I have reached the final leg of my research and for the last few days I’ve been in Florence meeting GPs with experience of working with refugees and asylum seekers in the city and surrounding towns and suburbs. From my interviews I’ve learnt that, ostensibly, refugees and asylum seekers have full access to Italy’s State-funded national health system. Undocumented migrants are provided with a ‘Temporary Present Foreigner’ card (which must be reapplied for periodically) that also enables access to healthcare, in theory. However, in practice it can take months for an asylum request to be processed with one of the GPs I met suggesting that the authorities were deferring this process purposely to limit migrants’ rights for as long a period as is possible. Responsibility for health is devolved to the regional level so there are differences in how migration is managed across Italy. Whilst devolution could, as one GP reflected, provide the opportunity for responses tailored to local circumstances, it has only created inconsistencies between regions and a lack of data and information sharing between health services.
It was really interesting to hear about the challenges facing the GP sector in Italy and how they may act as a barrier to effective primary care for refugees and asylum seekers. The sector is ‘fragmented’, in part due to regional variations, but also because there are numerous bodies that ‘represent’ the sector (with in-fighting between them) meaning that there is no shared ‘voice’. The GPs I met also described general practice as being under-recognised and seen as being separate from the ‘core’ national health system. As in Germany, quality of care is not assessed or measured, and neither is asylum seekers’ and refugees’ access to health services specifically.
But despite these difficulties, I heard examples of excellent work. One of the GPs I met works in a recently established Casa della Salute (House of Health) located in a suburb of Florence with high levels of socio-economic deprivation. The service is also directly opposite a disused building which has become a squat for refugees, asylum seekers, and undocumented migrants. Recently established, the aim of this State-funded service is to provide comprehensive and holistic primary care. Like the National Institute for Health, Migration, and Poverty in Rome, multi-disciplinary working is a key feature of the service’s approach: there are a variety of health professionals on site. The service also tries to resolve other difficulties that patients are experiencing that might be affecting their health and well-being; in particular, housing. I was told that even State-run housing for asylum seekers and refugees is poor quality and often unsafe, let alone conditions in the squats.
Similar to the approach at the National Institute for Health, Migration, and Poverty, the House of Health has a pool of around 200 Cultural Mediators who play a key role in the delivery of the service. In addition to providing interpretation (every Cultural Mediator is at least bi-lingual) during patients’ appointments, they also help the patient to explain their problem to the health professional therefore helping to overcome some of the differences in cultural understanding about health and illness. The GP I met described the Cultural Mediators as being vital for working with highly-sensitive concerns amongst their most vulnerable patients, including trafficked women and women that have experienced or continue to experience sexual abuse and violence. The Cultural Mediators also provide patients with information about their rights to health.
Given the direction that government’s migration policy is taking, it seems a likely possibility that refugees’, asylum seekers’, and undocumented migrants’ access to healthcare will be restricted. The voluntary sector plays a key role in supporting refugees and asylum seekers in Italy, including in addressing their health problems; the demand for NGOs’ support is likely to grow. Sadly, I ran out of time in Florence to meet a local NGO I’d been introduced to via email but I’m looking forward to arranging a Skype call when I’m back in the UK. Whilst my time on my trip is almost up, there are lots of ideas and leads I look forward to pursuing when I’m home…