Proceedings of                 Ü Czech Republic
    8th SEMINAR  SMES                
    Prague 17-19 June

    Dignity  and  Health

access for all

                                              to rights & services







support of

in  D&H-5P




WELCOME by Neil Davies - SAD (CZ)
by Luigi Leonori  President of SMES-EUROPA        


  Testimony from daily life of any current and former users of services

Presented by Pavel Penkava:

Ostrov nad Ohří State Penitentiary, 13th June 2004

Dear Sir or Madam

My name is Václav.

I am currently serving a stint in jail.

I am an homeless invalid with rich criminal record.  Sounds silly, doesn´t it ?

I am not wholly aware of the issues to be discussed at your conference, but I plead that you have it on your mind that we are, too, and perhaps just due to it, mere humans.

I beg you to stay always on the side of those who need help of any form.


Václav, a convict.

At name of all participants, Luigi Leonori asked to Pavel Penkava presenting to Václav many thanks for participation in the conference and insurance that SMES will implementing and improuving the promotion of  "human dignity and right's respect" with especially attention in prisons too.

   *  ...
   *  ...
   *  ...
 discussing with
Lucie Ripova, Pavel  Penkava and Neil Davies.


     Mr Neil Davies
 - Representing of SAD 
Ms. Hana Halová - Counsilor on Health and Social Affairs of Prague Municipality
Mr. Luigi Leonori  -
Presentation of  "D&H-5Project" and the 8° European Conference.         


THEME:  Human dignity and the right to health care

Chapter I of the Charter of fundamental rights of the European Union is entitled « Dignity » and Article 1 borrows from the German Grundgesetz the principle of inviolability of human dignity.

The following introductory remarks will be divided into two parts : first a short evocation of the philosophical sources of the concept of human dignity and second, a review of the modalities of access to the effective enjoyment of such right, namely in the field of health care.

I.  Philosophical Sources of Human Dignity

The very concept of human dignity goes back to the earliest Antiquity, Christian and pagan.  The human being is invested in the Creation and above all other living beings with a dignity which makes him according to a Cartesian expression “master and possessor of Nature”.  One is nowadays conscious to what excesses has been brought the exploitation of natural resources. Such criticism which is akin to ecological preoccupation is stressing the aristocratic ideal which seems inherent to human dignity.

The exploitation of nature and its consequence, the destruction of the environment is a violence made to nature — in Latin and in latin languages the word is feminine and it suggests that, as women have been and still are, nature is the victim of the violence and the greed of men. The word “rape” is perfectly fit to describe the exploitation of nature, which was assumed by rich peoples for the benefit of the rich at the expense of the poor, Indian communities, slaves, workpeople devoid of any right. It would be too simple to oppose North to South.  All inhabitants of the Northern countries do not share in the exploitation of natural resources and there exists in the South social strata which are helping in the looting.

The most actual philosophical expression of human dignity has been framed in the last years of the eighteenth century by a German thinker, Kant.  Human beings may not be treated as an object or a means, but as an end.  The Kantian golden rule is : “behave against the other as you wish to be treated yourself”.  Kant adds : “humanity is itself a dignity”.  The notion of humanity is universal : dignity belongs to every human being, whatever his or her race, religion, nationality.  The international provisions which forbid discriminations are only referring to such criteria.  Poverty, destitution, ignorance are no sources of discrimination because one does not want to be conscious that such discriminations are engendered by the social fabric.

The aristocratic origin of the concept of dignity is corroborated by a semantic usage which is more alive than the egalitarian approach.  The word points to a function or an attribute which distinguishes and separates their holder from all other human beings : such as the royal dignity, the episcopal dignity, etc.  In the dictionaries of theology, either of protestant denominations or of the Catholic church, the word “Dignities” makes no reference to the dignity of all men and women, but to the attributes invested on dignified persons.  According to Cicero, “dignitas” is a virtue of the male, corresponding to “venustas” (Venus) in the fair sex. 

II.  Juridical consequences of the concept of human dignity and their application to the field of health care

Some international instruments — but not the European Charter — set health among the fundamental human rights.

Art. 25,1 of the Universal Declaration of Human Rights (1948) :
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services …

Art. 12,1 of he International Covenant on economic, social and cultural rights (1966) :
The State Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 

See also Article 11 of the European Social Charter (1961).
In the European Charter, the enjoyment of health is dealt with in two articles.

Article 3, Right to the integrity of the person

Everyone has the right to respect for his or her physical and mental integrity.
In the fields of medicine and biology, the following must be respected in particular :
the free and informed consent of the person concerned, according to the procedures laid
        down by law,

the prohibition of eugenic practices, in particular those aiming at the selection of persons,
-          the prohibition of making the human body and its parts as such a source of financial gain,
-          the prohibition of the reproductive cloning of human beings.

Those provisions protect everyone against state’s immixtion within the bodily integrity.  It does not guarantee any effective access to health care, which is contemplated by another Article.

Article 35  Health care

Everyone has the right of access to preventive health care and the right to benefit from medical treatments under the conditions established by national laws and practices. A high level of human heath protection shall be ensured in the definition and implementation of all Union policies and activities.

The first sentence contains a notable restriction : ”under the conditions established by national laws and practices”.  The Charter hand over the protection of health to the legal order of each state.  No trace whatever of a fundamental right enjoying a higher level of protection. The second sentence is a pious vow.

As other economic, social and cultural rights the right to health care is handicapped by the necessity of requiring positive prestations of the collectivity. Traditional human rights, those which are fairly well guaranteed by the European Convention protect the subject against States’ aggression or immixtion.  Such is also the nature of Article 3 of the European Charter.  It is much more difficult to realize rights implying a positive performance of the collectivity.

No progress can be contemplated but for a strong action of the organs of the civil society.  Public authorities have to be required to implement a health policy favourable to the needs of the most destitute.  Health care expenses have become a burden of the collectivity.

The actual choices remain elitist : sophisticated medicine instead of a preventive one, favour to health care of already privileged people.  In democratic states, each citizen is, through the electoral process, able to influence the state : the access to health care for the most destitute should be an objective of political parties and NGOs should act in that direction.

I shall terminate by the quotation of a German poet : Friedrich Schiller, who had retained Kant’s doctrine, embodying it in a manner adapted to the subject-matter of this conference :  

Würde des Menschen
Nicht mehr davon, ich bitte euch.  Zu essen gebt ihm, zu wohnen,
Habt ihr die Blösse bedeckt, gibt sich die Würde von selbst.
(Schiller, Epigramme)

Human dignity
      Don’talk any more, please.  Give him food, lodging,
      Cover their nudity, dignity will follow by itself.
      (Schiller, Epigrams)

François Rigaux
Prof emeritus of the
Université catholique de Louvain

 1. HEALTH    :       Access on Heath /Mentale Health,             ? 1st seminar in  Prague, 
Neil Davies,  S.A.D.  (CZ)                                                                                                       

SMES-EU D&H-5P Workshop 1
Prague – November 2003
V Praze – listopadu 2003

> The presentation includes comments and observations made during the Czech Republic Workshop of November 2003.

> Attendees included only 11 Czech Representatives of NGOs and Academic Organisations.

> After initial meetings with the Ministry of Labour and Social Affairs and Ministry of Health, there was no response to the invitation to send a representative to the Seminar.

 > The right to medical services;

and, Access to those rights for socially excluded people.

Time Scale /
Časový harmonogram

> The Czech JIM was published after the Workshop was hosted.

> The Czech NAPSinc is currently being prepared.

Czech Context /
České problémy

> Generally there is a lack of knowledge about rights amongst:
>  the public;
providers of services:
      >  and, nusers of those services.

If people are not aware of their rights they cannot access them.

> There is also a lack of legislation about the system of mental health care management.

> No specific mental health law exists within Czech Legislation resulting in problems with financing and quality.

> However, there is a Health Act but the problem is in it’s implementation.

 > The quality of service, in theory, is discussed more, but is not based on the law as standards are being developed.

 > Professionals prepare the standards, but users are excluded from this process of preparation and evaluation.

 > People must be insured to receive health care and often the homeless or socially excluded are not insured.

 Czech JIM Actions / Iniciativa JIMu ČR

> to interconnect health and social care mainly at community level by creating so-called integrated community care;

> to complete and introduce standards which will ensure guaranteed minimum care from a qualitative and quantitative point of view;

> to support medical rehabilitation within the system of comprehensive rehabilitation for people with disabilities

> to establish a framework for issues related to short-term rehabilitation centres for disorderly alcoholics and drug addicts and for detoxification consulting rooms, including their financing;

> to ensure long-term financial viability of the health care system and, at the same time, take measures to ensure full access for members of disadvantaged groups.

NGO Experiences /
Zkušenosti neziskových organizací

> Acute cases are treated but after the life-threatening situation has been prevented, the person is then sent out from the hospital.

>  “Our experience is that clients are not treated with respect by medical staff.”

>  “This is not about the Government giving money but giving to fulfil needs. It is about empowering the people.”

SMES-EU D&H-5P Workshop 1
Prague – November 2003
V Praze – listopadu 2003

> Prezentace obsahuje komentáře a postřehy z Workshopu, který v listopadu 2003 proběhl v ČR

Mezi zúčastněnými bylo pouze 11 zástupců českých neziskových a akade-mických organizací

 > Po skončení vstupních setkáních s Ministerstvem práce a sociálních věcí a Ministersvem zdravotnictví nereagovalo ani jedno z ministerstev na pozvání na Seminář

> Důstojnost a Zdraví Právo na zdravotní péči

Přístup k těmto službám sociálně vyloučeným osobám

 Time Scale / Časový harmonogram

> Český JIM publikován po skončení Workshopu

Český NAPSinc je v současné době v přípravě

Czech Context /
České problémy

> Obecným problémem je nedostatek povědomí o právech mezi:
      >  Občany
      >  Poskytovateli služeb
Uživateli těchto služeb

Lidé nemohou využívat služeb, o jejichž existenci nevě

 > Chybí legislativní podpora správy systému péče pro mentálně postižené

> Nedostatek legislativy pro duševní zdraví má za důsledek problémy s financování a s kvalitou služeb

Přesto, že existuje zákon o zdravotnictví, jsou problémy s jeho implementací

> Diskuse o kvalitě služeb je na teoretické úrovni – není založená na právní normě spolu s vytvářením standardů pro kvalitu.

 > Příprava standardů kvality je zajištěna odborníky - uživatelé služeb jsou z tohoto procesu vyloučeni.

Zdravotní pojištění podmiňuje obdržení zdravotní péče, avšak lidé na ulici, nebo lidé vyloučení ze společnosti pojištěni nejsou.

Czech JIM Actions / Iniciativa JIMu ČR

> propojovat zdravotní a sociální péči především na komunitní úrovni, a to vytvořením tzv. integrované komunitní péče,

 > dokončit a zavést standardy, které by zajistily nepodkročitelné minimum péče z hlediska kvantitativního a kvalitativního,

> podporovat léčebné rehabilitace v systému ucelené rehabilitace osob se zdravotním postižením

> vymezit problematiku protialkoholních a protitoxikomanických záchytných stanic a AT ordinací, včetně jejich financování,

> zajistit dlouhodobou finanční udržitelnost systému zdravotní péče a zároveň zajistit, že nedojde k omezení přístupu znevýhodněných skupin.

NGO Experiences /
Zkušenosti neziskových organizací

> emocnice ošetří akutní případy, ale jakmile pomine přímé ohrožení života, pacient/klient je z nemocnice propuštěn

> “Ze zkušenosti víme, že zdravotnický personál se k našim klientům nechová s respektem.”

>  “Není to o tom, že vláda dává peníze, ale o tom, že vláda dává, aby uspokojila potřeby. Je to o zplnomocnění lidí.”

 2. RESOURCES:   Decent life ressources                                 ? 2nd  seminar in Bucarest          
 Marieta Radu, Casa Ioana (RO)


 3. HOUSING:          Housing - identity - privacy                            ? 3rd seminar in Sofia            
by Douhomir Minev, EAPN,  (BG) 


 4. JOB :                 Marginalisation & work                              ? 4th seminar in Warszawa         
   by Andrzej Czarnocki, Caritas, (PL)


  • 38 million inhabitants

  • 30% of people in direct risk of poverty

  • 30-80 thousand homeless people

  • 7-10 million people directly and indirectly affected by alcohol abuse;

  • 3% with serious psychic problems – another 17% diagnosable with psychic problems

  • 20% unemployment rate reaching is some areas 40% and more - 40% unemployment rate among young people - 14% employment rate among the disabled


  • Creating opportunities (external sphere)

  • Overcoming internal barriers


  • It is not about management and handouts

  • It is about creating conditions for a person to grow: a place in the world and internal recovery “Enlightened absolutism” still very much present. But there are some interesting ideas around: supported employment, self-help groups, social cooperatives...


  • Central & local national governments

  • Civil Society

  • The Marginalized Persons Wise influences leaving room for autonomy Dialogue Serving authority

The need to engage with young people and families of children to counter the wrong conditioning
          that is bound to take heavier and heavier toll on a person as the years go by.

 5. EDUCATION :     Appropriate & universal education               ? 5th seminar in Riga                     
  Rita Erle,  Street Children Project  (LV)


No dignity without exercising the citizen’s rights !

 Each workshop should be able to articulate, as regards reflection as well as exchanging experiences, the social field to the health fields in order to avoid – in as much as possible – a mere juxtaposition, where there is no relation. We would like to avoid the workshops to just focusing on poverty or on mental health of the tramps or homeless people. We would like them rather to explore the complex relationships that exist among all these social and health elements.

1.   No Health without mental health: accessibility & obstacles
       to quality health and mental health services
   Neil DAVIS - Preben BRANDT





Objective :

*  To increase the knowledge of the participants about : "EU common objective and application - legislations -
     health systems & resources – appropriate practices”, with reference to the NAPs /inc. and to JIM.

*  To analyse the efficient practices and the legislation (concretely and daily applied !..) about health & social
    system in order to propose innovative and adequate instruments for the promotion of equal access to :
    RIGHTS - HEALTH - Social and Care  SERVICES,  for excluded people.

  Strategies against social exclusion – the role of health and mental health services and their co-operation with other interested partners

As was emphasised in the Polish Joint Inclusion Memorandum, indices of health status of the population of our country (such as life expectancy and mortality data, especially infant mortality) are improving despite the fact that the number of public health care facilities and employment in health care are falling. It was also emphasised that relatively low indicators of infant mortality and mortality of children below 5 are not dependent on the class of locality (large agglomerations, smaller towns, rural areas). This situation was brought about not only by social, cultural and economic development but it is also an outcome of national health and social policy.

If the goals of “social inclusion” project are to be achieved, well-established and consistent health, social, cultural and economic policy should be developed. Such a policy should take into account not only infant mortality and average life expectancy, but also long lasting or so called chronic diseases and among them – mental disorders*. I would like to present some possibilities of participation in shaping such a policy by health care professions and self-help organisations, co-operating with local self-governments, research and educational institutions and other interested partners.

Their unique input in European social inclusion project and in the development of an inclusion policy is connected with their expertise and experience concerning the wide range of strategies against social exclusion.    
I would like to present some of these strategies, requiring local, national and international co-operation.

*According to the recent publications by the National Institute of Hygiene, during the last years the number of persons with mental health disorders treated in out-patient mental health facilities and in psychiatric hospitals, clinics, wards (in-patients facilities) is constantly increasing in Poland.

By the year 2000 the overall number of patients of mental health services (including persons with alcohol and substance abuse related problems) amounted about 1 000 000. The number of out- patients reached 2455 per     100 000 people (including 738 new patients).

Author:             Elzbieta Bobiatynska
Institution:        Partnership for Health Information Centre TOPOS
Address:           ul. Schroegera 82, 01-828 Warszawa, Poland


The coordinated work and results of the Unidad Móvil de Emergencias Sociales (U.M.E.S) – Social Emergency Mobile Unit – and the Equipo de Atención Psiquiátrica a Enfermos Mentales sin Hogar – Madrid Homeless People Mental Health Unit – are dealt with.

The Unidad Móvil de Emergencias Sociales is a service provided by Madrid Council and run by the Gabinete de Trabajo Social Grupo 5 S.L. It was created in 1990 and its main objective is to assist homeless people in their own environment: the street.

The unit consists of:

A mobile team, made up of a social worker, an outreach worker and a driver, which operates seven days a week,
     from 10am till 10pm.

An outreach team, consisting of a social worker and an outreach worker, which operates from Monday to
     Friday, from 9am till 4pm.

The mobile unit covers the whole of the city of Madrid in a van, detecting new cases and providing them with information about the different social resources available to homeless people.

Follow up work on existing cases is also a large part of the team’s remit. An individualised work plan is developed for each client by the outreach team.

The Equipo de Atención Psiquiátrica a Enfermos Mentales sin Hogar was created in May 2003 and is provided by Madrid Health Services (SERMAS). The team consists of a psychiatrist, two nurses and a youth and community worker.

The objectives of the unit are:

To improve the mental health service for homeless people

To evaluate and diagnose

To provide psychiatric treatment and follow up work for those homeless mental patients who do not or cannot
     reach mainstream mental health services

 To facilitate the integration of mentally ill patients into mainstream mental health services

 To coordinate with the necessary health and social services

To provide professional training for those working in the programme

To facilitate patients’ social-health integration and self-autonomy

The Homeless People Mental Health Unit provides engagement, follow up and treatment of homeless mental patients mainly in the street, following psychosocial, outreach and assertive community treatment models.

Address:     C/. Jardin de San Federico 9,3º, d. MADRID.SPAIN

  Street Nursing in Copenhagen :

Street nursing is a relatively new enterprise within the field of outreach work aimed at the homeless and socially excluded people in Denmark, e.g. mainly Copenhagen.
The first nurse began her activities in 1998 in an area of Copenhagen, which is known to be a well-established drug scene. In 1999 the next street nursing project followed, called: ‘Nursing on Wheels’. This clinic offered its services in different places in Copenhagen and in a few other places; the activities being part of ‘Projekt Udenfor’ (‘Project Out-side’). According to both the street nurses themselves and other actors in the field, these two first nursing projects broke new grounds, because they displayed that the physical and mental health conditions among drug addicts and other socially excluded people were much poorer than perceived on beforehand. The two projects operated for two and five years, respectively.

Today the Municipal-ity of Copenhagen offers nursing care for the homeless in three clinics as part of the Shelters’ services and as outreach work. The main principals of the work are not very different form other kinds of outreach work. Thus, street nursing is pragmatic, and the point of departure is ‘getting to know’ and ‘trying to understand’ the homeless in their ‘own’ environment. I have carried out five months of ethnographic fieldwork in Copenhagen among street nurses and the homeless, who receive their care, and who, by doing that, become ‘users’ (the concept of user is general in Denmark, and it describes a citizen who ‘uses’ which-ever (public) service).

The fieldwork was in preparation for my thesis to become an anthropologist. During the seminar I will discuss my analysis on how ‘identity’ and ‘agency’ are produced, negotiated and constituted in interactions between street nurses and users.

Author: Charlotte Siiger
Institution: projekt UDENFOR
Ravnsborggade 2, 3. sal
Fax: 45+33163540   -   Email:

  Has the Poor Socio-economic Status of the Patient Become the Most Powerful Factor of Prognosis?

In daily clinical practice for many healthcare professionals it appears that treating patients with mental disorders who lack family or society support, a home or even a decent income, is reduced only to an amount of difficulties and almost no possibilities.

            Starting with the emotional deprivation in childhood and poor life or/and educational conditions, which are without questioning trigger or aggravating factors for many mental (including personality) disorders, then confronting with the financial, administrative and legal problems of their hospitalization and with the decreased number of therapeutic alternatives due to reduced compliance probability after the hospitalization period, and completing this vicious loop with their return in the same environment (no home, or no job, or no family and friends, or very often all at once, and certainly without support and close monitoring  from any institution, medical or not), all these things may offset a very important part, if not all of the mental health professionals efforts.

            In order to improve the prognosis and the quality of life for this category of patients and not only them, RLMH developed in 2000 in collaboration with “Al. Obregia” Psychiatric Hospital, the “Pilot Center for Medical and Psychological Support – STEPS” addressed to adults with mental health problems and financed by Liaison Committee for French-Romanian Exchanges, France and Geneva Initiative on Psychiatry, Netherlands. The variety of activities and programs coordinated by psychologists, psychiatrists, nurses and a professional actor offers them a chance to develop and to maintain a much greater level of self-esteem and dignity, makes them feel that they have the right to life and something to offer. Moreover, the group of these project beneficiaries lately tends to become a loud voice against discrimination.

            Unfortunately and despite of the RLMH sustained efforts (projects, conferences, seminars etc.), in the Romanian society the absence of the support services for the mental illness people outside the psychiatric hospitals, dramatically reduces, both qualitative and quantitative outcomes of any therapeutic strategy developed for this patients.

Adina-Maria Bitfoi, MD
Romanian League For Mental Health 

  Clinical Case Management : programs with schizophrenic patients in Madrid (Spain):
                                                     Preventing exclusion between mentally ill .

The present study is about the social and clinical situation of schizophrenic patients included in three " Clinical Case Management (CCM)” programs in two catchment areas of Madrid (Spain) It’s part of an effectiveness study of this case management programs (Project IPSE) in schizophrenic patients that have been attended in three CMHC in two catchment areas in Madrid (Spain).
There has been carried out a differential analysis of the social and clinical characteristics of the patients that there are included in the programs by respect those that have not been included.
There have been studied 920 patients diagnosed of schizophrenia according to criteria CIE-10 and that have been attended from January, 2002 to October, 2003 in three CMHC (corresponding to a population of 552.000 inhabitants). Of them 241 were included in programs of CCM with different components (professional caseload, keyworker assignment, written individualized plan, team work, domiciliary visits and control of drop out). The assessment instruments that have been used are: Positive and Negative Syndrome Scale (PANSS) (Kay SR, Opler LA, Lindenmayer JP., 1989); World Health Organization Disability Assessment Schedule (WHO DAS); Global Assessment of Functioning Scale (DSM-IV); percentage of psychotic time in the last year, and adherence to treatment; Camberwell Assessment of Needs and SCHIZOM.

Author: Maria Fe Bravo Ortiz
Coauthor: A. Fernandez Liria; M. Muñoz, C. Gonzalez; A. Santos; M. Alonso
Institution: Ssm Fuencarral
Fax: 0034913732927   -   Email: 

  2.  RESOURCES:  basic, decent and adequate resources for
                                          the welfare of all.   
Marieta Radu and Serge Zombek





To increase the knowledge of the participants about : "EU common objective and application - legislations - health systems & resources – appropriate practices”, with reference to the NAPs /inc. and to JIM. To analyse the efficient practices and the legislation (concretely and daily applied !..) about health & social system in order to propose innovative and adequate instruments for the promotion of equal access to : RIGHTS - HEALTH - SOCIAL SERVICES and  ADEQUATE RESOURCES, for excluded people.

The income & health :   A substantial number of people living above a relative income poverty line may not be able to satisfy at least one of the needs identified as basic, due to the detrimental influence of such factors as health condition, security of work income, need of extra care for elderly or disabled members of the household, etc.
There is much evidence that children growing up in poverty tend to do less well educationally, have poorer health.

The Poor Health
:  There is a widespread understanding that poor health is both a cause and a consequence of wider socio-economic difficulties. The overall health status of the population tends to be weaker in lower income groups. The percentage of people claiming their health to be (very) bad was significantly higher for those below the risk of poverty line than for those above it in the Union ... the strong correlation between poor health and poverty and exclusion. Particularly vulnerable groups such as the Roma and Travellers have poor life expectancy and higher rates of infant mortality. This correlation depends on various factors but in particular on the extent to which adverse social and environmental factors, which are experienced disproportionately by people on low incomes, can make it difficult for individuals to make healthier choices.


Une catégorie de personnes peut ne plus vouloir rien demander : ceux qui vivent à la rue de manière chronique, sans avenir autre que cette quotidienneté répétitive émaillée d’offres d’assistances qui s’inscrivent rarement dans un projet de vie à long terme. Au bout d’un temps souvent long, très long, le désenchantement et les illusions de l’alcool finissent par avoir raison de toute demande d’aide. Derrière cet abandon majeur d’une quelconque accroche de lien social, c’est l’identité elle-même qui finit par être anéantie. Si, comme nous le pensons, en suivant Hannah Arendt, il n’est possible de parler de dignité qu’à partir du moment où elle s’attache à considérer l’homme dans son engagement de parole au sein de la cité, si donc la dignité sous-tend l’accession et la non remise en question pour l’homme de sa citoyenneté, alors, dans ces cas d’exclusion majeure et chronique, le refus d’assistanat pourrait être entendu de deux manières :
*  Dans les plus graves cas, ce refus témoigne de la perte de toute pulsion de vie autre que celle apportée par la satisfaction immédiate des pulsions primaires : manger, boire, dormir, boire de l’alcool, - parler de dignité est alors difficile, voire dangereux, car la pensée, le souvenir, le projet singulier est alors aboli.
*  Dans d’autres cas, heureusement plus fréquents, le refus peut au contraire s’entendre comme un ultime sursaut de dignité : au-delà de la honte, en deçà de l’accès à la citoyenneté active. La personne exclue, par son refus de l’assistanat, peut en effet être entendue comme celle qui attendrait d’être reconnue dans sa dignité : par un projet de vie qui la remettrait dans une position de sujet social.
Ces constats nous amènent à l’interrogation suivante : et si c’était notre propre dignité, à nous, soignants, intervenants sociaux et bénévoles, citoyens témoins de cet abandon majeur de toute une population, qui nous mettaient dans l’obligation de prendre la parole au nom de ces hommes, femmes et enfants devenus invisibles parce que silencieux ?
La dignité devient alors un concept important, qui permet d’interroger nos propres positions au-delà du seul aspect compassionnel ou humanitaire souvent mis en avant.

Sylvie Quesemand Zucca,
psychiatre psychanalyste,
Réseau Souffrance Précarité

 Samusocial de Roumanie: un dispositif d’intervention en urgence pour les personnes en crise socio-médicale

Quand on parle des ressources, on se réfère implicitement aux besoins. Pour ceux qui travaillent avec les personnes en crise psycho-socio-médicale la première démarche est de se focaliser sur l’identification des besoins des bénéficiaires. Une autre démarche, aussi importante, est d’évaluer et de connaître les services sociaux qui existent dans la communauté et auxquels on peut faire appel. A l’heure actuelle il existe à Bucarest une discordance entre les besoins de la population dans la rue et les services offerts, dans le sens que les nécessités vitales des personnes socialement exclues ne sont pas couvertes. Dans ces conditions, les travailleurs sociaux (assistants sociaux, médecins, psychologues) sont soumis à une suprasollicitation et souvent le phénomène"burn out" surgit. Le Samusocial de Roumanie offre un complexe de services socio-médicaux d’urgence pour assurer la survie, au moins décente, des personnes socialement exclues. On essaie en même temps d’établir des liaisons avec d’autres organisations et institutions en vue de créer un réseau de services qui se soutiennent reciproquement.

Victor Badea
Samu social din Romania
Fax: 0040212527623

  Street Work At night.

Solidarios NGO and RAIS Foundation, both SMES-Madrid Group members, work together on a collaboration proyect.
Our job is a very good example of networks, coordinate and cross-disciplinary works are the only way to fight social exclusion and homeless.
The proyect have started in January of 2003 and is a model for others: professional workers from RAIS Foundation and volunteers from Solidarios NGO, both working together to do a better streetwork with homeless people. Only instruments are coordination and complementarity.
We, Solidarios and RAIS, have the same goal: to make stronger our streetwork. Both organizations think street work is a fundamental step into a social rehabilitation process, but we can forget that encourage personal self-respect is an important element in that process, too.

Raquel Alonso & Pepe aniorte
RAIS Fundatión /solidarios NGO
C/ magallanes, 27 Madrid 28015
Fax: 0034915945752

  Medical assisance for elderly homeless

The elderly homeless are a very vulnerable category which oftenly foll pray to street violence and typical to he association cronycal degenerativ pathology ( cardiovasculaar, psychiatric, rheumatologyc)with acute disease, those that represente the main reason because which they turn to the medical consulting room.

Thanks to the periodic apointments which IM organizez for groups of elderly homeless, the medical check-up is easely realised but the living conditions of the elder prevent our actions from having the biggest resuls.

Maria Tilita & Lacramioara Catalina Hetel
The Swedish Organization for Individual Relief IM

  A mobile psychosocial team in Brussels, some experiences

The so-called "Homeless Mentally Ill" are living in a no man's land, somewhere in between the social sector and the mental health sector. Because of their psychic problems, they cannot be reached adequately by social services. At the same time mental health services donot reach them or feel helpless because of their complicated social problems. SMES-Belgium created a mobile psychosocial team in January 2002, at the demand of both some mental health services as well as social services in Brussels. This unit is at clients disposal but through professionals, who have won their trust. It aims at identifying the needs of the client and answering them, by creating a stable adequate network around him, where everyone feels responsible and competent. Some experiences, positive and negative, will be discussed.

Van Drimmelen-Krabbe, Jenny
Reza - Brunet Stephanie
Mobile unit of SMES-B
Rue des Rermparts des Moines 78, 1000 Brussels

  3.  HOME:  the right of all individuals and families to a decent,
                          affordable and sustainable  accommodation.
Douhomir Minev  and Xavier Vandromme






Health and Homelessness : The role of FEANTSA

Housing and Homelessness

  • Housing is an important element in tackling homelessness, but the housing dimension of homelessness varies from country to country:  
    Belgium:  housing is a priority in homeless policy
    -   Ireland  :  focus on other forms of support

  • Homelessness is not only a housing issue – education, independent living, employment, and health

  • Link between health and housing: Bad temporary shelter conditions/housing conditions are associated with a number of health problems – both physical and mental – e.g. little privacy or security, sharing facilities such as kitchens and bathrooms, typical problems of poor quality housing such as overcrowding, dampness, cold

Mental health and homelessness

  • Homelessness is really the end of an exclusion process – so homeless people tend to be excluded from all services, including health services

  • The health problems of the homeless: depression, anxiety, borderlines personalities, stress, lack of confidence (often due to childhood traumas)

  • Children of homeless families are prone to behavioural disturbances, poor sleep, etc

  • So from FEANTSA’s point of view, health is important in relation to homelessness:
    1.   It may be a factor which triggers homelessness

    2. Health treatment is a crucial step for reintegration – unmet health needs may contribute to trapping people in homelessness

Role of FEANTSA – link between homeless issues and EU policy

  • While the European Observatory on Homelessness carries out research on the causes of homelessness and the profile of the homeless, FEANTSA focuses on creating links between homeless issues and EU policy-making

  • Our members work with governments and ministries at national level - FEANTSA works with EU policy-makers to improve knowledge of homelessness and to improve policies addressing homelessness

  • Working groups – statistics, employment, housing/right to housing, health

Feed the results into the EU policy framework

  • EU policy framework: We monitor closely the EU Social Inclusion Strategy, European Employment Strategy, Services of General Interest, etc.

Open method of coordination - much potential/much scope for learning

  • Our aim is to continue strengthening the fight against homelessness – the best way is to establish an integrated strategy (within the framework of the EU Strategy). A strategy combining all relevant actors in the fields of health, housing, employment, social support, rehabilitation, etc, which works on two fronts: prevention and reintegration

Results of FEANTSA strategy

  • Homelessness is a complex and wide-ranging issue: unlike a targeted rough sleeping strategy which has a very clear target of getting people off the streets, FEANTSA tackles different types of homelessness : rough sleeping, sleeping in temporary shelters; sleeping in inadequate housing, sleeping in insecure housing

  • Nevertheless, the results are visible

  • Homeless statistics – FEANTSA is a member of the homeless taskforce coordinated by Eurostat. We offer our expertise to develop indicators for the EU Social Inclusion Strategy and EU Housing Ministers to develop homeless statistics/indicators

  • Publications of the European Observatory on Homelessness

  • Active Participation of FEANTSA in the EU Peer Review Programme on the England Rough Sleepers Strategy (FEANTSA carried out a “shadow” peer review amongst its members throughout the enlarged Europe)

Enlargement of the EU/Enlargement of FEANTSA

  • FEANTSA has now enlarged to encompass member organisations from all EU25 except for Cyprus.

  • Evaluation - We are currently therefore evaluating the impact of Enlargement on the objectives of FEANTSA by revising our strategies and our instruments taking into account the new challenges in the New Member States

  • The increasing differences in EU25 countries are perceived as a resource for improving policies and exchange

  • We encourage our members to work together  - transnational CATCH project, NAPs Awareness, etc, etc

  • But no sector can achieve its aims without partnership with other sectors – and FEANTSA is open to projects with organisations working on health issues or with mental health patients.

  4.  JOBS:  suitable employment for active participation in society.
Andrzej Czarnocki, Caritas Polska & Gianfranco Marocchi, Idee in Rete






Social Co-operation in Italy:                                                                                         
The Contribution to Working Insertion and Job Policies
Gianfranco Marocchi  -  Idee in Rete - Consorzio Nazionale


While in the eighties the third sector stimulated public welfare state and anticipated innovative services that would be later assumed from the public sector, in the nineties it developed a prominent role in direct production of social welfare services.

There are about 6,500 social co-operatives in Italy, with 200,000 estimated total workers. Their sphere of action consists of managing social welfare services (e.g.: elderly people house assistance; household communities and day services for disabled and children; drug addicts treatment) and of inserting disadvantaged people (disabled, prisoners, drug addicts, mental patients, diseased minors) in self supporting market productive activities.

The role gained in services production and the reinforcement of economic solidity (about 6.5 billion Euros of aggregated income) determined the entrepreneurial evolution of these organisations.

The two main social co-operatives spheres of action that are a) the supply of welfare services and b) the insertion of disadvantaged people in self supporting productive activities. The second of these fields is described in this abstract.

Working insertion social co-operatives provide job occasions and professional and personal growth chances to disadvantaged people; therefore these co-operatives can perform any enterprise activity – agricultural, industrial, commercial, tertiary activity – but they have to reserve to disadvantaged people almost 30% of job positions; social co-operatives predispose individual inserting projects that are often compiled in collaboration to social services. According to law 381/91, disabled, drug addicts, mental patient, prisoners, diseased minors are disadvantaged categories.

Insertion results can be, in case of success, both job finding in profit enterprise and permanent integration in the same social co-operative.

Many research state that working insertion project, frequently take to stable jobs; these research also state that anyway insertion projects bring to a personal and professional growth and also that economic advantages (lower assistance expenses, tax yield from disadvantaged people employed thanks to social co-operatives), are higher than costs (state coverage, possible local support measures).

Local administrators have appreciated this activity and they have reserved, according to law 381/91, job orders to social co-operatives to promote working insertion. In this way local administrators perform a social intervention through ordinary expenses like green areas maintenance or public buildings cleaning.

1. What Social Co-operatives are
1.1. Introduction
1.2. Birth, Development, and Juridical Acknowledgement of Social Co-operatives
1.3. Social Co-operation today in Italy
1.4. Social Co-operation Peculiarity

2. Social Co-operative Activities
2.1. Social Services Co-operatives in Welfare Renovation
2.2. Working Insertion and Job Policies
2.3. Developing Sectors: not Welfare Personal Services and Services to Local Community

3. Social Co-operatives Integration and Relationship with other Third Sector Organisations
3.1. Integration among Social Co-operatives
3.2. Integration among Social Co-operatives and other Organisations

4. Social Co-operation and Social Enterprise in Europe

President: Gianfranco Marocchi
Place: Piazza Vittorio Emanuele II°, 31 00185 Roma
Tel.: 06-490821    Fax: 06-491623   e-mail:

  5.  EDUCATION:  the right & access to education, especially for children and
            young people. 
Rita Erele and  Pierre








 Paris and SMES Network                                                                   

 SMES Network   E
 SMES Network   B 



   THEME:  Using NAPincl as an instrument for inclusion process                                      
  "ERADICATE  poverty - exclusion - homelessness ...:  between utopia and challenge"              
   by Mr. Huges Feltesse, repr. Of Unit E2 Politics and programmes for inclusion of the European Commission

The EU's Social Inclusion Process

The Lisbon European Council

The Open Method of Coordination Aim: "to make a decisive impact on the eradication of poverty and social
                                                                         exclusion by 2010"

Open Method of Coordination  - Key Elements

Common Objectives
National Action Plans
Commonly agreed indicators
Reporting and Monitoring - Joint Reports on Social Inclusion
Exchange of Learning - Community action programme

The common objectives of Nice

To promote participation in employment and access of all to goods, services, resources and rights
To prevent social exclusion
To support the most vulnerable
To mobilise and involve all stakeholders

Mobilise all Actors

Participation of excluded

Mainstream into overall policy
-   public authorities at all levels
coordination procedures and structures
-   responsive services

Promote dialogue and partnership
-   involve social partners, NGOs and social service provider
-   engage all citizens
-   responsibility of business

A Key Moment

July 2003 - 2nd National Action Plans on poverty and social exclusion
Dec 2003 - Joint Memoranda on Social Inclusion
March 2004 - Joint Report on Social Inclusion
July 2004 - 1st NAPs/inclusion for new MS
2005 - Review of Social Protection/Inclusion Processes & Lisbon Agenda
July 2005 - Implementation Reports on 2003 NAPs
2006 – 3 year NAPs for EU-25

Poverty/Exclusion still a Major Challenge

15% or 65 million people in EU at risk of poverty
highest risk in Ireland (21%), Greece and Portugal (20%) and Spain (19%)
lowest in Sweden (10%), Denmark, Germany, Finland, Netherlands (11%)

High Risk Groups

lone parent and larger families
unemployed, especially long-term unemployed
older women living alone

  • 1:5 live in poor household and 1:10 in jobless household

  • Poverty not Inevitable

    3% or more fall in poverty rate in Belgium, Germany, Portugal and UK between 1995 & 2001
    Investment in social policies works

  • risk of poverty before all social cash transfers 39% and after all transfers 15%

  • Risk of poverty and per capita social expenditure

    2003 NAPs/inclusion

    Better than 2003 but not sufficient


    good analysis and multi-dimensional
    better reflect diversity of national systems
    more mainstreaming
    majority set quantitative & intermediate targets
    better links between national, regional and local
    increased participation of civil society stakeholder

    2003 NAPs/inclusion

    To be improved

    linkages to overall expenditure priorities
    linkages between social, economic & employment policies
    more ambitious and quantified targets
    multi-dimensional approach: especially re housing, lifelong learning, culture, e-inclusion and transport
    monitoring the impact of policies
    raising awareness of wider public and decision-makers
    involvement of civil society in implementation & monitoring

    6 Key Policy Priorities

    increased investment and tailoring of active labour market measures
    ensuring adequacy of social protection for all to live life with dignity
    improved access to key services (health care, housing, education, culture…)
    early school leaving and transition from school to work
    eliminate child poverty
    reduce social exclusion of immigrants and ethnic minorities

    New Member States - Poverty An Urgent Challenge

    13% at risk of poverty (Czech Rep 8% - Estonia 18%) [EU15 15%]
    36% unemployed at risk of poverty
    18% children and young people (16%) at risk
    27% large and 21% one parent families at risk
    high deprivation & lack of basic household necessities 2
    × EU15
    high unemployment rate - 14.3% (EU15 8%)
    youth unemployment rate – 31.9% (EU15 15%)
    high long-term unemployment – 8% (EU15 3%)

    New Member States
    Poverty An Urgent Challenge 2

    Lower life expectancy than EU15 (men -5 % women -3 years)
    Poor basic services
    Big regional and rural/urban differences
    High risk Groups:
    -   Roma
    -   homeless
    -   people with physical/ intellectual disabilities
    -   ex-prisoners
    people with poor heath
    -   people in or leaving institutions
    -   the mentally ill
    -   alcohol and drug abusers

    New Member States  -  Key Structural Changes

    industrial and agricultural restructuring
    rapid growth of knowledge society and ICT
    ageing populations and higher dependency rates
    changes in household structures
    immigration – set to increase

    New Member States  -  Main Challenges

    Increasing labour market participation
    Improving education and lifelong learning
    Reforming social protection systems
    Access to health, social & transport services
    Decent housing
    Concentrations of disadvantage
    Including Roma and ethnic minorities
    Supporting families & protecting rights of children

    New Member States– Improving Infrastructure: Mobilising All Actors

    coordinate and mainstream policies
    strengthen national, regional and local links
    build capacity of all actors (esp. local authorities and NGOs)
    promote partnerships between government agencies and NGOs and social partners
    improve data and analysis

    Further Information
    DG Employment and Social Affairs web site on social inclusion:

    1.  Presentation of CZ Joint Inclusion Memorandum JIM                                            
    Ilja Hradecky,  Naděje Director

    A Brief History

          March 2000 Lisbon summit

       EU social inclusion strategy

          Dec. 2000 Nice summit

          2001-2003 first round of National Action Plans

          Dec. 2001 Joint Report on social inclusion

          2003-2005 new plans

    Aims of the JIM

          To prepare accession countries for full participation in the EU social exclusion strategy

          Identifying the principal challenges in relation to tackling poverty and exclusion

          Mobilising all stakeholders active in the fight against poverty and exclusion

    Table of Contents

    1. Economic development and labour market

    2. Social situation

    3. Key challenges

    4. Policy issues

    5. Promoting gender equality in all actions

    6. Statistical systems and indicators

    7. Support to joint social inclusion policies through the structural funds

    8. Conclusions


    Homelessness and Mental Health

          Contents 64 pages incl. Annexes

          9 x  term homeless or homelessness

          3 x  term mental (disability or health)

          2 x  term psychical (disability or health)

          !!! the term homeless is used for first time in history in a official document of the state

    National Action Plan (NAP)

    Dead line: July 2004

    Table of Contents

    1. Main trends and challenges

    2. Strategy, main tasks and key targets

    3. Policy issues

    4. Institutional provisions

    5. Examples of best practices


    NGOs & NAP

          Consultations for the MPSV (MOLSA)

          3 members organisations of the FEANTSA
       –   Naděje
       –   Armáda spásy (Salvation Army)

          EAPN CR is founded

          Services providing


    Ilja Hradecký
    Naděje, Varšavská 37, 120 00 Praha 2
    Telephone: 222 521 110, fax: 222 521 115

    2.    Presentation of "Piano Regolatore Sociale"
           Franco Alvaro,
    Director Dip. V of  Municipalité de Rome.


    The law no 328/2000, indicate the basic goals for a social service integrated system, the services have new tasks and resources, and represents a highly integrated public-private initiative.

    In the Plan there are six areas of action each with it’s own objectives and measures:
    welfare actions
       2.      system actions
       3.      integration actions
       4.      joined planning between Urbanistic Regulatory Plan and Social Regulatory Plan
       5.      objective projects (plans  for target group: child, older, immigrants..)
       6.      structure of the stretch budget

     In the welfare actions we have six actions:
            access to services
            civic responsibility
            responsible system of welfare
            social inclusion and autonomy
            welfare residential (type: elders, minors, homeless…)
            intervention of social emergency

     This structure assures both the unity of service for the overall dimension of the citizens of Rome  for all its citizens and for specific local needs (welfare for individual district).

     Our objective is to assure all social services at essential levels to all.

     Dignity and Health-Rights and Access, What does the Municipality of Rome do?


     We can estimate that around 2.000 people live on the streets and around 6.000 live in temporary accommodation and emergency shelters. 1/3 have psychiatric disturbances, 1/3 have alcoholism problems, and a 1/3 is made up of drug addicts.

    Extension of rights

    Residency represents a right/duty of each citizen, in spite of his or her living conditions. Residency allows one to be a citizen (renew documents, get the pension, exercise the right to vote).

    Since 2002 the homeless people can obtain Official Domicile at theirs District Via Modesta Valenti, an official domicile for the homeless  instituted in memory of an elderly woman who died in privation at the Termini Station after an ambulance didn’t care for her because she was dirty.

    In Rome there are 19 official domiciles Modesta Valenti, one for each District.

    Dignity to have first aid

    In February 2002  the Social Operation Room was launched with a view to guaranteeing rapid reaction in social emergencies: it is free of charge and active 24 hours a day, 7 days a week, holidays included.

    All citizens of the municipality of Rome can access the service by applying directly or after being brought to the attention of the relevant authorities. No formal requirements have to be met to use it. Applications are to be filed by telephone, calling a toll-free number. Emergency actions target all socially disadvantaged people.

    The SOS service consists in three integrated operational levels:

    1.        Operation room it is located in the premises of the municipality of rome’s 5th Department. Experts are always ready to take calls, analyse and interpret them, assess any request, define and activate actions accordingly.

    2.        Mobile Units   9mobile units are always operational in the field, and are permanently connected to the operation room through a satellite system. The personnel of each mobile units consist of two vocational trainers and a home carer with a total of 36 staff working in shifts. Those units react rapidly to any request by carrying out the required actions on the spot, meanwhile activating the relevant institutional actors in order to identify the resources available. Thanks to their constant presence in the field, mobile units can identify situations of marginalization that would otherwise be undetectable; they contact invisible users, who would otherwise only become visible when the situation is unmanageable, thus playing an extremely significant preventive role.

    3.       Office experts these social workers or psychologists act constantly as links with local social and health services.

    Those without a fixed abode are mainly an itinerant population. This shows the importance for a flexible articulation of the specific services geared towards them, therefore there is a need to provide the services for these people in two areas: citizen and municipal.

    Citizen related services for a population in transit which has not obtained residency or, even if with a residency, does not live in the defined territory

    • Social emergency

    • Primary and secondary shelters, the people who use these centres, night and day, are those which do not have significant connections with the area or they do have connections in the area which do not coincide with those at the shelter structures. These in fact, in relation to the type of population which they turn to, have relationships with more than one town hall.

    • Possible economical hotel structures.

    Services at municipal level or in proximity, geared towards a permanent population:

    • Family house: the area importance has shown the necessity, within a social reintegration programme, that this type of structure interweaves connections with the neighbourhood to allow a connection between the area and the people received.

    • Specific shelter for the resident family nucleus.

    Economic hardship - right to housing
    One of the most significant prevention areas regards the housing policy. Resolution number 163/98 which offers economic support, rent, has an important prevention function, necessary to avoid the entry into the circuit for people with no fixed abode to those who have just lost a home and the consequent chronic process of social exclusion.

    Proposals – Priorities

    1. Set up a permanent work table dedicated to people with no fixed abode open to the workers in the sector. The table will also be open to people who live with hardship.

    2. Carry on to increase the overall places in the first shelter (or called basic level) at a citizen level.

    3. Continue with the policy of small sized shelter structures spread throughout the area.

    4. To expect a system which allows the permanent stay of guests in the secondary shelter centres not any more on the basis of a prefixed time in a contract, but rather on the basis of intervention projects carried out periodically to check the situation, with also the participation of all the interested area services.

    5. Work for the projects. The micro project, as a starting point for the taking on the person with no fixed abode, which allows, a constant verification of the team’s work and the programme of the person taken on.

    6. Training of the social workers who work in the extreme poverty sector.


    Dignity to have medical treatment: in Rome there is a list of doctors on health insurance panel available to work with homeless


    Rome is a capital city without a mental hospital. In recent years much has been done in the mental health field, thanks to the joint cooperation between the City Council and the five Mental Health Departments of the Local Health Units. The collaboration with the departments has allowed, among other things, the setting up and running of 24 day centres, 16 social assistance residences and 19 personalised apartments. Certainly, regarding the needs and the new urgencies, the work to be done is still notable, which needs greater coordination of the forces in the field, so that all can use the services, the treatment, the resources. The collaboration and support initiatives between the council authority and the Local Health Units have identified different sectors:

    Day Centres

    There are 24 so called intermediate structures, located in a capillary way within the whole citizen area, they mainly receive serious psychotic patient, in the 20 to 45 age group. Each centre is open for eight hours daily, from Monday to Friday, with the presence of a multi skilled team from the Local Health Unit responsible for the therapeutic rehabilitation project and the health related activities, both for the workers within the social cooperatives, chosen by the Local Health Units, which manage the recreation and expression activities as well as the professional training. Within each centre it is foreseen, meetings between the workers and the patients and specific meetings with the families and the users to verify the work carried out and to build a rapport of collaboration, important for the development of the patient’s therapeutic project.

    Residential Stay

    The residences are low assistance level structures, directed towards patients who have reached a sufficient level of autonomy and who have a discrete possibility to experiment with normal living conditions. The residences are categorised into two types:

    1.   16 social assistance residences (low assistance level structures and/or self managed). They are structures which can receive up to a maximum of six patients. They represent a housing solution outside the protected psychiatric circuit and which foresee, organised assistance in daily living through the presence of trained personnel and/or volunteers for the support activities in daily life.

    2.    19 personalised apartments. They represent housing solutions for users with a sufficient level of autonomy. The project is carried out in owned apartments rented to the same. The increase in personalised housing is foreseen (from one to four people), that is the housing which allows to progressively leave the psychiatric structures for a definitive social integration.

    These are projects which aid the work integration of citizens with mental problems both, both through the setting up of new productive activities managed by the social cooperatives, and the setting up of schemes to recover and re qualify degraded green areas.
    articulated in the by now long term different experimented forms (short breaks, trips, week end) constitutes a fundamental opportunity to verify the rehabilitation and therapeutic interventions undertaken by the services during the year.

    Training, awareness and prevention
    these are initiatives geared towards the associations and family members, social health workers, social cooperatives, and even all citizens to encourage a cultural change and the change of attitudes regarding mental illness to increase the experience of social and employment reintegration of citizens with mental health problems.      

    Transfer of economic cheques
    the economic contributions for the realisation of personal projects (work placement, economic support, residency…) are paid annually to the psychiatric patients.

    3.  The National Action Plan (NAP) for inclusion Danish Ministry of Social Affairs
    Peter Juul,


    Realism and criticisme of NAPincl and JIM

    1.   A juridical vision: the right & access in reality,   Ieva Leimane-Veldmeijere,
      LV Centre for Human Rights.Open discussion of participants for recommandations


    2.   Social worker vision of the reality Pedro Meca


    3.   Illigal immigrants : job & health MSF I  - B                                                                                                   


    Medècins Sans Frontières – Mission Italie

    Prague, 17 – 19 June 2004


    Medecins Sans Frontieres – Mission Italie

    Mission Italy (MI) started its work in 1999. Since that time it has focused its efforts on provision of health care to undocumented migrants and assistance at the landings of boat people in the South of Italy.

    Medical context

    Despite the fact that Italy has a well-developed health care system, the statistics concerning the immigrants’ health are worrying. Among the general population, the perinatal mortality rate is 0,33% in the north of the country and 0,83% in the south; among immigrants all over Italy it is as high as 10,8%. A recent study revealed that the risk of contracting tuberculosis is 35 times for a migrant in Italy than for a resident  Italian.

    Access to health care for undocumented migrants

    The Italian law on immigration (commonly known as the “Bossi-Fini” law) guarantees health assistance for undocumented migrants by giving them an anonymous code (STP code). MSF has verified that several local posts of the National Health System (NHS) have not been implementing the law or have done so with several malpractices.

    Starting in 2003 MSF has opened clinics for undocumented migrants in several parts of Italy. This clinics are run as part of the NHS and are allowed to give out STP codes. The objective is to implement the Bossi-Fini law as it was intended and then hand the clinics back to NHS. Today, there are such MSF clinics in Sicily and Rome; a new one is due to open in Lombardia.

    Health care assistance for “boat people”

    Sicily is a major entry point for boat people. They flee war or other precarious situations and risk their lives on hazardous trips across the Mediterranean, before arriving on Italian soil.

    Lampedusa, a small island in the south of Sicily, hosts a First Reception Centre where the migrants are assisted after arrival. In this centre, an MSF nurse provides first aid. Thus, MSF assists more than 9,000 people per year.

    Similarly, MSF provides immediate aid to people arriving on Sicily’s southern coast; a mobile team is on call 24 hours a day to reach the places where people disembark and provide health care assistance as well as basic information on Italian immigration law.

    Tiburtina’s project

    In a derelict railway station in the centre of Rome some 400 asylum seekers are squatting. They have fled from Sudan, Ethiopia, Eritrea and other Sub-Saharan countries, and have found no place to stay. The sanitary and hygiene conditions in Tiburtina railway station are worrying; there are no facilities like running water, electricity or heating. In October 2003 MSF started providing health care assistance for the asylum seekers. The team is also involved in a lobbying and communication action to push the authority to find a sustainable solution: reconstruction works in the station area have begun and in the course of 2004 the entire asylum population will be evicted by the owner of the premises.

    The problem of asylum in Italy

    Italy is the only European Union member state without a comprehensive law on asylum. During 2002 the Italian government has enacted a new law on immigration and asylum (the “Bossi – Fini” law) that changed some of the previous procedure.

    When an immigrant lands or arrive in Italy has to been identified by the Italian authorities. At this moment the immigrant can apply for asylum and start up the procedure. Then he’s transferred in a First Rescue Centre (Frc) where he waits for a stay permit as asylum seeker and a contribution of 17.08 Euro for 45 days. The contribution can be output in three sessions. Sometimes the asylum seekers wait just for the first part of the pocket money and then he or she leave the centre.

    The asylum seekers have to wait for the interview at the Central Commission for the Refugee Status. The all procedure can last 12 or 14 months: during this period the asylum seekers are not allowed to work according with the Italian law on immigration and they have not the right to receive any kind of other contribution.

    When they leave the Frc sometimes they decide to go to the fields of South of Italy to be employed as seasonal workers in the harvest of tobacco, tomato and potatoes. The living conditions monitored by MSF during the summer 2002/2003 are worrying.

    When the harvest is over they try to join the capital or the north of the country in order to find better opportunities.

    The Italian Central Commission, in the last 10 years, has output the 95% of denies. This because the 70% of asylum seekers don’t receive the communication for the hearing as they’re scattered in the territory. This is the result of the lack of places in Second Reception Centres where only the 10% of them have access.

    During the 2002, according to provisional statistics, 7300 asylum seekers filed claims in Italy, 24% fewer than in 2001. The majority of applications came from Sri Lanka (1400), Iraq (1200), Yugoslavia (1100) and Turkey (520).

    Testimonies from Tiburtina     -     Alessandra Oglino

    The follow stories have been collected in Tiburtina railway station by the MSF-Mission Italy operators on 9th June 2004.

    Mohammed’s story:

    “My name’s Mohammed, I’m 22 years old and I am a student from Kornoi in Darfur, Sudan. I am Zaghawa. I left my hometown two months ago because of the war. Kornoi was bombed during two days; it was like a big earthquake. There were fires everywhere. All around were dead bodies of people and animals. My mother and two brothers died in the bombing. I was bleeding from my head.

    I walked to Tine on the Sudanese side of the border. Local people treated my wounds, but they were not doctors or nurses. Some people took me in their car to Lybia because I was wounded. I stayed in Lybia 53 days, working in the fields for having some pocket money. All people from Darfur in Lybia collected money for me so I could go to Europe.

    We were with 68 people in a small boat, not only Sudanese. Everybody had to crouch down, we could not sit normally. The boat trip took three days and two nights. We only had a little water and no food at all. The motor of the boat broke down, a police boat pulled us for a couple of hours and then we were picked up by another police boat. That is how we got to the police station (NOTE: Mohammed refers to the reception centre as “police station”) on Lampedusa.

    We were treated like prisoners. They took our belts, shoelaces and watches and I never got my possessions back. They made us stand naked to check us, but it was not a medical check. They gave us a shirt, underpants and shampoo in a coffee cup. Because nobody explained anything in Arabic, some people who were feeling ill thought the shampoo was medicine and drank it. I too drank the shampoo. Then we could take a shower; the water was very, very cold.

    I arrived in the police station at 3pm and they only gave us some food at 7pm. We got a liter of water per four people. We also got some pasta and a piece of meat, but because we did not know what kind of meat it was nobody touched it, fearing it might be pork.

    We stayed in Lampedusa for three days. We had to sleep on the floors. Nobody gave us any information, there was no interpreter and there was no medical care. They made us stand in line often, for up to an hour, so we could be counted. Twice they woke us in the middle of the night and lined us up for a head count.

    After three days they put us on a plane. Again, nobody explained anything. They took us to a centre in Crotone. We got no breakfast before the trip and only gave us some food at 4pm. They took our fingerprints in a rough way. We were given papers (NOTE: in Italian) that we had to sign, again without any explanation. Nobody asked me any questions, nobody gave me any information. At eight they gave us train tickets and brought us to the station; I went to Rome.

    I cannot go back to my country because of the war. Also, my family was killed and our house was destroyed.”

    NOTE: We have seen the papers Mohammed signed, they are expulsion orders. Name and date on the papers are consistent with his story (Erwin).

    Haysam’s story

    “I’m Haysam, 18 years old and I am from a village called Disa, not far from Kutum, in Darfur, Sudan. I am Zaghawa. I was living with my parents and two brothers and I was studying.

    On 2 November, 2003, my village was attacked. My father and both brothers were killed in the bombardments. My mother was still alive but I had to run to save myself. With four people we started running, but one was a 12-year-old boy who was too slow so we had to leave him behind. After one day and nine hours we reached Tine, where we crossed the wadi into Chad.

    There was nothing there. I did not eat while I fled and for four days in Tine I did not eat either. Seven days I ate nothing. Finally I met some other Zaghawa who gave me a little bit of food. An old man who was compassionate took me on a truck to Lybia; he did not ask any money. The trip took 8 days. It was very cold weather and I suffered a lot.

    In Lybia I stayed with other Sudanese for six months. I had no work and not much food. I tried to continue studying there but was not allowed in school. There is much racism in  Lybia; I was mistreated. Finally, my Sudanese brothers got me on a boat.

    The trip on the boat took 39 hours before the police picked us up. There was not enough space and everybody was crouching down. There were people suffering from headaches, the flu, seasickness.

    The place in Lampedusa they brought us to looked like a prison, with barbed wire and soldiers. I arrived at 9am but only got something to eat at 11pm. They took our stuff – our belts and laces –, made us stand up naked, and then gave us a T-shirt, underwear and a cup of shampoo. The shower was very cold, the water was salty like sea water. We didn’t receive a towel; I had to dry myself with paper tissues.

    I felt sick. I went to an officer and asked to see a doctor. I clearly said “Dottor” several times and I am sure he understood, but he just waved me away. In Lampedusa we got two meals a day, not from the officers but from an organisation. We had to eat on the floor. The people serving the food were wearing gloves and masks to cover their nose and mouth. I don’t know if the meals were halal.

    We got to Lampedusa on Wednesday (NOTE: 2 June). On Saturday they brought us to Crotone. We only got breakfast after the trip: water, pasta, a piece of bread and meat.

    In Crotone they took our fingerprints and gave us papers to sign. There was a Maroccan girl, a translator. I asked her many times what the papers were, but she told me to be silent (NOTE: I saw the papers, they are an expulsion order). She only asked us where we wanted to go in Italy: Rome, Milan, Napoli. I said Rome and they stuck a card on my shirts with the destination. Then they gave me a ticket and brought me to the train station.

    • If  I go back to Darfur, my life is at risk. The janjaweed will come and kill me.”

    Medici Senza Frontiere Onlus
    Via Volturno, 58 – 00185 Roma
    Tel. – Fax:




    Présentation de Médecins Sans Frontières Belgique
      - Laetitia Schul

    Médecins Sans Frontières en Belgique a entre autre, trois projets qui ont pour objectif d’assurer un accès aux soins de santé.  Notamment grâce à un soutien gratuit médical, social et psychologique pour notamment des demandeurs d’asile et des personnes en séjour illégal.

    Bien que la Belgique possède un système de sécurité sociale élaboré, les problèmes d’exclusion sociale et en particulier d’exclusion des soins de santé sont toujours présents.

    Pour les réfugiés comme pour les illégaux, il existe en Belgique une possibilité théorique d’accès aux soins.  Malheureusement, il faut constater que dans la pratique cet accès est souvent très problématique.  Les obstacles pour obtenir l’accès aux soins sont nombreux : la complexité, la diversité et la longueur des procédures administratives, le flou des dispositions légales et la méconnaissance de celle-ci par les acteurs de terrain, le manque d’informations des patients sur leurs droits, etc.

    Nos équipes soignantes sont confrontées quotidiennement à la souffrance psychologique des réfugiés et illégaux qui viennent à nos consultations.  Dans ce parcours du combattant en vue d’une vie meilleure, les personnes sont soumises à de multiples facteurs de stress extrêmes et chroniques (fuir son pays, quitter sa famille, l’isolation sociale dans le nouveau pays « d’accueil », la police, l’avenir incertain, …).  Tout cela génère de sérieux troubles psychiques.

    « Je ne peux pas vivre dans l’ombre encore longtemps.   Sans papiers, on ne se sent pas vivant »   m’a dit une patiente.

    Le simple fait de ne pas avoir de papiers fait que la personne n’est pas reconnue par la société dans laquelle elle vit.  Si la personne n’existe pas pour l’Etat, elle ne peut pas se développer et faire valoir ses droits fondamentaux.  Il est impossible pour une personne sans papiers d’avoir un accès à un logement, à un travail, à une éducation dans le système officiel.    

    Dans un contexte social et politique qui met à mal la santé mentale, nous appliquons et défendons une approche globale de la santé.  Ainsi, le soutien psychologique s’intègre dans les stratégies d’accès aux soins.  Car nous pensons qu’il n’y a pas de santé sans santé mentale.

    Difficile de parler de dignité, sans identité et sans droits.

    Parmi nos patients, nous voyons beaucoup de personnes sans domicile fixe et sans abris.

    Selon nous c’est une population très vulnérable.

    Pour conclure, nous pensons que ce sera un challenge pour tout le monde d’intégrer cet aspect multiculturel.



              SMES Statements of 8th SMES Seminar in Prague                


    Health is substantially dependant on socio-economic status. Those at the lower end of the poverty spectrum are much mort likely to experience chronic bad health

    Homelessness  is not a unique and separate category but is the final stage in a process of marginalisation  and social exclusion

    Some of the most socially marginalised and excluded are illegal immigrants, who often have no legal rights to any state provision.

    Legal rights need to be both:  

    • established

    • implemented

    “Guarantee”  – I don’t think this adds anything -  you can’t guarantee a legal right. It is either there or not, implemented or not.

    Services should engage with the socially excluded person as a whole person, not just as a “sick” part

    The different types of homelessness must be acknowledged and solutions tailored to the needs of each group

    European standards should be set for the training of professionals.


    ACTIVE EXCHANGE of information is needed between services for socially excluded people, for:

    •   Mutual support

    • To enable rapid dissemination of good practice

    As the problem of social exclusion is multi-national, this exchange should be multi-national

    Whatever other services are developed, street level services are needed to ensure access for rough sleepers, the most vulnerable and marginalised.

    Research, preferably informed by practitioners, is needed to clarify problems and to influence   policy.


    • The different professions involved in working with marginalised people have individual practices and values. Active efforts need to be made to ensure that these do not interfere with the service to the client

    • A specific issue is the frequent problems in joint working between health and social services

    • Active efforts need to be made to bridge the gaps between different parts of services within professional sectors, eg between hospital and community services.


    • A range of accommodation solutions must be developed to address the different needs of different groups of homeless people

    • Housing solutions need always to be considered as part of a multi-system intervention

    • Housing is a way to protect homeless people from risk

    • Housing is one aspect of belonging to a local community


    • The labour market should be used, where possible, as an inclusive mechanism

    • It must, however, be recognised that the liberal labour market based on competition will generate socially excluded groups of people

    • Attention needs to be given to:
      Exploring opportunities within the existing job market
         -   Creating multiple labour markets


    • The social work and school systems need to take the initiative in identifying & helping children with problems earlier rather than later

    • Professionals (doctors, nurses and SWs) should be trained to work with diverse populations, particularly with minorities


    • Users should be seen as a resource which can produce answers, not just be helped

    • Users should participate in the training of professionals

    • Users should be encouraged to give, not just to receive

    • Policies should be inclusive – by acknowledging users’ strengths




                       FUTURES INITIATIVES of SMES-EUROPA  

       Second Phase of D&H-5P
    approved  by the Commission, 25 November  2004 - 24 November 2005
       9th SMES seminar :
    7-10 October  2005 in Berlin as conclusion of the project D&H-5P/II

        Mental Health & Clandestine Immigrants :
    proposal for research/action project

       Proposal for an International Congress: "TO LIVE in DIGNITY & HEALTH "
    in Rome 2006 at time of the 10th SMES-EUROPA Seminars.


        As a conclusion:
                               The decent society is one in which
                                    the institutions and the people do not humiliate
                                    the person benefiting from their services... !


    Pietà Rondanini, (unfinished) 1552-64
                 Marble, height: 195 cm Castello Sforzesco, Milan.
                 This version, still unfinished at the artist's death.
                  Was probably begun not much later then 1555.


    The unity between Mother and Son is even more intimate.

    It is almost impossible to tell whether it is the Mother supporting the Son, or the Son supporting the Mother, overcome by despair.

    Both are in need of help, and both hold themselves up in the act of invocation and lament before the world !...

    Place Albert Leemans 3   1050 Brussels  -  Belgium
    Tel/Fax: +32 2 538 58 87 -