Health System Response during the European Refugee Crisis: Policy and Practice Analysis in Four Italian Regions

Abstract

The decentralization of the provision of health services at the subnational level produces variations in healthcare offered to asylum seekers (ASs) across the different Italian regions, even if they are entitled to healthcare through the national health service. The present study aims to map the healthcare path and regional policies for ASs upon arrival and identify challenges and best practices. This is a multicentric, qualitative study of migrant health policies and practices at the regional level within four Italian regions. For the analysis, a dedicated tool for the systematic comparison of policies and practices was developed. The collection and analysis of data demonstrated the presence of many items of international recommendations, even if many gaps exist and differences between regions remain. The analysis of practices permitted the identification of three models of care and access. Some aspects identified are as follows: fragmentation and barriers to access; a weakness in or lack of a governance system, with the presence of many actors involved; variability in the response between territories. The inclusion of ASs in healthcare services requires intersectoral actions, involving healthcare sectors and other actors within local social structures, in order to add value to local resources and practices, reinforce networks and contribute to social integration.

Health system governance in settings with conflict-affected populations: a systematic review

“…Barriers related to participation and coordination included poor coordination and siloed working between different stakeholders (Atun et al, 2007;Parmar et al, 2007;Cometto, Fritsche and Sondorp, 2010;Zwi et al, 2011;Olu et al, 2015;Marzouk et al, 2019;Akik et al, 2020;Altare et al, 2020;Amodu et al, 2020;Mammana et al, 2020), tension and lack of trust between different actors (Cometto, Fritsche and Sondorp, 2010;Palmer, Robert and Kansiime, 2017;Atallah et al, 2018;Aembe and Dijkzeul, 2019;Duclos et al, 2019;, hierarchical structures within organisations (Tanaka et al, 2004;Atun et al, 2007;Zwi et al, 2011;Olu et al, 2015), vertical programme delivery (Atallah et al, 2018;Aembe and Dijkzeul, 2019;Akik et al, 2020), a lack of understanding of referrals processes from primary care to specialist services (Palmer, Robert and Kansiime, 2017;, high turnover of health staff that affected relationships (Karemere et al, 2015) and NGOs needing to fill gaps left by government, which linked to coordination challenges (Pursch et al, 2020). Other barriers included, in the Syrian response, the presence of multiple coordinating hubs with different approaches implemented by humanitarian actors and the government, and fragmentation as a result of the conflict, all of which affected coordination (Akik et al, 2020).…”

“…In the post-conflict context of Sudan, stakeholder analysis and regular, individual engagement with each stakeholder helped to generate consensus (Cometto, Fritsche and Sondorp, 2010). Recommendations included integrating community-based approaches into governance systems in high-income settings like Italy and Canada (Mammana et al, 2020;, forming partnerships with different actors in Canada , and in LMICs, giving national/local actors a stronger role (Altare et al, 2020), engaging communities from the outset in the design and provision of the primary healthcare system (Atallah et al, 2018) and using donors to encourage coordination (Parmar et al, 2007).…”

“…Barriers related to effectiveness and efficiency tended to intersect with other governance barriers and related to fragmented or poorly-used financing structures Alameddine et al, 2019;Bozorgmehr et al, 2019;Amodu et al, 2020), poor coordination (Jones, Howard and Legido-Quigley, 2015;Cignacco et al, 2018;Cailhol, Gilson and Lehmann, 2019), the political motivations linked to funding affecting how countries form refugee policies (Lupieri, 2020). In a few high-income settings, different barriers arose around the use of differing models of care in Italy (Mammana et al, 2020), problems with referrals between primary care and specialist services in Canada , and government restrictions to care in France (Pursch et al, 2020), and. Observed facilitators included the adoption of service delivery structural reforms, for example using a family medicine model for implementation, which improved coordination and effectiveness (Atun et al, 2007).…”

“…Barriers related to equity and inclusiveness in LMICs included a lack of legal status that affected access to healthcare for refugees Marzouk et al, 2019) and the absence of a refugeeinclusive policy environment (Lupieri, 2020). In high-income settings, barriers included a lack of translation services for refugees in Switzerland and Canada respectively (Cignacco et al, 2018;, a lack of access to cultural mediators in Italy (Mammana et al, 2020), and a systemic/cultural barrier of law enforcement creating an environment of intimidation and fear to prevent refugees from accessing and NGOs from delivering services in France (Pursch et al, 2020).…”

“…Other barriers related to financing included fragmented financing structures (Cailhol, Gilson and Lehmann, 2019), lack of inclusive finance systems (Grit, den Otter and Spreij, 2012), inefficient resource allocation (Atallah et al, 2018) and a lack of clarity on financial needs (Rossi et al, 2006). Other barriers included poor coordination, mistrust, a lack of harmonisation and a lack of clarity on responsibilities within the health response (Parmar et al, 2007;Atun et al, 2007;Cometto, Fritsche and Sondorp, 2010;Ruano, 2013;Jones, Howard and Legido-Quigley, 2015;Olu et al, 2015;Palmer, Robert and Kansiime, 2017;Atallah et al, 2018;Cignacco et al, 2018;Aembe and Dijkzeul, 2019;Marzouk et al, 2019;Bozorgmehr et al, 2019;Duclos et al, 2019;Akik et al, 2020;Lupieri, 2020;Mammana et al, 2020;Altare et al, 2020;Amodu et al, 2020). The way donor interests may dominate decision-making, funding and policy-making was also cited as a barrier across multiple studies (Parmar et al, 2007;Zwi et al, 2011;Marzouk et al, 2019;Altare et al, 2020;Legido-Quigley, Leh Hoon Chuah and Howard, 2020).…”