or serious violence, issued by Decree on 3 April 2017 to implement Article 27(1-bis) of the Qualification Decree, also apply to asylum seekers (see Content of Protection: Health Care).
In order to ensure the protection of the health of foreign citizens in Italy, ASGI has collaborated with the Italian Society of Migration Medicine (Società italiana di medicina delle migrazioni, SIMM) since 2014, monitoring and reporting cases of violation of the constitutional right to health.
A protocol was signed in January 2021 by the Prefecture of Massa Carrara (Tuscany) and functional units of mental health for examining the cases of persons applying for international protection who are psychologically vulnerable, aimed at providing them with adequate care and enhanced protection.’[11]
In October 2023 the Regions of Emilia – Romagna, Lazio, Tuscany and Sicily created a training program, co-funded by the Asylum, Migration and Integration Fund of the European Union, aimed at improving the competences of healthcare professional employed in the public healthcare system and in refugees’ and asylum seekers’ hosting programs, especially concerning the forensic certifications for victims of torture.[12]
From 2022 to 2023 in the Veneto region the SPIRNET project was active, funded by the Asylum, Migration and Integration Fund of the European Union. It was aimed specifically at individuating and taking care of asylum seekers and refugees affected by severe psychological distress. The partners were Prefectures, Municipalities and local health authorities (ASLs)[13] (see also Content of international protection).
[1] Article 34 TUI; Article 16 PD 21/2015; Article 21 Reception Decree.
[2] Article 21 Reception Decree; Article 16 PD 21/2015.
[3] Article 21(1) Reception Decree, citing Article 34(1) TUI; 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”.
[4] Ministry of Interior Circular of 1 September 2016; Revenue Agency Circular No 8/2016.
[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] Ibid.
[9] Ministry of Health Circular No 5 of 24 March 2000.
[10] Civil Court of Milan, decision of 12 January 2023, available at: bit.ly/3LwUuDr.
[11] EC, EMN Bulletin, May 2021, available at: https://bit.ly/3Fioz4r, 5.
[12] Program available in Italian at: https://bitly.cx/cABp.
[13] Overview of the project available in Italian at: https://bit.ly/3UGXm3o.