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, among which Friuli-Venezia Giulia and Apulia, currently extend the exemption until the beneficiaries of international and national protection actually find a job.[3]
Following the adoption of DL 150/2015 distinctions can no longer be made between the unemployed and the inactive about the granting of the right to exemption from participation in health care costs. After ASGI and other NGOs urged the Ministry of Health to implement Article 17(4) of the recast Reception Conditions Directive and to put in place policies guaranteeing effective access to healthcare, 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, from 2017 to 2022 different Courts and Courts of Appeal repeatedly reaffirmed the right to exemption from healthcare spending for unemployed refugees, unanimously reiterated that the distinction between inactive and unemployed is not applicable for purposes of accessing health care services.[5]
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.[6]
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”.[7]
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.[8] 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.
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[9]
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 identifying and taking care of asylum seekers and refugees affected by severe psychological distress. The partners were Prefectures, Municipalities, and local health authorities (ASLs).[10]
[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; Civil Court of Rome, Decision 5034/2018, 13 June 2018; 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.
[6] Council of State, opinion published on 19 July 2022, available at: bit.ly/40byAK4
[7] Civil Court of Milan, decision of 12 January 2023, available at: bit.ly/3LwUuDr.
[8] 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.
[9] Program available in Italian at: https://bitly.cx/cABp.
[10] Overview of the project available in Italian at: https://bit.ly/3UGXm3o.