Healthcare deservingness at the front-line. A comparative ethnography of street-level practices towards migrants with precarious legal status in Northern Italy

Although scientific consensus exists about the importance of guaranteeing appropriate healthcare to all migrants, those with precarious legal status are often displaced to the margins of national healthcare systems. Nevertheless, while governments have the power to define the – often limited – entitlements to healthcare for migrants with precarious legal status, the responsibility of drawing the line between those who deserve access to scarce resources and those who do not is in the hands of street-level bureaucrats operating at the front-line of healthcare systems. Linking the nascent literature on healthcare deservingness to the street-level bureaucracy perspective in policy analysis, the paper analyses how assessments of healthcare deservingness are constructed on the front-line of healthcare systems, and how these perceptions may turn into discretionary practices of in/exclusion. It presents a comparative ethnographic study carried out between 2014 and 2017 in three Italian public health structures providing primary care to migrants with precarious legal statuses (undocumented migrants, EU migrants without formal residence rights, pending asylum seekers). The study points out how opposing practices of inclusion towards ‘vulnerable patients’ or exclusion towards ‘fraudsters’ and ‘clandestini’ derived from workers’ views about migrants’ ‘illegality’ (control, reciprocity and attitudes criteria of deservingness), and the ways street-level bureaucrats interpreted their own role in the system, regardless of their formal professional responsibility (administrative workers and doctors).