Navigating Directions to Improved Health Systems: Vertical, Horizontal…or Diagonal?

Health policy experts have long been debating whether vertical or horizontal approaches benefit health systems most. While there has been a bit of a shift away from the dominant disease-specific (vertical) approach, tensions are far from resolved. The time for compromise is here; a diagonal approach may offer the best of both.  A walk through the relative merits and limitations of these approaches allows a clear look at how this middle ground may be the best framework for creating more effective health systems.

Vertical approaches focus on a specific demographic population, disease or health issue, and promote targeted clinical interventions delivered by a specialized service. These programs have their own financing, management structures and staff, rather than relying on existing systems (Msuya, n.d.).  On the plus side, this approach targets specific resources to address high priority health issues and has defined objectives with measurable outcomes. Donors prefer vertical causes, as they are able to see a return on their investments when interventions and outcomes are monitored (Behague & Storeng, 2008).  On the minus side, the vertical approach can create a fragmented array of uncoordinated programs supported by multiple donors that recipient countries must struggle to manage.

The horizontal approach focuses on an integrated delivery system and tackles many interrelated health issues. It is more likely to provide greater patient and family-centered care, as it addresses multiple determinants of health. Some experts suggest that in these integrated systems, scarce funding is used more efficiently (Wilson, n.d.) But there are problems as well; in horizontal health systems, health workers may be poorly trained and feel overwhelmed by the multitude of interventions; outcomes are often poorly documented; and if the infrastructure is not well developed, it is difficult to sustain.

Proponents of these disparate approaches have been in conflict for some time, but this does not have to be the case; the diagonal approach offers a balance between them.  This middle ground is a way for individual disease programs to help develop the capacity of health systems.  By way of example, a Swiss development organization, SolidarMed, started an HIV/AIDS treatment and prevention program called SMART in  Tanzania, Mozambique, Lesotho and Zimbabwe in 2005. The organization believed that the key to fighting HIV/AIDS was to build the capacities of local health systems – a strong health workforce, outreach services to rural communities and adequate district health management capacities. They implemented three strategies: First, they integrated SMART into existing primary health care programs. Second, they used a multi-stakeholder approach to harmonise SMART with existing HIV/AIDS programs and bring it in line with national health policy. Third, they used SMART’s budget to strengthen capacity building interventions that are not specifically related to HIV/AIDS. While there were challenges, many positive outcomes resulted. Improvement of blood chemistry and hematology facilities meant that patients suffering from anemia began to receive adequate treatment. The focus on treatment of babies exposed to HIV/AIDS resulted in improved pediatric primary health (Gass, 2011).  Such is the promise of the diagonal approach; embedding specific interventions in wider primary health care strengthens the system while maintaining a focus on the priority.


Behague, D., & Storeng, K. (2008). Collapsing the vertical-horizontal divide: An ethnographic study of evidence-based policymaking in maternal health. American Journal of Public Health, 98 (4), 644-649.

Gass, T. (2011). Exploring a diagonal approach. In Fighting disease or strengthening health systems? Retrieved from

Msuya, J. (n.d.) Horizontal and vertical delivery of health services: What are the trade offs? Retrieved from

Wilson, C. Focused vs. integrated health programs- The conflict between the vertical and the horizontal. [Powerpoint Slides]. Retrieved from


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