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. 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. As highlighted by MSF in March 2016, problems related to the lack of accommodation and to the lack of a domicile for beneficiaries of international protection also affect the exercise of their right to medical assistance, as the renewal of the health card depends on the renewal of the permit of stay and many health services (such as the choice of a general doctor) are connected with the place of domicile given for the renewal of the residence permit.
Contribution to health spending
Similar to asylum seekers after their right to work is provided, in some regions – such as Lazio and Tuscany, beneficiaries of international protection are no longer exempted from contribution to health spending (partecipazione alla spesa sanitaria), also known as “sanitary ticket”, because they are considered inactive and not unemployed. In other regions such as Piedmont and Lombardy, the exemption is extended until asylum seekers do actually find a job. However, only a few regions such as Friuli-Venezia Giulia and Apulia apply the same principle to beneficiaries.
On 18 April 2016, ASGI and other NGOs sent a letter to the Ministry of Health, asking it to give effect 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 the Ministry to consider that, following the adoption of the LD 150/2015 for granting the right to exemption from participation in health spending, distinctions can no longer be drawn between unemployed and inactive persons. On 9 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.
While waiting for the Government to take an official position on the matter, ASGI lawyers have lodged an appeal against the refusal to exempt an Iraqi female refugee from contribution to health spending on the ground that she was inactive and not unemployed, since she was entitled to access the labour market. The Civil Court of Rome upheld the appeal and stated that, after the entry into force of LD 150/2015, the distinction between unemployed and inactive persons is no longer valid. Therefore even beneficiaries of international protection are entitled to the aforementioned exemption.
In 2018, the Civil Court of Rome confirmed the previous decision and upheld the appeal filed by a Sudanese citizen with subsidiary protection status, reaffirming the right to the exemption from the “sanitary ticket” provided to the benefit of people without employment and income.
Unfortunately, the law is not equally applied across the national territory. In 2018, ASGI filed numerous appeals in Lombardy against the denial of the right to exemption for inactive beneficiaries of international protection. In a ruling of 22 October 2018, the Court of Appeal of Milan upheld the appeal stating that under the law it is not possible to make any distinction between those who have already had a job and who lost it (unemployed) and those who have never had it such a, for example, asylum seekers and refugees (inactive people). The Civil Court of Brescia ruled on 31 July 2018 in a similar way.
As the problem persisted in 2019, the Court of Appeal of Venice has once again clarified that the distinction between inactive and unemployed cannot be placed for the purpose of access to health services.
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. The Guidelines, adopted by the Ministry of Health by a Decree issued on 3 April 2017, specify that they also apply to asylum seekers.
The Guidelines highlight the importance of early detection of such vulnerable cases in order to provide probative support for the asylum 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 into 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, without expressing any judgment on the veracity of the individual’s narrative but only being limited to an assessment of the consistency of the person’s statements with the verified outcomes. 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.
The organisation of a network collaboration as required by the Guidelines has not yet started in all the health care institutions across the national territory. At the moment, the guidelines seem to be applied in Rome, Parma, Trieste and Brescia.
 Article 34 TUI; Article 16 PD 21/2015; Article 21 Reception Decree.
 Article 42 PD 394/1999.
 See Note of Piedmont Region, Health Office, 4 March 2016.
 Article 19 LD 150/2015 states that “unemployed” are workers who declare, in electronic form, their immediate availability to exercise work activities.
 Civil Court of Rome, Decision 5034/2018, 13 June 2018.
 Court of Appeal of Venice, decision 15/2020 of 27 April 2020.
 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.