Health care development is sometimes classified as vertical or horizontal. Vertical programmes target specific diseases or disease clusters. For example tuberculosis, HIV and malaria, are targeted by the Global Fund. Horizontal programmes, by contrast, seek to strengthen the system within which health care is embedded. Such programmes are concerned with human resources, financing, education, and supply chains, among many other functions.
There has been a strong push to move from vertical to horizontal programmes from many corners, including from this News Blog. Supporters of such a change in emphasis cannot but acknowledge the massive successes that vertical programmes have notched up, especially in the fields of infant health, maternal health, and infectious diseases.
However, the limitations of a purely diseased-based approach have become increasingly evident. Logically, it is not even possible to instigate a vertical approach in a complete system vacuum. For example, it would be difficult, if not impossible, to instigate a programme to improve HIV care, if the supply chain could not make drugs available and if the health system could not support basic diagnostic services. That said, vertical surfaces should not be able to siphon off more than their fair share of the health services infrastructure.
A recent Lancet paper on health services in Ethiopia made a further important point, that vertical systems can make a very good platform to extend and deepen generic health systems. In fact, that is precisely what has happened in that country, with full support from the Global Fund and GAVI, the Vaccine Alliance. They refer to this combination of vertical and generic development as a “diagonal” investment approach. We would prefer to describe the relationship as one of symbiosis in which vertical and horizontal programmes are designed to reinforce each other.
The Ethiopian initiative involved strengthening the system at multiple levels, from health service financing, human resources policies, education, investment in primary care, and community outreach activities, along with support for community action and self-help (including the “IKEA model” previously described in this news blog). Certainly, Ethiopia, along with other countries such as Bangladesh, Thailand and Rwanda, stand out for having achieved remarkable improvements over many dimensions of health. In Ethiopia the reduction in mortality for children under the age of five years was 67% from the 1990 baseline, while there was a 71% decline in the maternal mortality ratio and deaths from malaria, tuberculosis and HIV were halved. This took place against a financial backdrop of declining international aid but increasing domestic expenditure. The combination of vertical programmes and health system strengthening seems to have ensured that the money was not wasted.
— Richard Lilford, CLAHRC WM Director
- Assefa Y, Tesfaye D, Van Damme W, Hill PS. Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia. Lancet. 2018; 392: 1473-81.
- Lilford RJ. Pre-payment Systems for Access to Healthcare. NIHR CLAHRC West Midlands News Blog. 18 May 2018.