Italy

Italy has one of the oldest populations in Europe. As of 2024, persons aged 65 and over represent approximately 24% of the total population, which corresponds to around 14 million individuals.

Although Italians have a greater life expectancy at 65 than in most EU-27 Member States, they have a lower one in terms of living in good health. Healthy life expectancy at age 65 is 9.5 years in Italy, below the EU-27 average level of 9.9 years.

Italy’s demographic changes risk affecting, among other things, the availability of informal carers. The ratio of potential carers aged 50-74 to individuals over 85 has been decreasing, highlighting a growing gap. 

Under an assumption of no policy change the Ageing Report scenario suggests that public expenditure on LTC as a share of GDP would rise from 1.7% to 3.0% by 2070 (EU-27: 1.6% to 3.1%). The impact of a progressive shift from the informal to the formal sector of care in Italy would entail an estimated increase by 104% in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).

This scenario underscores the need for innovative solutions to support Italy’s aging population.

Overview

The public LTC system consists of three main types of provision:

1. The most important one is the ‘companion allowance’ (CA / Indennità di accompagnamento), a cash allowance programme for individuals with severe disability. This is a national programme run by the National Institute of Social Security (INPS) and financed through general taxation.
2. The second consists of home-based and residential care services, run by two different subnational tiers of government. Healthcare-related LTC is a regional government responsibility, while social care-related LTC is a responsibility of local municipalities. Residential care is mostly provided through nursing homes even though, in recent years, there has been a broader diffusion of day centres.
3. The third is the carer’s leave system, which offers a combination of both short-term leave for urgent cases and longer leave provisions.

Spending

Public LTC spending was equivalent to 1.7% of GDP in 2019, equal to the EU-27 average.

The CA absorbed more than half of public resources invested into LTC, around 52% in 2019. In this respect, Italy is among the Member States that devote most of their LTC public spending to cash transfers, the EU-27 average being around 26%. Italy spent around 13.6 billion on the CA in 2016, covering around 1.83 million beneficiaries. Among these, the majority were aged 65 and over: 78.1%.

Limited resources are invested in homecare: 19.5% of the total public expenditure in this field in 2019. The equivalent value in the EU-27 is 25.5%.

The level of investment in residential care is also limited: only around 28% of total LTC public expenditure goes to this type of provision. The equivalent value in the EU-27 is around 48%.

Features of the Italian system

The structure of the Italian public system appears primarily cash-based. It prioritises allowances and leaves, rather than service provision. The limited availability of services creates a greater strain on reconciliation compared with other European countries and, as a result, many households use the cash allowances to hire (migrant) care workers on the private/black market to address their work-care reconciliation challenges.

Overall, the Italian model still predominantly depends on familial and informal care networks. The ‘2021 Long-term care report’ highlights this dependency as not only a reflection of cultural practices, but also as indicative of a significant shortfall in public provision, especially in non-medical support services.

Informal carers are essential to Italy’s home care landscape, but these vital contributors often remain disconnected from existing formal services. This disconnect not only hampers comprehensive care management but also diminishes the effectiveness and sustainability of the services provided.

Carer-friendly policy environment

Although respite care and counselling services are becoming more common, there is no statistical data available regarding the extent to which they are available and how they function in general.

Carer’s Allowance

The ‘companion allowance’ (CA / Indennità di accompagnamento) is a nationwide universal measure, accessible to all citizens, independent of age (including children) and income, certified as totally dependent. Its monthly amount is a flat rate equal to just above 500 euros.

This cash benefit is not means-tested, and is provided once healthcare authorities have certified the disability intensity of the concerned beneficiaries, but without any further accountability required of them. This lack of accountability requirements on beneficiaries often leads to the use of this cash transfer on the black labour market. Another shortcoming of the CA is the fact that benefits are provided on the basis of a flat rate, with no differentiation according to the level of severity of the disability, or family income.

Recently the Council of Ministers introduced the ‘Bonus Anziani’, a new universal benefit, aimed at citizens over 80 years of age with serious pathologies, who are not self-sufficient and have an annual income lower than 6,000 euros. This contribution will be granted on an experimental basis for the two-year period 2025/2026 and will be worth 850 euros per month. This will be added to the amount of the CA, for a total of 1,380 euros per month.

It is unclear whether the CA should be considered as an allowance for the dependent person or their carer. A judiciary sentence given by the “Court of Cassation” (Corte di Cassazione), the highest judicial authority in the Italian system, has nevertheless clearly stated that: “the CA is a peculiar type of provision whose main aim is mainly to support the family of a person with severe disabilities in order to encourage their family members to take care of them and, therefore, to avoid access to residential care, helping also to reduce public LTC expenditure” (Sentence n° 1268, 21st January 2005). As such, the CA can therefore be considered as a carer cash benefit, although the legislation is not sufficiently transparent.

Carer’s leave

The Italian care leave system is relatively substantial and developed. It offers a combination of both short-term and longer leave provisions.

The carer is entitled to two different types of care leave:

• 3 working days of paid leave per month for short-term leave. Parents and close relatives of people with disabilities can access this, even when there is no cohabitation. The three working days can be taken in half days or on a piecemeal hourly basis, in order to tend to a relative in case of an emergency or to accompany them to medical appointments. This leave is paid at 100% of the latest salary.
• Up to 2 years of paid leave for longer leave provisions in order to care for a seriously disabled child or relative. The leave was paid at 100% of earnings up to an annual ceiling adapted over time according to inflation (it amounted to 48,495.36 in 2019). Parents, close relatives and individuals with severe disabilities can access this type of leave. However, there is an important limitation to access to this type of paid leave: the informal carer has to live under the same roof as the person receiving care. This limits the access to the paid leave only to co-resident working relatives caring for frail older people. The reason is that the regulation was initially designed for working parents with seriously disabled children. Only recently did it become important for informal carers of frail older people.

Only public and private employees are entitled to these types of care leave. The self-employed and those employed in domestic and household services are excluded.

Recent attempts to reform the Italian LTC system

Between 2023 and 2024 the Italian Government passed legislation to attempt a reform of the national LTC system, focusing on active ageing and care services for older people who are not self-sufficient. These two areas of intervention are addressed together for the first time in the Legge Delega 33/2023 and Decreto Attuativo 29/2024, suggesting a willingness to adopt a holistic approach to LTC.

One of the most relevant aspects of the reform is the establishment of the ‘Interministerial committee for policies in favour of older adults’ (CIPA), which involves seven ministries, and is charged, with adopting a ‘National plan for the assistance and care of frailty and non-self-sufficiency’ and with harmonising the minimum reference standards for healthcare (LEA) and social assistance (LEPS). Additional provisions were made with the same goals in mind, such as the operational integration of the processes underlying the provision of performances, interventions and services by the health districts and social territorial ambits; the establishment of single access points (PUA) to access both health and social care; and the harmonisation of assessment procedures.

At the same time, the reform is also promoting ‘ageing in place’ (ageing at home). Among the measures that go in this direction are the aforementioned ‘Bonus Anziani’; the extension of palliative home care; the recognition of the role of informal carers and the promotion of their collaboration with professional care services (e.g. during the multidimensional assessment and elaboration of the Individualised Care Plan, or for information and training purposes); and fiscal and training measures provided to facilitate the employment and qualification of the many care professionals privately hired by Italian families (known as ‘badanti’).

However, experts have pointed out limitations of the reform as it is currently set out. The Legge Delega 33/2023 outlined the role of the newly established ‘National System for the Elderly Population Assistance’ (SNAA) for unitary planning and governance of all health, social and welfare measures in the sector provided by state, regions and municipalities. The implementation of this provision was partly reversed in the Decreto Attuativo 29/2024, which entrusted SNAA only with the planning of social services and interventions – excluding health services, INPS benefits, and the local level. As it currently is, the legislation falls short of promoting the integration of all the entities involved in the provision of care services, and the adoption of a national monitoring system. Additional limitations were also identified in terms of timeline of implementation (which will require further legislative over time) and scarcity of financial investments to back up such ambitious reforms.

A coalition of 60 experts and Civil Society Organisations has emerged against the backdrop of these long-awaited attempts to reform the LTC system. The initiative presents itself as a ‘Pact for a new welfare and for non-self-sufficiency’ and aims to participate in social dialogue on current and future developments of the reform. The coalition played a vocal role in highlighting that the Decreto Attuativo 20/2024 fell short of providing the expected indications to implement the Legge Delega 33/2023. In reality it was a rewriting of the original legislation, which changed its content in several key passages, weakening its remit.

The coalition also pointed out that the Decreto Attuativo 20/2024 uses a partial definition of informal carers. Only individuals caring for someone who is receiving disability benefits or the companion allowance are formally recognised as informal carers, leaving out those who are still going through the assessment process and those that have not started it yet. Furthermore, the definition only applies to spouses and family members, and does not extend to friend carers who play an increasingly important role in the provision of informal care among older adults.

Recognition and definition of carers

Recently, several relevant developments have taken place in Italy with regard to informal carers.

In August 2019, a bill entitled ‘Disposizioni per il riconoscimento ed il sostegno del caregiver familiare’ was submitted at the national Parliament. It was a unified proposal, combining all of the proposals submitted in the previous year. The bill intended to systematise and recognise the activities of carers in a more explicit and formal way than in the present legislation. Carers are defined as “individuals who take care in a continuous, voluntary and free way, of a person for whom they feel affection, who is not able to perform daily tasks autonomously”. The informal carer should be helped by a “support network” made up of social workers, nurses, general practitioners and voluntary organisations. The support should be based not only on services and care allowances but also on psychological and “relational” help (including self-help). The bill also favours early retirement for carers, especially for those who have difficulty in reconciling work and care. While the text is perfectible, it includes numerous positive aspects, such as a broad definition of carers and a wide range of support services for carers. The bill is currently being examined by the Parliamentary Committee for Social Affairs, and in July 2024 several Parliamentary hearings took place to consult stakeholders on the remit of this legislative proposition. It is not yet clear whether the cohabitation requirement will apply, when the bill will be voted on.

In September 2019, the Minister for Gender Equality and Family was conferred responsibility for the use of a specific Family Caregiver Fund to support the provision of care and informal carers. The Fund was created along with the budget law in 2018, and should herald the awaited law on informal carers. Moreover, the 2021 Budget Law established a ‘Fund to Boost Non-Professional Caregiver Activity’, managed by the Ministry of Labour and Social Policies, with an annual budget of €30 million for 2021-2023.

Various regions in Italy have implemented specific programs to support caregivers, offering training, financial assistance, and respite services. Emilia-Romagna, leading all regions, acknowledged the role of caregivers with a regional law in 2014 (L.R. 2/14). The law provides training and diverse support, from home health services to flexible work hours. Lombardy also stood out with trial projects, such as financial aid for families of the terminally ill, and a dedicated scheme for caregivers of people with severe disability, backed by a budget of €3.9 million. Both regions aim to integrate caregivers into the care network by offering services and financial support to improve the quality of care provided.

• UNECE Policy Brief on Ageing No. 22, September 2019 Country Report – Italy: emerging policy developments in the long-term care sector, CEQUA 2018
• The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
• ESPN Thematic Report on Challenges in Long-Term Care, Italy, EC, 2018
• Implementation of the Council Recommendation on access to affordable high-quality long-term care (2022/C476/01), Italian report 2024
• OECD, Towards person-centred integrated care in Italy. Inception report, 2023
• European Commission, Long-term care report. Vol.2 country profiles, 2021
• Giovanni Lamura, La riforma dell’assistenza ai non autosufficienti. Welforum.it, 2024
• Patto per un nuovo welfare sulla non autosufficienza, Alla ricerca del futuro. Una guida per conoscere la riforma e promuovere il confronto pubblico, 2024