Key messages
• We found very limited evidence on how financial arrangements affect access to rehabilitation services. Only one study conducted in China specifically addressed rehabilitation outcomes in relation to insurance coverage.
• More research is urgently needed to understand which financial strategies best support equitable and effective rehabilitation services.
What are financial arrangements?
Financial arrangements refer to the methods by which health systems manage their finances to deliver care. This includes how funds are collected (such as taxes or insurance premiums), how insurance schemes are structured, how services are paid for (such as salaries or reimbursements), and whether financial incentives or penalties are used to influence the behavior of providers or patients.
What did we want to find out?
We wanted to understand what current research says about financial arrangements in rehabilitation. Specifically, we wanted to find out how different funding models and payment systems affect access, quality, and use of rehabilitation services around the world.
What did we do?
We searched for systematic reviews published between 2015 and 2024 that evaluated financial arrangements in rehabilitation.
What did we find?
We found two relevant non-Cochrane systematic reviews. We excluded one of them from our analysis because it was of low methodological quality. The other review included 18 primary studies, but only one study focused on rehabilitation. Based on this single study, conducted in China, the non-Cochrane systematic review reported that children with intellectual disability who have health insurance may be more likely to use rehabilitation services than those who have no health insurance.
What are the limitations of the evidence?
The evidence is very limited and fragmented. Most studies did not focus on rehabilitation. The only study that provided data directly relevant to our review question was conducted in a single country in a specific population (children aged birth to 17 years). We have little confidence in the evidence from this study because the participants were not randomly placed into the insurance/no insurance groups. This means that differences between the groups could be due to factors other than having or not having health insurance.
We cannot draw conclusions about which financial arrangements work best for organizing rehabilitation services. Further high-quality research is needed, especially in low- and middle-income countries, to guide policy decisions and improve access to rehabilitation.
How up to date is this evidence?
This evidence is up to date to November 2024.
Baca abstrak penuh
Cochrane Rehabilitation and the World Health Organization (WHO) Rehabilitation Programme have collaborated to produce four Cochrane overviews of systematic reviews that synthesize current available evidence from health policy and systems research (HPSR) in rehabilitation. Each overview focuses on one of the four pillars of HPSR as identified by the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy: delivery arrangements, financial arrangements, governance arrangements, and implementation strategies. This overview focuses on financial arrangements, which Cochrane EPOC defines as changes in how funds are collected, how insurance schemes are structured, how services are purchased, and the use of targeted financial incentives or disincentives.
Matlamat
This overview aimed to synthesize the current evidence on financial arrangements in rehabilitation from a health policy and systems research (HPSR) perspective. Our series of four overviews, incorporating evidence on governance arrangements, delivery arrangements, financial arrangements, and implementation strategies, have the following overarching objectives.
• To offer a broad synthesis of the existing evidence on health policy and systems interventions' effects.
• To direct end-users, including policymakers, towards systematic reviews that may address their health policy questions.
• To identify current research gaps and set priorities for future primary HPSR.
• To pinpoint the needs and priorities for new evidence syntheses where no reliable, up-to-date systematic reviews currently exist.
We searched the Epistemonikos database, the Health Systems Evidence database, and EPOC Group systematic reviews to identify reviews published between 1 January 2015 and 17 November 2024. We applied no language limitations. We included Cochrane and non-Cochrane systematic reviews of randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) that evaluated the effectiveness of health policy and systems interventions for rehabilitation in health systems, specifically related to financial arrangements as defined in the EPOC taxonomy. All four overview teams collaborated to screen reviews and extract data. We used AMSTAR 2 to critically appraise the quality of the reviews. Reviews with ratings of high-to-moderate confidence are reported separately from low-confidence reviews.
Keputusan Utama
We identified two non-Cochrane systematic reviews relevant to rehabilitation and the EPOC category of financial arrangements. We excluded one review from the synthesis due to low methodological quality. The other review included 18 primary studies, but only one study reported data relevant to rehabilitation. This study, conducted in a single country (China), compared insured and uninsured children aged birth to 17 years with intellectual disabilities, focusing on the likelihood of receiving at least one rehabilitation service. The review reported that, based on this single study, enrollment in social health insurance, national health insurance, or community-based health insurance schemes may be associated with increased utilization of mental health services, including outpatient rehabilitation. However, due to the complexity and variability of mental health service utilization across contexts, the review authors noted that it was difficult to draw definitive conclusions about the overall impact of insurance enrollment on mental health outcomes and services.
Kesimpulan Pengarang
We identified two non-Cochrane systematic reviews aligned with the EPOC classification of financial arrangements that addressed rehabilitation. One review including one single-center study on rehabilitation offered low-certainty evidence on insurance schemes and access to rehabilitation services. As a result, this overview cannot provide a clear understanding of the effects of financial arrangements for rehabilitation or offer meaningful signposts to end-users, including policymakers. Future Cochrane overviews in HPSR should broaden their scope to include qualitative and mixed-methods study designs. Robust primary studies and inclusive systematic reviews are urgently needed to guide financial policy decisions that integrate rehabilitation into resilient and equitable health systems.
Funding
PC, CK, and SN were supported and funded by the Italian Ministry of Health (Ricerca Corrente). The funder played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Registration
Protocol (2025): DOI 10.23736/S1973-9087.24.08833-6.
