Here’s One Global Health Tool to Help Integrate the Vertical with the Horizontal

With today being Universal Health Coverage (UHC) Day, many stakeholders are rightly concerned about the stalling progress towards the Sustainable Development Goal (SDG3)—"Good Health and Well-being,” of which UHC is an integral part. Since many SDG indicators of progress are outcome-focused, they cannot tell us why progress is stalling and therefore what needs to be done. To advance toward SDG3, policymakers need to shed light on why progress is stalling. For that, we need different data—and we argue that health facility surveys can help move the policy community forward in the right direction.

Global health has been mostly vertical

Most SDG indicators are tightly linked to a vertical perspective, often about reduced mortality from a particular disease or about coverage rates for a given service, further linked to what you could argue is the movement for results and its keen focus on outcomes and “lives saved” (see here and here, for example).

The focus on these types of indicators is not surprising, given the vertical organization, funding streams, and the politics thereof. Global health organizations such as the World Health Organization are dominated by the biomedical construct as viewed by medical professionals and there are entire global health agencies that are focused on a particular disease or sets of diseases (such as the Global Polio Eradication Initiative; the Global Fund to Fight Aids, Tuberculosis, and Malaria; or Gavi, the Vaccine Alliance).

Here are some tools for integrating the vertical with the horizontal

Although horizontal approach to service delivery has been championed since the 1978 Alma Ata Declaration underlining the importance of comprehensive primary health care, the global health community remains weak on integrating the vertical and horizontal. There are few examples (e.g., the Health Systems Funding Platform) and we need more experimentation and lessons learned from such integration. One of us recently argued that the newly established Pandemic Fund could be such an opportunity to integrate the vertical with the horizontal. Even the recent Future of Global Health Initiatives report focuses on the “fragmentation” problem, not just of many donors but also many vertical priorities.

One way to integrate was through the focus on UHC. UHC focuses on building country systems that cover people with a cost-effective package of high-quality services across multiple health priorities and protecting people against the financial risks of falling ill.

But integrating and moving towards UHC are not just high-level buzzwords. We need tools and approaches. Some key tools or topical areas for advancing UHC include priority setting, value for money, and health benefit package design (see here, for example).

But there’s another set of tools to consider: health facility surveys. Such survey tools are crucial for providing evidence on what and how services are being delivered, and why and where gaps exist. They help shed light on what’s happening at the facility, on service delivery by providers and its receipt by patients, and can offer key insights on quality and availability of care.

Why health facility surveys?

Large scale, in-person, health facility surveys are valuable because they can shed light on why progress toward global goals like UHC is sluggish. They do so by looking under the hood at drivers of health outcomes and care quality: evaluating patient experiences, provider adherence to guidelines, and treatment appropriateness, in addition to availability, such as whether a facility has running water, electricity, or health workers. Particularly when nationally-representative and measuring both public and private sector health services, such surveys are an important form of data and evidence for decision-making because they provide insight into tangible areas of improvement. They can help to complement, verify, and validate against routine administrative data (see here and here) and provide a backbone of depth to newer phone survey data.

For those interested in advancing towards UHC, there are three key health facility survey programs: USAID’s Service Provision Assessment (SPA) Surveys; WHO’s Service Availability and Readiness Assessments (SARA); and the World Bank’s Service Delivery Indicators (SDI) Health Surveys. The necessity of enhancing quality measurement and service delivery assessment, as well as the potential and limitations of these survey tools in expediting progress towards UHC, has been explored previously. These discussions have proven instrumental in driving the revision of these tools. The revamped SDI health survey is now taking the lead in addressing this crucial need for high quality data on system performance.

The key advantage of the World Bank’s revamped SDI health survey is that it brings an integrated vertical and horizontal approach to the table: it’s all about systems. While the tools still capture details of individual disease-specific services, this survey takes a comprehensive 360-degree view. It places the average citizen's experience at the forefront of its design, exemplified through patient interviews, which are a cornerstone of the assessment, ensuring that real-life experiences and satisfaction drive the evaluation.

But the SDI doesn’t stop there—it delves into the realm of healthcare providers, considering factors like their work environment, job satisfaction, and overall well-being. This survey recognizes that the health workforce is the lifeblood of any healthcare system. By combining these insights with best practices in survey design and nationally representative data collection, the result is a recipe for a comprehensive evaluation and a significant leap forward in measuring the quality of care. In essence, the SDI health survey is groundbreaking in how we measure and enhance healthcare systems.

But regardless of a policymaker or bureaucrat’s choice of survey vehicle (be it the SPA, SARA, or SDI), these surveys are a linchpin for measuring health systems quality and moving towards UHC across multiple diseases and vertical priorities. These surveys offer independent, reliable measures of clinical quality, while offering a comprehensive and holistic assessment of the quality of care across multiple diseases and populations seeking care at a given health facility. These surveys can also help us understand the frictions and gaps of “health systems strengthening.” There are only so many health workers in a country or area, and if any are diverted to focus on a single disease, there can be a cost to the delivery of other services.

What’s next?

It’s not enough to say that we need better health data. Policymakers need to invest strategically in data to inform decision-making. We need better and different types of health data, including mortality data (see here and here, for example) as well as health facility data as we’ve argued here. Health facility survey data isn’t going to solve all your “health system strengthening” problems or “vertical/horizontal” problems, but it’s one very good place to start.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.