Delimiting social membership across multi-level states of immigration: policies and everyday practices regulating the access to health care for undocumented migrants in Piemonte and Andalucía
(R. Perna, M. Bruquetas Callejo e F.J. Moreno Fuentes)
The enactment of the right to health care is the conditio sine qua non for every human being’s autonomy and dignity. Legitimated by humanitarian, public health and economic considerations, consensus exists about the importance of guaranteeing appropriate health care to migrant groups, including undocumented migrants (UMs). However, since health care is conceived both as a human right and a right related to membership, the provision of health services to UMs may be considered to conflict with States’ efforts to limit access to welfare provisions on the basis of insider-outsider criteria that demarcate the community of legitimate beneficiaries of health care services, differentiating – and eventually excluding – users according to their legal status.
However, the exclusion of UMs from a county’s health care system is never absolute, but rather intertwined with concurrent processes of in/formal incorporation ‘from below’. On the one hand, and particularly relevant in countries characterised by multi-level health care systems, sub-national governments have increasingly played a central role in the definition of citizenship rights. These actors may or may not share and conform to national orientations, therefore shaping the parallel course of action established at the level of the state. Accordingly, research has provided evidence on how regional and local authorities are fundamental actors in favouring the access to health care for UMs.
On the other hand, and in spite of governments’ authority to delimit migrant categories and their associated degree of eligibility to health care, the responsibility of drawing boundaries between those who should be considered members of society, and those who should not, is to a large extent in the hands of ‘street-level bureaucrats’ operating in the front-line of health care systems. Accordingly, several studies suggest that committed providers often modify and even bend restrictive health policies, adopting benevolent discretional practices to guarantee the access to health care for UMs. At the same time, however, front-line workers have the responsibility of ‘getting the job done’, as they are officially charged of the implementation of governments’ rules and procedures. This task might be particularly challenging when front-line workers are confronted with ambiguous and incoherent multi- layered institutional frameworks. However, the question of how such vertical institutional inconsistences are dealt with by – and simultaneously shape – front-line workers’ practices has remained unanswered.
By linking the multi-level governance literature with the street-level bureaucracy approach and drawing on a cross-national comparison between the Region of Piemonte, in Italy, and the Autonomous Community of Andalucia, in Spain, this paper analyses how institutional categories delimiting access to public health care for UMs are defined, assessed and re-framed across multiple levels of health care systems. It suggests that the practices carried out by front-line workers are embedded in and reflect ambiguous multi-layered institutional frameworks. Confronted with institutional incoherence, these actors re-produce existing institutional categorisations while creating new ones through their discretional decisions, guaranteeing or hindering the access to health services for UMs on discretional basis.
Piemonte and Andalucía are representative case studies for analysing the relation between vertical in/coherence in multi-layered institutional frameworks and practices of policy implementation in regionalised health care systems. In Italy, UMs are entitled to access “urgent and essential care”, which must be provided free-of-charge at the point of access of the Sistema Sanitario Nazionale. Conversely, in Spain UMs living in the country had been entitled to the Sistema Nacional de Salud on equal grounds as Spanish nationals until 2012, when the central government restricted their eligibility to health care services, limiting access to public health care for emergency, maternal and child care only.
In both cases, however, ambiguity in eligibility requirements and in the definition of the basket of services UMs are entitled to, have come to characterise this policy field, in relation to which sub-national authorities have responded in the most different ways. In both Piemonte and Andalucía, regional governments have adopted inclusive policy frameworks, re-defining eligibility criteria and broadening the basket of services to which UMs are entitled to at the regional level. Hence, they are ideal cases for analysing the relation between multi-layered institutional frameworks and practices of policy implementation.
To compare cases and identify similarities/difference across them, qualitative data has been collected from official documents and grey literature, including health and immigration policy documents adopted at the national and sub- national levels, legislative actions, policy reports and other documents produced by concerned civil society organisations. Moreover, semi-structured interviews have been conducted with key actors involved in the regulation of the access to health care for UMs in both contexts, including regional policymakers, high-level civil servants, health professionals, front-line administrative workers, and representatives of CSOs at the different levels of governance of the health care system.