Here is a figure from Ravishankar et al., 2009 showing the amount of development assistance for health provided for various diseases over the last two decades:
If you missed it, that little purple sliver is the amount provided for general health-sector support.
Over the past decade, we’ve seen an exponential increase in the amount of funding directed toward disease-specific, “vertical programs”, but funding for health systems strengthening (so called “horizontal programs”) have remained stagnant. I haven’t done anywhere close to an extensive literature search (and chances are, given our current inability to effectively assess quality of care or system-level indicators, rigorous evaluations for the merits of horizontal programs vs. vertical programs may not even exist), but here are at least some conceptual reasons why we need to start focusing on health systems strengthening:
1. Vertical programs may constitute inefficient use of resources. Spend a dollar on training a health worker to provide HIV/AIDS treatment and HIV/AIDS patients may benefit, but spend that same dollar on training primary care doctors/nurses or on creating a more sustainable health financing mechanism, and everyone can benefit. Furthermore, separate, uncoordinated vertical programs can lead to duplication of efforts (for example, separate reporting systems and procedures for HIV, tuberculosis, malaria, etc. rather than one integrated system that also functions as an electronic medical record system).
Nevertheless, isn’t an inefficient use of resources still better than using no resources at all? That’s certainly true, and I am in no way aligned with the argument that we should end aid, but we need to keep in mind that health care works within a dynamic system, in which intervention on one end can have reverberating consequences—good or bad—on other parts of the system. Which brings me to my second point…
2. Overly focusing on individual programs may draw resources away from the general health care system. Resources for health are not infinite, and in a 2010 Lancet review, Samb et al. finds that “the urgency of an agenda for tackling specific diseases such as HIV/AIDS, tuberculosis, malaria, and vaccine-preventable diseases has exacerbated previously existing pressures in each of the six health-system components.” For example, if funders are knocking on your door with money for TB treatment, but demand that you first provide TB-specific training for health workers, what are you as a resource-strapped country likely to do? Divert general health workers from other parts of the system.
3. Individual programs/NGOs may focus on immediate outcomes but neglect long-term results. It’s highly gratifying to tell donors: we delivered drugs to 500 patients over the course of two months. It’s much harder to be able to tell them: 500 patients consistently used the drugs we gave them and actually got better two years later. (And donors often have short attention spans.) As an example, in China I heard countless doctors in both Sichuan and Guangdong province complain about the “Health Express”, a local NGO that provides free cataract surgery out of a train…but then leaves the patient without providing any follow-up care, resulting in complications that local hospitals are often left dealing with.
There are some more shortcomings of disease-specific programs, and readers who want to find out more might want to read this Financial Times article from 2007. Finally, I want to leave you with one last thing: Ruth Levine at USAID has written a great article criticizing exactly the kind of “vertical vs horizontal program” clamor that I’m drumming up, and she has many valid points, such as whether the level of funding we have for global health today would even exist without the tangible rallying points that disease-specific programs provide. However, there’s reason to believe that a gradual but pervasive shift is occurring in the focus of global health, and that the stage may be set for great advancements toward health systems strengthening. More on this in a subsequent post.
Not a counterargument of any sort, but realistically, when is aid the biggest to a country? When the country is in crisis. So where does the money go usually? To the thing making the loudest noise.
Also, PF talks so much about this in the Haiti after Earthquake book. I feel like you have been interested in public health issues for far, far longer than I have. What other suggested readings do you have for me? I am thinking of picking up a copy of Partners in the Poor.
Thanks for pointing that out, and I do agree that we shouldn’t neglect prominent individual diseases and pour all money into building up health infrastructure. But two points: First, it certainly does make sense to respond to specific diseases during an outbreak or an emergency crisis, but in the long run, a focus on developing the health system can reduce the severity of the public health crisis when the next disaster hits. Second, community health workers oftentimes are very much a part of a country’s health care system (and, as some would argue, should become an even bigger part of it). However, the system shouldn’t consist of stand-alone workers trained only to deliver HIV/AIDS treatment, who aren’t also capable of recognizing and referring patients with diabetes, high blood pressure, etc., or aren’t connected to a wider health system that is capable of treating other general conditions. Otherwise, you expend resources to screen for patients with a certain illness, but ignore patients you find with conditions other than that which your mission is to treat.
The problem of limited resources that you raise is definitely an important one, especially during this time of budget tightening. Many developing country governments have reduced their own spending on health in the last few decades (in response to increased donor funding, as some would point out), which has further fragmented the delivery of health services. Ideally in the long run governments would invest more in their own healthcare systems, and it would not be a zero sum game between vertical and horizontal programs.
I think you bring up many valid points but I also think many of these points vary on a country to country basis. As a counterargument to 1, for example, when an epidemic (such as cholera) is going through a country, it actually makes a lot of sense to focus resources on that specific epidemic rather than diluting resources. Another argument to your first point is that a lot of the times, community health workers require far less resources to train than a regular physician and so the same amount of funding can reach far more patients than giving more training to a few primary care doctors, which is already a limited resource in a lot of developing countries.
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