Health Assistance to Immigrants in the Italian Region of Puglia: Effectiveness of General Practitioners’ Care

Background: Health promotion aims at reducing differences in health status and ensuring equal opportunities and resources to enable all people to achieve the fullest health potential. Methods: The assistance model provided to immigrants in the Italian region of Puglia was evaluated by using a questionnaire administered to both immigrant patients and general practitioners (GPs). Results: Results indicate that both regular and illegal immigrants were satisfied of the overall assistance provided declaring no difficulties in accessing care. GPs indicated the understanding of specific needs as the way to improve assistance. Discussion: These findings are important since in Italy, GPs represent a valuable resource for the promotion of health and education. The peculiarity of the Apulian model is given by the global health management of migrants including urgencies and chronic diseases.

Check for updates ropean continent, Italy represents a frontier land for the arrival of desperate individuals, a high number of them remaining for a long time legally not regular.
The Italian Region of Puglia [1] adopted the Italian regulation on the "Right to health for migrants" and further extended entitlements within its local jurisdiction by delivering a specific Regional Law: "Rules for the reception, civil coexistence and integration of immigrants in Puglia". This law is based on the principles of the "Ottawa Charter for Health Promotion" [2] which aims at reducing differences by ensuring equal opportunities and resources to enable all people to achieve their fullest health potential.
By respecting the fundamental principles and inviolable rights of the person, the Apulian law contributes to the protection of migrants present under any form in its territory, guarantees their social inclusion and offers equal opportunities to access health services by eliminating all forms of discrimination (gender, culture, language,…). This law ensures continuity, affordability and quality of care, overcomes administrative barriers, and legally protects doctors that assist migrants. Main recipients are non-European stateless persons, asylum seekers and refugees present in Puglia.
This law gave to local health authorities the chance to extend care to all immigrants including those irregular (STP, strangers temporarily present): • Legally resident foreigners, who are permanently

Introduction
The number of migrants moving from poorer to richer regions is dramatically increasing in the last two decades and this phenomenon pushes the Authorities of Western countries to design models for health assistance and social inclusion of these people. Because of its position between the Mediterranean Sea and the Eu-tionnaire. Thirty-one were Albanians, 9 from Morocco, 6 from Georgia, 5 Tunisia, 4 Mauritius, and few from East Europe, China, Middle and South America.
In detail, 47% of migrants declared to need only brief medical consultation and have had no or only little difficulties in explaining health problems. The access to the GP's offices was easy for all of them with excellent availability by GPs and the perception of no existing cultural barriers including the talking about sexual problems. Migrants (73%) declared high collaboration in helping GPs about history, visit and general communication including prognosis, treatment and cures. However, at this regard, over 30% of them preferred "traditional" methods or natural remedies. GPs visited 40% of migrant patients also at home. The understanding of the particular needs and the obtaining of the whole family trust especially in the case of Islamic patients was an important point in GPs-migrant patient relationship. In turn, GPs indicated the understanding of specific needs as the way to improve assistance.

Discussion
The continuous arrival of migrants from poor countries of Africa, Middle East and East Europe is putting in crisis the social and the health care of Western Countries finding them unprepared to face the impact of needs and requests. Although human rights are protected by various international and regional instruments, great differences exist about the level of provisions, the economic involvement and sensibility of Governments. Indeed, different local interventions have been predisposed to help and assist these people and promising local practices in Europe really facilitate access to health care and services for migrants. However, most diffuse models of assistance are confined to urgencies and to hospital settings. The peculiarity of the Apulian model is given by the global health management of migrants not only for urgencies or not postponed needs but also for chronic diseases and prevention even included assistance for addiction and motherhood. This model ensures continuity and quality of care, overcomes administrative barriers and assigns a GP also to irregular migrants. The strength of this model is based on understanding the needs of the single migrant patient as the key to improve the quality of care even by assisting them in the place in which they live.
The results of this survey clearly indicate that both regular and illegal migrants in Puglia are satisfied of the health assistance provided by the RHS. They also refer difficulty neither in relationship with GPs nor in accessing care. The appreciation and collaboration of migrants, including STP, towards their GPs were excellent registered with the regional health service (RHS), enjoy full equality treatment with Italian citizens, with extension to legally resident family members.
• Legally resident foreigners with a permit longer than 3 months are required to sign an insurance policy against the risk of illness, injury and maternity.
• Unregistered non-European persons (permit < 3 months) are not required to register with the RHS but in case of need are entitled to receive full assistance.
• Non-European foreigners without a residence permit or not in order with the rules to entry and stay (STP) receive a specific code to register with RHS and obtain a general practitioner (GP) for six months, renewable.
• European citizens, who are not assisted by their State of origin, lack the requisites for enrollment in the RHS and pay in conditions of poverty, receive a specific code for assistance.
• Detained foreigners, with or without a residence permit, must be registered with the RHS.
To all of them, the Apulian RHS guarantees free of charge: a) The access to essential and continuous care for acute and chronic illnesses and injury with extension to preventive medical programs including mental health service, gynecology, abortion, pregnancy, motherhood, vaccination, addiction treatment and rehabilitative care, by engaging the regional network of general practice; b) The provision of pharmaceutical assistance, upon prescription by a physician. To favor these innovative actions and to better approach foreign users, the Region organized the presence of linguistic-cultural mediators in health centers and promoted training programs for health personnel.
To evaluate the effectiveness of this law and the quality of the assistance provided, the opinion of migrants about the level of satisfaction of the received care and that of GPs about the needs of migrants, were gathered with the final aim to search for margins of improvements.

Methods
Over a period of two weeks, regular and illegal immigrants attending the offices of 10 GPs of Bari, the capital of Puglia, and its surrounding area were asked to anonymously fill a questionnaire containing 22 items investigating country of provenience, religion, accessibility and quality of care and needs. Both migrants and GPs were also asked about the way to improve relationship and assistance. Data were registered according to gender and legal condition. Results were analyzed and expressed as percentage.

Results
Migrants (n = 73, 43 women, 26 STP) filled the ques-for most of them with a good propensity to trust even for thorny problems. Although many expressed the desire to receive traditional remedies or natural medicine, most migrants well accepted the cure prescribed by GPs.

Conclusion
Taken together these findings are important since in Puglia, and more generally in Italy, GPs are a valuable resource for the promotion of health and for the management of chronic conditions, which affect 40% of the whole population. In conclusion, this analysis points to understanding the needs of the single migrant patient as the key to improve the quality of care, thus ensuring that no one is left behind.

Key Points
• In agreement with the respect of human rights, promising local practices in Europe facilitate access to public health care and services for migrants by applying various international and regional instruments.
• Differently from most diffuse models of assistance which are confined to urgencies and to hospital settings, the Apulian model ensures continuity and quality of care also in the case of prevention and chronic diseases by overcoming administrative barriers and by assigning a General Practitioner also to irregular migrants.
• The strength of the Apulian model is based on understanding the needs of the single migrant patient as