A garbage collection crisis has left tons of trash piling up on the streets of Naples. Efforts to sell the loss-making national carrier Alitalia are up in the air after a proposal by Air France-KLM has encountered the opposition of unions and political powers. A buffalo mozzarella health scare has hurt exports and one of the country's culinary treasures.
Berlusconi, 71 and vying for his third stint as premier in the last 14 years, blames the outgoing center-left government and vows to put Italy back on its feet. Despite a questionable record during his five-year term between 2001-2006, he says he is the man to do the job.
His main opponent, former Rome Mayor Walter Veltroni, is almost 20 younger and has promised deep reform and an ideology-free approach to tackle the country's problems.
The campaign mantra of Veltroni has been, "We need to turn the page."
Polls opened at 8 a.m. and the voting is scheduled to last until 10 p.m., then it will resume Monday until early afternoon.
Berlusconi entered the race as the front-runner, capitalizing on the unpopularity of the outgoing center-left government of Romano Prodi, whose early collapse forced the vote three years ahead of schedule.
But Veltroni has appeared to narrow the gap, according to polls released before a pre-election ban on publishing polls took effect.
Analysts say a crucial factor might be the undecided voters - a significant chunk in the electorate of 47 million. Turnout will be another factor amid campaigns to boycott the vote and punish a political class seen as collectively responsible for the nation's problems.
Italy's economy has performed worse than the rest of the euro zone for the past decade. The International Monetary Fund predicts Italy's economy will grow by just 0.3 percent this year, compared with a 1.4 percent average growth for the 15-country euro area. While the cost of living has grown, Italian salaries have not.
The main candidates have both promised to lower taxes, cut red tape and reduce the costs associated with politics, from the number of lawmakers to their salaries and perks.
While Berlusconi and Veltroni are the only candidates with a realistic shot at the premiership, there is the usual plethora of parties trying to win some of the 945 parliamentary seats that are up for grabs.
They include a group of former Christian Democrats, an alliance of radical leftists, a far-right party, an anti-abortion list. Their showing will be significant insofar as they can take away precious votes from either mainstream bloc.
Prodi, whose last government lasted only 20 months, is not running.