2001: constitutional reform

1. “Tuscany (Italy) and immigrant people: good practices in health care system”Ilaria TagliaferriUniversity of Pisa

2. Italy’s administrative division:20 Regions108 districtsmore than 8000 municipalities

3. 2001: constitutional reform Devolution of powers from central state to Regions Main power: organization and management of the health care system Almost the 80% of regional resources are spent to manage the health care system

4. Tuscany is one of the 20 Regions. Some data about it 3,6: millions of inhabitants (the 6,2% of the Italian population) 320.000: foreign citizens 275.000: resident; they represent the 7,5% of the whole regional population

5. In Tuscany’s school 6% of students don’t have Italian citizenship and the 12% are born in ItalyThat means immigrant people want to set with their family in our territory and so it’s necessary to build a multicultural society, in particular in two areas: • Health care • Education

6. But there are many barriers that keep immigrant people from the access on health care system and that’s because the incapacity of public institutions to refer to their particular situation. we must overcome our “mono-cultural” health care system and work on to create a new system that takes care of these new patients Their rate of hospitalization is lower than those ofItalian citizens but that’s not because they are healthier: that’s because there are barriers.

7. Their economical situation: the most part of them have humble jobs so they often live in poverty and prefer not to use the services of health care2. They usually suffer privation and many of them believe that health is not a priority. Their presence has shown a number of new situation: • High percentage of job accidents • High percentage of mental disease due to the way they get to Italy ( their fearsome journeys through the desert and then by boat in the Mediterranean sea). • Big percentage of abortion in immigrant women

8. The high percentage of abortion in immigrant women is a very big problem: in 2006, 8879 abortions have been registered in Tuscany and the 37% was referred to them. Three nationalities have the highest rate:Rumania (the 28,7% of the total), China (the 11,5%) and AlbaniaThe town where is the highest percentage of abortion in immigrant women is Prato

9. To face this situation, in 2001 an important project has been created in the city of Prato, called “L’ ALBERO DELLA SALUTE”.Why Prato? Because it’s the most industrialized town in Tuscany and here there is a strong textile industry Here live the 11% of foreign resident of the whole Tuscany: citizens from China, Rumania, Morocco, Albania and Pakistan.

10. This is a multicultural context where there are of course problems of cohabitation between Italian resident and immigrants. “Albero della salute” is realized due to the need of information of foreign citizens INITIALLY, the work was oriented on interaction with local society: public meetings about health were organized with the participation of immigrant’s communities. That was a great way to start “talking” to the ethnic groups. LATER, around the “Albero” grown a big network of people and associations and through this “collaborative strategy”, people who worked on this project could build a strong knowledge of immigrants’ culture.

11. In 2003 strategies of the project changed: using the acquired knowledge to organize a strong system of public services for immigrant people’s request of health care assistance It was necessary to form the staff, in particular in the area of administration, front office, gynecology and obstetrics: consequently public funds increased. In 2005, the “Albero” was officially recognized as a regional structure for cultural mediation in health care area

12. But immigrant women come into contact with Tuscany’s health care system during their pregnancy: from 2001 to 2007, the rate of immigrant women who gave birth to a child is doubled ( 10,8% of the total in 2001, 20,1% in 2007).They choose the public service of health care (most of Italian women choose the private one) but there are two problems: • They decide to go to the public services for their first control very late, compared to the average Italian women; • Statistics have revealed that there is an “under-exposure” of them in medical care.

13. This experience takes form with the objective of fill up the deficit of information about migration: initially they decide to implement a successfully strategy based on a direct contact with the several groups of foreign citizens: they have requested to take part in the initiatives.The “Albero” was not a no-profit organization, but an inter-institutional body: this way it could realize a strong dialogue with associations and immigrants’ communities in an equal way

14. Where are they from? In particular from: • Rumania • Albania • Morocco Where do they live? • For the largest part in Florence, Arezzo, Prato

15. In 2006 another project started its activity:“MUM HEALTH”,that is a regional program for the promotion of the global well-being of women The Tuscan Region’s Mum Health program has been set up in response to the ever-increasing numbers of migrant women in this country and in Tuscany and the need to safeguard women’s health, their reproductive health in particular. According to national research (Istisan Report 1999 and 2006) many social and linguistic barriers impede migrant women’s access to and taking advantage of socio-medical services, thus presenting a risk in terms of inadequate help in pregnancy, incorrect use of contraception and greater recourse to elective terminations of pregnancy. “When women are well, the whole world feels better” (A. Sen, 2001)

16. The project now under way includes the implementation of training sessions for socio-medical operators in all the health centers within the Tuscan region, which will last for several months. In parallel, multimedia material on reproductive health is being produced in several different languages in an endeavour to encourage the awareness and utilization of advisory bureau. A series of themed meetings will also be held in Florence on Thursdays, “I Giovedì de L’alberodella Salute”, which will publicize and set out the program objectives. • Mum Health aims to instill a sense of responsibility for personal health, reproductive health in this particular case, among migrant women within the Tuscan territory, to the greater benefit of child and adult well-being, given women’s role as nurturers. The program aims to develop women’s health skills and promote access to health services through participatory events. Experiences of countries with high immigration rates, such as England, have shown the value of involving migrant groups in the implementation of programs, promoting the health services’ “active offer” role, which involves focusing on people’s needs and their own ability to meet them.

17. The Tuscan Region’s Mum Health Program has been conceived in collaboration with the Tuscan health centers and is coordinated by “L'alberodella Salute”, the Reference Structure for Cultural Health Mediation, within the framework of the implementation of programs for the requalification of advisory services, responsible male and female parenting, and sexual awareness.

18. Objectives and Strategies The ultimate aim of the program known as Mum Health is to promote and improve the health, taken to mean the “global health”, of migrant women living in the Tuscan territory, with the rebound impact that this has on the well-being of entire migrant communities and on children in particular, given women’s pivotal role as care givers The project objectives are: 1. To raise migrant women’s awareness of health services both in terms of their right to benefit from them and in terms of what they have to offer 2. To raise migrant women and men’s awareness of contraceptive methods and thus cut down on elective terminations of pregnancy 3. To raise migrant women’s awareness of screening for female tumors

19. 4. to promote the “PercorsoNascita” among migrant women 5. To intensify the use of socio-medical services by migrant groups during the post- partum period 6. The strategies involved are: • promoting health literacy among migrant women; • involving migrant communities in the identification and setting up of activities; • empowerment of migrant benefits with particular reference to women; • operator training; • dissemination of information

20. • networking; • provision of services geared to the difficulties migrant women and men have in terms of access; • teaching and information about socio-medical services. Activities 1 Analysis of context, mapping of migrant clusters and programs aimed at women’s health 2 Programmatic and support meetings in which operators from all the Tuscan Health Centers will take part, with a view to promoting the active offer of services in the area of reproductive and maternal-infantile health 3 Consolidation of mediator training in the sphere of reproductive health

21. • Planning and drafting of multimedia health education materials (audio CD with information booklet and sub-titled video) • Themed Thursday meetings intended to popularize issues relating to the health of migrant women: I Giovedì de “L’alberodella Salute”• Mass media sensitization • Publication of the methods and strategies employed for setting up the activities, the results achieved and the principal instruments devised and put into practice

22. This is a good practice because it is based on a the will to adapt our health care system to foreign citizens: re-oriented public services taking care of the necessity of aimed interventions to specified ethnical and cultural realities Its strong spot is the strategy of “going to” immigrants, not just “wait” them. This way we can create a relationship based on confidence with immigrants in particular because of the will to place this relationship in an equal way