Mafia: The Old Country is a third-person action-adventure game set in early 1900s Sicily. It follows Enzo Favara, a former forced laborer who joins the Torrisi crime family in search of a better life and becomes involved in the violent world of organized crime.

The game follows a linear narrative structure and combines gunfights, knife combat, stealth, and exploration. Enzo travels across Sicilian towns and countryside on foot, horseback, and in period automobiles while carrying out assignments for the Torrisi family.