Should All Vertical Programs Just Lie Down?

"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.