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Private Assistants in the Italian care system; facts and policies

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Private Assistants in the Italian care system; facts and policies
  Observatoire de la sociétébritannique 14 (2013)Politiques familiales et politiques d'emploi « genrées » au Royaume-Uni et en Europe ................................................................................................................................................................................................................................................................................................ Giuliana Costa Private Assistants in the Italian CareSystem: Facts and Policies ................................................................................................................................................................................................................................................................................................ Avertissement Le contenu de ce site relève de la législation française sur la propriété intellectuelle et est la propriété exclusive del'éditeur.Les œuvres figurant sur ce site peuvent être consultées et reproduites sur un support papier ou numérique sousréserve qu'elles soient strictement réservées à un usage soit personnel, soit scientifique ou pédagogique excluanttoute exploitation commerciale. La reproduction devra obligatoirement mentionner l'éditeur, le nom de la revue,l'auteur et la référence du document. Toute autre reproduction est interdite sauf accord préalable de l'éditeur, en dehors des cas prévus par la législationen vigueur en est un portail de revues en sciences humaines et sociales développé par le Cléo, Centre pour l'éditionélectronique ouverte (CNRS, EHESS, UP, UAPV). ................................................................................................................................................................................................................................................................................................ Référence électroniqueGiuliana Costa, « Private Assistants in the Italian Care System: Facts and Policies », Observatoire de la sociétébritannique  [En ligne], 14 | 2013, mis en ligne le 01 février 2014, consulté le 01 février 2014. URL : ; DOI : 10.4000/osb.1536Éditeur : Université du Sud-Toulon-Varhttp://osb.revues.orghttp://www.revues.orgDocument accessible en ligne sur : généré automatiquement le 01 février 2014. La pagination ne correspond pas à la pagination de l'éditionpapier. Tous droits réservés  Private Assistants in the Italian Care System: Facts and Policies2 Observatoire de la société britannique, 14 | 2013 Giuliana Costa Private Assistants in the Italian CareSystem: Facts and Policies Pagination de l'édition papier : p. 99-117 Introduction 1 In the last ten to fifteen years, Italian families taking care of dependent individuals at homehave received massive help from personal assistants, mostly immigrant women. This ‘privateto private’ arrangement fits into the welfare system characterized by a very modest provisionof in kind services for people with care needs and it has been called a “hidden welfare” (Gori2002) since private services provided by personal assistants “worked” for many years withno public input in terms of regulation. The relative success of this solution has not beenaddressed either by explicit or by specific caring policies, or by migration policies despite thegrowing numbers of individuals and families involved as dependent people and care workers.Awareness of the existence of this private market entered Italian public debate very slowly,at a particular moment when the accelerated ageing of the population and the social risksinvolved in it came to the fore in the public agenda, mainly in relation to the pension systemsustainability issue. 2 This article will focus on the policy dimensions connected with the emergence andconsolidation of this solution for dependent people in Italy, whilst also looking at the issue fromthe care workers’ perspective. The main features of the Italian care system are characterizedby a strong “familism” as family members are almost completely responsible for care dutiesand by weak entitlements in terms of public care policies, with the development of an ad hocprivate long-term care system. 3 In the following sections, national and local regulation towards care policies will be addressed,showing how paradoxically, central government inertia has, to a certain extent, boost the use of personal assistants without dealing with the many dilemmas that co-opting personal assistantspose to public policies and to Italian society as a whole. A local and context based experimentin Milan will also be described as an illustration of ways forward. In the conclusions someimplications for those involved in this private market will be presented and discussed from agender perspective. The article draws on different research projects conducted over the pastfive years and is mainly based on institutional data and qualitative interviews to policy makers,activists, trade union actors and NGO leaders. Main Features of the Care System in Italy 4 As a wide corpus of research has pointed out, care remains a family task even in those contextscharacterized by generous publicly funded personal services as the Nordic European countries(Öesterle 2001). The Italian welfare regime, along with other Mediterranean countries, hasbeen defined as “implicitly familistic” (Saraceno 2010) due to the huge duties assigned tofamilies in coping with caring needs and because policies assume that family members arealways capable and available to provide care. Formal services are indeed scarce and interveneonly residually, in very urgent and complex cases. This approach is embedded in social policiesas well in the wider normative framework, for example concerning financial responsibilitiestowards relatives. 5 The extent to which care is a family issue can be gauged by analyzing caring arrangements of Italian households that have at least one elderly person (65+). Informal care is by far the mostwidespread form of support (ISTAT 2011), the only exceptions being households with veryold (80+) and/or severely dependent members, but even in this case almost 40% of them donot receive any kind of formal help (Table 1).  Private Assistants in the Italian Care System: Facts and Policies3 Observatoire de la société britannique, 14 | 2013 Table 1. Percentage of Italian households with elderly people by type of help received (2009)  Kind of family Households with formal (public/private) help Households that rely only oninformal (family) helpWith 65+ 29.270.8 With 65+ severely dependent  49.650.4 With 65+ dependent  31.168.9 With 80+ 45.055.0 With 80+ severely dependent  61.538.5 With 80+ dependent  43.956.1 Source: ISTAT (2011) 6 Formal support is modest in terms of coverage and intensity throughout the country but withdifferences which correspond to historic inequalities between north Northern and SouthernItaly (Table 2). Table 2. Coverage rates of Italian public support for care (2008-2011) % of over 65 receiving:ItalyCentre-Northern ItalySouthern Italy IA (Attendance Allowance)(2011) 11.610.414.7 Social Home care (2009)  Nursing Home care (2009)  Residential and Day care(2009) Note: the figures of social home care (run by Local Authorities) and nursing home care (run by the National HealthService) cannot be simply added together because they partially refer to the same beneficiaries.Source: own computation from ISTAT (2011), ISTAT (2012) 7 The institutional design of public care policies has not varied over the last decade and publicspending for caring services increased by merely 12% between 2004 and 2010, rising from1.05% of GDP to 1.18% (Costa 2013), in a context where care needs grew significantly.The only public support that followed the increasing demand for care is the indennità diaccompagnamento , an attendance allowance for individuals with severe care needs andassessed as completely dependent (unable to perform the basic activities of daily livingwithout help) on a long-term basis. A flat rate allowance of €480 per month (2010), it is notgraduated to the severity of caring needs and can be used freely, with no checks on its use.Services in kind (residential and home-based ones), be they socially oriented or concerninghealth issues, are planned at a regional level and implemented at the municipal one. Thisinstitutional architecture reinforces the historical fragmentation of welfare policies. The onlybenefit regulated by the central State is the indennità di accompagnamento  which is also thesingle enforceable support by those who are severely dependent. That is the reason why thiscash allowance constitutes the pillar of the Italian caring system. It is widespread and it canbe used by individuals and families to cope with their care needs. 8 A further specific aspect of the current Italian care system is that families’ capacity to care ona long term and intensive basis is decreasing because of a complex combination of societaltransformations (demographic, socio-economic and cultural ones at the same time). The fastageing population, the reduction in the household size, the multiplication of caring tasks andthe progressive participation of women in the labor market can explain why informal care forolder people cannot be taken for granted any more. It is important to remember that Italy is oneof the oldest countries in the world and, together with Germany, its ageing rate is the highest inEurope. Spouses, sons and daughters, grandchildren and elderly parents are “competing” witheach other to be cared for, mainly by middle-aged / mature women because Italian householdsare getting more and more “thin and stretched”, as, compared to previous decades, they arecomposed of fewer members who coexist for longer, producing different care needs (Costa2012). The proportion of the 65+ population is 20.6% according to ISTAT (2012), a rate thatgrew by around 38% in the last two decades and almost doubled in less than 50 years. In theearly 1990s, there were 8.7 million elderly people living in Italy, which had risen to around 12  Private Assistants in the Italian Care System: Facts and Policies4 Observatoire de la société britannique, 14 | 2013 million by 2012: a net increase of 3.3 million individuals. The number of dependent people inneed of care is therefore growing in absolute numbers, as well as the severe dependency rate(defined as being confined at home) (Costa 2012). However, empirical evidence shows thateven if family members “are still there”, they are taking care of elderly dependent membersless intensively (ISTAT 2010). Emergence of the private care market 9 Such was the context in which the employment of personal assistants spread as a privatesolution for families with caring needs. They are nowadays crucial actors in the Italian careregime. In fact the gap between the expanding demand for care services, the modest publiclong-term care services provision and the reduced capacity of families to care on a long-termbasis, has largely been filled by low-cost care work provided by private workers hired byfamilies to take care of their frail and dependent members. The vast majority of those involvedin these private arrangements are migrant women coming from less developed countries evenif a small number of them are Italian (Catanzaro and Colombo 2009) 1 . 10 The old word – badante  - has been re-used to name those who care (from Italian verb badare , totake care of) for someone on a long term basis in Italian households and families 2 . The badanti or personal assistants are the protagonists of what Castegnaro called “the hidden revolutionin caring elderly people” (2002). Widespread social reorganization has occurred concerninglong-term care needs and dependency in Italy in the last fifteen years but within an institutionalframework characterized by inertia (Costa 2012; Ranci and Pavolini 2011). As stated before,the public long-term care provision is nowadays almost the same as two decades ago. Co-opting a co-residing personal assistant is today the best solution to cope with caring needs ona long-term basis and a good and less expensive alternative compared to residential services.Hiring a badante  is not only less costly than other care providing schemes 3 , it is also morepractical because they ensure long hours of care ( badanti  are often complementary to publicservices, which are not organized to give care on a 24 hour basis or in the long term 4 ), theyare flexible (arrangements can be made over the 24 hours) and assist people at home 5 . Theuse of a badante  has become a common practice in Italy, even by less affluent families, andsupply has raised demand (Colombo 2005). The availability of this kind of worker has raisedexpectations that such a solution is reliable and “ready to go”, even if recent research showsthat emotional, material and organizational relationships can be very problematical. 11 In general terms, it can be stated that the Italian care regime has been profoundly redesignedby the emergence of a private care market and the use of migrant care workers. The model of care experienced a transition from being family-based to a more mixed one. Some scholarshave argued that the consolidation of a private care market, composed of foreign migrants,changed the nature of the Italian model of care with a “‘transition from a ‘family’ to a ‘migrantin the family’ model” (Bettio et al. 2006: 272). Many empirical research results show thatpersonal assistants are not completely replacing families in their caring activities but ratherthey are complementing them (Eurofamcare 2006; ISTAT 2010). Families provide the bulkof personal care and domestic help as well as health and psychological assistance and havea crucial organizational role in monitoring financial aspects, coordinating different kinds of care resources. Migrants are though supporting Italian families and not substituting them intheir care responsibilities. They are, as shown by empirical evidence, doing the “hands on”caring work (Costa 2012). 12 The badanti  are mainly employed to care for elderly people. According to a survey carriedout by Iref (Istituto di Ricerche Educative e Formative) on behalf of the ACLI 6  (2007), 29.5%of them take care of a lonely old person, 19.5% look after a couple of them, 7.5% work ina household where an old person live. The duties are heavy. 78.7% of those who have beenco-opted to take care for a lonely old person perform different activities (personal care, homecare, bureaucratic duties, etc.). According to another survey conducted in 2004-2006 (Fullin,Reyneri and Vercelloni 2009), 76.4% of personal assistants live with the person the care, inco-residence even if this arrangement is declining along with the number of years they stayin the country (Fullin, Reyneri and Vercelloni 2009). Co-resident personal assistants’ weekly  Private Assistants in the Italian Care System: Facts and Policies5 Observatoire de la société britannique, 14 | 2013 working time is much longer (59 hours) than that of those who do not live with her or hisemployer (39 hours) (ACLI 2007). 13 In 2009, more than 14% of families with an older relative (aged 65+) employed a personalassistant. The rate increases with the level of dependency and with the age of the elderly.Almost 32% of families with a severely dependent 80+ person employ a badante  (ISTAT 2010;Costa 2012). According to recent estimates, Italian families spend around €9.5 billion a yearto pay for personal assistants (Pasquinelli and Rusmini 2011). Many badante  are not registeredas formal employees and many are illegal migrants, so numbers are difficult to estimate, butrecent estimations indicate that around 750.000 persons are personal assistants, more than 50%of whom have no regular contract and/or are undocumented migrants (Pasquinelli and Rusmini2011). In fact informality (which in some cases turns to illegality) plays an important rolein the personal assistants success in the Italian context because, together with the attendanceallowance described above, it fuelled a low-cost private market. The growth of this privatemarket is due to many different factors including the availability of a large immigrant femalelabor force, the scarcity of and difficult access to public personal care services, the traditionalpreference for caring at home, the increase of the female employment rate in the countryand finally, the availability of an adequate income for a significant proportion of the currentgeneration of Italian pensioners (Costa 2012; Da Roit 2007; Spanò 2006). Migrant care work regulation & national public policies 14 Ignored for many years, the emergence of this private care market entered the public arena veryslowly, when personal assistant and particularly migrant ones were already in place in Italianhouseholds. This “homemade welfare” or “hidden welfare” (Gori 2002) started to be the objectof careful attention by politicians, policy makers, media, trade unions, private organizationsin mid 2000s. Its role in the Italian local welfare is now given permanent attention by thepress. But national policies (be they social care ones, migration or family ones) have notexplicitly addressed this issues related to the presence and the relevance of this type of caremarket for a long time (Costa 2012). The regulation of this private care market is a realpuzzle for the policy makers for many reasons: first of all, it concerns several social policies(health, immigration, family, employment and housing policies and taxation choices) whichare conceived and implemented at different institutional levels (local, regional, national andsupra-national levels). To local authorities is left the burden of settling the resulting conflicts,with limited jurisdiction, tools and money. It involves a great number of care workers (750000 assistants) and a large number of families employing them. The private care market is onewhere differing interests collide: cost and efficiency, quality and justice, equity and privacyand so on. The care-giving market is very fragmented: supply and demand are representedby individuals who are not organized; contracts are concerned with goods and services thatare not defined or that are difficult to define (this is a typical case of “experience good” thatinvolves duties that are peculiar, that change over time and are not standardized) and wherelabour relationships are “one-to-one”. Furthermore, this market is composed of relatively frailactors, both those that require help and assistance (the elderly and the less able-bodied) andpersonal assistants (who are often migrants in difficult economic and personal conditionssituations). Besides, transactions in this market are often unbalanced: on one side personalassistants frequently lack official documents (new migrants), on the other hand, labor laws arefrequently incorrectly applied. 15 As personal assistants are mostly migrants, it is important to remember that their co-optationand employment by Italian families require (as in other countries) an analysis of the dualinstitutional contexts in which this employment is located, be they state policies towards careor the intersection with immigration policies (Shutes and Chiatti 2012; Williams 2012). 16 Immigration policies in Italy are mainly based on two policy tools. Firstly, amnesties( sanatorie ) for migrants living and working in Italy; and, secondly, a yearly planning of thetotal number of migrants allowed to come to Italy to work ( decreto flussi ). Amnesties aimto regularize the position of migrants who are already living in the country. Such amnestiesoccurred in 1986, 1990, 1995, 1998, 2002, 2009 and 2012. If they are compared with the use
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