Targeting equity in early childhood: resource allocation in Sweden's Extended Home Visiting Program.

backgroundSweden allocated SEK 354.5 million (approximately EUR 31.5 million) between 2018 and 2022 to extend home visiting services for families in socioeconomically disadvantaged areas. This initiative operationalises proportionate universalism within a decentralised welfare system where 21 regional governments hold authority over healthcare delivery. We examined whether program resources reached areas of greatest need and how targeting varied across regions and over time.

methodsWe analysed Swedish administrative register data aggregated to 12,258 small statistical area-year observations across four implementing regions during each region’s post-rollout period. Program dosage was measured as probability-weighted exposure based on patient registration patterns between areas and child health centres. Socioeconomic need was measured using the Care Need Index (CNI). We estimated targeting associations using linear regressions with year fixed effects and standard errors clustered at the area level. We assessed equity using the Concentration Index and a proportional allocation benchmark, and evaluated within-area heterogeneity in household vulnerability.

resultsProgram resources were positively associated with area-level need (beta = 0.101, 95% CI: 0.091–0.111, p < 0.001). Where the program operated, targeting exceeded proportional benchmarks (proportionality ratio = 1.33) and the Concentration Index was positive (CI = 0.074), indicating pro-poor allocation. However, only 47% of high-need areas had any program presence, and regional variation was substantial: Stockholm’s targeting association was over three times stronger than Skåne’s (beta = 0.145 vs. 0.043). Within-area analysis revealed that more heterogeneous areas received slightly lower dosage, suggesting area-based allocation partially misses within-neighbourhood inequalities.

conclusionsSweden directed resources toward higher-need areas, with targeting that exceeded proportional benchmarks where the program was implemented. The primary equity challenge was not targeting accuracy but coverage: more than half of high-need areas lacked any program presence. Achieving equitable outcomes through proportionate universalism requires both accurate allocation formulas and sufficient implementation capacity to reach all areas of need.