Access to healthcare for migrants in Italy The NIHMP experience Seminar THE RELATIVE POSITION OF MIGRANTS Brussels, 7 May 2010 dr. Raffaele Di Palma NIHMP Scientific coordination Office
PRESENTATION OUTLINE A NON CONCLUSION THE NIHMP EXPERIENCE MIGRATION IN ITALY
Migration in Italy The problem we have been confronted in the last thirty years, a new issue for Italy, is how to meet the needs and demands for social security and cohesiveness of our native citizens, and the needs and demands for reception and inclusion of a great number of citizens from foreign countries
Migration in Italy As we now know better, the great risk of entering a foreign country illegally is mostly taken when extremely serious economical and political conditions force people to the devastating decision of leaving one s own country and seek survival elsewhere
Migration in Italy Since long the S. Gallicano Hospital has devoted attention, study and activity to the international dimension of migration,, as regards scientific research, treatment and assistance concerning human mobile populations health
Migration in Italy It was soon perceived that is only to the extent that we invest in, and give support to, the Health conditions of the most needy and neglected citizens that we shall be able to promote development and welfare of the totality of our populations, enlarge their horizons, start new initiatives.
Migration in Italy Indeed migrants, even if bearing the great burden of the hardships and suffering endured in their homelands, turn out to be a fruitful resource for the receing countries with their great capability of work, with sharing their rich cultures, and with thier substantial contribution to national income
Migration in Italy
Migration in Italy 1 st january 2008: in Italy more than 4 million (4.328thousand) immigrants, 346.000 more than in 2007 Legal immigrants are 3.677thousand (or 6,7% of total population), while irregulars are assumed to be approximately 650thousand, or one out of five Source: XIV ISMU Report on Migrations, Caritas Statistics Dossier, 2008
The main foreign communities in Italy The first three immigrant communities by numerical importance are: Romanians (especially/mainly in Piemonte, Lazio and Lombardia) Albanians (especially/mainly in Toscana, Marche and Puglia) Moroccans (especially/mainly in Emilia-Romagna and Piemonte) Source: ISTAT Report, 2009
The main foreign communities in Lazio Lazio Region: one of the most affected areas of the country by migration In 2007: more than 500.000 foreign citizens, including 440.000 only in the Province of Rome. Foreigns mainly come from Central and Eastern Europe (37,9%) The first Countries by number of presence: Romania Philippines Poland Ukraine and Albania Asian Countries Latin America Countries AfricanCountries Women represent 56% of foreign population Foreigners are predominantly young Among the stay (living) reasons, prevails work (57,3%) and family reunification (21,6%). Source: Caritas/Migrantes Statistical Immigration Dossier, 2008
The main foreign communities in Rome and Province Rome and Province: more than 181 nationalities foreign residents by citizenship: first 10 (31.12.2007) Province of Rome Country v.a. % Romania 92.258 28.7 Philippines 25.888 8.0 Poland 18.151 5.6 Albania 11.856 3.7 Peru 11.358 3.5 Bangladesh 9.961 3.1 Ukraine 9.627 3.0 China 8.840 2.7 Egypt 7.899 2.5 Ecuador 7.417 2.3 SOURCE: Caritas/Roman Observatory on Migrations. Elaborations on Istat data
The main foreign communities in Rome In Rome: at 1 st january 2008, 269.649 foreign residents, 7,6% increase compared to 2007 (Statistical Bureau, Municipality of Rome) Municipality of Rome: foreign residents by citizenship: first 10 (31.12.2007) City of Rome Countries v.a. % Romania 41.391 18.9 Philippines 24.521 11.2 Poland 11.361 5.2 Bangladesh 9.537 4.4 Peru 9.501 4.3 China 7.949 3.6 Ukraine 7.018 3.2 Egypt 6.620 3 Ecuador 6.420 2.9 Sri Lanka 5.082 2.3 SOURCE: Caritas/Roman Observatory on Migrations. Elaborations on Istat data
PRESENTATION OUTLINE A NON CONCLUSION THE NIHMP EXPERIENCE MIGRATION IN ITALY
The Italian National Institute for Health, Migration and Poverty (NIHMP) NIHMP was established in Rome through Financial Bill for Year 2007 and began to function on 29 October 2007 INMP consists of the new National Institute in Rome working with three Regional Centres in Lazio, Apulia and Sicily INMP is co-operating with all the Italian Regions
The Italian National Institute for Health, Migration and Poverty (NIHMP) NIHMP builds on 25 years of research, training and clinical services experience at the Department of Preventive Medicine for Migrations, Tourism and Tropical Diseases of the S. Gallicano Institute (IRCCS) in Rome
The Italian National Institute for Health, Migration and Poverty (NIHMP) The Santa Maria and San Gallicano Hospital, seat of the NIHMP, was established by Pope Benedict XIII in 1725 as one of the first dermatological centres in Europe
The Santa Maria and San Gallicano Hospital For over 25 years has been welcoming, examining and studying an extremely varied population consisting of: Undocumented immigrants Refugees and Asylum seekers The homeless Female victims of the prostitution trade Abandoned children and adolescents Roma Retired poor people Women and girls with FGM Victims of torture
The Italian National Institute for Health, Migration and Poverty (NIHMP) The mission of INMP is to strengthen TRANSLATIONAL RESEARCH building on research in improving health care for migrants and other disadvantaged people to develop, coordinate, and carry out initiatives aimed at promoting the health care of disadvantaged population groups and to share know-how and experiences
TRANSLATIONAL RESEARCH Translational as a means of translating research into practice: ensuring that new treatments and research knowledge reach the patients and/or populations for whom they are intended and are implemented correctly Translational research seeks to close the gap between research and services and improve access to care, reorganize and coordinate systems of care, help clinicians and patients to change behaviors and make more informed choices, provide reminders and pointof-care decision support tools, and strengthen the patient clinician relationship. Wolf SH. JAMA 2008;299(2):211-213
The Italian National Institute for Health, Migration and Poverty (NIHMP) The implementation of these tasks is carried out by ascertaining the needs and demands of recipient groups and by working out appropriate strategies and tools to meet their needs, in collaboration with a network of public research institutions and of Italian Regions
The Italian National Institute for Health, Migration and Poverty (NIHMP) The main expected outcome is The development of innovative approaches to improve health care provision by the Italian National Health Service Easy access to health service Holistic approach Keep in touch with patient, his/her family and his/her community by means of cultural mediators
The Italian National Institute for Health, Migration and Poverty (NIHMP) The NIHMP carries out for all citizens (italians and foreigners): Prevention Clinical assistance Training Research activities To access the Outpatient Services no appointment is needed no waiting list
The Italian National Institute for Health, Migration and Poverty (NIHMP) The specialised health care services provided by the NIHMP are included in the public National Health System The NIHMP provides the entitled persons with the codes STP (Foreigner Temporarily Present) and ENI (European Person not Registered with the national Health Service)
The NIHMP social and health care services The specialised health care services provided are: Laboratory Tests Plastic and Reconstructive Surgery Dermatology Tropical Dermatology Dietetics Gynaecology Infectious and Tropical Diseases Tourism Medicine Internal Medicine Microbiology Child Neuropsychiatry Social Ophthalmology Paediatrics Ethnopsychiatricoriented Psychology
The Italian National Institute for Health, Migration and Poverty (NIHMP) 30 doctors (dermatologists, physicians, surgeons, paediatricians, gynaecologists, psychiatrists, dentists, oculist, lung specialist, infectious diseases specialist, epidemiologist) 6 nurses 8 psychologists 4 sociologists 6 biologists 5 anthropologists 4 social assistants 32 transcultural mediators 3 lawyers 10 researchers 3 technical officers 40 administrative officers
What would be a health systems approach to improve the access to healthcare for migrants? Increase participation of the migrant community in planning, implementation and evaluation Strengthen cultural and linguistic competencies as part of PERSON - oriented services Tuscany Region (Italy) case study; the Plum Flower Centre integrating Chinese and Western medicines.
What would be a health systems approach to improve the access to healthcare for migrants? Improve information systems, through dissagregation by relevant categories including migrants health system usage, health behaviours and health outcomes, as well as additional research on barriers to access. It may be important to include data on the children of migrants. Sustain commitment to migrant health, as short-term funding and service provision cannot be expected to produce long-term results. Ensure accessibility to the provider network, particularly in disadvantaged areas wheretheremaybea higher density of immigrants and other vulnerable groups such as Roma or homeless.
What would be a health systems approach to improve the access to healthcare for migrants? Strengthen the ability of specific programmes to meet the needs of migrants, particularly for communicable and non-communicable diseases which may have higher prevalence rates among migrant populations. Account for adverse socioeconomic conditions in detection and treatment (e.g., through early screening and efforts to decrease detection time, treating multi-morbid patients, and measures to facilitate patient compliance).
What would be a health systems approach to improve the access to healthcare for migrants? X Raise demand for services among migrant populations, by understanding the persons perspective and increasing their knowledge of the system; this may require social advocacy and outreach Czech Republic case study: Information Brochures about the healthcare system were created to increase demand for available services among immigrant groups.
What would be a health systems approach to improve the access to healthcare for migrants? Increase capacity to address diseases where there are significant differences in prevalence between migrant origin and destination locations (e.g., Hep B, Tuberculosis, leishmaniasis), and for concerns including female genital mutilation and the needs of victims of torture and trafficking Strengthen Primary Health Care to provide regular preventative and health promotion services for migrant populations, to avoid the development of more advanced illness and levels of care (e.g., emergency) that could have been managed with reduced costs
Eliminating barriers Eliminate other barriers, such as: requirements to register at municipality or other authority; have documentation to recieve care; lack of insurance; prolonged/complicated procedures for reimbursing the costs of care of unisured persons. as all of these infringe on the basic human right to health. SALUTE SALUTE SALUTE Source: Norwegian Ministry of Health Care Services, 2007
What would be a health systems approach to improve the access to healthcare for migrants? Ensure competent human resources are available according to current and future health service needs for migrant populations this may include: Training of health professionals Using transcultural mediators Provision of translation services
What would be a health systems approach to improve the access to healthcare for migrants? Increase health professionals capacity to address health issues associated with socioeconomic disadvantage and population movements, by providing and/or integrate migration and health issues into existing education/training activities. AIDS&MOBILITY AT NIHMP With Migrants, For Migrants provides training courses to help health professionals work better with immigrants and reach migrant communities.
What would be a health systems approach to improve the access to healthcare for migrants? Formalize use of transcultural mediators, by establishing: selection requirements, initial training and methods for continued capacity building, compensation and necessary investments, performance management mechanisms.
What would be a health systems approach to improve the access to healthcare for migrants? Equip services to conduct community outreach for active case finding and early screening activities and efforts to ensure patients compliance to assure adherence and reduce resistance among populations at higher risk if deemed necessary. Promote greater transparency in the system, particularly with regard to migrants awareness of both their entitlements and obligations. Ensure that access is not denied because of legal/administrative barriers, and in insurance-based systems, that pre-existing conditions are not a barrier to coverage, as this infringes on the basic human right to health.
Stewardship Engage with other sectors to address the socioeconomic determinants of migrants health: directly at the health service points, through open window/one gateway functions that facilitate access to social services through multi-sectoral programmes that work to improve both health and socioeconomic conditions by lobbying other sectors to address migrant needs in their policies and programmes
Stewardship Advocate for using a health in all policies approach to improve migrant health (e.g., immigration policy and occupational health issues) Build coalitions with representatives from migrant populations, NGOs, voluntary organizations, and other civil society groups to inform, help implement and monitor interventions to improve migrant health
Stewardship Engage in international cooperation on migrants health among countries involved in the whole migratory process (origin or return, transit and destination).
What would be a health systems approach to improve the access to healthcare for migrants? It is essentially a question of improving the standard of services: - making easier the access to these services - rationalizing their costs - eliminationg inappropriate and unless health interventions - avoiding the prescriptions of drugs for non medical problems Increasing the efficiency of the services
PRESENTATION OUTLINE A NON CONCLUSION THE NIHMP EXPERIENCE MIGRATION IN ITALY
Facing an exiting challenge For populations experiencing multidimensional extreme poverty and social exclusion the risk of being deprived of their right to health is more and more high. This includes the social, economic and environmental conditions required for health.
Facing an exiting challenge (World Health Report 1995 The state of world health - WHO: Geneva) The world s biggest killer and the greatest cause of ill-health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given the code Z59.5 Extreme poverty
Facing an exiting challenge Taking care of a person implies much more than treating him/her. They are not customers, patients, but persons with their stories, diseases, anxieties, dreams, projects and emotions Source for photo: UNFPA State of the World Population 2006: A Passage to Hope
Facing an exiting challenge Migration represents a challenge but also a great opportunity to remodulate a health care service fit to guarantee a gold standard of health starting from the poorest persons reducing health inequalities
Facing an exiting challenge It is indeed the challenge launched by marginalized population groups which calls for effective actions. In this sense, they can be considered a real resource, as in a more and more globalized society they lead the way, also for other groups not at present liable to the same conditions, and prompt us to tackle the situation and find the ways out of their disadvantaged conditions in a more determinate way.
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