Supply shortages of the occupational therapy workforce in Italy: cross-regional and nationwide analysis against key benchmarks

Abstract

Background

Developing the Occupational Therapy (OT) workforce is key to supporting the growing global burden of disability. The OT workforce is underdeveloped in many countries, including high-income countries. Italy experiences significant gaps in the supply, training, and regional distribution of the OT workforce. However, no in-depth national and cross-regional analysis of the Italian OT workforce has been conducted to inform effective policy and resource planning. This study aims to (1) quantify the number of Italian OT personnel and compare numbers against national and international benchmarks, (2) identify regional workforce imbalances, and (3) identify national and regional gaps in undergraduate workforce training capacity.

Methods

Secondary, comparative analysis of OT personnel supply and undergraduate OT training capacity in Italy and its 20 regions was undertaken. Multi-sourced professional registration data was used to compute regional workforce-supply densities for 2024 and compared to international benchmarks. Ministry-based data was used to determine the number of available student places on OT undergraduate training programs in 2020–2024, compared to actual student uptake. Spearman’s rank-order examined the association between regional training capacity (i.e., density of training positions, averaged for the last five years) and the current workforce personnel density across the 20 regions.

Results

In 2024 Italy had 4.4 OTs per 100,000 people: 7.2 times lower than the European average and 17 times lower than the international recommendation. Substantive regional variations were noted: from 0.74 density in Sardinia to 20.72 in Trento-Bolzano. Yet, no Italian region met these European average (34.8–97.7% shortage) or international recommendations, with OT personnel shortages of between 72.3% and 99.0% evident. The gap between the actual and the required training capacity widened over time: from a 4.3% shortage in 2020 to a 50.4% shortage in 2025. The regional training capacity and regional workforce density were significantly correlated (estimate: 0.67; p = 0.002).

Conclusions

Italy experiences large OT workforce shortages with significant geographical inequities and widening disparities between undergraduate training needs and capacity. Both large and targeted investment which re-balances regional inequalities is critical to address Italy’s substantive undersupply and inequitable distribution of the OT workforce.

Background

Occupational therapy (OT) promotes health, autonomy and participation across the lifespan by enabling individuals, groups, and communities to engage in meaningful occupations such as self-care, work, education, and social participation [1]. According to the World Federation of Occupational Therapists (WFOT), OT services support people in doing the things they want, need, or are expected to do, using evidence-based and person-centred approaches [2]. Rehabilitation, which includes OT, is formally recognized by the World Health Organization (WHO) as an essential health service and a core component of Universal Health Coverage and is instrumental to achieving Sustainable Development Goal 3 on health and wellbeing [3].

In 2019, the WHO published Rehabilitation in Health Systems: Guide for Action, providing a global framework to support countries in systematically strengthening rehabilitation within national health systems. This commitment was reaffirmed and expanded in 2023 with the adoption of World Health Assembly Resolution WHA76.6 – based on the report EB152/10 – where all Member States, including Italy, pledged to strengthen rehabilitation governance, planning, and service delivery [4, 5] These advances are needed to address the high and increasing population need for rehabilitation. Current global data estimates that 2.4 billion people have health conditions or disabilities that would benefit from rehabilitation [6]. Furthermore, the population need for rehabilitation, which includes OT, has increased by 17% per capita worldwide since 1990, an increase that has been observed across countries of varying income levels [7]. Furthermore, the global ageing of the population and rising rates of chronic and non-communicable conditions is likely to continue to increase over time and often associated with increased disability rates and population need for rehabilitation and OTs [8, 9].

In this context, the WFOT has developed the Global Strategy for the OT Workforce [10, 11], which includes a focus on strengthening workforce data, expanding education, and improving geographical distribution. For instance, the focus on data strengthening also arises from the current lack of data specifically for OTs in major international databases, such as the National Health Workforce Accounts that provides nation’s data for 40 specific cadres, including physiotherapists and non-professional physiotherapy assistants, but not OTs [12]. Part of that gap arises from the historical exclusion of OTs as a unique occupational category is the International Labour Organization’s International Standard Classification of Occupations, rather part of a broader category of health professional not elsewhere classified [13]. This study for Italy is framed in the context of the need to improve the understanding of the current status of the OT workforce, especially in undersupplied contexts.

In Italy, the OT workforce is likely experiencing personnel shortages. According to the recent data published by the national associations of OTs to the WFOT, Italy has amongst the lowest rates of practicing OTs per population, among high-income nations [14]. Moreover, the same dataset shows that the number of Italian OTs per population size are < 50% of that for 10 low- and middle-income countries in Africa, Latin America, or Asia, such as 13% of the rate of OTs per capita in Argentina [14]. Finally, Denmark (i.e., the country with highest rate of OTs worldwide) has 60 times more OTs per capita than Italy does. These numbers may also reflect a professional imbalance between OTs and other rehabilitation professions such as Physiotherapists (PTs).⁴ For example, a study using data from 35 high-income countries found that Italy has the lowest ratio of OTs per PTs (1 OT per 48 PTs) in stark contrast to other countries where the ratio is close to 1:1⁵. While these global comparisons evidence an undersupply of OTs in practice, the available data are estimations or collected via different methodologies, for example, through professional organizations and not regulatory bodies. Hence, there is a need for more comprehensive and methodological data collation and integration of data sources. Moreover, there is also a need to understand regional imbalances in the distribution of qualified OT’s, and availability and uptake of undergraduate training places, in addition to the expected shortages of the available workforce nationwide [15].

In line with WHO and European Observatory perspectives, this study interprets workforce planning and organization within a health system governance lens. Governance, understood as the processes through which health systems set strategic direction, regulate professions, ensure accountability, and coordinate stakeholders, provides a useful framework for interpreting the observed workforce imbalances. While multiple governance models exist, this analysis draws on WHO’s understanding of governance as a core health system function that encompasses stewardship, policy coherence, and performance oversight [16, 17]. Within this framework, one can leverage national workforce data against national requirements and international benchmarks as key tools for enabling an effective stewardship, aligning policies across sectors, and driving performance improvements in the Italian rehabilitation system. In this context, the aim of the present study is to quantify Italian OT workforce shortages against national and international benchmarks, identify any regional imbalances, and finally determine any national and regional gaps in undergraduate OT training capacity, relative to nationally-established requirements.

Methods

Overview

This study is a secondary, comparative analysis of OT workforce supply and undergraduate OT training capacity for Italy and its 20 regions. Multi-sourced professional registration data was used to compute regional workforce-supply densities for 2024, compared to international benchmarks: (i) data on the Italian OT workforce were obtained from the FNO TSRM-PSTRP registers as of December 31, 2024; (ii) data for the WHO European Region was collected by WFOT and Council of Occupational Therapists for the European Countries (COTEC) public databases; (iii) Ministry-based data was used to determine the number of OT undergraduate university programs and available places on these undergraduate programs (2020–2025), compared to the yearly, government -established requirements for the number of OT undergraduate places needed that year. Finally, Spearman’s rank-order examined the association between the availability of training positions and the respective workforce density across the 20 regions. The study involved the use of public domain records and direct inquiries to local professional bodies to obtain OT supply data. Given the non-identifiable nature of the data collected from local professional bodies, individual consent was not required. The study protocol was classified as exempt from ethical approval by the Institutional Ethics Committee of Link Campus University.

OT workforce: data sources

In Italy, practicing OTs must register annually with the regulatory body of the profession and maintain professional liability insurance [18]. These regulatory bodies operate at the provincial or inter-provincial level under the supervision of the Ministry of Health (MoH) and are responsible for licensing and for assuring professional conduct and public protection. Within the rehabilitation sector, eight professions are officially recognized, including Physical Therapists (PTs), OTs, Speech and Language Pathologists, among others. Among these, only PTs have a profession-specific regulatory body. All other rehabilitation professions, including OT, are integrated into a multi-professional body: the Federazione Nazionale degli Ordini TSRM e delle Professioni Sanitarie Tecniche, della Riabilitazione e della Prevenzione (FNO TSRM-PSTRP). This multi-profession body operates through national, regional, and provincial “Commissioni d’Albo” (Professional Boards). For OTs, these boards oversee registration, standards, and disciplinary matters.

Data on the absolute number of registered OTs as of 31 December 2024 was obtained from the FNO TSRM-PSTRP. When regional or provincial figures were not publicly available, the authors submitted standardized email inquiries to the corresponding local Professional Boards requesting data on the number of registered OT personnel. Altogether, the number of registered OTs were then transformed into a rate per 100,000 inhabitants (i.e., OTs density), enabling regional and international comparisons. To allow this, a resident population count for each region was retrieved from the Italian National Institute of Statistics (ISTAT) for the same reference date [19]. The authors appreciate that the number of registered OT’s does not necessarily translate accurately into the number of actual working OT’s, however, as registration is annual, the difference is considered minimal. All data was collated in a secure database and underwent consistency checks: entries provided by local orders were cross-referenced against national records, and any local Professional Boards failing to supply confirmed counts after two requests were flagged for sensitivity analyses ¹⁶.

Data on the occupational therapy workforce within the WHO European Region were obtained from two primary sources: the Summary of the Occupational Therapy Profession in Europe compiled annually by COTEC [11], and the WFOT Human Resources Project [14]. The COTEC summary draws on information provided by its Member Associations and includes data on workforce size, professional regulation, and education across Europe. The WFOT project collected comparable demographic and workforce data from 105 Member Organisations worldwide, achieving a 98% response rate. Both databases rely on data reported by national associations, representing the total number of registered occupational therapists, irrespective of their current employment status, ensuring definitional consistency across countries and enabling valid international comparisons.

OT undergraduate training data – supply and need (data sources)

Data on the number and geographical distribution of OT BSc programs (i.e., entry-level bachelor programs) and the number of training positions available (TPA) in each program for the five-year period 2020–2025 were obtained from the Ministry of University and Research (MUR).

The National Training Requirement (NTR) for OTs represents the government’s estimate of the number of undergraduate training positions needed annually. The NTR is updated every year and, for the reference period, was obtained from the agreement ratified by the Conferenza Stato-Regioni on July 11, 2024 (Rep. atti n. 130/CSR). Issued by the MoH, the NTR defines the estimated number of healthcare professionals that should be trained to meet the needs of the Italian national health system and serves as a national benchmark.

Italy defines its national training requirements through a quantitative stock-and-flow forecast model, mandated by Article 6-ter of Legislative Decree No. 502/1992. This model projects medium- to long-term workforce needs by comparing the current stock of active professionals (in both public and private sectors) with anticipated inflows (e.g., university graduates, licensed but inactive professionals) and outflows (e.g., retirements, mortality), using demographic projections and survival probabilities derived from ISTAT life tables. Key parameters include the estimated demand per 100,000 inhabitants, university admission capacity, academic success and licensure rates, and the activation potential of licensed professionals not yet employed. Scenario analysis is applied to simulate workforce balances under different assumptions concerning demography, retirement patterns, and educational capacity.

Regional health authorities, in consultation with professional boards, adapt this model to define their local training needs and submit them to the MoH. These regional contributions are centrally reviewed to ensure alignment with national health planning objectives. The MoH then conducts a negotiation process involving the MUR, the Regions, professional boards, and universities. The outcome is an agreement ratified by the Conferenza Stato-Regioni, which establishes the national training requirements for each healthcare profession.

Subsequently, the MUR consults individual universities. Although universities retain academic autonomy, they are requested to declare their training capacity for each program. The proposed admission numbers are then reconciled with the national requirements defined in the agreement, resulting in the TPA. The outcome is the official numerus clausus, which reflects both model-based workforce demand forecasts and the actual training capacity of academic institutions.

Comparing the OT workforce supply (registered) and training supply against benchmarks

Nationally, and for each region, the OT personnel, or workforce supply (i.e., density of OTs registered in the given locations) against two international benchmarks were compared. The first is the WFOT’s recommendation of 75 OT per 100,000 inhabitants, also reported in WHO policy document [20]. This figure represents an estimate of the workforce required to meet rehabilitation needs, and it was chosen as a needs-based planning standard rather than relying on the current global average, which reflects availability rather than need. The second is the European average 31.76 OTs per 100 000 population [11], which is a data-based peer comparator international benchmark. The expected rate in each of the 20 Italian regions was thus:

with “org” equal to WFOT recommendation or EU average. The absolute gap G_i^(org) between observed and expected density rates was expressed as

and the relative gap R_i^(org) in the form of percent difference as

To illustrate geographic variability from a visual-analysis standpoint, choropleth maps of density and relative gap measures were produced using a geographic information software: Datawrapper.de [21].

Finally, for each year in the five-year period from 2020 to 2024, the yearly need for additional OTs (as determined by the NTR for each Italian region) was compared with the number of OT training positions available in the respective regions (based on Ministry-level educational data). Percent differences were also computed for that early data, which were further aggregated into five larger Italian areas (Northwestern; Northeastern; Central; Southern; Islands) and subsequently at national level.

Associating OT-BSc undergraduate training to OT- personnel workforce supply

Spearman’s rank-order correlation was used to test whether the population-adjusted rate of OT undergraduate training positions (i.e. average of the fiver last years) in each of the 20 Italian regions is associated with their population-adjusted rate of registered OTs in 2024. That helps determine whether there are regional OT training imbalances and if these are associated with workforce imbalances. This would inform if there is a need for great region-focused capacity building. Non-parametric testing was implemented due to a low number of regions/observations (i.e., 20), while the registered OT density (which would be the outcomes variable for a linear regression) had a significant result (W = 0.668, p < 0.001) using the Shapiro–Wilk test for normality. That indicated departure from normality, precluding parametric techniques for subsequent analyses.

Results

OT personnel workforce availability against benchmarks

A total of 2,749 OTs were registered across the 20 Italian regions and included in the analysis, with a national ratio (i.e., density) of 4.4 per 100,000 inhabitants. This number ranged from a minimum of 0.74 in Sardinia to a maximum of 20.72 in Trento-Bolzano, with most regions reporting fewer than 5 OTs per 100,000 inhabitants. Results are synthetized in Table 1.

Table 1.

Density of occupational therapists per 100,000 population, across 20 Italian regions, and the percent gaps recommendations of the WFOT

Italian regions	Population (in thousands)	OTs x 100k	Percent gap: International (%)	Percent gap: EU (%)
Abruzzo	1,265	11.86	-84.2	-62.7
Apulia	3,839	2.87	-96.2	-91.0
Basilicata	5,39	4.64	-93.8	-85.4
Calabria	2,096	1.81	-97.6	-94.3
Campania	6,804	2.91	-96.1	-90.8
Emilia Romagna	4,262	3.64	-95.1	-88.6
Friuli Venezia Giulia	1,201	4.08	-94.6	-87.1
Latium	5,565	10.69	-85.7	-66.3
Liguria	1,582	1.83	-97.6	-94.2
Lombardy	11,141	4.27	-94.3	-86.6
Marche	1,501	1.8	-97.6	-94.3
Molise	296	3.72	-95.0	-88.3
Piedmont and Aosta Valley	4,660	4.14	-94.6	-87.0
Sardinia	1,344	0.74	-99.0	-97.7
Sicily	4,639	1.79	-97.6	-94.4
Tuscany	4,224	2.11	-97.2	-93.5
Trento-Bolzano	1,086	20.72	-72.3	-34.8
Umbria	854	1.87	-97.5	-94.1
Veneto	4,040	4.21	-94.9	-86.8

Our data reported a significant gap in each Italian region between the WFOT’s recommended OT personnel density and the 2024. Actual density of registered OT’s, with gaps ranging 72.3–99%. Measured against European recommendations, a gap was also evident which ranged from 34.8 to 97.7%.

Figure 1 provides a comparative overview of OT personnel workforce density across selected European countries, expressed per 100,000 inhabitants, offering contextual insight into Italy’s position relative to broader European trends.

Fig. 1.

Density of occupational therapists (OTs) in Europe per 100,000 inhabitants

Figure 2 presents the distribution of registered OT personnel density across Italy at the level of professional boards. These are organized by provinces or regions, depending on the administrative structure, visualized through a choropleth map with graduated color scales. Figure 3 illustrates the same indicator aggregated at the regional level, emphasizing geographical disparities in workforce availability during the year of 2024/2025.

Fig. 2.

Density of occupational therapists / 100.000 inhabitants by each of the 20 Italian regions

Fig. 3.

Granular-level density of occupational therapists / 100.000 inhabitants, i.e., by local professional registration body

OT BSc undergraduate workforce training: need versus supply

Figure 4, focused on Italy overall, highlights the growing yearly gap between National Training Requirements (NTR) and Training Positions Available (TPA) for OT programs. Essentially, the NTR (equating to the nationally-established training needs) has grown substantially especially between 2020 and 2022 to require > 500 OTs per year nationwide, while the TPA continues to revolve around 250, with no observable tendency for an increase. Consequently, the gap between yearly training needs and training supply has widened considerably over the observed period, increasing from 4.3% in 2020/21 to 50.4% in 2024/25.

Fig. 4.

Yearly National Training Requirements (NTR) and Training Positions Available (TPA) for Occupational therapy programs and their respective gaps

Table 2 strategies these results per each of the 20 Italian regions and five major areas of these, compensating for some regions with no training programs or training expectations. The Southern region consistently experienced the most critical shortages, with percentage difference increasing from − 66.3% in 2020/21 to a maximum of -81.4% in 2023/24, followed by a modest reduction to -74.1% in 2024/25.

Table 2.

National training requirement (NTR) vs. training positions available (TPA) for occupational therapy, university-based BSc programs

		2020/21			2021/2022			2022/2023			2023/2024			2024/2025
Larger area	Region	NTR	TPA	% gap	NTR	TPA	% gap	NTR	TPA	% gap	NTR	TPA	% gap	NTR	TPA	% gap
Italy		280	260	-4.3	343	251	-26.8	530	274	-48.3	532	210	-60.5	530	263	-50.4
Northwestern	Aosta Valley	0	0	-37.6	0	0	-37.6	1	0	-41.7	3	0	-59.2	3	0	-61.9
	Piedmont	15	16		15	16		20	16		20	0		19	10
	Liguria	20	0		20	0		20	0		20	0		20	0
	Lombardy	50	37		50	37		55	40		55	40		50	25
Northeastern	Emilia Romagna	15	28	56	28	28	-7.9	35	28	-25.7	30	28	-40.8	30	28	-21.2
	Veneto	30	30		30	30		30	30		30	30		30	30
	Trentino Alto Adige	5	20		5	0		30	20		28	0		27	20
	Friuli Venezia Giulia	0	0		0	0		10	0		10	0		12	0
Central	Tuscany	0	0	97.1	5	0	-1.3	20	0	-45.2	10	0	-43.1	10	0	-45.2
	Latium	10	69		40	74		75	74		75	74		75	74
	Umbria	10	0		15	0		20	0		20	0		25	0
	Marche	15	0		15	0		20	0		25	0		25	0
Southern	Abruzzo	8	27	-66.3	8	27	-68.2	27	27	-79.9	27	27	-81.4	27	22	-74.1
	Campania	30	0		30	0		30	0		45	0		45	15
	Calabria*	10	0		8	0		20	0		20	0		22	0
	Molise	2	0		3	0		12	0		8	0		4	0
	Apulia	30	0		30	0		35	0		40	0		40	0
	Basilicata	0	0		6	0		10	0		5	0		5	0
Island	Sardinia	0	0	30	10	0	-13.3	25	0	-35	25	0	-36.1	25	0	-36.1
	Sicily	30	39		35	39		35	39		36	39		36	39

Table 3 presents the correlation between regional OT training density and regional OT workforce density supply.

Table 3.

Spearman’s rank-order correlation between the density of occupational therapy (OT) training capacity (i.e., population-adjusted training positions) and the density of the registered OT workforce per Italian regions

Group	Median OT/100 000 (IQR)	Spearman’s rho 95% CI	p-value
Registered OTs (density)	3.64 (2.49)	0.67 (0.29–0.86)	0.002
OTs training capacity (density)	0.00 (0.63)

Discussion

This secondary analysis of the Italian OT personnel workforce production and availability supply identifies substantive workforce shortages (against international benchmarks), regional supply imbalances, and regional gaps in the OT undergraduate BSc training capacity, relative to the nationally established requirements. Nationally, the density of registered OTs was found to be 7.2 times lower than the European average and 17 times lower than the WFOT recommendation. While substantive regional variations were identified, no Italian region came close to meeting the European average or international recommendations for the availability of OT’s. Furthermore, the OT training capacity has not increased and the gap toward the nationally-established training needs has been widening over time. Finally, workforce density across Italian regions was significantly correlated with the regional training capacity, or lack thereof. All these findings are worth-discussing [22].

The Italian rehabilitation sector is characterized by overlapping professional roles and fragmented scopes of practice. This fragmentation blurs professional boundaries and often leads to the partial substitution of OTs by other cadres in certain service settings. While such arrangements may temporarily mitigate immediate workforce shortages, they risk diluting role-specific expertise and reducing the overall efficiency and coherence of rehabilitation care. In Italy, several related professions, such as professional educators, psychiatric rehabilitation technicians, and neuro- and psychomotor therapists for developmental age, perform valuable functions but lack international recognition as rehabilitation professionals. For instance, professional educators are affiliated with the International Association of Social Educators [23], whose domain focuses primarily on social work rather than rehabilitation, while Psychiatric Rehabilitation Technicians and Neuro- and Psychomotor Therapists for Developmental Age have no direct equivalents in most other European or global health systems.

The coexistence of multiple cadres with partially shared scopes of practice thus creates a workforce structure that may appear numerically adequate as a whole, but whose role overlaps and skill mix insufficiencies are not aligned with international standards. Consequently, the observed undersupply of OTs may go beyond an absolute Italian deficit in the supply of rehabilitation worker, but more accurately reflect an inefficient or imbalanced distribution of roles and competencies [15, 22]. Therefore, rehabilitation-workforce strengthening activities may need to target an absolute and regional increase in the OT workforce, but at the same time clarify professional boundaries, ensure appropriate task allocation, and recognize OT as a profession within a unique and needed scope of practice, in line with WFOT [1, 2] and WHO standards [5]. Such recognition would enhance workforce planning, strengthen professional visibility and accountability, and a fit for purpose rehabilitation workforce, with an adequate skill mix beyond whole supply [1, 2, 5].

In recent policy discourse in Italy, the FNO TSRM-PSTRP has proposed a strategic vision for health workforce reform, emphasizing interprofessional collaboration and task-shifting [24]. While aligned with international frameworks that promote integrated service delivery [25], task-shifting must be implemented cautiously to prevent the erosion of key professional identities and safeguard the specific competencies that underpin high-quality, occupation-centered rehabilitation care. In the current context of OT undersupply, several professional groups in Italy already perform functions defined as core OT roles by the WFOT and recognized by the WHO as essential to rehabilitation. Without clearer boundaries and stronger regulatory harmonization, task-shifting may reinforce functional overlaps, weaken accountability, and hinder professional development where shortages are most acute [26]. We argue instead for a competency-based and evidence-informed delineation of scopes of practice, consistent with WHO and WFOT frameworks. Redistributing tasks across professions should enhance, rather than blur, professional identities, ensuring that each cadre contributes according to its full scope and global standing [27]. Regulatory reforms should also harmonize Italian professional profiles with European or international classifications to support workforce comparability, quality of care, and cross-border mobility [28]. In this light, the strategic perspective offered by FNO TSRM-PSTRP represents a welcome effort to elevate allied health professions within health policy discourse. However, its implementation must be grounded in clear professional boundaries and international standards [29–31] Otherwise, reforms risk institutionalizing ambiguities and perpetuating a fragmented, inefficient rehabilitation workforce landscape.

To address the current fragmentation, partial overlaps, and skill-mix imbalances, regulatory reform in the rehabilitation workforce field is likely essential for Italy. Such a forward-looking reform should engage all relevant stakeholders to clarify competencies and scopes of practice, promoting an alignment with international professional standards and definitions as possible. All of that would enable clear role definitions, which in turn could lead to a more balanced rehabilitation-workforce supply, and more alignment with international supply benchmarks [26, 32]. Interdisciplinary situational assessment of the whole Italian rehabilitation workforce, for example using WHO’s Guide for Rehabilitation Workforce Evaluation (GROWE), including with competency-analysis focus, might enabling that reform and clarification [32, 33]. Reforms should also be extended to undergraduate OT educational programmes, as only 44.5% are WFOT-approved for meeting international standards [34]. There is great variation in the quality of the undergraduate education of OTs, possibly failing to meeting international standards of competency, and affecting the international recognition and mobility of the Italian OTs trained in non-WFOT-approved programs.

Regional inequity in OT workforce availability adds to the overall Italian OT shortage. Our mapped data shows that OT’s (i.e., density adjusted for population size) are especially concentrated in highly urbanized areas (e.g. around Rome, Milan) and other smaller communities (e.g. Padua) where OT training positions are available. This association is supported by a significant correlation (p = 0.002) and Spearman’s rho of 0.67 95% CI (0.29–0.86) among regional training positions and regional workforce registration. Less-densely populated areas typically face difficulties in attracting and retaining skilled health workers, including OTs [25, 35]. That imbalance may be more pronounced in the context of a national undersupply. For example, that phenomenon has been observed in Australia [36] as well as in South Africa, where most OTs are based in urban, densely populated provinces [26]. In Italy, the same scenario seems to happen, of smaller density of OT even when compared to South Africa, i.e., Italy has 40% of the overall OTs density of South Africa’s [14]. In turn, the availability or opening of OT training programs or positions in less densely-populated Italian regions (e.g. following Padua’s example) may be a path moving forward in reducing the overall Italian undersupply of OTs as well as its inequitable regional distribution [15, 35, 36].

The Italian OT-workforce undersupply and maldistributions trending towards increasing. Our data show that the number of OT undergraduate training positions are not increasing in Italy, while many of the less-densely populated Italian regions continue to have no training positions available in 2024/2025. While the OT-training needs (established by a health-system authority) have increased, the numbers of training positions (deployed by a higher-education authority) have not followed suit; hence, the need-available training gaps have been widening over time. A silo-based approach from two different sectors and authorities may partly justify the disconnect [33, 37]. Moreover, the used models to estimate OT-training needs in Italy may also need an update, especially with a focus on underserved regions. For example, Sardinia had zero training needs for OTs in our data. That is difficult to reconcile with demographic and epidemiological indicators. Sardinia has one of the highest proportions of elderly residents in Italy, while rehabilitation-need rates are highly associated with the population aging [8]. Sardinia also consists of mainly rural territories and small, often isolated communities. These are among the conditions in which OTs can help managing functional decline among older populations, promote occupational engagement and social participation, design age-friendly environments, and delivering rehabilitation approaches through community-based approaches [35, 38]. Overall, the methodology and criteria used for regional workforce forecasting may need to be revised. In Italy, the healthcare workforce is shaped by the interplay between national directives and regional autonomy. While the MoH sets general strategies in collaboration with regions, based on demographic trends and epidemiological profiles, final determination is decentralized. As a result, substantial heterogeneity persists across regions, particularly in the rehabilitation sector. The absence of a unified, long-term forecasting model aligned with international standards may limit the more cohesive, equitable development of health professionals, including OTs.

Overall, there is a need for a multi-pronged, systematic, and equity-oriented approach in Italy to develop the regulatory, forecasting, and both national and regional training landscape for strengthening the OT workforce, which severely lags in supply relative to international standards and European counterparts. Our data also showed a significant correlation between the regional training capacity and regional workforce registration. This finding goes in lone with global evidence indicating that the health workforce supply is closely linked to the availability and geographic proximity of professional education [26]. It is not expected that a large chunk of those OTs trained in more urbanized regions are attracted to practice elsewhere in underserviced regions just by market dynamics; hence, more regionalized OT training programs, tailored in number and scope [15, 35, 36], may be needed for the most underserved regions of Italy.

Limitations

This study and results have the following limitations. First, the analysis was based on the OT workforce registered for practice, without accounting for those who, although registered, may be unemployed, engaged in part-time work, or employed in non-OT roles. Consequently, the actual OT workforce in terms of full-time equivalents is likely to be overestimated. Second, international comparisons of densities among rehabilitation professions, albeit grounded into international professional standards, do not account for the different regulatory and competent landscape within jurisdictions, including presence or not of other cadres, licensed therapy assistants, and others that may be present in some contexts and not in others; hence, affecting the demand for specific professions [9, 22, 32]. Third, the analysis was based on the number of available training positions (i.e., installed training capacity), rather than on the number of graduates, which would additionally account for unfilled vacancies, non-completion rates, or changes in educational pathways. While there are no system-wide graduation numbers available, some Italian OT programs anecdotally reported to the national association of OTs some concerns about attrition. If so, this would aggravate the undersupply scenario and deserve further research on both the system-wide numbers and reasons why. Strengthening the OT workforce in Italy may require not only building more capacity, equitable across regions, but also mechanisms to increase attractiveness, reduce attrition, and improve deployment of new graduates, including in underserved areas. Moreover, our significant correlation between densities of training and workforce supply across regions should not be understood through the lens of causal inference. It is a simple correlation of population-adjusted ratios, i.e. not accounting for regional socio-economic and demographic covariates. More complex analytical approaches were prevented by the analysis of 20 regions/observations only. Finally, This study used a rapid assessment approach as a pragmatic first step to generate preliminary, evidence-based insights on the OT workforce, pending a future comprehensive (e.g. stakeholder-engaged, multi-professional, mixed-methods) situational and health-labour market assessments.

Conclusion

This study highlights a critical undersupply and uneven distribution of OTs across Italy, with workforce density and training capacity falling far below European and international benchmarks. These findings should not be interpreted as a mere supply shortage of one profession but as a structural and systemic challenge requiring coordinated action at national and regional levels. For instance, there is a need for developing comprehensive rehabilitation workforce governance in Italy - inclusive of oversight, stewardship, and policy coherence functions – that promotes the monitoring of this whole workforce needs, while clarifying and further regulating the scope of practice of related professions and cadres, in alignment with both local needs and international standards.

Derived from our results, the following rehabilitation strengthening recommendations can be provided:

First, strengthening workforce data systems is essential. Establishing an integrated national database on rehabilitation professionals, covering education, employment, and vacancies, would enable continuous monitoring, accurate forecasting, and promote the development of health-labour market assessments. Second, clear delineation of scopes of practice among rehabilitation and related professions is needed to reduce functional overlap, safeguard role-specific expertise, and promote efficient, team-based care. Third, enhancing regulatory and quality standards should be prioritized. Aligning national professional classifications, accreditation mechanisms, and educational programs with WFOT and WHO frameworks would strengthen accountability, comparability, and international recognition. Finally, investment in regional training expansion might be needed towards a more equitable development and deployment of the Italian OT supply. However, expansion must be guided by evidence-based workforce planning that reflects population health needs, system capacity, and the actual ability of services to employ and retain new professionals.

Overall, a multi-pronged strategy combining better data, clearer roles, stronger regulation, and context-sensitive investment will be fundamental to ensure that Italy develops a balanced, competent, and internationally aligned OT workforce capable of responding to the country’s growing rehabilitation demands.

Abbreviations

COTEC

Council of Occupational Therapists for the European Countries

FNO TSRM-PSTRP

Federazione Nazionale degli Ordini TSRM e delle Professioni Sanitarie Tecniche, della Riabilitazione e della Prevenzione

ISTAT

Istituto Nazionale di Statistica (Italian National Institute of Statistics)

MoH

Ministry of Health (Italy)

MUR

Ministry of University and Research (Italy)

NTR

National Training Requirement

OT

Occupational Therapy / Occupational Therapist

TPA

Training Positions Available

WFOT

World Federation of Occupational Therapists

WHO

World Health Organization

Author contributions

RS and MT conceptualized the study design and led the analysis. AG, GC, and MT contributed to data collection, verification, and interpretation. RS, MT and TSJ drafted the manuscript. All authors reviewed, revised, and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets analyzed during the current study are available from the corresponding author (RS) on reasonable request. Aggregated national data are also publicly accessible through the Italian Ministry of Health, the Ministry of University and Research, the Italian National Institute of Statistics (ISTAT), and the World Federation of Occupational Therapists (WFOT).

Declarations

Ethics approval and consent to participate

This study did not involve human participants directly. It relied exclusively on secondary, publicly available, and aggregated data (e.g., national registries, government reports, and official statistics), none of which contained personal or identifiable information. In accordance with national regulations and institutional policy, the use of such data does not require informed consent. The study protocol was reviewed and classified as exempt from ethical approval by the Institutional Ethics Committee of Link Campus University. All procedures were conducted in compliance with relevant national legislation and with the ethical principles outlined in the Declaration of Helsinki.

Consent for publication

Not applicable. The manuscript does not contain any individual person’s data in any form.

Competing interests

The authors declare no competing interests.