In Italy the legal source for protection of people with disabilities lies, first of all, in Constitutional principles. Article 2 introduces the duty of political, economical and social solidarity, and Article 3 states the need for the removal of social and economic bar- riers limiting freedom and equality among citizens. Moreover, Article 38 specifies types of intervention towards citizens incapable of work and without means of living and workers with reduced or abolished work capacity.
Citizens incapable of work and “disabled” people have the right to a means of living and social assistance. They also have the right to education and vocational training [1].
These rights are guaranteed by the National Health System (NHS) and Social Security System.
The Italian NHS – rehabilitation services
In 1998 the Italian Minister of Health defined guidelines for the organisation of rehabi- litation services as until then rehabilitation had been delivered in a non-structured fashion across the country (i.e. treatments were performed in varying modes, times and contexts for similar conditions) (Act 7th May 1998).
Therefore guidelines for medical rehabilitation were drawn up promoting a network of structures included in the NHS. The guidelines were designed to preserve the auto- nomy of the Italian Regions and leave them free to devise their own programs within a framework of national regulations. Among others, the guidelines stress the importance of appropriate individual rehabilitation projects and programs (in order to optimise the effectiveness of the interventions), and the need for assessment of the residual capacity of the disabled (more than of the severity of damage) and for a proper occupational and social settlement of people with disabilities.
An efficient network among different clinical departments and units was established, the main goal of which was to “take charge of the rehabilitation patient”, aiming at ensuring the best level of autonomy and quality of life. The network is also intended to provide systems for continuous quality improvement and program evaluation, and N. Pappone, C. Dal Pozzo and F. Franchignoni
progressively identify the best treatment protocols and practice standards. The proce- dures to follow start from the early stages of the disease, pointing out the links between emergency (either surgical or medical) departments and rehabilitation units.
The guidelines of the Ministry of Health take into account both “intensive” and
“extensive” rehabilitation programs. The “intensive” activities deal with significant disabilities (particularly those due to severe brain damage and spinal cord injury) that require major medical care and rehabilitation treatment in terms of complexity and duration of intervention, while “extensive” rehabilitation activities (mainly delivered in day care, outpatient services, long-term care facilities, nursing homes, home services, etc.) are directed at the treatment of transient and/or minor disabilities, or of stabili- sed functional conditions and require a lower intensity of therapeutic commitment.
Some NHS structures for rehabilitation interventions include laboratories for the assessment of the residual functional capacities, and units for occupational therapy and vocational training. These structures are identified as tools for both medical and social rehabilitation aimed at (re-)allocating the disabled to work whenever possible;
they strictly collaborate with the Work Integration Services (see below). In particular, according to the new ICF classification, the procedures to analyse the residual capacity of disabled people consist of a comprehensive vocational evaluation, assessing the whole person (on the basis of biological, vocational, and technical-professional cha- racteristics) and the environment, and including abilities, skills, interests, physical capacities and other crucial factors affecting vocational potential. Physiatrists (suppor- ted by the rehabilitation team) play a pivotal role in this kind of assessment and inter- vention.
The Italian Social Security System
The Social Security System in Italy is divided into two parts: one is based on public assis- tance for citizens incapable of work (i.e. who never entered the labour market or suffers from acquired disability); the other, for working citizens, deals with social insurance res- pectively against: a) common illnesses; b) industrial injuries and occupational diseases.
Special categories are civil servants and military forces, which will not be specifically exa- mined here.
This approach reflects the above mentioned Constitutional principles and the com- plex history of Social Security System development in Italy. However, a debate has been going on for years about the opportunity of merging different policies on disability and offering disabled persons a global approach to managing their needs. The Table sum- marises the economic and non economic benefits of our national Social Security System.
Social assistance: non contributory benefits
The Ministry of Economy and Finance administers non-contributory benefits to those people who were born with disabilities or never entered the labour market or did not pay the set contribution because of an acquired disability. Subjects below 18 years with per- sistent disabilities have the right to an indemnity if they attend school. Subjects over 65 years receive health and social welfare assistance. Subjects between 18 and 65 years (working age) with a reduced work capacity of over 33% qualify for Civil Invalidity, of over 45% have right to “compulsory” employment (quota system) [2, 3], of over 74%
receive a monthly allowance when not employed. In the case of complete loss of work capacity they receive a monthly pension. At any age the incapacity to walk or to perform basic activities of daily living entitles the subject to an extra indemnity.
Insurance against common illnesses: contributory benefits
INPS (National Institute for Social Security) administers, besides short term sick pay, the invalidity allowance and inability pension for people that become disabled during wor- king life due to “common illnesses”. The term of reference for the invalidity allowance is a more than two-thirds reduction of work capacity according to education and work
Legal nature of Disabled People who People who become People who become disability did not pay a set contri- disabled during working disabled during working
bution or never entered life (common illnesses) life (industrial injuries
the labour market (civil and occupational
invalidity) diseases)
Board Ministry of Economy INPS INAIL
and Finance
Cash benefits Not applicable Sick pay Temporary
(short term employment-injury
benefits) benefits
Cash benefits Monthly allowance for Ordinary invalidity Indemnity (lump-sum) (long term unemployment periods allowance (>2/3 loss (6-15% reduction of benefits) (>74% loss of work of work capacity) psychophysical
capacity) integrity)
Monthly benefit Inability pension Inability pension (>16% reduction of (100% loss of work (complete loss of work psychophysical integrity)
capacity) capacity)
Work (re-) Law 68/1999 (2) – Law 68/1999 and
integration Quota system (>45%) 38/2000 (2,3)
loss of work capacity) Quota system (>34%
loss of work capacity) Table – Economic and non economic benefits of the Italian Social Security System.
experience. The requirement for the inability pension is the loss of all-work capacity.
These benefits represent a sort of early retirement [4, 5].
Insurance against industrial injuries and occupational diseases:
contributory benefits
INAIL (National Institute against Industrial Injuries and Occupational Diseases) admi- nisters benefits granted to workers that become disabled due to an industrial injury or an occupational disease.
The legal framework is complex. The former legislation (TU n. 1124/1965) was based on the assessment of impairments causing reduction of work capacity (invalidity), so- called “barèma”. The worker with an invalidity between over 10 and 100% was entitled to receive a proportional monthly allowance. This law is still operating for some benefits (i.e., long term allowance for continuing assistance for special categories of disabled wor- kers, and as a basis for qualifying return to work in the quota system according to law 68/1999 [2] when invalidity is over 34%) but the core of the system is the statutory order 38/2000 [3]. The novelty of this small revolution is the introduction into an insurance system of the principles of the liability. The term of reference is no longer the incapacity for work but the reduction of psychophysical integrity of the individual assessed via a legal baréma. This implies that the value of an individual lies not only in the capacity to produce income but in all aspects of personal life (e.g. in the previous law scars were irre- levant; today they must be assessed). The economic benefits are a daily compensation for total temporary disability (as in the past); a lump sum for injury to psychophysical inte- grity resulting in a 6-15% invalidity and a monthly annuity for invalidity over 16%.
The other major change brought about by law 38/2000 is the global approach to the subject: not only is economic protection taken into account but all other relevant aspects of social security, ranging from prevention to rehabilitation and return to work. In the field of industrial injuries and occupational diseases it is common experience that small impairments are easily compensated and return to work is relatively simple, particularly in semi-skilled jobs, but - as the level of impairment grows - finding a job or returning to work may be critical without intensive vocational rehabilitation programs and speci- fic support for work integration (see below).
Role of the National Institute against Industrial Injuries
and Occupational Diseases (INAIL)
INAIL is an integral part of the National Social Security System. As part of its main goals it pursues the reduction of accidents at work (prevention), the insurance of workers involved in risky activities and the re-integration into the labour market and in the social life of work
accident or occupational disease victims. In the past the Institute’s aim was to protect only a few categories of workers (such as factory employees and farmers), but more recently many other categories have been included (e.g., clerical jobs, housewives and sporting pro- fessionals). Moreover it is involved in the assessment of many other potentially disabling conditions since the decree N° 179/88 of the Constitutional Court extended the protection to any other disease that could be proved to have been caused by a working activity.
In recent years INAIL has had a growing interest in the areas of prevention, rehabili- tation and research into all occupational diseases (“new and old”).
One could say that protection of workers is becoming a fully encompassing protec- tion system aimed at re-integration in social and working life.
At present, clinical rehabilitation is provided by the National Health System (through the local health authorities) and INAIL acts only to control and co-ordinate treatments for its clients.
However, the Institute is committed to carrying out several initiatives in the field of rehabilitation.
A major commitment of INAIL is in the supply of prosthesis and assistance to people with work-related amputations, as well as the supply of all technological aids to increase the activities and participation of its clients in social and working life.
The INAIL Prosthesis Centre at Vigorso di Budrio (BO) is an avant-garde research institute at the forefront in both the production and research of prosthetics. The centre implements customised prostheses and ortheses, as well as holding rehabilitation and training courses aimed at a more effective use of these prostheses, which are a funda- mental step along the individual path towards autonomy.
In the framework of rehabilitation INAIL has promoted several projects. In the field of New Technologies, the Institute has implemented a call centre and a web portal for the disabled called “SuperAbled”. This provides an integrated information and counselling service on issues such as architectural barriers, autonomy and mobility, rules and regula- tions, rehabilitation, technological means and prostheses, travel, sport and leisure.
In the field of return to work, INAIL gives a contribution to remove architectural bar- riers at the workplace, at home and in public places.
With regard to work re-integration, a multidisciplinary team in each INAIL Unit car- ries out an individual rehabilitation project for those clients qualifying for the “quota sys- tem” (Law 68/99 see above). The method is matching the residual abilities with the requi- rements of the workplace offered in the areas of residence. The individual rehabilitation projects are vocational rehabilitation projects contracted to dedicated institutions or associations and subordinated to a real job offer.
Italian policies for raising the employment level of people with disabilities
All countries of the European Union have cash benefits for people with disabilities and special policies to promote work integration. But, as in many other countries, a large
number of Italian disabled people (regardless of aetiology) have remained on benefits rather than been actively helped to return to work through special rehabilitation pro- grams. In fact, rehabilitation - which should precede the economic phase of social pro- tection - is not recognised in Italy as a pre-condition for a cash benefit. At present, in our country (as more generally in Europe) people with disabilities have a rate of employment at least 20-30% lower than that of the general population [4, 5].
For these reasons, enhancing the employment level of people with disability is an Italian as well as European goal, as reported in the European Community Household Panel (1994), the European Employment Strategy, the 1998 Member States’ National Action Plans and many other official documents.
The strategy is to open the following fronts to tackle the unemployment rate of disa- bled people:
Upgrading disabled people’s skills: improving education (mainstream); facilitating transition from school to work (vocational training and counselling). Disabled people are involved in the mainstream education with a support teacher if needed. Vocational training is actively interfaced with the open labour market, within a continuing educa- tion strategy, rather than limited to a pre-employment phase.
Creating suitable jobs for people with disabilities: facilitating self-employment; sus- taining sheltered and supported employment; encouraging social cooperatives. Social cooperatives, as non-profit organisations, are especially tailored to promote the work integration of people with disabilities, have lower working costs and greater facility to obtain work opportunities from public institutions.
Adjusting work organisation to the needs of individuals with disabilities: building a safer workplace (risk maps); harnessing new specific technologies. The framework on handicap law 104/92 foresees Regional interventions aiming to introduce technical equipment in the workplace of people with disabilities. At regional level the law 46/80 gives the NHS Units responsibility to take such action.
Building an equal opportunity environment (e.g. through non-discrimination pro- visions, quota system, and persuasion measures), and enhancing the employability of people with disabilities, moving from passive to active measures such as retraining, rehabilitation, and work integration services.
The quota system (although regarded as one of the most significant anti-discrimina- tion measures) has been revealed as insufficient to solve the problem of raising the employment level of people with disabilities in Italy [2, 3]. As shown in Table, disabled people who never entered the labour market with invalidity > 45% are entitled to enrol in job centres (from 18 to 55 years) according to the law 68/1999; for people with work- related invalidity the minimum level is set at 34%. Those people whose level of invalidity is 74% or higher receive a monthly allowance for periods of unemployment. Low employment growth and lack of enforcement of the previous law on compulsory employment (Law 482/1968) has transformed the monthly allowance into a permanent income replacement for many people with disabilities.
Data from the Ministry of Labour in 1995 showed that 158,416 disabled people entit- led to a benefit according to the Law 482/1968 were employed (43%) versus 207,150 on the waiting list (57%).
In the meantime, at regional and local level, new procedures and active policies have been tested to facilitate an exchange between disabled job seekers and businesses.
Work Integration Services (WISs) are special Guidance and Placement Services within the Social Services of the NHS Units. They represent the interface between disa- bled job seekers and local businesses. Typical tasks of WISs are: 1) to help the disabled person to assess his/her potential and personal motivation and training needs; 2) to understand the local labour market and increase awareness on the issue of work integra- tion for disabled people; 3) to build a work integration project orientated to individual training needs, adjustments of the workplace, choice of right tasks and support for rela- tional problems; 4) to counsel companies on legislation and management of work inte- gration.
In general, regional laws assign NHS Units’ specific functions to mediate between people with disabilities and the labour market based on the assumption that leaving them out of the productive context is not only economically expensive but – more importantly – socially incorrect. As disabled people have different needs and capacities, WISs develop flexible projects according to the individual’s characteristics and beha- viours. The projects can include orientation (to assess in real work contexts the potential and attitudes of the person with regard to independence, socialisation and learning in view of a possible work integration), training (to promote development of personality, enhancement of psychological, psychomotor and social functions, and learning of work skills), and other kinds of support to promote specific job skills and obtain and maintain a job. The instrument to carry out these projects is often that of a temporary engagement or “stage” in real work situations. As an example, in the Veneto Region (4.5 million inha- bitants), WISs users were 1,140 in 1991 and 2,805 in 1997 (69% physically disabled, 25%
mentally disabled, 5% addicts and 1% others). In 1997, 1,607 stages were promoted in the Region in public employment (367), industry (323), social co-operatives (302), hand- craft industries (251), trade (141), agriculture (46), and others (177): 56% of stages were for training, 28% a mediation for employment, and 16% for work orientation. With regard to the subsequent employment, industry employed the highest number of sub- jects, followed by social co-operatives, trade, handcraft, public employment, and others.
Almost 70% of work contracts were made in private companies. Public employment is keener to help in orientation and training projects rather than in employment.
For severely disabled people a social integration program within real occupational contexts is a valuable alternative to sheltered workshops. It is not related to the quota sys- tem and does not lead to an employment. However, severely disabled subjects who would not be successfully integrated as workers in the labour market may benefit from spending their time in real work contexts to practice their skills and to consolidate their level of independence.
WISs work in co-operation with job centres, local offices of the Ministry of Labour created to promote work integration for all unemployed citizens regardless of disability.
Job centres are contacted by enterprises with vacancies, and directly or via the mediation of WISs may promote work integration. Job Centres have also been given responsibility to receive subscriptions of those disabled people who are entitled to benefit of the quota system, and to allocate them.
In conclusion, WISs promote co-ordination among forces involved in active work politics, creating a so-called Guidance Group for employment of people with disabilities:
this includes local authorities, the national social security system, NHS units, training centres, job centres, trade unions, user associations, and enterprises.
References
1. Law no. 104 (February 5, 1992) on assistance, social integration and rights of people with han- dicap.
2. Law no. 68 (March 12, 1999) on norms on the right of job for people with disabilities.
3. Statutory order no. 38 (February 23, 2000) on employment injuries and occupational diseases.
4. Missoc – Mutual Information System on Social Protection in the EU Member States and EEA (web site: http://europa.eu.int/comm/employment_social/missoc2001/index_it_en.htm).
5. Blöndal S, Scarpetta S. Early retirement in OECD countries: the role of social security systems.
Organisation for Economic Co-operation and Development (OECD) Economic Studies No. 29, 1997/II.
