Asylum seekers and beneficiaries of international protection are required to register with the National Health Service. 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 to access to health care
The right to medical assistance is acquired at the moment of the lodging of the asylum application but 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.
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. 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 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 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 had been 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. Such obstacles were reported with regard to access to health cards in 2019 too. 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, 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 newborn babies of parents registered with the National Health System.
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. 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.
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. 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, 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 with 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 and not unemployed. In other regions such as Piedmont and Lombardy, 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.
The entry into force of Decree Law 113/2018, implemented by L 132/2018, which abolished civil registration of asylum seekers (see Civil Registration), has also created difficulties for access to health treatment with exemption from a medical ticket. In Italy, people can in fact benefit from an exemption from medical costs not only in the case of unemployment but also on the basis of (low) income. However, to do so, one must produce documentation that certifies income based on the Equivalent Economic Situation Indicator (Indicatore della situazione economica equivalente, ISEE). However, such documentation is only issued to residents by the Fiscal Assistance Centres (Centri assistenzia fiscale, CAF) Although the Decree Law clarifies that all services must be ensured to asylum seekers on the basis of their domicile only, in the absence of internal circulars, health service offices are denying this right.
In addition, during 2019, some health districts have refused to register asylum seekers without residency. This was the case, for example, until July 2019, of the health district of North Naples. With an order filed on 10 July 2019, the North Civil Court of Naples accepted the appeal of an asylum seeker, clarifying that the lack of residence does not affect the right of registration in the national health system.
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 holders 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.
Since 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. 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. More recent information is not available.
 Article 34 TUI; Article 16 PD 21/2015; Article 21 Reception Decree.
 Article 21 Reception Decree; Article 16 PD 21/2015.
 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”.
 Ministry of Interior Circular of 1 September 2016; Revenue Agency Circular No 8/2016.
 Article 42 PD 394/1999.
 Article 22 Qualification Decree.
 See M Benvenuti, La protezione internazionale degli stranieri in Italia, Jovene Editore, Napoli 2011, 263.
 Ministry of Health Circular No 5 of 24 March 2000.
 Civil Court of North Naples, order no. 40687 of 10 July 2019, available in Italian at: https://cutt.ly/DyO8rjp; see also ASGI, I richiedenti asilo hanno diritto all’iscrizione al SSN anche in assenza di residenza, 11 July 2019, available in Italian at: https://cutt.ly/eyO8r3T.
 MSF, Fuori campo, February 2018, 39.