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.

The share of people aged 80+ in the Country is expected to more than double by 2060, increasing from 6.3% to 13.2% (EU-27: 5.1% to 11.8%), with most of the growth happening after 2030. These projections are confirmed and reinforced in the European Commission’s Ageing Report 2024, which shows Italy among the countries with the steepest increase in very-old age dependency ratios. (2024 ageing report).[1]

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 among the caregiving workforce. The growing imbalance between care needs and caregiver availability risks undermining the sustainability of home- and community-based care services, unless adequately addressed through policy intervention)[2]

Under an assumption of no policy change, the Ageing Report scenario suggests that public expenditure on Long-Term Care (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 EU-27).

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

[1] The 2024 Ageing report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2024, https://economy-finance.ec.europa.eu/document/download/82b762d7-21ce-4992-aa97-888fd2c66205_en?filename=2024-ageing-report-country-fiche-Italy.pdf 

[2] Implementation of the Council Recommendation on access to affordable high-quality long-term care (2022/C476/01), Italian report 2024

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 care provision:

1. The most important provision type is the ‘companion allowance’ (CA / Indennità di accompagnamento), a cash allowance programme for individuals with a severe disability. This is a national programme run by the National Institute of Social Security (INPS) and financed through general taxation.
2. The second provision type 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 provision type 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 0.86% of GDP in 2023, below the EU-27 average which stands at 1.71%. [1]

The companion allowance (CA) continues to absorb approximately 51.3% of the public resources invested in Long-Term Care (LTC) in Italy, confirming the trend observed in 2019. In this regard, Italy remains among the Member States that devote the largest share of their LTC public spending to cash transfers, while the EU-27 average stands at around 26.5%. Italy spent approximately 14.2 billion euros on the CA in 2022, covering about 2.2 million beneficiaries. Among these, the prevalence of those aged 65 and over has further consolidated, representing the vast majority of recipients. [2]

Limited resources are invested in homecare: 19.5% of the total public expenditure in 2019 in this field. The equivalent value in the EU-27 is 25.5%. OECD data up to 2025 show that Italy continues to underinvest in home-based services compared to most EU countries, despite policy commitments to strengthen domiciliary care.[3]

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%.

[1] Eurostat, Long-term care (health) expenditure,  https://ec.europa.eu/eurostat/databrowser/view/TPS00214/bookmark/table?lang=en&bookmarkId=b7e42601-5edd-4620-b05b-082f366d9b46

[2] Rapporto RGS 2024 – Le tendenze di medio-lungo periodo del sistema pensionistico e socio-sanitario, 2024 https://www.rgs.mef.gov.it/_Documenti/VERSIONE-I/Attivit–i/Spesa-soci/Attivita_di_previsione_RGS/2024/Ltdmlpdspess-2024.pdf

The 2024 Ageing report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2024, https://economy-finance.ec.europa.eu/document/download/82b762d7-21ce-4992-aa97-888fd2c66205_en?filename=2024-ageing-report-country-fiche-Italy.pdf

Welforum, La spesa pubblica per Long-term care in Italia (2023), https://www.welforum.it/la-spesa-pubblica-per-long-term-care-in-italia/

[3] OECD, Towards a Structured and Systemic Integration of Home Care for the Non-Self-Sufficient in Italy, 2025 https://www.oecd.org/en/publications/towards-a-structured-and-systemic-integration-of-home-care-for-the-non-self-sufficient-in-italy_a204ba8c-en/full-report.html 

 

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 offering a combination of both short-term and longer leave provisions based on two main legislative pillars: Law 104/1992 and Legislative Decree 151/2001.

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

• Short-term leave (Law 104/1992, Art. 33)[1]: 3 working days of paid leave per month. 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. Recent updates (Legislative Decree 105/2022[2]) have further enhanced this benefit by abolishing the “sole carer” rule, allowing multiple family members to share the assistance.
• Longer leave provisions (Legislative Decree 151/2001, Art. 42)[3]: Up to 2 years of paid leave for longer leave provisions in order to care for a seriously disabled child or relative. The leave is paid at 100% of earnings up to an annual ceiling adapted over time according to inflation (which reached 56,586 euros in 2024 and has been further adjusted for the 2025/2026 period[4]). Parents, close relatives and individuals with severe disabilities can access this type of leave. However, there is an important limitation to accessing this type of paid leave: the informal carer has to live under the same roof as the person receiving care. This limits the paid leave access 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 more important for informal carers of frail older people due to demographic changes.

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.

[1] Law 104/1992, Art. 33 https://www.normattiva.it/uri-res/N2Ls?urn:nir:stato:legge:1992-02-05;104~art33-com3

[2] Legislative Decree 105/2022 https://www.normattiva.it/uri-res/N2Ls?urn:nir:stato:decreto.legislativo:2022-06-30;105

[3]  Legislative Decree 151/2001, Art. 42 https://www.normattiva.it/uri-res/N2Ls?urn:nir:stato:decreto.legislativo:2001-03-26;151~art42

[4] INPS Circular n.21/2024 https://www.inps.it/it/it/inps-comunica/atti/circolari-messaggi-e-normativa/dettaglio.circolari-e-messaggi.2024.01.circolare-numero-21-del-25-01-2024_14451.html

INPS Circular n. 23/2025 https://www.inps.it/it/it/inps-comunica/atti/circolari-messaggi-e-normativa/dettaglio.circolari-e-messaggi.2025.01.circolare-numero-23-del-28-01-2025_14803.html

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 Enabling Act 33/2023 and Implementing Decree 29/2024,[1] 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). Within the framework of the National Recovery and Resilience Plan, Italy has introduced reforms aimed at improving access to LTC services through the creation of single social and health access point (PUA), multidimensional needs assessments, and individualised care plans designed to promote de-institutionalisation.[2]

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 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 Enabling act 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 Implementing Decree 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 elements 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 Implementing Decree 29/2024 fell short of providing the expected indications to implement the Enabling act 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 Implementing Decree 29/2024 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 who 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.

Despite these recent reform efforts and policy innovations, structural weaknesses continue to characterise the Italian LTC system. Persistent regional disparities remain a defining feature, with northern regions offering more extensive services than southern areas, resulting in unequal access and affordability across territories and socioeconomic groups within the country. These shortcomings disproportionately affect women, who continue to bear the largest share of informal caregiving responsibilities making the gender inequalities a critical and unresolved dimension of Italy’s LTC system[3]. If left unaddressed, the prevailing feminisation of care will lead to women later experiencing pension penalties and likely old-age poverty.

A detailed analysis of Italy’s Long-Term Care framework against the standards set out by the European Council highlights persistent deficiencies in the integration of the LTC component. The Italian system continues to rely heavily on familial and informal care networks to compensate for gaps in formal service provision[4].

[1] The Enabling act 33/2023 provides the general framework of the reform, while the role of the Implementing Decree 20/2024 should be to translate it into practical indications for implementation.

[2]  European Commission, Recovery and resilience scoreboard, Thematic Analysis – Long-Term Care (2025) https://ec.europa.eu/economy_finance/recovery-and-resilience-scoreboard/assets/thematic_analysis/scoreboard_thematic_analysis_long_term_care.pdf 

[3]– OECD, Towards person-centred integrated care in Italy. Inception report, 2023; https://www.oecd.org/content/dam/oecd/en/topics/policy-sub-issues/people-centred-health-systems-and-integrated-care/towards-patient-centered-integrated-care-in-italy-inception-report-nov2023.pdf

– Implementation of the Council Recommendation on access to affordable high-quality long-term care (2022/C476/01), Italian report 2024;

– European Commission, Long-term care report. Vol.2 country profiles, 2021

[4] Implementation of the Council Recommendation on access to affordable high-quality long-term care (2022/C476/01), Italian report 2024

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 to 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, created with the 2018 Budget Law, did not result in the immediate adoption of a comprehensive national law on caregivers. Subsequently, 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 euros for 2021-2023. These preliminary financial measures eventually led to the integration of caregivers within the broader reform of the LTC system through Enabling Law 33/2023 and its implementing measure, Implementing Decree 29/2024. However, this reform focuses primarily on the elderly care system rather than constituting a dedicated legal framework that recognises caregivers as autonomous rights-holders.

Various regions in Italy have implemented specific programmes 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[1]). The law provides training and diverse support, from home health services to flexible working 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 a severe disability, backed by a budget of 3.9 million euros. Both regions aim to integrate caregivers into the care network by offering services and financial support to improve the quality of care provided. It has meanwhile emerged that several Italian Regions have adopted specific legislative measures addressing informal caregiving. Eight out of twenty Regions have enacted dedicated regional laws on the subject, reflecting a growing territorial commitment to the formal recognition and support of family carers. [2]

[1]Legge regionale Emilia-Romagna n. 2/2014, https://www.gazzettaufficiale.it/atto/regioni/caricaDettaglioAtto/originario?atto.dataPubblicazioneGazzetta=2014-04-19&atto.codiceRedazionale=14R00159

[2] INRCA, Calvi et. al, Le politiche regionali di supporto ai caregiver informali di persone anziane non autosufficienti in Italia, 2025. 

References

• 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
• The 2024 Ageing report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2024
• INRCA, Calvi et. al, Le politiche regionali di supporto ai caregiver informali di persone anziane non autosufficienti in Italia, 2025.
• OECD, Towards a Structured and Systemic Integration of Home Care for the Non-Self-Sufficient in Italy, 2025
• European Commission, Recovery and resilience scoreboard, Thematic Analysis – Long-Term Care (2025)
• Law 104/1992, Art. 33
• Legislative Decree 151/2001, Art. 42
• INPS Circular n.21/2024
• INPS Circular n. 23/2025
• Legislative Decree 105/2022
• Enabling act 33/2023
• Implementing Decree 29/2024
• Legge regionale Emilia-Romagna n. 2/2014