Financial arrangements for rehabilitation services in health systems: an overview of systematic reviews

Background: 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. Objectives: 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. Methods: 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. Main results: 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. Authors' conclusions: 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.