Finding our balance in a vertical, horizontal and diagonal world

Systems are constantly at work in our lives helping us navigate intricate issues and create efficiencies in the ways in which we operate.  Unfortunately, they do not always work as efficiently as we’d like and thus we are left with conceptual imbalances and a lack of coordination amongst moving parts. This is certainly the case with the current state of health systems and the fragmented strategies that are being employed to tackle global health issues in low and middle-income countries today[1].

Over the past 50 years, two outwardly opposing strategies have been utilized to tackle global health concerns.  The first strategy, known as the vertical approach, focuses on creating disease-specific solutions to global health issues.  Individuals working under this approach operate financially and administratively on their own to reduce the incidence and prevalence of a particular disease. The second strategy, known as the horizontal approach (which received a great deal of attention in the 1970’s and has once again gained attention since the G8 summit in 2008) focuses on a health systems approach, emphasizing the need for a more general multifaceted operating plan in managing health care needs[2].

Both have advantages and have faced challenges in making forward progress.  The vertical approach gained traction with donors early on because of its focus on tangible goals that could be more easily tackled.  However, those practicing this approach have been known to work independently of other health-related services, which in some case has led to duplication of services or a lack of comprehensive care in others.  The horizontal approach, on the other hand, aims to provide comprehensive preventative and curative health-care along with equitable access for all but requires time and cooperation for development.

Both approaches are ultimately working towards improving access to quality health care, so why do we compare the two as if mutually exclusive?

Tension between the vertical and horizontal approaches still exists today due to their opposing philosophical and structural differences1.  While a focus on disease specific programs is still reflected in programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and services continue to expand under this approach, increased emphasis from the public health community to develop more integrated health systems continues[3].   Fortunately, there is hope for alleviating this tension.

By integrating these approaches, there is opportunity to create a balance between the vertical and horizontal strategies that are currently at work in low and middle-income countries.  This new spin on the old is known as the diagonal approach and has the potential to serve as the bridge between these two extremes.  For example, under the diagonal approach, countries could pool funding from disease specific health programs to ensure broader access to resources and less duplication of services[3].   The diagonal approach is beginning to make an appearance on the world stage and allows for the benefits of both the vertical and horizontal strategies to be utilized in strengthening health systems[2].

So is it really necessary to side with one approach as opposed to the other?  My feeling is no.

To make lasting health system improvements, I agree with Reich and assert that it is more important that we find ways to integrate elements of both strategies to create a hybrid approach for developing global health solutions[2].  Too often, health systems are disjointed in their attempts to create efficient organizational structures due to their lack of support from those implementing disease-specific strategies.  It is essential that we consider how we can integrate both the vertical and horizontal methods to create a diagonal approach to strengthen and create balance in health systems that continue to operate inefficiently.


[1] Mills, A, Rasheed, F, Tollman, S. (2006) \Strengthening Health Systems.” In Disease Control Priorities in Developing Countries (2nd Edition), pages 87-102. New York: Oxford University Press.

[2] Reich, MR, Takemi, K, Roberts, MJ, Hsiao, WC. (2008) \Global action on health systems: a proposal for the Toyako G8 summit.” Lancet 371: 865-869.

[3] Murray, CJL, Frenk, J. (2000). A framework for assessing the performance of health systems.” Bulletin of the World Health Organization 78(6): 717-731.

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