Article 32 of the Italian Constitution states that the Republic protects health as a fundamental right of the individual and in the interest of the community, and guarantees care to the indigent. It is the only article of the Constitution that refers to the concept of individual, rather than the concept of citizen.
It calls on Italy to adopt inclusive health policies, highlighting how access to health is a fundamental right of the person. Despite this fundamental characteristic, those who don’t have Italian citizenship frequently experience barriers in accessing healthcare.
Often threatened by economic disparities, conflicts and humanitarian crises, an efficient health system is an indicator of development and social well-being. The Covid-19 pandemic, whose health and socio-economic consequences are still being observed, has dramatically brought to the fore the criticalities of the health system which is unable to adapt and respond effectively to contemporary emergencies.
In Italy, a long debate ensued on the quality of the National Health Service (SSN in Italy) and the state of a collapsing public health system, bogged down in long bureaucratic procedures and unreasonable waiting times for diagnosis and treatment.
Since the establishment of the SSN in 1978, the national approach to health has seen a progressive decentralisation in favour of regional autonomy and local health authorities.
First, there is a huge territorial gap between North and South in terms of economic resources and infrastructure. Therefore, regional disparities have the effect of undermining access to health services in certain areas of the country, whose residents are consequently less protected.
The score of the Essential Levels of Care (ELS), which measures the relationship between health expenditure and the quality of services, showed this gap even before the pandemic: for instance, Veneto's score on the ELS was almost double that of Calabria,back in 2019.
A further critical issue is the process of defunding the national system, which in the decade 2010-2019, has seen the value of state funding fall steadily in relation to GDP. As a result of this convergence of factors, the increasingly real risk of giving in to privatisation is amplified exponentially, with the danger of marginalising sections of the population unable to resort to expensive private services.
This is the case for foreigners, but unfortunately it is not the only border they have to overcome.
In accessing care in Italy, foreigners encounter different types of barriers that can be physically constraining and psychologically deteriorating. For instance, barriers linked to economic and working conditions, territorial accessibility to services, geographical distance, and the availability of public transport.
Above all, barriers of a cultural nature, linked to the inefficiency if not the absence of a supportive network of linguistic and cultural mediation. For a foreigner who has just arrived in Italy, it becomes particularly complex to move through a highly structured healthcare system and within the meanders of a complicated and demotivating bureaucracy.
While it is true that public healthcare in Italy is considered to be among the most inclusive and efficient, the shortcomings mentioned above persist: the defunding, the local autonomies that result in reception times and application practices that often greatly differ from one area of the country to another, but also the increasingly worrying shortage of specialised medical and healthcare personnel.
In spite of the rhetoric that speaks of migration in terms of the crisis, in 2023 there were 5,141,341 foreign citizens resident in Italy, i.e. around 8% of the total population. Foreign citizens who do not have a valid residence permit cannot register with the National Health System (SSN), but still have the right to be treated in urgent and essential cases. This treatment is provided by all certified public and private outpatient clinics and hospitals, but the regions have also activated Temporarily Present Foreigners Outpatient Clinics, or STP ambulatories.
The same applies to foreign EU citizens, who cannot be registered with the national health system due to the lack of the tax code or proof of regularity of residence. For EU citizens, the situation is therefore even more paradoxical: although they are EU citizens, they are not entitled to registration.
To make up for this problem, a code called ENI is issued, similar to the STP code, with the difference that ENI patients pay the health ticket in full (shared health expenditure with the state) and are only entitled to exemptions by pathology.
But the paradoxes of access to healthcare for immigrants in Italy, unfortunately, are not over. In spite of international conventions on the protection of children's rights, among the most ratified in the world, even foreign minors are not exempt from the risk of encountering impactful barriers in their access to medical care.
According to ISTAT (30th Annual Report 2022) the total number of 0-18 year olds with a foreign background is 1.3 million and about 1 million are minors born in Italy to foreign parents (the so-called second generations).
The first step to guarantee all foreign children the best possible level of health protection is to fully implement the rule that guarantees registration with the SSN and the right to a family paediatrician to all children, regardless of their legal status or that of their parents. A right sanctioned in 2012 by a State-Regions Agreement and provided for in the Livelli Essenziali Assistenza (LEA) in 2017.
However, this legislation has remained unimplemented for a decade, resulting in a right that is often disregarded. The bureaucratic obstacle that has so far prevented the full application of the law has been the lack of national operational guidelines regarding the application of tax and exemption codes.
Therefore, in the absence of such practical guidelines, each region, as a local and autonomous health authority, has practically implemented the legislation in different ways and with different timing.
Thus, it can happen that children, who would be even more in need of being guaranteed the right to the best possible health protection and the possibility of being looked after by specialists throughout their growth, instead remain in limbo.
The child not only needs urgent and unpostponable care; he or she needs a guiding figure to take care of periodic growth balances, a vaccination system, but also and above all prevention: some disorders in particular, such as neurodivergent, require a full-degree approach from childhood onwards.
Even more serious is the psychological exposure to trauma and discrimination: every child, whether arrived in Italy or born in Italy of a foreign parent, is even more exposed to conditions of fragility and socio-economic hardship, having to deal with migratory baggage that befits little the lightness that should distinguish childhood.
Southern Italy are among the regions that suffer most from marginalising policies in terms of funding, infrastructure and health personnel.According to the independent organisation GIMBE, the implementation of differentiated autonomy, which has been proposed for several years by the northern Italian regions, i.e. the granting of legislative autonomy in health matters, would lead to the collapse of healthcare in the south.
In these regions, even where it is unable to resolve legislative gaps, the intervention of the third sector is fundamental as a means of compensating for cultural, linguistic and social shortcomings, as it is in charge of following patients along their path toward autonomy and empowerment, via the process of raising awareness of their rights and the means to see them recognised.
Therefore, on a theoretical level, both the healthcare system and the legislative apparatus that supports it appear perfect as a model of accessibility and inclusiveness. From a practical and concrete point of view, the road to be taken to guarantee uniform application of the right to health and accessibility is still long and tortuous.
Photo Source: Fondazione ISMU
Edited By: Jaya Jha
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