Following the introduction of Millennium Development Goals, global health aid has seen a tremendous increase, allowing many of the poorest countries in the world to make significant progress towards increasing the coverage of key health interventions across diseases such as HIV, TB, malaria, vaccine-preventable diseases, diarrhea, and pneumonia. The organizational model used to achieve these rapid gains against the backdrop of resource constraints has been the “vertical program approach,” in which funds were channeled by global health donors focused on controlling diseases in silos, reflected in the emergence of large funding organizations such as Gavi for vaccines and Global Fund for HIV, TB, and malaria. This has often imposed separate financing, human resources, supply chains, infrastructure, information systems and governance arrangements for “priority” diseases such as HIV, TB, malaria, maternal and child health. While these vertical programs have, for the most part, succeeded in increasing coverage, an overreliance on them has neglected the remaining functions of the health system such as building or expanding facilities, purchasing or repairing medical equipment, paying health workers, delivering non-program drugs such as antibiotics or painkillers, as well as decreasing the ability to control significant drivers of the disease burden such as non-communicable disease.
Vertical programs can also threaten sustainability: as countries received funds for these diseases, they often reduced their own health spending and given the rapid scale-up of costly diseases and lack of fiscal space they will not be able to pick up the tab when these donors scale-down or pull-out of these countries. As such, countries have received successful outcomes in specific diseases, but without the potential for sustainability or a stronger health system, sustaining these gains is in peril. For example, many countries, particularly in sub-Saharan Africa, have initiated thousands of patients on HIV treatment but cannot treat the same patients for a fever or hypertension given their lack of funds for cross-cutting drugs and their supply chains, or lack of health workers who are trained to treat these conditions.
Further, the growth in global health aid has flat-lined particularly since 2010, indicating that many of these vertical programs are now at risk. Many large, populous middle-income countries are graduating from donor support, and in many instances, they do not have the domestic resources or the political will to make up for these declines.
With these programs ending, and in a political and economic environment where resource mobilization is difficult, a way to mitigate these challenges is to frame it from the perspective of efficiencies. This past summer, I was at the World Health Organization’s headquarters in Geneva, and I worked with the team within the Department of Health Systems Governance and Financing which developed a system-wide approach to analyzing efficiencies across health programs. The motivation for this program of work is to take on the issues raised above in a collaborative way, in order to improve and even expand coverage as countries consider how to take a more integrated approach to organizing priority disease interventions and related financing. This approach starts with the premise that vertically organized health programs within the overall health system have duplications across four core functions of financing, service delivery, resource generation and governance, as each of these programs work in silos. In order to increase efficiencies and tackle these challenges, it is imperative to focus on how these different disease programs interact with each other as well as the broader health system and identify misalignments, overlaps, and duplications between each entity, with the goal of harmonizing them to improve health outcomes.
The cross-programmatic, system-wide approach looks into how these four health systems functions interact with each other across the programmatic and non-programmatic aspects of the health system and seeks to solve these issues using the health system of the country as a unit of analysis, looking into the functions, objectives, and goals listed above. This is done through consulting with key stakeholders in the country, documenting and analyzing the inefficiencies within the health system across the four health system functions, and finally developing targeted options to address the sources of these inefficiencies. I was able to work on implementing this approach in Ghana, building on experience in South Africa and Estonia, and we worked very closely with many stakeholders in the government to identify these cross-programmatic inefficiencies.
Often, it is difficult to see the immediate impact of work in health systems, and this is precisely why the vertical approach has been favored by donors and governments: it is easier to quantify how many lives are saved through scaling up access to antiretroviral therapy, but significantly more difficult to do the same for introducing a sustainable health insurance scheme, or scaling up a community health worker system. By linking vertical programs into the broader health system, and by having effective coverage and efficiency as intermediate goals and health status, responsiveness, and financial protection as the ultimate goals, it can be possible to transition towards a more proactive discussion in ensuring sustainability for all aspects of the health sector.