Immigrants' access to healthcare: the case of Italy

1 
 
 
1. Introduction 
 
 
The empirical analysis of inequities in healthcare’s access is quite challenging due to the set of 
demographics, socioeconomic, territorial and cultural factors which are context-specific and 
which influence the individual’s health needs and demand for healthcare. Inequities exist if 
there are systematic variations in access to healthcare that are unrelated to health needs and that 
are beyond individual’s control (Devillanova and Frattini, 2016).  
Ensuring equitable access to healthcare has been largely recognized by governing institutions 
around the world as the main tool to reduce health disparities. The European Union’s legislation 
partially addresses the issue: it provides protection against discrimination in access to healthcare 
on the grounds of “racial, ethnic origin and sex” (Directive 2000/43/EC
1
 and Directive 
2004/113/EC
2
), but it ignores other individual characteristics such as religion, belief or sexual 
orientation. Directive 2011/24/EU
3
 protects against discrimination on grounds of nationality, 
but it refers only to nationality of patients originating from other Member States. Moreover, the 
Treaties assign to the Member states the responsibilities for the organization and delivery of 
health services and medical care, leaving the issue of equity of access to healthcare 
disharmonized and largely dependent on national regulations (Orzechowski et al., 2020). In the 
Italian legislation, the Constitution recognizes health protection as an inviolable right and 
guarantees it to all individuals, regardless of their individual characteristics and citizenship.
4
 
Interestingly, the Legislative Decree 286/98
5
 made Italy the first in Europe to address migrants’ 
health and access to health services through specific policies (Listorti et al., 2022). 
Nevertheless, as the empirical evidence suggests, migrants still face a lot of barriers in accessing 
 
1
 European Union. Council Directive 2000/43/EC of 29 June 2000 implementing the principle of equal treatment 
between persons irrespective of racial or ethnic origin. Official Journal of the European Union L180. 2000.  
 
2
 European Union. Council Directive 2004/113/EC of 13 December 2004 implementing the principle of equal 
treatment between men and women in the access to and supply of goods and services. Official Journal of the 
European Union L373. 2004. 
 
3
 European Union. Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the 
application of patients’ rights in cross-border healthcare. Official Journal of the European Union L88. 2011. 
 
4
 Costituzione della Repubblica Italiana, Parte I, Titolo II, Art 32, comma 1.  
 
5
 National Legislative Bodies. Legislative Decree 286/98, art. 35, Paragraph 3. National Legislative Bodies; 
Rome, 1998.
2 
 
healthcare and they have lower levels of utilization of preventive care (see Chapter 2, Section 
2.3). 
 
Inequalities in access to healthcare in Italy have substantially increased in the past decades and 
the most vulnerable socio-economic groups report higher levels of unmet medical needs 
compared to those who are better-off. In the period 2008-2017 the percentage of people in the 
lowest income quintile suffering from unmet medical needs had been steadily growing, 
becoming as high as 15.5% in 2015. By contrast, the number of people in the highest quintile 
reporting foregone care was below 1% and it has also diminished during that period
6
. (Falco, 
2019; Eurostat, 2019). 
In the period 2010-2017, in Italy, despite a growing demand for healthcare services largely 
induced by the aging of the population and the greater spread of chronic pathologies, the per 
capita public health expenditure as percentage of GDP has decreased from 7% to 6.5% (OECD, 
2019). In the same period, out-of-pocket health expenditures have increased, reaching the value 
of 21% of the total health expenditure in 2020, which is a particularly high value compared to 
the European average of 15% (OECD, 2022).  
The many years of underfunding of the Italian public healthcare system affected the ability of 
Italy to organize an appropriate response to the Covid-19 pandemic in 2020 (Buzelli and Boyce, 
2021). The pandemic has uncovered the weaknesses of the system, further worsening pre-
existing inequalities. Immigrants experienced on average a 1-month delay in diagnosis of 
Covid-19 compared to Italians and in the first phase of the pandemic they faced a higher risk 
of hospitalization and of intensive care once infected. Immigrants coming from poor countries 
also faced a higher mortality rate than natives (Petrelli and Di Napoli, 2022). 
 
 
 
  
 
6
 Eurostat (2019), “European Union Statistics on Income and Living Conditions (EU-SILC)”.
3 
 
1.1 Motivation 
 
The aim of the present analysis is to identify inequities related to the immigrant status in Italy 
and to shed light on the barriers immigrants face to access healthcare. The existence of these 
barriers is indeed an interesting topic to investigate since, at least from a legal point of view, 
access to healthcare should be guaranteed to all immigrants in Italy. The increasing 
vulnerability to which immigrants in our country are exposed, also as a consequence of a 
somewhat hostile social and political environment, and the legal and moral obligation of 
ensuring them an equitable access to healthcare make this topic even more crucial.  
Moreover, from a strictly economic point of view, guaranteeing fair access to healthcare is also 
a wise and efficient economic decision, since late diagnosis and the worsening of health 
conditions of the disadvantaged groups leads to higher future medical expenses and increased 
burden on the public healthcare system. 
 
This analysis also intends to focus attention on immigrant women’s access to healthcare. More 
specifically, the preventive care of immigrant women will be looked at by including in the 
analysis some unusual healthcare outcomes such as the mammography and the pap test. Gender 
differences in accessing healthcare will also be put in relation with immigrants’ duration of stay 
in Italy. Adopting a gender perspective to understand migrants’ health is a quite new approach, 
especially in some recent destination countries such as Italy, where empirical evidence on 
immigrant women’s health and access to healthcare is scarce (see Section 2.4). Therefore, the 
results of this analysis will integrate the existing evidence on gender issues related to migration 
and health, and encourage the adoption of a gender perspective in future quantitative research 
on this topic.   
 
Finally, compared to the previous literature on immigrants’ access to healthcare (see 
Devillanova and Frattini, 2016), more recent data at the national level have been available for 
the present analysis (ISTAT, 2013 edition of the Italian National Health Survey (Indagine 
multiscopo sulle famiglie – Condizioni di salute e ricorso ai servizi sanitari). This update in the 
data allowed me to include in the analysis immigrants’ duration of stay in Italy, which is surely 
an important factor shaping access to healthcare, but which was not available in the previous 
editions of the survey. Distinguishing between newly arrived migrants and long-residence
4 
 
migrants may be helpful to check whether some access barriers weaken over time. A long time 
of residence may also lead to a change in the healthcare requirements for migrants, reflecting a 
convergence of their health needs towards those of the native population.    
Addressing some of the specificities within the migrant group, such as time of residence and 
gender, may result in useful suggestions for inclusive policies that are tailored on the diverse 
needs of immigrants.
5 
 
2. Conceptual framework and Literature review 
 
 
2.1 Background 
 
Differences in health outcomes and access to healthcare between immigrants and natives have 
been widely addressed by the empirical economic literature, especially by the foreign one.  
A large portion of research has focused on the health status of immigrants, which should in turn 
have an impact on their need for healthcare in the host country. On the one hand, evidence 
suggests that immigrants may be less likely to need healthcare with respect to the native 
population when they arrive in the host country. Given the huge monetary and non-monetary 
costs of migration, a positive-selection mechanism of migrants leaving their original country is 
observed: the healthier and more educated among young people are more likely to leave 
(Norredam et al., 2012). This “healthy immigrant effect” has been widely supported by data in 
most countries and is today widely acknowledged by the literature (Kennedy et al., 2016; 
Riosmena et al., 2017; Lubbers and Gijsberts, 2019; Ichou and Wallace, 2019). On the other 
hand, this effect has been shown to deteriorate after few years of residency in the host countries 
(e.g., Khlat and Darmon, 2003; Newbold, 2005; Antecol and Bedard, 2006). Several 
explanations have been proposed to justify the loss of the migrant-health advantage and the 
migrant-native health convergence (Trappolini and Giudici, 2021). First, a potential driving 
factor could be the exposure to the new cultural and social context of the hosting country, which 
can influence attitudes and behaviours towards health. In addition, the worse job and living 
conditions to which immigrants are exposed surely play a role in the deterioration of their 
health. Furthermore, the migration experience and disruption of immigrant social network may 
lead to isolation, lack of emotional support and subsequent worse physical and mental health 
status (Dourgnon et al., 2023).  
 
Being in a situation of economic and social isolation not only directly impacts the health status, 
but it is also an impeding factor when it comes to access healthcare, especially when the public 
health-care system is weak or absent and/or when out-of-pocket expenses for medications and 
visits are substantial. A vicious circle has been documented by the literature: poverty reduces 
access to healthcare, which leads to increased morbidity, which leads to increased poverty and 
further reductions in access to care (McMaughan et al., 2020). However, the socio-economic