Access to healthcare services and social inclusion of immigrants: a multifaceted and unregulated challenge?

The access to healthcare services represents an important step of the process of social inclusion of immigrants [Labonte, 2004]. Immigrants typically face a number of difficulties in accessing healthcare services in destination countries [Dean and Wilson, 2010]. These difficulties can be synthesized considering the following issues [Leclere et al, 1994; Derose et al, 2007]: limited proficiency in the local language, a partial knowledge of the healthcare system of destination countries, residential and/or working segregation, differences in the perception of health needs. Moreover, the possibility of accessing to healthcare services can be reduced by the institutional arrangement of the welfare system, which may provide immigrants a limited eligibility for public services. Finally, immigrants may be unable to afford the economic costs of healthcare services. A growing number of studies [Riccucci and Meyers, 2004; Brodkin, 2011; Bjerregaard, 2011] have provided evidence that these challenges are mainly tackled at local level directly by those actors who stand at the front-line and who are typically described as street-level bureaucrats [Lipsky, 1980]. This means that, although the access of immigrants to healthcare services is a multifaceted issue, its regulation is heterogeneous and unstable. A variety of micro-policies and initiatives have been proposed and tested, yet the overall picture – from a national point of view – is quite fragmented and inhomogeneous. The paper aims at investigating the dynamics which lead to the differentiation of the practices of regulation and promotion of immigrants’ access to healthcare services. The paper discusses the main findings of a research project that examined the practices for regulating and promoting the access of immigrants promoted by six healthcare providers (hospitals and family planning bureaus) in the urban area of Milan, in the Northern part of Italy. Following the approach of the extended case method [Buroway, 1998], these experiences are presented as case studies which contribute to the analysis of a broader institutional issue, combining three analytical dimensions: the professional, organizational and societal levels. The paper focuses on a specific area of healthcare service: the services provided for pregnant women before and soon after the birth of a child. The analysis has been restricted to Chinese, Philippine and Morocco women, who represent the most numerous groups of immigrants in the area of Milan. The findings of the research emphasize the relevance of professional and organization discretion in the promotion and regulation of access to healthcare services. The practices of regulation and promotion of the access can be described as a “bricolage” process [Duymedijan and Ruling, 2010; Binder, 2007], which results in a puzzled mosaic of experiences and initiatives. Beyond this fragmentation of practices, it is important to state that access to those specific healthcare services partially provides a sense of social inclusion to immigrants, as long as practitioners do not share a common view on their role of “agents” for social inclusion: their action seems to be mainly driven by their professional cultures, rather than by their institutional identity.