Financing intersectoral action for health: a systematic review of co-financing models

Intersectoral co-financing (hereafter referred to as ‘co-financing’) cases were conceptualised according to two criteria. First, co-financing requires the joint commitment of resources towards an intervention or interventions by at least two budget holders. Resources can include financial or in-kind contributions. Second, the budget holders must have dissimilar programming objectives, or more specifically, they must be allocating their resources to achieve distinct end outcomes. These outcomes can be defined at a sectoral or sub-sectoral level (e.g. population health outcomes, such as lives saved or quality of life gained; or disease-specific outcomes, such as HIV infections averted). Two health sector budget holders combining their resources to achieve the same outcome (such as a Ministry of Health and an external donor) would not classify as co-financing given the shared objective.

The approach draws conceptually on health system financing, with its three distinct functions: revenue collection (to raise money for health); pooling of resources (to share the financial risks of paying for healthcare); and purchasing of services and interventions (to optimise the use of health resources) [22]. Although health financing focuses primarily on how to pay for healthcare services and public health interventions, co-financing focuses more on how to raise money for health outcomes across public sector payers, and then how to use those funds to purchase healthcare and non-health interventions that maximise health outcomes [23]. Clearly, what is considered ‘revenue collection’ for one sector (health, in this case) is a form of purchasing outcomes for the contributing sector. Moreover, the programmatic financial risk is shared across sectors, as no single-payer takes on the full cost of delivering the intervention/service, but this is quite distinct from the risk-pooling of individual health risk.

Co-financing can, therefore, involve sharing the revenue collection and/or purchasing functions across payers from different sectors. For the health sector, this would allow for non-health sector resources to be leveraged for health gain, and for strategic purchasing of non-health interventions with co-benefits. The types of financial mechanisms used to operationalise co-financing can be further sub-categorised, based on the typology summarised in Table 1 that is adapted from Mason et al. (2015) [20].

The review process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A systematic search of peer-reviewed and grey literature was performed using a three-level process. First, sixteen electronic bibliographic academic databases were searched: Africa-wide Information, Applied Social Sciences Index & Abstracts, CINAHL Plus, EconLit, EMBASE, ERIC, Global Health, Health System Evidence, HMIC, IBSS, MEDLINE, PsycINFO, ScienceDirect, SCOPUS, Social Policy & Practise and Web of Science. Second, grey and policy literature was identified through a structured search of Google, Open Grey, the OECD iLibrary, the World Bank eLibrary, and ADOLEC Lit. Finally, reference snowballing or hand searches of included articles was used to identify any previously unidentified articles. No geographical or publication date constraints were applied. The search was limited to articles published in English before March 2018 (see additional file 2 for search strategy).

After removal of duplicates, each record (title and abstracts) was independently screened and categorised by two authors (FM and MR), and disagreements were resolved through discussions. Table 2 lists the inclusion and exclusion criteria for studies. Both qualitative and quantitative study methodologies and data were included – qualitative for establishing typologies and themes on the enablers and barriers, and quantitative to assess the effectiveness of co-financing models. Exclusion for poor methodological quality was not performed to provide a critique of current methods to inform future research design.

Data from included articles were extracted using a customised tool (in Microsoft Excel) with domains including the description of the programme or intervention, country, and actors, administrative level of operation, payers, purpose of model, financial mechanisms, governance structures, study design, reported outcomes/effects, barriers and enablers of the co-financing cases. Where there were multiple publications on a specific co-financing case, these were included and used to extract the required information. Extracted data was used to develop a typology of co-financing models, drawing on the conceptual definition and financing mechanisms presented above.

Qualitative data on the enablers and barriers to uptake, implementation, and continuation of the co-financing approach was extracted when reported in a study. This was first coded using open unfocused coding, based on emergent in-vivo themes (non-a priori). Next, these open codes were grouped into higher-level categories and sub-themes, that were constructed based on an understanding of the text and context.

The initial search identified 2751 publications (after duplicates removed). After screening, 198 publications were identified as eligible for inclusion (see Fig.1) and covered 81 separate implemented cases of co-financing. Most excluded cases involved integration or coordination without co-financing or co-financing between budget holders with identical objectives.

The included cases and articles reflected co-financing arrangements between the health, education, environment, agriculture, social care, housing, economic and labour sectors, with different end-objectives, or set of outcomes. Table 3 outlines the cases identified. More descriptions of included cases are provided as Additional file 1. 

The first characteristic that differentiated the co-financing cases identified was the objectives that they were trying to achieve. All co-financing cases found were broadly similar in their ultimate objective, that is to improve each participating sector’s outcomes and/or reduce their costs. However, we observed two distinct approaches for how the models would allow them to do so, which we define as ‘integrative’ co-financing and ‘promotion’ co-financing cases. Integrative models engaged in co-financing to integrate or better coordinate service provision across sectors, often for a specific population group. They tended to involve sectors with regular simultaneous or consecutive service provision. Most commonly, this involved financing the coordinated provision of health and social care services for a pre-defined population. For instance, integrated health and social care commissioning were introduced in Scotland in 2014 in response to the recognition of the importance of the social care sector in stemming rising expenditure in the health care sector [24‐28]. Financial pressure on the health care system was predicted to worsen with the elderly population projected to increase by 85% between 2014 and 2039 while 34% of the household include at least one individual suffering from a chronic health problem or disability. The aim of the integration is to provide high-quality care and joined-up services that support people to stay in their homes. Similarly, the System for Integrated Care for Older Persons (SIPA) case implemented in Canada was aimed at community-based elderly individuals who are at-risk of requiring institutionalisation and frequent access to acute health care services [29‐31]. The objective of the programme was to meet the health and social care needs of individuals in an integrated manner, through multidisciplinary team service provision.

Promotion models involved one sector investing in another sector, and leveraging its resources, to address upstream factors that affect its own sectoral outcomes. These were often models for health promotion. For example, the Prince Edward Island province in Canada, recognising the breadth of the factors that influence health, designed an explicit financial and governance mechanism to facilitate cross-sectoral action [32‐34]. This mechanism included several sectors, i.e. health, education, housing, social security, employment, justice and city planning). Two promotion cases in Kenya and Zambia focused on the school-based provision of health services, specifically deworming, which involved the health and education sectors [35‐41]. The education sector contributed resources to the intervention because of the recognition of the promotional effect of good health on education outcomes.

Unlike integrative models, promotion co-financing cases tended to involve sectors with less service overlap. Broadly speaking, integrative co-financing was population-centric, while promotion co-financing was more intervention-centric. The tables presenting the co-financing cases identified are disaggregated by co-financing typology and included as supplementary material.

The financial mechanisms that were used to operationalise these co-financing cases are summarised in [Table 4. Most of the integrative cases involved sub-national pooling of budgets, whereas most promotion cases were transfer payments or grants from a health payer, based on intersectoral project proposals. It should be noted that while the co-financing cases have been broadly categorised based on their primary function, several cases combined both revenue collection and purchasing functions. For example, the North-West London Integrated Care Pilot utilised lead commissioning, in tandem with the additional alignment of financial incentives whereby participating organisations agreed to share any savings that materialised from the pilot for joint re-investment [82, 94, 95].

Table 3 also categorises case descriptions according to the financing typologies. In promotion cases, co-financing between health, education and other sectors (excluding social care) were most common, and arrangements where the health sector as lone coordinators (n = 6; mostly providers of intersectoral grants) was only apparent in promotion cases. All cases from Africa, Asia, and South America were promotion-based, occurred after the year 2000, and the six cases from Africa and South America all involved the health and education sector (mostly targeting children and adolescent populations) with two of these cases also including the agriculture sector. The single Asian case (from South Korea) only included the health sector as a coordinating body of earmarked sin tax that was distributed to intersectoral partners [115, 116]. Co-financing in Africa and South America also involved financing from international donor and development agencies, such as the World Bank, UNDP, the Japanese International Cooperation Agency (JICA) and the Gates Foundation.

In addition, the cases could be further distinguished according to whether the financing first flowed through sectors or not. Ex ante co-financing were cases where funds were pooled prior to allocation across different sectors (e.g. national pooled budgets with grant applications, or sectoral grant mechanisms requiring intersectoral proposals) while ex post co-financing occurred when sectors that had already been allocated sectoral funds from a central authority subsequently dedicated those funds to co-financing arrangements. Although certain mechanisms, such as cross-charging, only fall under the post-allocation characterisation; others like pooled budgets were created before or after funds were allocated at the sectoral level. It was not always possible to identify the origin of the funds dedicated in co-financing cases.

The core themes identified across both barriers and enablers included: (1) conceptual buy-in; (2) model planning, design, implementation and framing; (3) organizational capacity, resources and time horizons; (4) relational factors and organizational culture; (5) finance and accounting practices; and (6) evidence, monitoring and accountability. Table 8 outlines the synthesised categories and themes of reported barriers and enablers, along with examples of open codes that were grouped into the thematic categories.

A critical theme for the implementation of co-financing models was the accounting, financial practices and organizational capacity to implement change. Co-financing often required the reprogramming of financial resources by at least one budget holder, which was difficult given its impact on vested interests and the legacy of competition within the public sector [117]. Furthermore, in the face of constrained budgets, several studies reported an understandable desire for public actors to behave conservatively, reverting to traditional core functions, and safeguarding resources. A lack of financial resources and high resource requirements of activities perceived as the core, such as acute health care, was commonly cited as a barrier for any or further engagement with co-financing. Additionally, rigid budgets and the lack of budgetary autonomy were stated as barriers to co-financing uptake and implementation [118]. Government ministries and departments often had mandates to provide certain services or received budgets ring-fenced for certain activities. The degree of autonomy over financial resources differed across levels of governance and level of fiscal decentralisation, with more flexibility reported at the decentralised level. Interestingly, limited financial resources were perceived as both a barrier to the implementation of co-financing and an enabler to getting cross-sectoral buy-in. Depending on the context, limited resources was discussed as a reason to pool resources with other sectors, and in separate cases, were also discussed as a limiting factor that prevented the implementation of co-financed programmes [43, 83, 119, 120].

Differential organizational capacity, resources, regulatory requirements and operational processes were also cited as barriers to implementation. The legalities of co-financing were found to be complex in some cases, given sectors’ different regulatory and accountability systems. For example, this was raised in relation to co-financing of adult health and social care in England, where health care provision is universal and free while social care is means-tested and any joint working must take this into account [43‐48]. Relatedly, the theme of relational and organisational cultures emerged as key factor in the initiation, and implementation of co-financing, which was enabled by trust and matched partnerships. From the cases identified, it was clear that certain sectors were more amenable to co-financing, given historical connections of working together. Leveraging these historical relationships could be an enabler to establishing co-financing arrangements. It could be argued there is an inverse relationship between past integrated activities and the strength of the rationale required for adopting co-financing. Additionally, failures from past programmes were also observed as catalysts to try new approaches.

The importance of data, monitoring and accountability frameworks was highlighted across studies, as a means to foster initial and ongoing conceptual buy-in amongst resistant actors and to track benefits from co-financing for the partners involved. A key theme on barriers to uptake was uncertainty around the value of co-financing in practice, due to a lack of evidence, and uncertainty around the objective and scope of the co-financing approach, particularly if imposed in a top-down manner. Conversely, a key enabler for co-financing continuation was demonstrated success from co-financing pilots [121], which could lead to the replication or scaling up of the model. For instance, the adoption of a National School Health Policy in Zambia originated from a pilot programme with rigorous evaluation and positive impacts, which encouraged the Ministries of Health and Education, among others, to formalise the programme and scale up nationally [35]. Additionally, the creation of interagency performance targets was shown to be a potential catalyst for the initiation of co-financing arrangements [121]. By holding several agencies collectively responsible for achieving pre-specified targets, governments incentivised intersectoral partnerships in New Zealand [57].

This endeavour to systematically assess the implementation of co-financing is not without its limitations. First, there is a debate about what constitutes a case of co-financing and the boundaries of the concept. We have applied our rational conceptualisation of co-financing to categorise cases, but the reality is that co-financing can be framed and achieved in multiple ways; this can be politically advantageous, but it also makes objective classification difficult. Second, our approach to data extraction and synthesis relied on the clear identification of the objectives of payers. While theoretically, it is simple to distinguish organisations with a health objective from those with an education objective, in reality, this distinction is not always clear. Relatedly, with growing recognition of the value of multi-sectoral approaches that address upstream determinants of health (and other social outcomes), organisations are frequently expanding their operational space. Third, whereas McDaid and Park classified fiscal incentives (such as tax breaks) as joint budgeting [19], we excluded these cases, since resources coming directly from the Ministry of Finance are yet to have a sector-specific objective assigned to them. Finally, given the international scope of the cases identified, the English language restriction in the search may have excluded several non-English reports in the synthesis process. In the snowball retrieval of literature, a small number of non-English texts were identified for included cases from Sweden and Brazil (e.g. SOCSAM, Ceará Multi-Sector Social Inclusion Development Programme), but these were not analysed.

More research is needed to establish a credible evidence base on the impact of co-financing. Evaluation was frequently constrained by several factors. First, the systematic review revealed the lack of documented co-financing cases and a risk of publication bias. Secondly, of the small number of implemented cases, many did not engage in any formal evaluation. Thirdly, when there were evaluations, their study design often lacked the rigour required to make conclusive statements about the success or failure of the case and convincingly attribute observed changes to the implementation of co-financing. Future implementers of co-financing should consider more rigorous design and dissemination of impact evaluations, economic evaluations, and implementation research.

Given the emphasis placed on synergies between goals and targets in the SDG agenda, co-financing could be an innovative financing mechanism to help sectors work together to more efficiently achieve their respective SDG goals in a coordinated manner. From our analysis, we find that the health, education and social care sector are established intersectoral partners for co-financing, based on extensive historical relationships and interactions in many high-income countries. Although no attempts were made to prioritise any sectors in the search strategy, publication bias cannot be ruled out, where some sectors may be more likely to conduct and publish evaluations. It is also possible that health may have been the most prominent sector in the identified studies, because it is relatively more advanced in analysing and addressing upstream determinants. The health and social sectors could qualify as ‘first-movers’ in adopting the principles of co-financing, given the clear overlaps and targets for coordinated service delivery.

A number of clear opportunities for SDG synergies between sectors have been identified in literature [10, 124, 125], including from sectors that do not have a history of coordination or collaboration. In many circumstances, interested actors may still need to ‘make a case’ to engage in new financial relationships across sectors, but could benefit from framing co-financing as an opportunity to advance prominent health agendas.

Almost all of the cases from LMIC involved domestic public sector actors, in collaboration with international donors. Only one case appeared to be fully driven by public sector ministries (Mozambique). Many public funders in LMICs are faced with the task of enhancing domestic spending, optimizing the fiscal space for health amongst other public goods, and reducing dependence on out-of-pocket expenditures and overseas development assistance. Leveraging external financing to catalyse the development of innovative context-adapted models can create potential ways to expand allocations for health or other sectoral spending.

The inclusion of co-financing in national and local planning and financing frameworks for the SDGs, including those agreed between national authorities and development partners, could therefore be an opportunity [23]. The United Nations Development Programme (UNDP) has developed the Mainstreaming Acceleration and Policy Support (‘MAPS’) approach to SDG implementation at country-level to support countries to identify interventions with high-impact across sectors. The MAPS approach aims to align UN support to member states in making trade-offs in relation to SDG targets, and in identifying policies and interventions that have impact and ‘reach’ across multiple targets. Co-financing could be a potential fiscal instrument to realise efficiency gains, should the MAPS-generated political will extend to reformulating budgetary practices. Also, UNDP’s network of 60 country-based ‘accelerator labs’ (in development) aims to identify challenge-solution pairs through iterative learning and experimentation, for which co-financing could have potential for ‘SDG accelerator financing’.

At an international level, multi-lateral organisations and global donor agencies that have health and cross-sectoral mandates could also play a role in breaking the dominant siloed approach to global health financing, and driving co-financing initiatives, experimentation and research forward. For instance, The Global Action Plan for Healthy Lives and Well-being [126], which is a joint initiative of 12 global health institutions, offers a window of opportunity to adopt co-financing approaches for greater efficiency and joint impact. The plan includes the acceleration of sustainable financing goals, with sub-aims to increase domestic spending on health and the use of national fiscal and public financial management reform, efficient investments, and innovative joint financing strategies including multi-donor trust funds to achieve these outcomes.

At national levels, influential political champions (individuals and sectors) drive the uptake and integration of co-financing in national policies and strategies [127]. The political dimensions of co-financing appear as, if not more, important than the technical details. The few national level pooled funding arrangements identified focused on issues or population groups (e.g. older persons, children and better care) with relatively broad political buy-in and visibility.

Notable barriers to co-financing uptake and continuation are the lack of supporting evidence, ambiguous risk profiles and capacity to organize and implement. The SDGs have placed a heavy emphasis on measurable targets, and to determine whether co-financing could be an evidence-based approach to financing the SDGs, there is need for a body of evidence on its benefits, trade-offs or limitations. Co-financing does not, by definition, increase aggregate efficiency or lead to cost-savings. In fact, Mason and colleagues suggest that if integrated care and funds are successful, they are more likely to uncover unmet need and lead to increased costs, as well as improved health. This is also to be expected in the context of expanding universal health coverage. Cost-effectiveness and value for money may therefore be more relevant considerations than cost-savings. The potential gains that are likely to be achieved through using a co-financing approach, needs to be assessed alongside the transaction costs and likelihood of success of initiatives.