Sergio Flores: Targeting, Implementation, Effectiveness, and Costs of an Extended Home Visiting Programme in Sweden

Abstract

Background: Sweden’s Extended Home Visiting Programme (EHVP) was originally framed as an operationalisation of proportionate universalism within the universal child health system. The programme provides six structured home visits during the child’s first fifteen months, conducted jointly by a child health nurse and a municipal parental advisor, and is offered to all first-time parents in socioeconomically disadvantaged areas. Between 2018 and 2020, the government allocated 354.5 million SEK to support regional implementation.

Aim: To evaluate the EHVP across four dimensions: targeting accuracy, implementation experiences, effects on healthcare utilisation, and costs of national scale-up.

Methods: Paper I analysed programme dosage across 3,398 small statistical areas (DeSOs) using regression and concentration index methods to assess targeting equity. Paper II used qualitative interviews with 12 of 21 regional child health service teams to explore implementation barriers and facilitators. Paper III employed a stacked difference-in-differences design with propensity score matching (49,292 firstborn children; 158 implementing and 599 comparison DeSOs) to estimate programme effects on healthcare utilisation. Paper IV estimated scale-up costs under varying implementation scenarios using scenario-based micro-costing, with costs identified and reported in alignment with the relevant items of the CHEERS 2022 checklist to ensure transparency and comparability.

Results: The EHVP achieved accurate pro-equity targeting (Concentration Index = 0.074), directing resources to higher-need areas at rates exceeding proportional benchmarks. However, 73% of DeSO-years had no programme exposure, and fewer than half of high-need areas were reached. Implementers described annual project funding, unclear mandates, and cross-sectoral coordination barriers as structurally constraining programme delivery. No statistically significant effects on emergency visits, avoidable hospitalisations, or other healthcare utilisation outcomes were detected, with narrow confidence intervals consistent with no more than very small absolute effects. These estimates capture the average effect of programme availability at the area level, not the effect of programme receipt at the individual level. Costs ranged from EUR 556 to EUR 1,180 per family, with national scale-up estimated at EUR 5.6–11.9 million annually.

Conclusions: The EHVP reached the right places but not enough of them, was implemented under governance conditions that undermined its relational logic, produced null effects on healthcare utilisation, and is financially feasible to scale. Whether the transition to permanent funding from 2025 will resolve the cross-sectoral coordination challenges that shaped, and constrained, what the programme became in practice remains an open question.