Scaling an equity-oriented extended home visiting programme in Sweden: costs and cross-sectoral fiscal distribution

Inequalities in early childhood health persist across high-income countries, and structured home visiting is a principal policy response. Because such programmes are jointly produced by health and social services financed from separate budgets, the authority that pays is often not the authority that saves. We estimated the annual public-sector cost of scaling Sweden's extended home visiting programme nationally, and how it distributes between regional healthcare and municipal social services. A scenario-based costing analysis from a public-payer perspective. National registers gave an annual target population of 14 349 families. Unit costs came from micro-costing four pilot sites in disadvantaged areas in 2021. Three scenarios were modelled: a National Standard base case, a Facility-Based Adaptation, and an Enhanced Pilot. Costs are in 2023 Euros. Unit cost per family ranged from EUR 512 (Facility-Based) to EUR 1128 (Enhanced Pilot). Scaling the National Standard model would cost EUR 8.31 million annually, the Enhanced Pilot EUR 11.33 million. Regional healthcare carried 70%-76% of costs under every delivery model, because coordination, supervision, and training are overwhelmingly nurse and midwife time. Implementation choices change total cost but not its distribution between payers. Moving contacts from the home to a facility halves the cost and removes the setting through which the programme is theorized to reach marginalized families, without rebalancing the burden. Because the asymmetry follows from how the programme is staffed, scale-up requires explicit cross-sectoral financing agreements wherever health and social care budgets are held separately.