On Creating “Diagonal” Health Systems

The climate for treating the diseases of the global poor has fundamentally changed. In the past five years, multi-lateral players like the WHO, the Global Fund for AIDS, TB, and Malaria (GFATM), the Gates Foundation, the Clinton Foundation, and the President’s Emergency Plan for AIDS Relief (PEPFAR) have poured billions of dollars into impoverished nations to stem the rising tide of preventable and treatable diseases. The time of standing idly by while millions die of HIV, TB, and malaria is purportedly over, yet, mortality rates are still sky-high and all this money doesn’t really seem to be working. I think it’s ultimately a failure of well-executed healthcare delivery.

One major obstacle to providing efficient, effective care is the conflict between so-called horizontal versus vertical programs. Horizontal programs have been traditionally provided by national governments. A good example is the UK’s National Health Service. While I’m not super-familiar with the inner-workings of the NHS, it seems to me that the primary care physician serves as a gate-keeper and coordinates all aspects of care. These include preventative services (vaccines, screening tests, etc), basic curative services, social work, counseling and mental health, and referral to specialists. The NHS model is touted as the blueprint for district-health services in Anglophone developing countries, but due to scarce resources (human and capital), health care falls woefully short. Some pundits argue that international aid for heath should go to strengthening these comprehensive horizontal programs contending that providing food, social support, housing, economic opportunities like microfinance are integral parts of improving health. The major problem with these programs is they take a long time to develop, require infrastructure and human resources, and, assuming fixed health sector spend, may provide good care to few while neglecting many. Good horizontal programs are very hard to develop and spread, and because of their bulkiness, do not do well adapting to local environments.

Vertical programs, as the name suggests, focus on one disease area, like HIV/AIDS. In contrast to horizontal systems, vertical programs are agile, able to scale up quickly, and often do one thing very well. Because they don’t provide a comprehensive package of services, they are able to adapt and change to local environments, can task-shift routine processes down to less-educated workers, and are able to develop simple tracking systems to follow patients over time. A good example of a vertical program is the Center for Infectious Disease Research in Zambia (CIDRZ). Funded by PEPFAR and GFATM, CIDRZ was able to rapidly put 100,000 people on AIDS therapy in three years at a relatively low cost (~230 dollars per person per year). The coverage in some places was 80% of the affected population. What they didn’t do was provide vaccines, accompaniment (a form of directly observed therapy), economic advancement, maternal care, etc. They were solely focused on responding to the AIDS crisis, and approached the problem like a disaster-relief organization. Get the treatment out. Fast.

Obviously, both approaches have their significant drawbacks, and most places are focusing on developing and sustaining vertical programs. In Uganda alone, there are over 600 foreign-based non-govermental organizations all doing different things, often overlapping in the same places. I suggest we start thinking about diagonalizing health care in poor countries. Julio Frenk, the new Dean of the Harvard School of Public Health and former Gates Foundation big-wig, has advocated for diagonality saying that the attention focused on HIV/AIDS provides a unique opportunity to capture “spill-over.” HIV is a big problem, no doubt, but once the frenetic initial response has finished, focusing on the broader health concerns of the population has to take precedence. If successful HIV programs like CIDRZ are in an area, consolidate services for TB, malaria, vaccine delivery, bednets, food, etc and combine the NGOs personnel under a unified umbrella. Of course, most organizations won’t like this, but it will take strong national governments with the guts to rebuke NGOs that don’t fall in line to make this happen. Country coordinating mechanisms must be set up, strengthened, and supported by funders otherwise we run the risk of having individual programs each with their own little fiefdom. If things stay the way they are now, everyone will think they’re doing good for individuals, but the population won’t get any better.