10 Can we reconcile horizontal versus vertical approaches to global health?

Question 1

Heading Subheading

Answer 1

Text

Question 2

Overview Summary

Answer 2

Welcome to this session on horizontal versus vertical approaches to global health. In this session, you will be introduced to the debate between the horizontal and the vertical approach to programming and how it relates to funding and disease burden in low- and middle- income countries. You will learn about the historical background that led to this dichotomy and the main actors supporting each approach. Finally, some alternatives to these two approaches will be presented. Programming is an issue in all nations, but we will focus on the situation in low and middle-income countries where disease burdens tend to be higher since there is greater need for strategic planning to deal with diseases that claim a large number of lives.

Question 3

Overview Aims

Answer 3

This session aims to provide students with an understanding of the distinction between horizontal and vertical approaches, how this longstanding debate is relevant to global health development, and how it continues to inform collective efforts to tackle global health needs.

Question 4

Overview Learning outcomes

Answer 4

By the end of this session you should be able to: Differentiate between vertical and horizontal approaches to health development, their strengths and weaknesses; Identify how these approaches have informed key health development initiatives over time; Discuss which institutional actors have advocated these approaches and why; Understand how the debate has influenced global health policy and the emergence of the “diagonal” approach; and Critically evaluate which approach might be the most pertinent for a particular context within global health.

Question 5

Key terms Vertical approach

Answer 5

The selective targeting of specific interventions not fully integrated in health systems (Msuya, 2004).

Question 6

Key terms Health system

Answer 6

All organisations, people and actions whose primary intent is to promote, restore or maintain health (WHO 2007).

Question 7

Key terms Horizontal approach

Answer 7

The approach that seeks to tackle the over-all health problems on a wide front and on a long-term basis (Gonzalez 1965).

Question 8

Key terms Diagonal approach

Answer 8

Strategy that aims for disease-specific results through improved health systems (Ooms et al. 2008).

Question 9

Key terms Global health initiatives

Answer 9

a standard model for financing and implementing disease control programs in various countries and in different regions of the world (Brugha 2008).

Question 10

Key terms Sector-wide approaches

Answer 10

A programme where all significant funding for the sector supports a single sector policy and expenditure programme, under government leadership, adopting common approaches across the sector, and progressing towards relying on government procedures to disburse and account for all funds (Foster 2000).

Question 11

1.1 Historical background

Answer 11

The Alma Ata Declaration on Primary Health Care signed in 1978 provided the starting point for collective action towards achieving primary health care. Building on a World Health Assembly resolution adopted in 1977 to achieve health for all by the year 2000, this agreement took place during the international conference on primary health care and was signed by 134 countries, 67 UN organisations and NGOs. The main premise of the declaration was for all people to have access to basic health care, with primary health care including access to education, methods for preventing and controlling health problems, food supply and nutrition, family planning, immunization, access to safe water and basic sanitation, maternal and child health, provision of essential drugs, etc. But shortly after the health care officials were left with the question of how to achieve these lofty goals?

Question 12

1.1 Historical background

Answer 12

One year after Alma Ata, a group of researchers proposed Selective primary health care, an “interim” strategy to begin the process of primary health care implementation. They argued that the best way to improve health was to fight disease based on cost-effective medical interventions that can save and improve lives immediately. They identified four factors to guide the selection of target diseases for prevention and treatment: prevalence, morbidity, mortality, and feasibility of control (including efficacy and cost). Early applications of this included child immunisation, infectious disease programs and oral rehydration therapy, all of which seemed to have a simple solution at the time. The motivation behind this was that successful interventions, with proven results would encourage more investment from donors, thereby ensuring sustainable programmes.

Question 13

1.1 Historical background

Answer 13

By the 1990s it was already evident that the view of achievement of health for all by 2000 was not that optimistic. Furthermore, the policies promoted by the World Bank (WB), International Monetary Fund (IMF), Organisation for Economic Co-operation and Development (OECD) and other bilateral aid agencies lead to downsizing of governments, privatization or services and decentralization. Specifically, in the health sector, this meant managed competition, the creation of the public-private mix, cost recovery and prioritizing cost-effective interventions. Countries were encouraged to make government less of an actor in health, thereby making their health systems leaner. The WHO on the other hand, had a small role in this since at the time it was hampered by weak leadership and was overwhelmed by the wide range of health programmes it had attempted to fulfil its broad mandate.

Question 14

1.1 Historical background

Answer 14

The WB and other international development banks were taking more leadership as lenders to the health sector and there was little confidence that WHO’s approach to health for all was that effective. The following years were characterised by a worsening of international health with a greater gap between the rich and the poor, one billion people with lack of access to water and sanitation and a growth in the HIV/AIDS cases, as well as Tuberculosis (TB) becoming more of an international emergency. The election of Gro Harlem Brundtland in 1997 brought renewed hopes that WHO’s role would increase in global health. Her legacy has been in restructuring WHO by focusing on developing core values a clear marketing strategy in an increasingly crowded development environment. WHO subsequently adopted the Roll Back Malaria and Tobacco Free Initiative as their flagship initiatives; the organization was divided into clusters and attention was given to developing evidence to support the work.

Question 15

1.1 Historical background

Answer 15

The proliferation of Public-Private Partnerships in the early 2000s was supported by fears of emerging and re-emerging diseases such as HIV/AIDS and TB that potentially threaten high-income countries, as well as the risk of bioterrorism. Dr. Jong Lee was elected Director-General of WHO in 2003, as Dr. Brundtland’s successor. Although he acknowledged the dichotomy between health for all and donor-led initiatives, he declared communicable diseases (especially HIV/AIDS, TB and malaria) as his priorities. He argued that progress towards Alma Ata had been great, but that much more efforts should be put towards AIDS. The entry of Dr. Margaret Chan and then her predecessor Dr. Tedros Adhanom Ghebreyesus, the current Director-General at WHO, marked a focus on the Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs). Chan’s main priorities consisted on promoting maternal and child health and more focus has been put on addressing health systems. Dr. Ghebreyesus’ stated priorities have been achieving the SDGs via a focus on achieving universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all (WHO, 2017).

Question 16

1.2 The health system

Answer 16

In simple terms, vertical and horizontal programming approaches consist of two different ways you can address a health issue. This necessarily requires interacting with the health system, which is the space where these approaches are implemented. But what is a health system? According to the WHO, the health system “consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health” (WHO, 2007). WHO subdivides the health system into various components, or building blocks, as this image shows. These building blocks are governance, information, financing, service delivery, human resources, medicines and technologies and people.

Question 17

1.2 The health system

Answer 17

As this framework shows, people are at the centre of the health system continuously interacting with the different blocks. The other building blocks are briefly explained below: 1 Leadership and governance primarily involve steering the entire health sector and dealing with challenges; and defining national health policies, strategy and plans that set a clear direction of the health sector. 2 The health information systems entail a national monitoring and evaluation system plan that specifies core indicators (with targets), data collection and management, analyses and communication and use; and making information accessible to all involved, including communities, civil society, health professionals and politicians. 3 The health financing block involves a system to raise sufficient funds for health fairly; a system to pool financial resources across population groups to share financial risks; and a system supported by relevant legislation, financial audit and public expenditure reviews and clear operational rules to ensure efficient use of funds. 4 Human resources for health require ensuring sufficient numbers of human resources and the right mix; developing appropriate payment systems and incentives; and regulatory mechanisms and enabling work environments. 5 Medicines and technologies involves creating a medical products regulatory system; creating and managing a supply and distribution system that works; and developing a price monitoring system and rational prescribing mechanisms. 6 Service delivery entails networks of close-to-client primary care and developing mechanisms for accountability.

Question 18

1.2 The health system

Answer 18

As we will see in the following sections, vertical and horizontal approaches interact with the health system in different ways. A vertical approach works by targeting specific interventions that are not fully integrated in health systems, whereas the horizontal approach provides a more holistic approach to addressing health issues by bringing together common functions within and between organisations.

Question 19

2 Vertical approach

Answer 19

Msuya (2004) provides a straightforward way of describing vertical programmes as the ‘selective targeting of specific interventions not fully integrated in health systems’. Examples of the success of vertical programs can be found since the 1920s where great strides were made in the control of hookworm, yellow fever and malaria. The latter in regions outside southern Africa. After the success of these mass campaigns came others such as the eradication of smallpox and decrease in tuberculosis cases worldwide and decrease in TB cases worldwide.

Question 20

2 Vertical approach

Answer 20

Moreover, HIV/AIDS is a clear example of how a targeted approach to a disease can lead to success in reducing the incidence of a disease. HIV/AIDS has notably changed from an epidemic emergency to a manageable chronic disease. In addition, these focused programs have also contributed to improving the access to low-cost pharmaceuticals for low-income countries, especially for HIV/AIDS drugs.

Question 21

2 Vertical approach

Answer 21

Among some of the benefits of the vertical approach, we can identify: 1 This approach to programming is most useful in highly constrained countries, such as countries in conflict, with poor governance due to corruption or other reasons. At the same time, it is in these areas that measures are required to strengthen and develop the capacity of health systems. 2 It produces rapid and easily measurable results. 3 It fosters the engagement of stakeholders that may have been previously ignored within the countries, such as NGOs of survivors of these diseases. 4 Donors prefer this type of program because it establishes a tangible program that is easy to recognise and to promote to other outside sources as a clear example of work. 5 Money goes towards one source, making program monitoring easier; although, in practice this does not always happen. 6 Some of these programmes have been implemented in areas where little was known about the burden of disease. The presence of these programmes has increased the availability of data and research in these places.

Question 22

2 Vertical approach

Answer 22

Among the criticisms of vertical programming we find: 1 It ignores social and economic factors related with health since they tend to follow the goals of the programme rather than the realities on the ground. Vertical programmes are frequently developed by people who are unaware of the context these programmes are being implemented in or they follow political or other motivations. 2 There is little coordination leading to duplication and imposing administrative burdens on already overworked health care workers. 3 The creation of parallel programs which undermine the efforts of the government and how external impositions may refocus government priorities, ignoring areas that may have greater needs in the country, such as diarrheal or respiratory diseases. 4 It may take up the country’s scarce human resources, by hiring local capacity with higher salaries, making it difficult for the government to keep these workers.

Question 23

2.1 The role of global agreements on health programming

Answer 23

As we saw in the previous section, aid has had a tremendous effect on the direction of programming in low and middle-income countries, since quite often they sustain the entire countries’ response to a certain disease. The Millennium Development Goals (MDGs), a grouping of 8 goals that were established in 2000 in the Millennium Summit of the United Nations and that were signed by all 191 UN member states, spurred substantial growth in global funding for health but they were also criticised for promoting a vertical approach.

Question 24

2.1 The role of global agreements on health programming

Answer 24

These goals primarily focused on disease-specific programs (namely HIV/AIDS, tuberculosis and malaria, which had their own separate goal) without integration into broader health systems strengthening.

Question 25

2.1 The role of global agreements on health programming

Answer 25

This is exemplified by the fact that MDG5 that focused on maternal and child health, was most significantly underfunded and other areas were left out of the MDG priorities entirely. Some of these were a focus on health systems as a whole, non-communicable diseases (including mental health and cancer) and Neglected Tropical Diseases (NTDs).

Question 26

2.1 The role of global agreements on health programming

Answer 26

To sustain the progress towards MDGs and address the failure to meet some of these by 2015, the Sustainable Development Goals were agreed upon in a more inclusive manner. These 17 goals were negotiated over a two-year period at the United Nations and agreed to by nearly all the world’s nations, on 25 Sept 2015. However, these goals have also been criticised for being too ‘vague and aspirational’ and consisting of a voluntary agreement rather than a binding treaty.

Question 27

2.1 The role of global agreements on health programming

Answer 27

The MDGs left an important legacy regarding aid. Development Assistance for Health (DAH) nearly tripled from US$10.7 billion in 2000 to $28.2 billion in 2010 resulting in a 164% increase. In addition, a range of new donors and health financing mechanisms emerged.

Question 28

2.2 The role of global health initiatives

Answer 28

Global health initiatives (also referred to as global health partnerships) are one financing mechanism for health. These institutions were initially set up as an emergency response in scaling-up control of major communicable diseases, namely HIV/AIDS, tuberculosis and malaria. Brugha (2008) defines a global health Initiative as a “standard model for financing and implementing disease control programs in various countries and in different regions of the world”.

Question 29

2.2 The role of global health initiatives

Answer 29

They were also the response of the lack of leadership from major international organisations such as the World Health Organisation and the World Bank in responding to these problems.

Question 30

2.2 The role of global health initiatives

Answer 30

Generally, they are characterized by: Being established to address one or more global health problems; Being relatively institutionalized with a set structure and long-term goals; Combining public and private organizations and both have a voice in decision-making policies and procedures; and Involving governments, civil society, international organizations, the private sector and affected communities under an umbrella framework

Question 31

2.2 The role of global health initiatives

Answer 31

These partnerships at the time were seen as innovative since they allocated funding through country-led grants rather than imposed by donors. In addition, they pooled funds from diverse groups of actors, primarily governments. They avoid large overhead costs by relying on country institutions and they also included stakeholders that were previously ignored in policy-making (such as minorities and affected communities) in the discussion table. The view was that health is a good economic investment and that diseases like HIV/AIDS were not only causing deaths but affecting the country's future economic and social outcomes. There are more than 100 global health initiatives, but the four main initiatives, where most of the donor money is concentrated are the World Bank's Multi-country HIV/AIDS programme, the Global Fund to Fight AIDS, TB and Malaria, the US President's Emergency Plan for Aids Relief, and the Gavi, a global vaccine alliance. The first three providing for many years more than two-thirds of all external funding for HIV/AIDS.

Question 32

2.2 The role of global health initiatives Criticisms of global health initiatives

Answer 32

Criticisms to global health initiatives are that the limited flexibility of funding through earmarks imposes constraints on the governments where they cannot address gaps in their health system as they emerge. Furthermore, they have been known to work independently from other coordination mechanisms such as the Sector Wide Approaches. The Sector Wide Approaches are mechanisms where funding for public health supports a single sector policy and expenditure programme, under government leadership, we will talk more about these later in the session. Global health initiatives require stronger coordination of the variety of donors at the country level, in accordance to the government's priorities. Several studies have also found that global health initiatives create more transaction costs due to the multiple funding proposals, country visits, trainings and meetings that already overburdened health professionals have to address; as well as weakening local capacity by hiring human resources offering them higher salaries and taking them from their government jobs. The Maximising Positive Synergies Collaborative group consisted on a network of researchers studying the interaction between global health initiatives and country health systems providing recommendations for more productive interactions and investment of resources.

Question 33

2.2 The role of global health initiatives Criticisms of global health initiatives

Answer 33

Among their recommendations we find (WHO Maximizing Positive Synergies Collaborative Group, 2009): Infusing the health systems strengthening agenda with the sense of ambition, the scale, the speed and the increased resources that have characterised the GHIs; Agreeing on clear targets and indicators for health systems strengthening; Promoting country capacity for strong national planning processes and better alignment of resources with national planning processes; Promoting the meaningful involvement of communities and civil society organisations in the governance of health systems and the delivery of health services; Improving evidence-based decision making in health by building the capacity of countries to generate and use knowledge; and Calling on WHO to lead and coordinate the efforts to implement specific health systems-strengthening policies and plans.

Question 34

2.2 The role of global health initiatives Criticisms of global health initiatives

Answer 34

In the last decade, these initiatives have made significant steps towards rectifying their past mistakes. For example, the Global Fund now accepting national health plans as funding proposals, rather than narrowly focusing proposals on HIV, TB or malaria projects, which was a very burdensome process for low-income countries. In addition, these institutions are now more conscious of their effect on countries’ health systems and are providing funding to ensure the long-term sustainability of programmes.

Question 35

Activity 1 Click on the link which will take you the gapminder website where you can create interactive graphs

Answer 35

Select the bubbles option and search data for three countries of your choice. The x axis should represent the aid received, the y axis, the number of newly infected with HIV. The size of the circles represents the population of the country. This interactive tool allows you to choose countries to compare (tick boxes on the left) and look at changes over time (year slider on the bottom). Press the play button on the lower left-hand corner to see how it has increased over the last thirty years. What are the main things you notice? List your most interesting finding on the discussion forum and respond to one related post by another student.

Question 36

3 Horizontal approach

Answer 36

C.L Gonzalez, a WHO consultant and official at the Ministry of Health in Venezuela, described horizontal programmes, as the ‘approach that seeks to tackle the over-all health problems on a wide front and on a long-term basis through the creation of a system of permanent institutions commonly known as "general health services"’ (Gonzalez, 1965). The World Health Organisation defines the horizontal or ‘integrated’ approach as the process of bringing together common functions within and between organizations to solve common problems, developing a commitment to shared vision and goals and using common technologies and resources to achieve these goals (WHO Study Group 2013).

Question 37

3 Horizontal approach

Answer 37

The Good Health at Low Cost Study (Balabanova et al., 2013) provides an example of the application of primary health care principles and the importance of political and social will on the health outcomes of the populations. China, Costa Rica, Sri Lanka and Kerala were all found to have surprising improvements in mortality and high life expectancy rates despite having lower resources than many high-income countries. These societies were characterized by being committed to equitable distribution and access to public health and health care among the populations, beginning at the primary level and supported by the secondary and tertiary levels.

Question 38

3 Horizontal approach

Answer 38

Cuba is a country that maintained its focus on primary health care since Alma Ata. This progress has maintained steady even after the collapse of the Soviet Union and many years of embargo by the United States. Cuba’s population health indices are on a par with those of high-income countries that have several times its budget: Life expectancy is almost seventy-nine years, and the infant mortality rate is 4.2 per 1,000 live births, making Cuba among the twenty-five countries in the world with the lowest infant mortality rates.

Question 39

3 Horizontal approach

Answer 39

Among the benefits of the horizontal approach, we find that: 1. It ensures health services are delivered appropriately given that the entire health system is involved in the response. 2. It promotes long-term financial and programmatic sustainability given it is embedded in the health system so there is continuous learning and adaptation to the context. 3. It encourages health promotion instead of disease focus 4. It also uses human resources more efficiently which is particularly important in resource-constrained settings where health workers need to be trained in several areas.

Question 40

3 Horizontal approach

Answer 40

Among the criticisms of the horizontal approach, we find that: 1. Primary health care requires a change in the socioeconomic status, distribution of resources, a focus on health system development, and emphasis on basic health services. Therefore, it was considered too idealistic and expensive. 2. The implementation of a horizontal approach takes much more planning and therefore it takes longer to show results. 3. The type of general funding also makes it difficult to follow funding flows, which is why donors are weary of corruption, plus it brings up the question of how to allocate priorities, when you are looking at the entire system?

Question 41

3.1 Health System Strengthening

Answer 41

An example of the push to horizontal programming is health systems strengthening. We previously discussed what a health system is and how it is composed by different elements or ‘building blocks’. Health Systems Strengthening involves all of these blocks, towards a holistic approach to health. Health Systems Strengthening is a concept that has gained great popularity in the past decades, which retakes the holistic approach to care, where the individual and not the disease is to be treated and where all of the components of the system come together towards the common goal of improving health. This health system strengthening agenda also emerged partly as a result of failure to make progress towards the MDGs. The goal of health systems strengthening is to provide health services that ensure universal access for all citizens, that are of good quality and that respond to actual needs of the population. Some issues to consider with health systems strengthening is that it requires continuous development to improve the performance of the health system and this is highly dependent on the status of the system.

Question 42

3.1 Health System Strengthening

Answer 42

For example, in a country with shortages of medications, lack of doctors and nutritional supplements, training will do very little to decrease the disease burden. Health system strengthening also entails analysing the root causes of the problems, the power structures and differing actor interests. It may lead to tensions between these actors and resistance to change because it affects the distribution of resources and requires actors to adapt to new ways of working. Finally, health system strengthening also requires true coordination of the government, NGOs, donors and other actors involved to avoid duplication and to align all activities towards the common objective and it also needs the creation of mechanisms to set priorities, so things actually get done.

Question 43

4 The Geometry Continuum

Answer 43

Of course, nothing is black and white and not all programmes follow the horizontal or vertical approach. The figure below, adapted from a paper published in the journal of international development, shows some examples of the continuum of vertical and horizontal programmes.

Question 44

4 The Geometry Continuum

Answer 44

How vertical or horizontal a programme is delivered in a country depends on a number of factors such as the structure of the health system, the health system capacity and dependence on aid for infrastructure, the health profile in the country and other policies. The expanded programme on immunization is said to be less vertical since, as its name implies, it includes immunizations on several diseases, these are measles, diphtheria, pertussis, tetanus, polio and TB. Whereas the integrated management of childhood illness is a package which addresses various childhood conditions through interventions related to prevention, treatment, training of health workers and improving health systems.

Question 45

4 The Geometry Continuum

Answer 45

Molyneux (2004) describes how disease control programmes can build capacity for the long term and that, eventually, these programmes may become more advisory and less structured, thereby transforming from vertical to horizontal programs.

Question 46

4 The Geometry Continuum

Answer 46

This can be observed in several countries. In Pakistan, primary health care was built on the experience of TB and leprosy clinics. In China, vertical programs for disease control purchased time from health service operational staff members, thereby ensuring that funds flowed into the health service infrastructure. In seven countries in Southern Africa, a successful combined strategy for measles immunization started with a single, nationwide catch-up campaign in which mobile teams vaccinated all children in a particular age group. These examples show us that the structures provided by a vertical program can support the health care system and eventually become part of it.

Question 47

Activity 2 “Integration is one of the first steps towards trying to make a vertical program more horizontal." Read the essential reading “Kabatereine NB et al. (2010) How to (or Not to) Integrate Vertical Programmes for the Control of Major Neglected Tropical Diseases in Sub-Saharan Africa. PLoS Negl Trop Dis 4(6): e755” and answer the following questions: 1. Who were the actors involved in this process? 2. What did the process entail? 3. What were the obstacles they encountered? Once you complete the activity read the feedback below.

Answer 47

After reading the article you should have reached the following answers: Concerning the actors, the ministry of health should spearhead the efforts, and seek the collaboration of different national instances, such as other government ministries and NGO's, as well as international actors, such as the World Health Organization, UNICEF, World Food Programme, World Bank and other multilateral agencies and donors. Once the plan has been put in place, this requires the further step of training of the various cadres of workers, implementing the program at the different levels and developing reporting systems for continuous monitoring and evaluation. Among the challenges they encountered in the process was that it was costly and difficult to scale-up, there were conflicting interests among the actors and it increased the administrative burden, where integration put greater strain on already constrained systems. Hopefully, this case example has provided you some insight into the complexities of trying to integrate vertical systems. Although the benefits of primary health care are evident, results are difficult to come by, but not impossible. It just takes some careful planning, based on evidence and the collaboration of all stakeholders.

Question 48

5 Other Health Programming Approaches 5.1 Sector Wide Approaches

Answer 48

Sector wide approaches (SWAp) are another type of initiative that first emerged in the 1990s from the need to make development aid more effective, overcome fragmentation and give the government the leading role in deciding country priorities. Foster (2000) describes a SWAp as a programme where all significant funding the sector supports a single sector policy and expenditure programme, under government leadership, adopting common approaches across the sector, and progressing towards relying on government procedures to disburse and account for all funds. The idea is that a sector programme will be defined consistently with the national strategy and government and donor resources will be coordinated for this programme. Thereby it is most similar with a horizontal approach. They are found exclusively in highly aid dependent low-income countries, with most of them being based in Sub-Saharan Africa.

Question 49

5.1 Sector Wide Approaches

Answer 49

Health and education are the most common sectors covered by these approaches. However, common criticisms to the SWAp is that it is based on a top down policy which is one of the most common threats to aid effectiveness. Furthermore, in many places it has been unsuccessful in involving other actors outside the government and donors such as civil society and it has failed to respond to local realities and priorities. In many cases, SWAp arrangements were by-passed due to international priorities and global health initiatives, such as those addressing the HIV/AIDS epidemic. This demonstrates that despite good intentions, initiatives such as the SWAp depend on greater government oversight and strategies that are able to balance the need for targeted initiatives and health system support (Peters, Paina, Schleimann 2012).

Question 50

5.2 Diagonal approach

Answer 50

Given the ongoing debate between horizontal and vertical systems, another form of programming has been proposed, the diagonal approach. In simple terms, the diagonal approach can be described as a combination of the vertical and horizontal approaches, aiming for disease-specific results through improved health systems (Ooms et al. 2008). Frenk and Sepulveda (2006) explain that in a diagonal approach we use explicit intervention priorities to drive the required improvements into the health system, dealing with such generic issues as human resource development, financing, facility planning, drug supply, rational prescription and quality assurance. The reasoning behind the diagonal approach is that funding for specific diseases for treatment and prevention can drive the focus towards increases in resources for health. By using the example of the management and treatment of breast cancer in Mexico, Knaul and colleagues’ (2015) explain how the diagonal approach is a good strategy to achieving better results with limited resources. This helps address the interrelations between the different components of the health system in order to strengthen existing platforms to provide better care to patients.

Question 51

5.2 Diagonal approach

Answer 51

Similar strategies have taken place in the past although they were not defined as a ‘diagonal approach’. For example, in the United States, measles elimination played a central role in the development of their national immunization programme. Following several failures, a presidential initiative on immunization was created that concentrated on improving the delivery infrastructure for all routine immunizations. A focus on surveillance was key in addressing the outbreaks and demonstrating the weaknesses in the immunization system that had to be corrected (Orenstein and Seib 2016). The Ooms and colleagues’ (2008) article uses the Global Fund as an example of a potential programme to follow a diagonal approach becoming a Global Health Fund which would also support the hiring and training of an expanded health workforce, the integration of sexual and reproductive health and child and maternal health services with AIDS treatment and implement broader measures of health system strengthening. The authors note that some obstacles to achieving this diagonal approach, specifically for the Global Fund, are the policies of the IMF, the need for increased funding and corruption scandals that have plagued the institution. It is important to note that while the Global Fund now provides some funding to address health systems, more than a decade after this proposal was set on the table, it has not yet become a Global Health Fund.

Question 52

5.2 Diagonal approach

Answer 52

The IMF represents an important institution in the development world since it is whom signs off on a country's macroeconomic policies before it is eligible for some forms of development assistance. Historically low and middle-income countries have been constrained by public sector wage ceilings that are imposed on aid general budgetary support but not for foreign-financed project lending. This means that vertical financing is not under the ceiling, but horizontal financing is, giving greater advantages to funding projects instead of providing health sector budget support. Moreover, there will be a need for increased funding if this initiative is to succeed, which is unlikely given overall reductions in aid in the past five years.

Question 53

6 Integrating activity

Answer 53

Select a health programme or initiative in a country of your choice and research what type of programming approach it uses. Describe your programme in the discussion forum and discuss some of the strengths and weaknesses of your chosen programme. Remember to make use of examples and if possible, statistics to support your points. Respond to at least one other students' post.

Question 54

Summary

Answer 54

In this session, we have learned about the events that led to the dichotomy between vertical and horizontal approaches, what each of these programming approaches entail and other creative ways to address health programming. In this session, you should have also learned how global health initiatives transformed the health aid landscape investing significantly in low and middle-income countries and how they innovated the way funding is allocated, distributed and pooled, including new actors within health discussions. So which programming approach is the best? Of course, the answer is “it depends”. These different approaches to health programming are not mutually exclusive and they address different needs. The vertical approach is relevant for immediate changes but the horizontal approach or health systems strengthening is more sustainable in the long-term. Furthermore, changes from one to another type require paradigm shifts in all stakeholders.

Question 55

Summary

Answer 55

Therefore, before implementing a programme you must consider: The size of the disease burden, for example if it is a disease with high incidence an emergency response may be needed, which could warrant a vertical approach; The time-frame required, for example do you have a long time period or shorter? The horizontal approach necessarily requires long-term investment and planning, whereas the vertical approach can provide a targeted quick response; The funding levels necessary to respond to the issue; The size of the resources mobilized; and The country’s political environment, which many times limits or facilitates the most appropriate course of action to address health needs.