An End to the Vertical Vs. Horizontal Debate?

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For decades, global health experts, policymakers, and others have been debating the merits of disease-specific initiatives versus broader efforts to strengthen health systems. It’s the old the vertical vs. horizontal argument.

No one has settled that debate. But maybe we should stop asking that particular question. Or at least start asking some new ones.

 “It’s not a helpful way to frame the issues,” Peter Berman, a lead economist on the health, nutrition and population team at the World Bank said today at a brown bag lunch exploring what TB and AIDS programs can contribute to health system strengthening in Africa.

He said all health initiatives, whether focused on one disease or on something broader, are aimed at improving results, i.e. health outcomes. So it’s not productive to engage in a debate that pits one approach against another. Instead, Berman suggested, we need to start asking more “why” questions. Why is the quality of a country’s TB program so poor? Why are the primary care clinics in another resource-poor country crumbling?

“We need to think more about the casual analysis,” he said. If we don’t ask the why questions, he said, we’re at risk of introducing “technical solutions” that improve things in the short term, but that fail to make enduring fundamental change.

Berman’s remarks came near the end of the World Bank session, which featured two experts from Family Health International.

First, Bruno Bouchet, FHI’s acting director of health systems assessment and development unit, talked about FHI’s work to improve the quality of tuberculosis treatment in Senegal. He and his colleagues used a model that promotes “system thinking.” That involved getting the health care workers to spell out very specifically each step of TB treatment, from identification of chronic coughers to final assessment and discharge, and then identifying problems and failures, as well as possible changes or solutions, at each point.

That approach leads to more fundamental change. “You link bad health outcomes to a support function that is not working,” he said.

One concrete benefit to the underlying health system: a more integrated approach to TB-HIV care. At the beginning of the project, Bouchet said, no TB patients were tested for HIV. That stemmed in part from a policy under which HIV tests were reserved for prevention of mother-to-child transmission services. Reassessment of the TB control program led to a new policy under which TB patients are now offered an HIV test.

The World Bank session also featured Dr. Leine Stuart, who talked about FHI’s study in Rwanda documenting that HIV scale-up coincided with significant increases in several non-HIV primary care health services, particularly antenatal care. She said in the Rwanda program, HIV funding has been used to rehab dilapidated clinics and develop integrated, electronic patient medical records, among other improvements.

Although the study was limited in scope, Stuart said it was a good place to start as this argument that HIV/AIDS programs were harming health systems seemed to be gaining steam. She said that when FHI’s Rwanda team heard that contention, they felt like they were living in a “parallel reality” because it so flatly contradicted what they were seeing on the ground.

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