Street-Level Bureaucrats, Organisational Fields and Institutional Crisis: Policies and Practices Regulating Access to Health Care for Migrants with Irregular Status in Italy

In Italy, health care is the policy field in which migrants with irregular status enjoy the greatest degree of legitimacy. They are granted access to urgent and essential care, provided free-of-charge in case of indigence. Repatriation may be halted when they are diagnosed with severe pathologies requiring medical treatments that are not available in their origin counties, and it is prohibited in the case of pregnant women. However, in the dual context of fiscal austerity measures and increased migratory pressures, this policy domain has experienced a legitimacy shortfall, as its established policy frames, organisational structures and modes of policymaking have been increasingly criticised by field actors. By presenting an ethnographic case study carried out in three public health organisations in Piemonte, a Northern Italian region, this contribution aims at explaining changing policy implementation dynamics in times of multiple crises, focusing on the individual, organisational and institutional factors that simultaneously shape daily practices of health care for migrants with irregular status. It suggests that, next to workers’ individual positioning towards migrants’ (un-)deservingness of health care, practices of policy implementation are mediated by a constellation of factors operating at the micro, meso and macro levels, which have turned access to health care for migrants with irregular status into a conflictive arena, ultimately affecting migrants’ eligibility to public health care in practice.