Vertical vs. Horitonal and the Future of PEPFAR

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With PEPFAR seemingly at risk of being shortchanged by the Obama administration, there was a special urgency to Wednesday’s Capitol Hill briefing about the future of global health programs.

The debate was framed, in health advocate speak, as vertical vs. horizontal. In other words, are vertical programs like PEPFAR, focused specifically on HIV/AIDS, draining money and talent from developing-country health systems? Or are such efforts strengthening health systems by building new lab capacity and training community health workers?

The panel tilted heavily toward the latter argument, fearing Joanne Carter of RESULTS and Paul Farmer of Partners in Health.

Farmer said the argument over whether HIV/AIDS, thanks to PEPFAR, is getting too much money and attention is “silly” when examined in a historical context. “Before we decide its overkill, we need to realize this program is brand new,” Farmer said.

Pat Daoust, of Physicians for Human Rights, said in the beginning, vertical programs like PEPFAR did drain resources from developing country health systems. But that has now changed dramatically, with much more emphasis on integrated care, developing a health care workforce, and other strengthening elements.

“It was the Trojan Horse that opened our eyes to the extreme need,” she said. PEPFAR taught us “how to launch effective health programs” and to pull back now would be devastating.

Farmer said that comprehensive integrated care should be the ultimate goal and that PEPFAR is one way of working toward that. Ultimately, he said, the debate should be further broadened to look for ways of breaking the cycle of poverty.

“Why is AIDS more important than maternal and child health? The answer is it’s not,” said Farmer. “When you’re dead, you’re dead.”

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