Executive summary
Italy has long aimed to reform its disability policies to address at least three long-standing policy issues: discrepancies with the UN Convention on the Rights of Persons with Disabilities calling for a change in disability assessment; the fragmentation of disability assessments and disability supports; and resulting inequalities across Italy’s regions in the provision of disability services and take-up of disability benefits.
Social and employment outcomes for people with disability in Italy are ambivalent and difficult to interpret. Employment and poverty gaps between people with and without disability are both relatively low, and lower than the OECD average. However, this finding is not explained by higher employment rates of people with disability in Italy, or lower poverty rates. The lower disability gaps in Italy result from poor income and employment outcomes also for people without disability. This points to more general reform issues to boost social and employment outcomes for all people in Italy, which would also benefit people with disability.
Available disability benefits and services are quite adequate in Italy, and people entitled to benefits and services are, therefore, relatively well supported. However, take-up of supports is often low, because of both system complexity and lacking resources, and people excluded from support are often vulnerable. This shows the critical importance of disability assessment in deciding who is supported, and who is excluded. Many of those left out from support face considerable barriers to work and integration.
Support for people with disability varies across regions. The wealthier regions in the Northern part of the country are better placed to provide essential disability services than poorer regions in the South. Instead, the take-up of disability benefits, which are funded exclusively from national budgets, is much higher in the South and has been increasing over the past decade. The higher benefit take-up in the South (57% of the working-age population, compared to only 23% in the North) is also in part a consequence of stronger financial incentives to apply for benefits for people living in poorer regions: Being identical across Italy, non-contributory disability payments are more appealing, compared with the lower wages and poorer economic conditions in those regions, even though payments are not overly generous.
Regional inequalities are also the result of differences in disability assessment both across and within regions. The disability status assessment, which determines the degree of “civil invalidity” and the eligibility for nationally provided benefits and services, is overseen by the National Institute for Social Security but implemented at the provincial level, with a significant degree of discretion. Moreover, Italy operates five different disability status assessments in parallel, making the system inefficient and difficult to navigate. Needs assessments determining entitlement to sub-national services are implemented at the local level, with considerable variation across the country but, generally, a strong focus on the actual needs of people with disability. The two assessments – of people’s degree of civil invalidity and of people’s needs – are disconnected from each other.
Recent legislation in late 2021 points to the direction of forthcoming disability policy reform, which will start with a reform of disability assessment. Currently, civil invalidity assessment tends to discount mild-to-moderate health impairments, which nevertheless can lead to considerable disability, such as certain mental health conditions, and vice versa tends to overlook the abilities of people with severe health impairments. Incorporating the WHO Disability Assessment Schedule (WHODAS), which assesses people’s functioning and performance into the medically oriented civil invalidity assessment, would rectify this bias: disability assessment would become more accurate, be aligned with today’s interdisciplinary understanding of disability, and ensure a better connection with any subsequent individual assessment of actual support needs.
A pilot of a new assessment conducted in four diverse regions of Italy – Campania, Lombardy, the Autonomous Region Sardinia, and the Autonomous Province of Trento – demonstrates that social workers in Italy can apply the WHODAS tool in a valid and reliable way, irrespective of the regional context. The evaluation also shows that WHODAS could be used effectively to flag to the assessors any significant disparity between functional capacity and health impairment, indicating the need for a more in-depth assessment. The weight given to the functional component of disability in the decision process, compared to the medical component, is a political choice.
To make disability policy more efficient and more effective for people with disability, the government should consider:
Merging the five existing disability status assessments and adding a functional component to the narrow medical assessment of people’s disability status by using the WHODAS questionnaire, which should be operated by social workers.
Using WHODAS scores to flag discrepancies between the medical and the functional dimension of disability, with the aim to examine more closely the actual situation and capacity of about one-third of all people accessing the disability system.
Reducing the discretion in disability assessment through clearer guidelines, harmonising needs assessments across the territory, and better linking disability status and needs assessments.
Helping people with disability navigate the complex system through single points of entry (Punto Unico di Accesso, or PUA), which exist already in some regions and municipalities. PUAs should ideally be the only point of entry to the disability system, operate uniformly across the country, and have sufficient human capacity.
Improving the efficiency of the social protection system through better data collection and systematic data sharing practices, financing mechanisms that prevent duplication of benefits and services, and better co-operation at the regional and national level.
Reducing territorial differences by improving the capacity to deliver effective health and social services in the Southern regions and strengthening work incentives and work opportunities for people potentially entitled to disability benefits to address problems stemming from the model of a single income threshold and a single payment across Italy.
Making employment integration of people with disability a priority by linking disability benefits to activation provisions, enabling public employment services to support people with disability able to work, and focusing on early intervention to prevent labour market exit.