THE POLITICS OF LONG-TERM CARE IN SOUTHERN EUROPE: A CROSS-CASE COMPARISON OF SPAIN, ITALY AND PORTUGAL

Long-term care (LTC) has emerged as one of the most politically consequential domains of contemporary European welfare states, positioned at the intersection of social and health policy and shaped by intersecting demographic, epidemiological, and labour market transformations. Yet despite the rapid growth of sociological and institutional scholarship on LTC, the political dynamics underpinning its reform remain comparatively undertheorised. This dissertation addresses that gap by examining how configurations of power and ideational resources — in interaction with institutional legacies and contextual factors — shape LTC policy development across national contexts. Focusing on Southern Europe, the dissertation asks why Spain, Portugal, and Italy have followed divergent institutional trajectories in the reform of LTC despite broadly comparable demographic pressures and similar policy legacies. The central argument is that LTC reform is driven less by gradual, path-dependent institutional change than by strategic political exchange: contingent bargains between governments and organised actors that convert temporary windows of opportunity into moments of reform, each shaped by specific coalitional alignments and negotiation dynamics. Three structural features of the LTC sector — low mass salience, high policy complexity, and fragmented organised interests — make this mechanism particularly consequential and analytically tractable. Through comparative historical analysis and process tracing, the dissertation reconstructs the major structural reforms enacted in Spain (2006), Portugal (2006), and Italy (2023–2024), drawing on parliamentary and policy documents, administrative records, media archives, and sixty-one elite interviews conducted between 2023 and 2025. The Spanish case illustrates how a cohesive pro-reform coalition successfully reframed care dependency as a universal social right, institutionally consolidated through compensatory bargains with regional governments and market actors. The Italian case demonstrates how a broad advocacy coalition leveraged the COVID-19 crisis and EU fiscal conditionality to advance a national LTC framework, subsequently narrowed by partisan alternation and the resurgence of familist policy logics. The Portuguese case reveals how a corporatist bargain among professional groups and third-sector providers enabled incremental institutionalisation of an integrated health–social care network, without generating universal individual entitlements or inducing systemic de-familialisation. From these empirical findings, the dissertation derives three theoretically grounded propositions. First, policy ideas operate as coalition-building devices — cognitive and normative resources that enable actors to converge around shared problem definitions and compatible modes of policy design. Second, the strategic activation of political cleavages — including state–family, state–market, state–church, and centre–periphery — mediates the translation of ideas into coalitional alignments, typically at the cost of concessions that leave durable imprints on policy design. Third, partisan configurations — particularly the party in office, parliamentary composition, and levels of party-system polarisation — shape both the ideational repertoire available to reform advocates and the boundaries of feasible political exchange. The interaction between puzzling and powering ultimately defines the scope of possible reform outcomes.