Who Is Accountable for Long-Term Care in Italy? National, Regional and Municipal Governance Responsibilities

When an older person in Italy needs assistance with daily living, the question of who is responsible for providing that support can be surprisingly complicated. A hospital may identify the need for continuing healthcare, a regional health service may assess clinical requirements, municipal social services may consider practical assistance, and the family may arrange privately paid support. Each organisation has a legitimate role, but responsibility for the person's overall experience can become difficult to identify.

This distribution of responsibility is a defining feature of Italian long-term care governance. Italy does not operate a single national agency that assesses, funds and delivers every form of support. Instead, national legislation, regional healthcare administration, municipal social assistance, social security benefits and independent provision interact through a combination of legal obligations, administrative procedures and territorial partnerships.

The wider architecture is explored through the Italy Ageing, Long-Term Care and Community Support Knowledge Hub. Within that system, accountability deserves particular attention because population ageing, growing care complexity and reforms under Law 33/2023 and Legislative Decree 29/2024 are increasing the importance of coordination between institutions.

The central governance question is not simply which organisation is responsible for a particular service. It is how responsibilities connect when a person needs several forms of support, how decisions are explained, and how institutions respond when the intended care pathway cannot be delivered.

Understanding these relationships is essential to evaluating whether Italy's long-term care system can combine regional autonomy and local responsiveness with consistent access, quality and protection of older people's rights.

Italy's Constitutional and Administrative Foundations

Italian long-term care governance reflects the country's constitutional distribution of responsibilities. The State establishes important national legal frameworks and essential standards, while Regions and Autonomous Provinces exercise substantial responsibilities for healthcare organisation. Municipalities have significant functions in social assistance, frequently operating through intermunicipal arrangements.

Article 117 of the Italian Constitution is particularly relevant. It allocates legislative responsibilities between the State and Regions, including national responsibility for determining essential levels of civil and social rights that must be guaranteed throughout the country. Health protection involves shared legislative responsibilities, with national principles and regional organisation operating together.

This constitutional structure helps explain why Italian long-term care is neither fully centralised nor simply a collection of unrelated local services.

The State has important responsibilities for establishing national frameworks, financing arrangements and minimum entitlements. Regions organise healthcare systems and develop territorial service arrangements. Municipalities administer social assistance functions within the applicable national and regional legal framework.

Responsibility also depends on the type of support involved. Clinical treatment, nursing, rehabilitation, social assistance, financial benefits and privately purchased care do not necessarily follow the same rules.

The distinction matters because organisational accountability cannot be established simply by naming one institution as responsible for long-term care in general.

Effective governance requires an understanding of which institution holds authority over each decision, how responsibilities overlap and what happens when several organisations need to act together.

National Government: Setting Rights, Standards and Policy Direction

National government provides the legal and policy framework within which Italy's long-term care arrangements operate. Several ministries and national institutions contribute, reflecting the fact that long-term care includes healthcare, social assistance, income support, employment and broader ageing policy.

The Ministero della Salute is responsible for national health policy and plays a central role in the framework governing the Servizio Sanitario Nazionale (SSN). The national system establishes the essential levels of healthcare assistance, known as Livelli Essenziali di Assistenza (LEA), which Regions are required to guarantee through their health systems.

The Ministero del Lavoro e delle Politiche Sociali has important responsibilities for social policy, including national frameworks and funding arrangements relating to non-self-sufficiency and social assistance.

The Ministero dell'Economia e delle Finanze is central to public finance and national budget arrangements, while other ministries contribute to policies affecting housing, accessibility, disability, employment and active ageing.

INPS, the Istituto Nazionale della Previdenza Sociale, administers major national social security and assistance benefits, including Indennità di Accompagnamento, subject to the relevant statutory criteria.

National responsibilities can therefore be understood through several connected functions:

• Establishing legal rights and national policy frameworks.
• Defining essential healthcare and social assistance standards within the applicable legislation.
• Providing and allocating national financial resources.
• Administering national benefits through designated institutions.
• Monitoring territorial implementation and supporting policy coordination.

These responsibilities do not make national government the direct provider of every service. Rather, they establish the framework within which territorial institutions organise and deliver support.

Accountability becomes particularly important when national requirements depend on regional or municipal implementation. The State may establish a standard, but the practical availability of services depends on territorial capacity, administrative decisions and the applicable funding arrangements.

Organisations examining comparable multi-level governance questions can use the Impact Guru Governance Maturity Assessment to structure consideration of leadership, responsibilities and assurance. It is a general analytical resource, not an Italian legal or regulatory instrument.

Regional Governments and the Organisation of Healthcare

Italy's twenty Regions, including the five with special autonomous status, occupy a central position in healthcare governance. The Autonomous Provinces of Trento and Bolzano also exercise important health administration responsibilities within their constitutional arrangements.

Regional authorities organise the SSN through their respective healthcare structures. They establish territorial planning arrangements, allocate resources, oversee service organisation and determine many of the operational mechanisms through which healthcare is delivered.

Aziende Sanitarie Locali (ASL), or equivalent regional health bodies, administer services within these frameworks. Their responsibilities may include primary and community healthcare, integrated home healthcare, rehabilitation, prevention and relationships with accredited providers.

Regional health systems also establish arrangements for residential and semi-residential healthcare services, including relevant elements of support provided through Residenze Sanitarie Assistenziali (RSA).

The organisational structures are not identical across Italy. Some Regions have developed different health authority models, territorial arrangements and relationships between hospitals and community services.

Regional autonomy therefore creates opportunities for service design that reflects geography, population needs and established institutional capacity. However, it also creates differences in access, service availability and administrative procedures.

The central accountability requirement is that regional flexibility should operate within national obligations, including applicable essential healthcare standards.

Regional governance must consequently address both service performance and the distribution of access. A Region may demonstrate substantial activity in community healthcare while still facing important inequalities between metropolitan areas, smaller towns and remote communities.

Quality oversight needs to examine these differences rather than relying exclusively on regional averages.

Municipalities and Ambiti Territoriali Sociali

Municipalities, or Comuni, are essential to Italy's social assistance system. Their functions may include social assessment, home assistance, support for vulnerable residents, social inclusion and contributions towards particular care arrangements, subject to the applicable legal and financial framework.

Many municipalities cooperate through Ambiti Territoriali Sociali (ATS), territorial social service areas that provide a structure for coordinating social assistance across several local administrations.

This is particularly important because many Italian municipalities are relatively small. A single municipality may lack the professional capacity or resources to organise every specialist service independently.

Intermunicipal cooperation can support shared professional teams, common access arrangements, service purchasing and more coherent territorial planning.

However, cooperation does not eliminate differences in municipal resources, administrative capacity or local service availability.

Municipalities may also face difficult decisions about the relationship between assessed needs and available social assistance budgets. Some services are governed by national or regional obligations, while others depend on locally administered arrangements and eligibility criteria.

For older people and families, this distinction may be difficult to understand. A clinical professional may recommend support that is not automatically available through municipal social assistance.

Effective municipal governance therefore requires transparent information about eligibility, assessment, contributions, service availability and routes for reconsidering decisions.

The relationship between municipal services and multi-agency working is especially important where health needs, family circumstances and social vulnerability interact.

National Reform and the Search for Stronger Coordination

Law 33/2023 and Legislative Decree 29/2024 seek to strengthen Italy's policy and service arrangements for older people, including those experiencing non-self-sufficiency.

The reform framework recognises that fragmented responsibilities can create difficulties for people whose needs extend across healthcare, social assistance and family support.

The Sistema Nazionale per la Popolazione Anziana non Autosufficiente (SNAA) forms part of the institutional framework intended to strengthen coordination. The Comitato Interministeriale per le Politiche in favore della Popolazione Anziana (CIPA) provides a mechanism for coordination across relevant national policy responsibilities.

These arrangements are important, but they should not be interpreted as replacing Italy's regional healthcare systems or municipal social assistance responsibilities.

Instead, reform seeks to improve the relationship between existing institutions and establish more coherent approaches to access, assessment and personalised support.

The Punto Unico di Accesso (PUA), multidisciplinary assessment arrangements and individualised care planning are particularly relevant to this objective.

During 2026, elements of the reform programme remain subject to phased implementation, experimentation or further territorial preparation. It would therefore be inaccurate to describe every intended arrangement as fully operational nationwide.

The governance challenge is to ensure that reform produces clearer responsibilities rather than introducing additional administrative layers.

For national institutions, this means understanding implementation differences. For Regions and municipalities, it means translating policy into workable procedures. For people using services, it should mean greater clarity about where to seek assistance and who is responsible for responding.

Operational Scenario: Accountability Following Hospital Discharge in Emilia-Romagna

Consider an illustrative 83-year-old woman living in a municipality in Emilia-Romagna. Following hospital treatment for a fractured hip, she is medically ready for discharge but requires rehabilitation, personal assistance and temporary support with daily living.

The hospital team identifies her clinical and functional needs. Territorial healthcare professionals consider the appropriate rehabilitation and home healthcare arrangements, while municipal social services assess the assistance that may be required with personal care and household activities.

Her daughter can provide some support but works full-time and cannot safely undertake all the required tasks.

The difficulty arises because several organisations contribute to the discharge arrangements. The hospital is responsible for its clinical discharge decisions, territorial healthcare services for relevant continuing healthcare provision, and municipal services for assistance within their responsibilities.

A coordinated pathway identifies a professional contact responsible for helping the family navigate the arrangements. The relevant teams clarify which services are authorised, when they will begin and what remains dependent on further assessment.

The woman participates in planning and expresses a preference to return home rather than enter a temporary residential setting.

However, the availability of rehabilitation visits and personal assistance does not align perfectly. Professionals consider appropriate interim arrangements, explain the limitations and identify any risks requiring further review.

At territorial level, repeated discharge delays associated with coordination problems are examined collectively. Health and municipal organisations distinguish delays caused by clinical complexity from those resulting from service capacity or administrative arrangements.

The scenario demonstrates that accountability does not require one organisation to control every service. It requires each organisation to fulfil its responsibilities while ensuring that decisions and unresolved needs are communicated across the pathway.

Funding Accountability Across Different Care Responsibilities

Italy's long-term care financing arrangements reflect the distinction between healthcare, social assistance, national financial benefits and privately purchased support.

The SSN finances healthcare through national and regional public funding arrangements. Regions organise and administer relevant services, including healthcare delivered in community and residential settings.

Municipal social assistance is financed through a combination of resources that may include municipal budgets, regional allocations and national social policy funding.

The Fondo per le Non Autosufficienze supports measures addressing non-self-sufficiency through the applicable national and territorial arrangements. It does not represent a single consolidated budget covering every form of long-term care.

National benefits administered by INPS follow separate eligibility and payment rules. Indennità di Accompagnamento, for example, provides financial support to eligible people but is not itself an integrated care service.

Households may also pay directly for privately employed care workers, residential accommodation components or additional services.

These financing streams create important governance questions. Who authorises a service? Which institution is responsible for the expenditure? How are household contributions determined? What happens when an assessment identifies support that cannot immediately be provided?

In residential care, the distinction between healthcare and accommodation or social components can be particularly important. The allocation of costs depends on the applicable service classification, national rules and regional arrangements.

Funding accountability must therefore consider more than total expenditure. It should examine whether resources are allocated according to relevant obligations, whether decisions are transparent and whether people experience avoidable financial barriers.

The relationship between funding decisions and internal controls and assurance is relevant to any system involving several institutions and expenditure streams.

However, general governance frameworks must be adapted to Italian public administration, accounting and service regulations rather than treated as substitutes for them.

Provider Governance, Accreditation and Service Quality

Long-term care services in Italy are delivered through a combination of public organisations, accredited private providers, social cooperatives, voluntary organisations and privately arranged assistance.

Providers operating within regional healthcare or social assistance systems are subject to the relevant authorisation, accreditation, contractual and quality requirements.

These requirements differ according to the type of service and the applicable regional framework. It would be inaccurate to describe Italy as having one national long-term care inspectorate applying identical operational standards to every provider.

Regional authorities establish important requirements governing healthcare facilities and services. Municipal and territorial social assistance arrangements may involve separate authorisation, contracting or oversight responsibilities.

Provider accountability includes the safe delivery of agreed services, appropriate staffing, professional competence, documentation, complaints handling and the management of risks affecting people receiving care.

Public institutions remain responsible for their own decisions about authorisation, purchasing, reimbursement and oversight.

These responsibilities intersect but are not interchangeable. A provider may be accountable for delivering care safely while a territorial institution remains responsible for a decision about service eligibility or the allocation of publicly funded assistance.

Effective oversight should also distinguish formal compliance from the experience of people receiving services. A provider can maintain required documentation while still facing problems with continuity, communication or responsiveness.

For this reason, quality monitoring systems should connect regulatory and contractual requirements with practical evidence about safety, dignity, independence and outcomes.

The Impact Guru Quality Dashboard Builder offers a general framework for organising quality indicators and assurance information. It is not an Italian accreditation tool and does not replace applicable regional oversight arrangements.

Operational Scenario: Residential Care Quality Concerns in Lombardy

An illustrative family in Lombardy raises concerns about an older relative living in an accredited residential care facility. The resident has dementia and requires assistance with mobility, nutrition and communication.

Family members report inconsistent information about changes in her condition and are concerned that her daily routines are becoming less personalised.

The provider's management team reviews the concerns, examines relevant care records and discusses the resident's needs with clinical and care staff. Where appropriate, the resident's preferences and communication abilities are considered directly, rather than relying exclusively on family accounts.

The review identifies that changes in staffing arrangements have affected continuity. Although essential clinical interventions have continued, information about personal routines and communication preferences has not always been transferred effectively between workers.

The provider strengthens handover arrangements, reviews individual care planning and establishes a process for monitoring whether the agreed changes are maintained.

The family receives an explanation of the response and information about the relevant complaints and escalation arrangements.

If concerns suggest breaches of applicable requirements or remain unresolved, the appropriate regional or territorial oversight mechanisms may become involved according to their legal responsibilities.

At organisational level, the provider examines whether similar problems are occurring elsewhere. Staff turnover, supervision arrangements and feedback patterns are considered alongside individual care records.

The case illustrates the distinction between provider responsibility and public oversight. The provider must address the quality of its own service, while the relevant public authorities retain their statutory and administrative functions.

It also demonstrates why governance should examine the relationship between staffing, communication and lived experience rather than treating complaints as isolated administrative events.

Accountability for Family Care and Privately Employed Workers

A distinctive feature of Italian long-term care is the substantial contribution made by family caregivers and privately employed badanti.

Many older people remain at home through a combination of family assistance, privately purchased care and selected public services. This arrangement can support continuity and personal preference, particularly where older people wish to remain in familiar communities.

However, family and privately arranged care sit partly outside the formal governance structures that apply to publicly administered services.

A privately employed care worker has an employment relationship governed by applicable labour and employment requirements. This does not automatically make the worker part of a regional healthcare organisation or municipal service.

Families may act as employers while also managing care decisions, household finances and relationships with clinical professionals.

The resulting responsibilities can be demanding, particularly when an older person's needs become more complex.

Formal healthcare professionals may need to communicate with family caregivers and privately employed workers where appropriate, while respecting confidentiality, consent and professional boundaries.

Public institutions should also recognise the limits of informal care. An assessment that assumes a daughter or spouse can provide extensive daily assistance may overlook employment commitments, health limitations or caregiver exhaustion.

The relationship between family partnership and caregiver support is therefore an important governance concern.

Accountability should include understanding whether formal service arrangements are sustainable and whether the burden placed on families is recognised in planning and review.

Digital Information and the Visibility of Shared Responsibilities

Digital systems can support accountability by making relevant information available to authorised professionals and reducing unnecessary duplication.

Italy's Fascicolo Sanitario Elettronico (FSE) provides a national framework for electronic health information, with implementation and operational arrangements involving regional health systems.

However, healthcare information, municipal social assistance records, national benefit administration and privately arranged care do not necessarily operate through one integrated information environment.

This creates practical challenges for care coordination. Professionals may hold different information about the same person, and the absence of a shared administrative process can make responsibility difficult to trace.

Improving information exchange requires attention to lawful processing, data protection, professional access, information quality and the purposes for which records are shared.

Italy's obligations under the General Data Protection Regulation and relevant national legislation remain applicable. Integration does not justify unrestricted access to sensitive personal information.

Technology should support decisions rather than merely increase the quantity of information recorded.

The strongest opportunity lies in developing clear information flows between relevant organisations so that assessment outcomes, agreed actions and unresolved needs are visible to those responsible for responding.

The Digital Transformation Readiness Assessment can help organisations examine general questions of digital capability, security and implementation preparedness. Its framework would require adaptation to Italy's legal and institutional context.

Operational Scenario: Shared Accountability in a Rural Municipality in Calabria

Consider an illustrative older couple living in a small inland municipality in Calabria. The husband has significant mobility limitations, while his wife provides most daily assistance despite experiencing health problems herself.

Their adult children live elsewhere in Italy and can visit periodically but cannot provide regular care.

A general practitioner identifies increasing frailty and recommends further assessment. Territorial healthcare professionals consider clinical and rehabilitation needs, while municipal social services examine the couple's practical circumstances and available community support.

The assessment identifies a need for regular assistance, but the territory has limited local care-worker capacity. Travel distances and the availability of suitable providers make arranging consistent support difficult.

The municipality explores the assistance available through its own arrangements and relevant intermunicipal cooperation. Healthcare services consider appropriate clinical interventions, while the family receives information about national financial benefits and privately arranged options.

The couple are involved in decisions and express a strong preference to remain in their community.

Professionals agree an initial support arrangement but recognise that some needs remain unresolved. Rather than describing the case as completed once assessment has taken place, the relevant organisations identify the outstanding issues and arrange review.

Territorial managers subsequently examine whether similar difficulties are affecting other older residents. The pattern suggests that limited workforce availability and geographic isolation are restricting access to support.

These findings inform discussions about service organisation, shared territorial resources and the relationship between regional healthcare planning and municipal assistance.

The scenario demonstrates why accountability must extend beyond individual decisions. Each organisation may fulfil its immediate administrative responsibilities while the overall care arrangement remains insufficient.

Effective governance requires the unresolved outcome to remain visible until an appropriate response is developed or the limitations are clearly understood and managed.

Regional Inequality and the Challenge of Consistent Rights

Italy's regional differences are a central consideration in long-term care governance. Healthcare organisation, service capacity, municipal resources, professional availability and household circumstances vary across the country.

These differences do not mean that every northern territory performs well or that every southern territory performs poorly. Significant variation can exist within Regions, between metropolitan and rural areas, and across municipalities with different population characteristics.

Nevertheless, territorial variation can affect how quickly people receive assessments, which services are available and how much support families need to arrange privately.

National essential standards provide an important foundation for consistency, but their implementation depends on administrative capacity and service resources.

The development of Livelli Essenziali delle Prestazioni Sociali (LEPS), essential levels of social services and benefits, is relevant to the broader objective of strengthening consistency in social assistance. Their practical scope and implementation must be understood through the applicable legislative and funding arrangements rather than assumed to be universally complete.

Regional accountability therefore needs to consider whether statutory and policy commitments are reflected in actual service access.

Monitoring should distinguish between differences justified by local population needs and those arising from avoidable organisational barriers or insufficient provision.

This is closely connected with health inequalities and prevention, particularly where older people have limited financial resources, live alone or face geographic barriers to formal services.

National coordination can help identify patterns, but improvement ultimately depends on the ability of territorial institutions to respond.

How Governance Evidence Should Inform System Improvement

Long-term care governance produces many forms of information, including service activity, expenditure, assessment records, complaints, quality monitoring, professional reports and feedback from older people and families.

The value of this information depends on whether it helps institutions understand how the system is operating.

For national authorities, evidence can reveal patterns in implementation and territorial variation. For Regions, it can inform service planning, resource allocation and oversight. For municipalities and ATS, it can identify local access difficulties and gaps in social assistance.

Providers can use quality and operational information to improve staffing, care planning, communication and service reliability.

However, reporting arrangements should avoid creating excessive administrative burdens without improving decisions.

A useful evidence framework would distinguish:

• Access and assessment activity, including delays and unmet demand.
• Service availability and continuity across different territories.
• Quality, safety and the experiences of people receiving support.
• Workforce capacity and the sustainability of delivery arrangements.
• Financial responsibilities, expenditure and household burden.
• Progress in resolving recurring coordination problems.

The objective is to connect evidence with responsibility. Information about a service problem has limited value if no institution is clearly responsible for considering and responding to it.

Equally, accountability should recognise that some problems cannot be resolved by a single provider or municipality. Workforce shortages, regional service gaps and funding constraints may require decisions at a different administrative level.

Governance therefore needs reliable mechanisms for communicating unresolved issues between institutions.

This is where continuous improvement becomes a system responsibility rather than simply an internal provider activity.

International Lessons From Italy's Multi-Level Governance Model

Italy offers a valuable example of how long-term care accountability operates in a decentralised system where healthcare, social assistance and financial benefits follow different institutional arrangements.

The first lesson is that national standards and territorial autonomy are not inherently incompatible. National government can establish essential requirements while regional and local institutions organise delivery around population needs.

However, this balance requires reliable evidence about implementation and mechanisms for responding to persistent differences in access and quality.

The second lesson concerns shared pathways. Where several organisations contribute to one person's support, accountability cannot depend exclusively on each institution completing its own administrative tasks.

There must also be clarity about how decisions connect, how information moves and how unresolved needs are addressed.

The third lesson concerns financing. Separate budgets and benefit systems may reflect legitimate legal responsibilities, but they can create complexity for people seeking assistance. Better coordination should make these responsibilities understandable without implying that all funding has been consolidated.

The fourth lesson concerns informal care. Family caregivers and privately employed workers provide substantial capacity, but their contribution should not conceal unmet need or substitute automatically for formal service responsibilities.

Finally, Italy illustrates the importance of local evidence in national reform. The experiences of municipalities, providers, professionals and families can reveal where formal policy arrangements are not translating into effective support.

Other countries may adapt these principles without reproducing Italy's constitutional distribution of powers or its particular healthcare and social assistance institutions.

Conclusion

Accountability for long-term care in Italy is distributed across a complex but established network of national, regional, municipal and provider responsibilities. This reflects the country's constitutional arrangements, healthcare organisation, social assistance traditions and extensive reliance on family and privately arranged care.

National government establishes important legal frameworks, essential standards and financial arrangements. Regions organise healthcare and oversee substantial elements of service delivery. Municipalities and ATS administer social assistance, while providers remain responsible for the quality and safety of their own services.

The challenge arises where these responsibilities intersect. Older people rarely experience healthcare, personal assistance, financial support and family circumstances as separate administrative categories. They experience them as connected parts of everyday life.

Italy's developing reform framework provides an opportunity to strengthen coordination, improve access arrangements and clarify responsibilities across institutions. Its success will depend on practical implementation rather than the creation of additional structures alone.

Effective governance requires transparent decisions, appropriate information sharing, reliable quality evidence and clear arrangements for responding when agreed support cannot be delivered. It also requires attention to regional inequality and the pressures experienced by family caregivers.

The strongest direction is therefore not necessarily to centralise every responsibility, but to ensure that the institutions already responsible for long-term care operate with greater coherence and accountability.

For Italy, the ultimate test is whether older people and families can navigate the system with confidence, understand who is responsible for decisions and receive support that is coordinated, dignified and responsive to changing needs.