Abstract

The LTC system in Italy is characterised nowadays by a broader universalism in public financing, along with a strong privatisation in service delivery and little attention to care quality. This is the result of a deep change occurred in the last two decades as a consequence of a multiplicity of social and political factors. This paper is aimed at reconstructing the process through which the Italian LTC system has shifted from a traditionally familialistic system to a new system, characterised by a novel combination of familialistic cultural orientation, universalism in public financing and marketization of care delivery.

The paper reconstructs a causal sequence structured in four steps:

1. since the 1990s, the traditional familialistic care model has entered into a deep crisis; this is the result not only of increase in the number of older people with disabilities, but also of the increasing female participation to the labour market. Therefore, not only the ageing of the population but also an increasing difficulty in reconciling paid work and unpaid care, in a context of unchanged family organization, have weakened the traditional intergenerational solidarity on which the familialistic system was historically grounded;

2. the national public welfare system has formally reacted to this crisis with institutional inertia. Given a dual LTC public system based on highly residual in-kind services and a nation-wide cash-for-care programme, more and more dependent older people started requesting cash measures; as a consequence, the Italian public care system has strongly radicalized the cash-based character of LTC provision;

3. the care deficit has been filled up with a dramatic growth in private care provision. This has been largely favoured not only by a loose migration policy tolerating the entry of high numbers of (female) undeclared immigrants, but also by the availability of unconditional public cash transfers. Therefore, the inertia of LTC policy, tied to an automatic increase in the beneficiaries of universalistic cash-based programmes, has driven the dependent population towards a new market-oriented, but partially publicly financed, solution, largely relying on the low-paid care provided by migrant workers directly hired by private households;

4. the growth of this private care market cannot be simply interpreted in terms of a marketization of the Italian care system. The huge reliance on ‘family assistants’ is to be considered as a reaction of the traditional familialistic system to an increased female employment rate and the subsequent increased re-conciliation difficulties; the inertia of public policy has paradoxically facilitated a solution that makes it possible to adapt the traditional care regime to the new labour market and social conditions.

The paper supports this interpretation by analysing the characteristics and reactions of the public system and illustrating the main social changes causing the crisis of the traditional familialistic model. It goes on to focus on the coping strategies adopted by families, giving specific attention to the growing role of private care providers. Finally, it identifies the central challenges faced by Italian public policy-makers, including the issue of low care quality in the LTC system.