Among EU countries, Italy presents particular demographics: it indeed has one of the oldest populations with the highest life expectancy at birth and at 65 for both men and women. Meanwhile non-healthy life expectancy has recently increased.
The share of people aged 80+ in the Italian population is expected to more than double by 2060
Life expectancy for men and women at age 65 is projected to rise from 18.1/21.7 years (EU-27: 17.2/20.7) in 2010 to 22.4/26.1 years (EU-27: 22.4/25.6) in 2060. From 2005 to 2012, healthy life expectancy for both men and women decreased by 2.1 and 3.0 years, respectively, and is now below the EU average.
Under an assumption of no policy change the Ageing Report scenario suggests that public expenditure as a share of GDP would rise from 1.7% to 3.0% (EU-27: 1.6%-3.1%) by 2070. 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).
The Italian level of LTC expenditure on the elderly in 2016 increased only slightly in real terms in comparison with 2005 (+3%) to reach around €19 billion or 1.13% of GDP. This increase took place before austerity plans were put in place in 2011, following the economic crisis and at a time when the number of elderly people living in Italy increased by 17% (around +1.9 million over 65). As a result, the per capita expenditure per elderly person decreased drastically (-12.6%). Projections by the Ministry of Finance for the next 15 years (MEF-RGS, 2017) show that LTC expenditure, as a share of GDP, should gradually increase and could reach a value equal to 1.31-1.39% by 2030, depending on envisaged scenario (3 out of 4 scenarios lead to estimated values of around 1.31-1.32% of GDP).
In Italy the supply of long-term care (LTC) has traditionally been characterised by a highly selective public services system set against the considerable capacity of family (especially women) and kinship networks to internalise caring functions. The Italian LTC public system is organised around two institutional pillars. The most important one is the ‘companion allowance’ (CA / Indennità di accompagnamento), a cash allowance programme for individuals with severe disability, which is run by the National Institute of Social Security (INPS) and financed through general taxation. In recent years the CA has absorbed more than half of public resources invested in LTC (around 55% in 2016). Italy spent around EUR 13.6 billion on the CA in 2016, covering around 1.83 million beneficiaries (INPS, 2017). Most of these beneficiaries (78%) were aged 65 or older. The coverage level of the CA is high as about 13.5% of 65+ individuals benefitted from it in 2016. The CA amounted to around €500 per month in 2017, with no variation in terms of the level of needs. Over the years 2005-2016, CA expenditure increased in real terms by around 25%. This growth was particularly strong before the crisis but continued (at a slower pace) even after the onset of the crisis and the austerity plans. The Italian LTC system for the elderly therefore appears primarily cash-based and even more so than in the past. These cash benefits are not means-tested but provided once health care authorities have certified the disability intensity of the concerned beneficiaries but without any further accountability required of them: frail elderly people can use their monthly allowance without the need to justify how it is used. 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(unlike in most other EU countries: for example, Germany – which has a three-level system, France, the United Kingdom and Spain).
The second institutional pillar is made of home and residential care services, provided by municipalities (for social care) and regions (for health/nursing care). There are two main types of home care provision: support for daily living tasks (cooking, cleaning, etc.) and nursing activities. Residential care is mostly provided through nursing homes even though, in recent years, there has been a broader diffusion of day centres. Most of the expenditure on LTC services for the elderly stems from the NHS (around 69% of total LTC services expenditure in 2016). Admission is based on both needs and income levels – co-payments can therefore be a relevant part. The criteria regarding access to residential and home care and the level of co-payment tend to differ within the country, depending on the region and the municipality of residence.
In addition to these two main pillars, care leave plays an important role in the provision of LTC in Italy. The Italian care leave system is indeed fairly generous as it offers a combination of both short-term leave for urgent cases and longer leave provisions. A Care leave is granted to public and private employees who have to care for severely disabled relatives or children; according to the principle of the ‘sole carer’, which means that no more than one worker in a household has the right to care leave as a carer for a severely disabled person. In addition, it is fully compensated and receives pension coverage. Beneficiaries can expect 3 working days of paid leave (at 100% of the last salary) per month; and up to 2 years of paid leave (at 100% of the last salary, but within an annual ceiling – EUR 47,446 in 2016).
Overall, the structure of the Italian system around leaves and allowances, rather than services, seems to allow a certain level of reconciliation, but it also has important limitations
Against this backdrop and given the fact that the weaknesses of the Italian system are not related to care leave and carer’s cash benefits per say but rather to the provision of LTC services and carer’s benefits in-kind, three pathways for policy improvement should be explored:
- First, respite care and counselling services should be further developed and, in general, a more robust system of home and residential care put in place.
- Second, policy reforms in LTC should aim at optimising expenditure rather than adding new one.
- Third, the regulation around the main cash allowance scheme, the CA, needs to be revisited.
Number of carers
Although no recent precise figures are available, given the lack of a formal definition of informal care at the national level, the number of carers in Italy has been estimated at over 3.3 million among the population of working age (15–64), taking into account only those who care for an adult person (i.e. excluding child care) (ISTAT 2011). Since carers aged 65 and over represent about a fifth of all carers of older people (Quattrini et al. 2006), it can be estimated that the overall number of carers of adult people in Italy is well over 4 million. According to some studies (e.g. OECD, Help Wanted, 2011) as much as 26% of the country’s population in involved in caregiving.
Access to respite care
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.
The Italian care leave system is relatively substantial and developed. It offers a combination of both short-term and longer leave provisions. The care leave is fully compensated and receives pension coverage (pension contributions are paid during the care leave – contributi figurativi).
Care leave is granted only to workers who have to care for severely disabled relatives. Law No 183/2010 introduced the principle of “sole carer”, which means that in a household, only one worker can attend the needs of a severely disabled person. 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 the person with the disability can access this, even when not living together with the person in need. 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.
- 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 €47,351 in 2014). 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 with a 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.
Recognition and definition of carers
Recently, many interesting developments have taken place in Italy with regard to informal carers.
At national level
In August 2019, a bill entitled ‘Disposizioni per il riconoscimento ed il sostegno del caregiver familiare’ was submitted at the national Parliament. It is a unified proposal, combining all of the proposals submitted in the previous year. The bill intends 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 continuously, voluntary and free way of a person for whom she/he feels affection who is not able to perform daily tasks by herself/himself”. 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 (e.g. a broad definition of carers and a wide range of support services for carers).
In addition, the programme of the Conte II Cabinet – sworn in on 5 September 2019 – clearly includes the recognition of informal carers (Point 6: “At legislative level, we commit to value informal carers, via the recognition of their social function”). As of September 2019, the Minister for Gender Equality and Family has been conferred responsibility for the use of a specific 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.
At regional level
The regional law of the Emilia-Romagna region, introduced in 2014 defines an informal carer as “a person who voluntarily and free of any charge takes care of a person with care needs who allows him/her to do so”. The care may involve assistance with housekeeping, mobility, accessing services and social relations. In November 2019, a resolution by the Emilia Romagna Region allocated 7 million euro to support informal carers in 2020.
 Regional Law n. 2, 28th march 2014.Regulations concerning the recognition and support of the family caregiver (a person who voluntarily provides care and assistance) http://sociale.regione.emilia-romagna.it/documentazione/norme/leggi/successivi-il-2010/lr-2-2014-1.
The ‘companion allowance’ (CA / Indennità di accompagnamento) is a nationwide universal measure, accessible to all citizens, independent of age (including children), certified as totally dependent. Its monthly amount is a flat rate equal to about €500. It is unclear whether the CA should be considered as an allowance for the dependent person or his/her 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 her/his family members to take care of her/him 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.
- UNECE Policy Brief on Ageing No. 22, September 2019Country 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
- ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Italy, 2016
- Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, EC, 2016
- Adequate social protection for long-term care needs in an ageing society, European Commission, 2014