Vertical and horizontal funding for health

What are ‘disease-specific’ or ‘vertical’ funding initiatives?

These initiatives are programmes that focus on one particular disease or group of diseases. Just as smallpox was ended through a global programme of action, the idea is that HIV, tuberculosis (TB), malaria and other devastating diseases can be addressed in a similar way.

Why have such initiatives become popular?

Many wealthy governments, institutions and individual donors have attached their names to high profile, disease-specific initiatives, with a very top-down approach. This is sometimes because they have found it more politically appealing to launch their flagship initiative to eradicate a particular killer disease.

Targeting resources at specific health problems can deliver direct and measurable results, more easily lauded as dramatic success stories. In contrast, developing and sustaining comprehensive health systems is inevitably more complex and subtle, offering results that are slower and harder to measure.

What are the arguments against vertical initiatives?

Vertical initiatives can certainly be effective in tackling a particular medical problem, but their overall effect on the health of poor people has in recent years been questioned.

Some people argue that vertical initiatives risk diverting attention from, or even undermining, broader health systems established to prevent and treat all forms of poor health. It is argued they do this by creating unsustainable demands on the health workforce, wage distortions and dramatic escalation in recurrent costs (for antiretroviral drugs for HIV, for instance) that can be met only with external funds.

The slow progress on tackling some of the key targets of the Millennium Development Goals, and then the Sustainable Development Goals such as on maternal and child mortality, which rely on a strong overall health system, has been partly blamed on this focus on vertical initiatives. With so much attention lavished on ‘vertical’ initiatives, ‘horizontal’ national health systems have too often been treated as the poor relation.

There can also be instances where people using health services have to make several visits to use different services – depending on whether they are run as part of a disease-specific programme or as an integrated part of national health services. Sometimes only part of the care they need may be available. A commonly quoted example is someone who may be receiving antiretroviral drugs, but who is unable to get treatment for opportunistic infections.

And the counter argument?

There are real issues with some aspects of vertical initiatives, but they have brought in relatively large amounts of money to global health.

Some issues such as wage distortions are also less about vertical initiatives and more about a general split between private and public sector work – with underpaid, overworked public sector staff voting with their feet in order to support their families.

Some specific diseases also threaten to undermine and overwhelm health systems if they are not tackled urgently.

So what is the answer?

Vertical initiatives have provided motivation and momentum to increase funding and improve health systems more generally, but they must integrate better and contribute more to the overall strengthening of health systems – both through funding and through building skills and capacity.