In pursuit of better global health, should we follow a horizontal or vertical approach?

The debate between horizontal versus vertical approach to global health is not new. The vertical approach focuses on fighting one disease at time.  The
horizontal approach, as defined by World Health Organization, focuses on “all the activities whose primary purpose is to promote, restore or maintain health.” In the past decade, the vertical approach has been a trend. The staggering amounts collected by multitude of donors from foundations to governments and disbursed to disease-specific initiatives proves the popularity of this approach. In its first eight years (2002-2010) the Global Fund to Fight AIDS, Tuberculosis and Malaria disbursed close to $11 billion to combat these three infections. The
popularity of these disease specific programs lies primarily in the relative
ease of measuring their impact compared to measuring the impact of more
horizontal approaches.

In the donors’ relentless quest for tangible results on the use of their funds, they might be undermining the overall health of large populations. Vertical approaches foster imbalances in provision of health care services.  By focusing on specific illnesses, they target only segmented populations and thus divert human and capital resources from primary health care services.  For
example, the Global Fund mandates on evaluation of grant performance burdens the national health system’ s administration with collecting such data. Worse, vertical approaches can impede the development of accountable national health care systems all together.  The international donors often use non-governmental
organizations to channel their disease-specific funds rather than country’s own
health care facilities. This not only redirects patients to NGOS but also
incentivizes national health ministries to assume laissez-faire approach to the
development of their health care systems.

There is good news though. The international community has started to recognize these counter-productive effects and has begun to shift the debate back to horizontal schemes. Even the G8 who only began discussing global health issues in 1996 recognized the importance of strengthening health care systems as a foreign policy objective during the 2008 summit in Toyako, Japan. In an follow-up article to this G8 summit, Professor Reich observed in the Lancet, “no consensus exists for the operational definition of health-system strengthening.”[1] It is, perhaps, impossible for consensus to even exist as each national health-system is unique.

Each health care system depends on the country’s political and economic system as well as its social values. As A.E. Birn writes, “health care systems are shaped by the extent to which health is viewed as a public good and human right as opposed to a commodity or privilege.” [2] The international community cannot dictate the trajectory and the type of health care system that a nation is to develop. Thus, rather than pursuing the elusive quest of universally “strengthening” health systems, it should focus on not weakening those that do exist this or impeding the development of where none exist. It could begin this work by not introducing any more disease-specific funds. Then, only  can we begin to discuss how to proceed in strengthening them.

[1] Reich, Michael. (2009) G8 and strengthening of health systems: follow-up to the Toyako summit.

[2] Birn A-E, et al. (2009) Textbook of International Health, 3rd Edition: Chapter 12


6 responses to “In pursuit of better global health, should we follow a horizontal or vertical approach?

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