As Dr. Calvin Wilson began his plenary presentation at the Sixth Annual Family Medicine Global Health Workshop in Denver earlier this month, he said to the audience of physicians, “Now class today we’re going to learn geometry.” As he began talking about the vertical approach, and the horizontal approach, Dr Wilson was joking but he was also making a point. As disparities related to health continue to be significant and much more is needed to be accomplished in order to achieve the Millennium Development Goals set by the United Nations, it is clear that a different approach is needed to address global health issues. Dr. Wilson, an associate professor of family medicine at the University of Colorado School of Medicine, and the director of the Center for Global Health of the Colorado School of Public Health, was attempting to deal with a controversial issue in global health today: the debate between vertical and horizontal funding of health initiatives. The vertical initiatives are programs that address a single area of focus, such as a disease like HIV/AIDS, or malaria. The horizontal initiatives are programs that attempt to improve aspects of the health care system in an area or a country. Dr. Wilson gave a careful and balanced approach to this issue and pointed out pluses and minuses to both sides. His presentation can be found through the website of the American Academy of Family Physicians.
Dr. Julio Frenk, the Dean of Harvard’s School of Public Health, and former Minister of Health for Mexico used examples from his home country to illustrate the importance of the diagonal approach when he was interviewed in the June issue of Global Pulse. Dr. Frenk sights, how work on HIV/AIDS in Mexico was designed to also enhance the healthcare system. “By starting with AIDS, we were able to build an entire insurance system that was then in place to start covering other diseases.” Dr. Frenk’s interview with Global Pulse can be found here
It is unfortunate that this debate has gone on for so long and that there is still no clear resolution to it. Perhaps two next steps are helpful in this process.
- Cease the Competition: It is sad that any debate has developed regarding this issue at all. Even more counterproductive is that at times there seems to be a competitive nature to the debate from one side or another. From the grassroots perspective, it is often obvious that these approaches are much more in concert with each other rather than in competition. Resources are needed for programs that implement specific treatments and for specific prevention methods but these programs are usually only as good as the infrastructure available to make things happen on the ground. The reality is that vertical strategies will, at some point, need to hit the ground and their implementation will involve: public health education, vaccination, or training to increase the competencies of treating healthcare workers. To utilize the existing infrastructure, no matter how lacking it might be, is preferable to starting from scratch or to creating parallel infrastructures. Building on the existing infrastructure allows the lessons of past implementation experiences to inform the future and, if done well, allows for culturally appropriate adaptations to be made for each setting that can improve the effectiveness of any implementation, while reducing the potential for inflicting unintended harm. In most resource-poor settings, when you bring in relatively small amounts of cash, you can make many things happen. Unfortunately when you pull out the cash, it often has the effect of inhibiting the local input.
- A workable Construct: While there has been a lot of talk about the need for a more balanced approach, there has not been a lot of action. It is hard to move forward without a method of implementation. Since we are talking about a very broad spectrum of health initiatives, it is unrealistic, and frankly not very helpful to propose anything that is too specific. One option has been proposed that appears very promising. 15 by 2015 is an initiative proposed by a partnership of the World Organization of Family Doctors (WONCA), Global Health through Education, Training and Service (GHETS), and the European Forum for Primary Care (EFPC). In an article published in the British Journal of General Practice in January, 2008, they make their proposal, “We propose that by 2015, 15% of the budgets of vertical disease-oriented programmes be invested in strengthening well-coordinated, integrated local primary healthcare systems and that this percentage would increase over time. 15 By 2015 is a very helpful construct. It raises the awareness of the need for both vertical and horizontal approaches that complement each other and creates a simple framework that allows customization as needed. The 15% threshold is not meant to be the highest possible for the horizontal component but it is a conservative number that can surely be an agreed upon minimum. In this way, new initiatives can build on the existing knowledge and experience, and leave the community with an incrementally improved infrastructure.
In his address to the Global Health Workshop in Denver, Dr. Wilson used some different language. Instead of consistently using “vertical” and “horizontal,” he used the terms disease focus approach and integrated systems approach. These are terms that seem to fit more logically to the conversation. Perhaps these terms can be seen to be more obviously collaborative than their geometric versions and help us bridge the gap by taking the shortest distance between these two points that should not be divergent at all.