Successful Health Reform: The Blended Approach

In Reich’s article regarding the proposal for the Toyako G8 Summit, he brings up a few interesting and somewhat controversial points with health reform.  Efforts to improve health conditions on a global level have focused on two separate strategies – the horizontal approach and the vertical approach.  After implementing each strategy one at a time, it was shown that both need to be implemented simultaneously in order for effective, tangible reform to take place in an area.

The article discusses when the horizontal approach was implemented in the late 1970′s, the movement focused on disadvantaged populations in countries, taking a “multisectorial approach”.  The problem with this became low funding and the poor infrastructure of health systems in some of the poorest countries, especially sub-Saharan Africa.  The second strategy, the vertical approach, focuses on specific diseases when tackling healthcare reform.  This proved to be beneficial and successful for a while – it meant the establishment of several organizations, funds and donors to combat specific illnesses that plagued developing countries.

However, the ironic part of both strategies, is that one doesn’t exactly work without the other.  The horizontal approach focused more on overall health infrastructures in place – a more general approach than something so specific as tackling certain diseases.  Although the vertical approach produced tangible results – assistance for health grew from $6 billion in 2000 to $14 billion in 2005 – it was found to be inefficient in countries that did not have strong health systems in place.  Many countries have made little progress on achieving key targets set by the UN Millennium Development Goals, mainly because these targets depend on strong health system performance.  The UN has stepped in and helped many struggling countries achieve the MDGs by implementing programs such as the Millennium Village Project intervention.  This project will target a specific problem in a community and implement effective solutions that are not only organized (a systems-oriented approach), but they target a specific area – so in essence, they are balancing both a vertical and horizontal approach to reform.

Another problem with a solely vertical approach to health reform is that so many disease-focused programs receive funding from multiple donors, that oftentimes the programs in these countries are uncoordinated and not strongly organized.  Similar to many of the UN projects (such as the MVP), we need to improve the programs and the infrastructure that support disease-focused strategies.  The World Bank is another contributor to successful, systems-oriented approach programs, with their Healthy Development Strategy.  To focus on a specific country that succeeded with an effective blending of both approaches is Japan.  After their health system was destroyed after WWII, their focus was not only to build up the destroyed system, but it targeted specific diseases in its reform as well.  It empowered the people by providing handbooks on good health practices and incentivized current health employees.  China, on the other hand, focused solely on training more village health workers, which just lead to an oversupply of physicians who couldn’t find jobs.

Although these examples show that successful health reform requires a simultaneous implementation of both horizontal and vertical approaches, it’s not always that straight-forward.  Climate change is another factor that could pose a negative effect on global health and that is generally out of our control.  Changes such as flooding in low-lying areas, also increases the range of tropical diseases.  The difficulties and barriers to health reform will always present themselves in some way; the most we can do is ensure we are using the optimal blend of best approaches in each country.


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