Global Health Policy
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October 05, 2007
Should All Vertical Programs Just Lie Down?
Posted by Ruth Levine at 02:33 PM
"Vertical" health programs are once again unfashionable, subject to a blistering set of critiques from all manner of experts - some of whom were instrumental, just a few short years ago, in promoting them. The most recent summary of the accusations that vertical programs destroy "health systems" can be found in the pages of the Financial Times, where Andrew Jack does an admirable job of rounding up the usual suspects and letting them get in their sound bytes; previous versions of the case against verticality have been made eloquently and passionately by Laurie Garrett and Roger England. Here, from the FT, seems to be the gist of it:
[T]here are concerns that the sums pushed into so-called "vertical" health programs, set up to tackle particular diseases, can have unintended negative consequences. In particular, they risk diverting attention from, or even undermining, broader "horizontal" health systems established to prevent and treat all forms of ill-health.
That certainly sounds sensible, and at any international meeting these days you can find a plurality of global health wallas nodding their heads sagely in agreement with anti-vertical program assertions. Yes, we recite, too much money for single diseases - think of the Global Fund, think of PEPFAR. Yes, we should strengthen health systems, in accordance with national priorities. Although I have been among those doing the nodding, and I think there is ample reason to be very worried about the state of global health aid these days, I am not at all sure that the "vertical vs. horizontal" dichotomy is useful. This is largely because the label "vertical program" means many things to many people, variously connoting "donor-driven," "using parallel financial and information systems," "centralized" and "target-driven." But it's also because we've been collectively vague about what the viable alternatives might be in many low-income countries where both public and private sectors are weak, and there are an uncountable number of hurdles to overcome to turn the input controlled by donors (namely, money) into what taxpayers in donor countries think they're buying (namely, better health). By using the shorthand of "vertical vs. horizontal," we are not pushing ourselves hard enough to really understand the nature of the problems - either the problems caused by particular ways of spending money, or the systemic problems that disease-focused programs are often established to work around. I have no magic answers, but let's start by asking just a few more questions to sort out whether the world would actually be a better place without all vertical programs and, if so, what should take their place.
Question 1: Are the worries, and the observed problems and distortions in the health sector of aid-dependent African countries today, really about vertical programs, or are they about "too much" money for AIDS, relative to other health priorities? I think a very large share of the push-back against vertical programs has to do with the growing fear that enthusiasm for addressing the AIDS pandemic has created a whole host of unintended negative effects, including unsustainable demands on the health workforce, wage distortions, dramatic escalation in recurrent costs that can be met only with external funds, and more. Virtually all critiques of vertical programs invoke striking examples of national health budgets dwarfed by external resources for AIDS. There are real problems, with real causes - and, we dearly hope, real solutions. But the problems may have far less to do with "verticality" itself than with the disproportionate sums to one very visible disease.
Question 2: Would there be relatively large amounts of money in global health these days if not for the vertical programs? At times, critiques of vertical programs seem to suggest that the same volume of resources could be made available to improving health system functions across the board, in ways that would increase the access to and quality of all manner of health services. But the (perhaps sad) fact is that those who are making decisions about how much development assistance to provide are motivated by factors that have a lot to do with the advocacy arguments around funding for specific diseases, interventions and classes of people. Without the images of individuals benefiting from particular types of help, the money might well dry up. Moreover, global health advocacy itself might fade without the active support of organizations and individuals who are associated with particular health causes. So, whether we like it or not, the genuine choice may be money for vertical programs or no money at all.
Question 3: Are we so sure it's a good idea not to "distort priorities"? It is not at all clear that money provided to strengthen health system infrastructure and functioning within aid-dependent environments could both be aligned with domestic priorities and achieve what we think of as broad health system goals. I have a feeling that when health experts imagine what a stronger health system is, they think of one that is more equitable, providing more and better quality services to the most excluded people in a country; and they think of one that produces good quality services efficiently, with staff, drugs and supplies well allocated to prevent and treat a range of diseases that cause the most suffering. But is this what would result if all the money now on offer for vertical programs was suddenly made available through, for example, unrestricted budget support? I have to admit that I don't think so. I think the political reality in virtually all low-income countries, as in many middle- and high-income countries, would drive resources and attention to high-cost services for families way above the poverty line, having relatively little public health impact and only reinforcing existing social inequality. If we are in an introspective mood, then, I think that those who are focused on health systems actually have their own version of "verticality" and priority-distortion in mind: they want to direct resources to the health system aims that they care about, not put all the control in the hands of authorities operating under domestic political incentives.
Question 4: Wouldn't virtually any effective approach to achieving better health need some centralized programs with earmarked monies? I cannot imagine a real-world policymaker in the health sector wanting to preclude the option of using a "vertical" program to achieve a particular aim - for example, when a new health priority is being established, and there is a need for targeted outreach, inservice training, creation and adoption of treatment protocols, etc. Some of the unimpeachable successes in global health (think immunization, think family planning) often have vertical elements to them. Regardless of funding source, some aspects of "verticality" - the top-down, "command-and-control" features - may well be needed to achieve public health aims.
The answers to these questions do not lead us to the conclusion that all "vertical" programs are the best way to get to better health in poor countries, or even a good way in most circumstances. But perhaps they can help lead us away from the knee-jerk, baby-with-bathwater criticism of verticality that is now a la mode. What is needed much more than debate and pendulum swings is a clear-eyed, non-ideological search for ways to use the new resources on offer in ways that both achieve specific health outcomes and contribute more broadly to the capacity of health workers in public and private sectors, to the effective management of health service organizations, and to enabling families to make choices that are good for health.
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Comments
My problem with 'vertical programs' is that i don't think AIDS or malaria work happens in a vacuum, but rather happens in the a real world environment of ineffective health infrastructure that can barely deal with common health needs that often get overlooked when there is a high emphasis on a single issue in a given area.
Posted by: Ian at October 9, 2007 11:25 PM
Thanks, Ruth. Great thoughts. I think that the crucial question that needs to be asked over and over is:
HOW are the vertical health programs being implemented?
Do they strengthen human capacity by training local health workers, epidemiologists, nurses, etc. so that they are better equipped to handle the next health challenge? Do they fit in with other health programs already in place, or do they weaken them? Is there coordination between different programs and organizations?
In short, do the vertical programs strengthen or weaken the health system?
Posted by: chads at October 11, 2007 06:04 PM
Firstly, all of your questions are those that should have been--and still need to be, debated more honestly by all of us. There has been a 'herd' effect in funding vertical programs, especially HIV/AIDS treatment, without looking at the consequences of what we are setting in train.
In this morning's Washington Post, Dr. A. Fauci is quoted as saying: "For every one person that you put in therapy, six new people get infected. So, we're losing that game." In the same article (Still Losing the AIDS Fight), Richard Holbrooke commented: "If current policies are not changed, we will face uncontrollable growth in the costs of treatment of the victims of a disease that should be, as Bill Clinton has said, completely preventable."
I was pleased to see your last para. We know so little about the specific health outcomes of those being treated for AIDS, yet we have gone off on a program target to treat 10 million by 2010. Families are inhibited from making choices that are good for health. Those choices are being made by donors. In cases where this involves ARV procurements, many of the drugs from India are being distributed to patients without their knowledge that WHO has issued a Disclaimer on their safety and/or efficacy if used in the treatment of AIDS.
Whether from the clinical consequences of treatment, or the ineffective prevention programs, our community is facing a virtual tsunami of unfunded liabilities--due all too soon.
Posted by: Jerry Norris at October 12, 2007 03:46 PM
I think these are all good points.
Three other dimensions that are imperfectly associated with, and sometimes orthogonal to, the vertical vs. horizontal dichotomy are: "public goods" vs. "private goods", "supply" vs. "demand" side interventions and public financing vs. public provision. Some of the brouhaha about vert vs Horiz must come from special interests on the side of respectively "private goods" (doctors want to be paid to provide them and patients want to be subsidized to consume them, but vertical programs sometimes focus on public goods), "supply side" (again doctors want to be paid to supply them and so do public health experts, while patients seem to have less voice) and financing vs. provision (insurance companies hate the former and public sector docs like the latter).
An alternative to both vertical and horizontal programs would be better health insurance/financing programs together with good certification/regulation of private providers. This would really put the decisions in the hands of individuals who could decide how the resources would best be used for the consumption of mainly private health services. This omits the public goods, and why not use vertical programs to address those?
Posted by: Mead Over at October 12, 2007 03:47 PM
Here are my thoughts on the questions you pose below:
1) I agree with the point. However, a spin off question is given that "AIDS pandemic has created a whole host of unintended negative effects, including unsustainable demands on the health workforce," and assuming that current total monies flowing into health systems for HIV and other issues all comes from the same set of potential resources for health care spending, if you shift priorities away from HIV to other areas...i.e. because funding for HIV is disproportionate, what does this mean for HIV? I.e., will it be receiving less money? To me, less money to HIV would imply that we are currently putting too much in, rather than grappling with the issue of it being such a cost burden that it eats up resources, limiting the ability to spend these on other priorities...
2) This is esp true with respect to HIV/AIDS and the impact of the media in bringing focus and dollars to health care systems issues.
3) Agree.
4) In my mind, vertical programs are necessary for delivery of certain, specialized aspects of health care issues associated with diseases (ie, DOTS for TB, Antiretrovirals for HIV) but in the end, there are systems issues that need to be addressed that impact on all of these, akin to what you mentioned in 1... ie, health workforce recruiting, health systems infrastructure etc…so I guess my comment is that perhaps to maximize the funds, the best ways to spend horizontally and make impacts across priority areas is also a necessary component.
Posted by: Danielle Kuczynski at October 12, 2007 03:52 PM
This working paper addressed a central empirical question of the vertical vs. horizontal debate in the context of a mission I was on to Mauritania in the late 1970's. The two public health docs on the mission had radically different views. One wanted to do a vertical program using mobile teams, the other wanted to do a horizontal program using fixed polyvalent health centers. The project design was never completed. The paper was my attempt to reconcile the two views.
Posted by: Mead Over at October 12, 2007 03:53 PM
I agree with all your points, Ruth - but am not sure whether it will move the debate forward, or possibly just give people an "out" so they can just go back to being satisfied with their vertical delivery approaches.
Yes, the current criticisms are superficial, and overblown. And as you say it is very fashionable to criticize verticality now. But, with respect to what is being done in global health funding and programs - I have seen no shift, except possibly further towards verticality (ITN distn via campaigns are now the rage, regardless of evidence and stated policies). This doesn't make me love the superficial criticisms better - like you I think it is harmful to lump together all health interventions when some have shown very amenable to vertical delivery and others not.
On questiton 3: Are we so sure that money provided to strengthen health system infrastructure and functioning within the aid-dependent environments could both be aligned with domestic priorities and achieve what we think of as broad health system goals.
Am I sure? No. But I think there are some options out there which show every sign of being better than vertical programs.
Contracting is the obvious one. It's proven an amazingly effective way at getting primary care delivered (to treat all the diseases at once), and allows an output and outcome focus. Sure gov'ts generally want to keep the money themselves, and don't like to go this way, but should that mean that we just give up and say lets do vertical programs to get around the persistently non-responsive, non-accountable public delivery system? I don't think so. The CLAS in Peru is another example where publicly funded autonomous PHC clinics, overseen by community boards, were able to improve quality and access substantially and quickly. I think CCTs - where required health care visits can be at the provider of choice (a la Nicaragua) are another example.
In a way, I think vertical disease (and popn group) programs are an organizational strategy to get around the fact that it seems impossible to improve the public health services (qualty and access) without creating an administrative enclave - that provides autonomous administration with flexibility and ability to emphasize accountability and performance in a monitorable way. And I think countries and donors often resort to them because they aren't willing to pursue the more "radical" models of contracting, autonomy w/ community oversight, or CCTs.
Given that I see it this way, I guess I don't feel comfortable coming out too strongly to defend them against their critics. I guess I may have an even more "unpopular view".
Posted by: April Harding at October 12, 2007 03:55 PM
I think this is a great round up of recent reflections on the issue and then a superb summary of the issues that make "verticality" a problem. So, yes I like the message that it is important to examine the issues that make verticality a problem and address those vs. just tossing out vertical programs per se.
I can't agree more that the verticality of AIDS programs have kicked off this debate once again BECAUSE of the enormous amounts of money that have been earmarked for a disease. It's almost certain that a vertical program designed to lower maternal mortality, for example, would never be challenged because donors wouldn’t be putting in a lot of money in to something that can't be treated. Maybe there is an operational impetus to design vertical programs when you know you have a drug or vaccine that works and you want to get it out? When you can "conquer" something (treatment or cure), it is worth concentrating your efforts to use these technologies, but it's about getting the balance between vertical programs and "the health system" that is the trickiest part...and whether one can "graduate" a vertical program in to a health system when it has presumably achieved what it set out to do in a very directed way? Any examples of the latter?
Posted by: Nandini Oomman at October 12, 2007 03:56 PM