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Table 4 Description of financial mechanisms used to implement the co-financing approach

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

Financial MechanismDescriptionReview findings: number of cases and examples
Integrative casesPromotion cases
Revenue collection
1. a) National pooled budgetPooled budgets were established at national level, with decentralised bodies developing plans for use of the funds related to local objectives and priorities. The aims of the individual decentralised cases were diverse and locally variable.
Some consisted of braiding financing streams, whereby funds were not fully integrated, and it was possible to trace the source of each expenditure, while other included blended financing streams, whereby the money in the pool lost its sectoral source identity.
6 cases
• Reshaping Care for Older People (Scotland) [24,25,26,27,28]
• Children’s Trust Pathfinders (England) [42]
• Better Care Fund (England) [43,44,45,46,47,48]
No case identified
1. b) Sub-national pooled budgetsThis mechanism was often enabled through national legislation permitting voluntary budget pooling by local government across sectors and the joint commissioning of multi-sectoral services.
Budget holders’ contributions were identified from the outset and expenditures were planned from inception in some cases, and not in others to allow flexibility in how the funds were used.
26 cases
• Health Flexibilities Act Section 75 for Clinical commissioning groups and local authorities (England) [47, 49]
• SOCSAM (Sweden)-legislation that enabled social insurance, social services and health care services to be jointly co-financed between government and municipals [50,51,52]
• Australian Capital Territory (ACT) Coordinated Care trial (Australia) [30, 53,54,55]
• System of Integrated Care for Older Persons (Canada) [29,30,31, 56]
5 cases
• Justice Sector Fund (New Zealand) [57,58,59]
• Prince Edward Island (Canada) [32,33,34]
• Ceará Multi-Sector Social Inclusion Development Program (Brazil) [60,61,62,63,64,65,66,67]
2. a) Aligned budgetsAligned budget tended to be adopted where partnerships were yet to mature or where there was a concern that partners would be over-cautious or under-fund pooled budgets.
whereby numerous ministries contributed to activities within the programme but the management and accountability for the resourcing remained entirely separate.
There were often no statutory hindrances or restrictions.
2 cases
• Financial Coordination of Rehabilitation Measures Act (FINSAM) (Sweden) [68,69,70]
• Community Health Partnerships (Scotland) [71, 72]
3 cases
• Programme for the Modernisation of Agriculture (Uganda) [73,74,75,76]
• Interagency Programme for the Empowerment of Adolescent Girls (El Salvador) [77]
• Pathfinder’s Geração Biz (“busy generation”) Programme for sexual and reproductive health and HIV (Mozambique) [78,79,80,81]
2. b) In-kind supportSectors contributed non-financial resources (e.g. human resources, infrastructure, and technology) towards the joint provision of an intervention or programme with a shared objective.
This mechanism was often used in circumstances where sectors were constrained by very limited financial resources, limited financial autonomy or in-kind support was more beneficial to service delivery than additional financial resources
No case identified2 cases
• School Health and Nutrition (Zambia) [35,36,37]
• National School-Based Deworming Programme (Kenya) [38,39,40,41]
3. Structural integrationFull organisational and budgetary integration of cross sector responsibilities into a single organisation.8 cases
• Care Trusts at local area level with full responsibility for the pooled budget and purchasing for health and social care (England) [47, 73, 82,83,84,85,86,87]
• Health and Social Care Boards commissioning services (Northern Ireland) [24, 88, 89]
No case identified
Purchasing
4. Joint/lead commissioningJoint commissioning was undertaken with and without pooled budgets.
The commissioning of services with pooled budgets could be undertaken through lead commissioning whereby one agency was delegated authority for purchasing services across the jurisdiction of all sectors contributing to the pool.
Otherwise, a joint authority was established with representatives of all pool contributors, managing the pool on behalf of partners, through agreed delegation arrangements.
6 cases
• Contra Costa County Community Services Department coordinated funds for early education (USA) [90,91,92,93]
• North West London Integrated Care Pilot (England) [82, 94,95,96,97,98,99]
• The Home Loans Equipment Centre (HLEC) (England) [80, 94, 100]
No case identified
5. Cross-chargingCross-charging was implemented as a form of Pigouvian taxation, where a sector’s performance incurred an externality on another sector.
It often involved little to no integration of functions, organisations or services.
3 cases
• National Health Service (NHS) mandatory daily penalties between local authorities and health care providers for delayed hospital discharges due to delays in social services (England) [101,102,103,104,105]
• Denmark cross-charging (Denmark) [106]
• ADEL reform (National Reform of Elderly Care) (Sweden) [105]
No case identified
6. Transfer paymentsThese mainly involved a grant-making mechanism set up by one payer that required intersectoral proposals. They were different from pooled budgets requiring grant applications in that the financial allocation originated from a single sector but was exclusively accessible for intersectoral action. Such grants were often disbursed by health promotion foundations.No case identified8 cases identified
• Road Safety Partnership Grant (England) [65,66,67]
• New York City Childhood Asthma Initiative (USA) [107, 108];
• National Development Programme for Social Welfare and Health Care Theme (Finland) [109,110,111,112,113,114]