Vertical versus Horizontal delivery of health services: The never ending debate!

Written by: Amrita Sankaranarayanan

Edited by: Helen Myrr & Sinéad O’Ferrall

The delivery of pharmaceutical products or services is usually levered by either a horizontal function or a vertical function. A horizontal function refers to the interventions provided by a country’s government through a public health system, while vertical functions are typically donor driven,disease specific and not always well integrated into the health system. Horizontal functions are an outcome of the WHO/UNICEF Alma Ata Declaration in 1978 which stated the importance of health systems strengthening through participation of the community-:

Primary health care ... relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”

Vertical functions on the other hand, are health intervention programs which focus and deal with one particular disease and the nuances surrounding it. They are a more recent trend,  with the rise of and increase focus on communicable diseases like HIV, malaria and TB and a rise in donor and public-private agencies like the Global Fund, GAVI, BMGF to name some. Political economics, donor interests and the emergence of newer diseases over recent decades have resulted in vertical programs gaining tremendous momentum, but also gaining much criticism. Increases in vertical programmes in the area of communicable diseases have been claimed to be responsible for a fragmentation of the health system and a disruption of services. An impact of the vertical program for HIV in the WHO European Region has been studied and found to be responsible for the highest number of rapidly increasing HIV and multidrug resistant TB species.[1],[2]

There has been an evidence based notion over the focus of the international community towards providing finances for a particular disease, resulting in dwarfed resources for other diseases which may have the country’s highest disease burden. Vertical programs for HIV and AIDS have been studied as donor prioritized diseases which may have mitigated the risk for displacement of resources (both in terms of funds and human resources) for other diseases. [3],[4],[5]

Let’s discuss the case of pneumonia. Pneumonia is a number one killer of children under the age of five. The mortality caused by pneumonia in children under five is greater than deaths caused by malaria and measles combined. In 2011, the overall assistance targeting pneumonia was 663 million dollars which was only 2% of the entire 30.6 billion dollars spent on overall global health financing. This is however an increase from 2008 figures which was about 308 million dollars. [6] One reason for this surge was the introduction of resources from GAVI Alliance – an international public private organization involved in vaccine coverage and vaccine supply chains. Pneumococcal vaccines were rolled out by the GAVI Alliance in specific resource limited countries which have a high burden of childhood pneumonia. [7]It is claimed that this vaccine introduction in Ethiopia was the reason for the significant decline in under five child mortality and achieving the MDG 4 much ahead of time. [8]

Some studies have questioned the rationale behind the decision by Government of Ethiopia to introduce the pneumonia vaccine PCV 10. The reasons that contributed to this decision were found to be political prioritization, availability of the GAVI funding and “the desire to address the burden of disease and seize the GAVI funding“. [9] This is an example of how advocacy and financing around an intervention can result in increased coverage of a pharmaceutical product and become the center of focus for country governments. What if there wasn’t any GAVI funding? Would the childhood pneumonia death still be lowered in Ethiopia? Debatable!

Studies of vertical programmes have not necessarily found them to be effective in terms of results, and have been blamed to have a largely single focus, ignoring the actual needs of the patients and to be largely bureaucratic in nature. [10],[11] It must however, also be kept in mind that some of the most successful interventions like polio eradication or family planning initiatives, all had a vertical component to them. [12]

Horizontal programs are reported to strengthen the health system and have a greater impact in terms of cost effectiveness and sustainability, much more so than vertical programs. Community based interventions are components of a horizontal program which provide a more patient centered approach and have shown to address the problems of a system as a whole rather than diversifying them into programs. There has been quite a lot of debate about the merits and demerits of both types of programs and no consensus has been made as to which approach is the best in what circumstances. With regards to this, WHO states that

The available evidence on the relative benefits of vertical versus integrated delivery of health services is limited and too weak to allow for clear conclusions about when vertical approaches are desirable.

In a generation where most of us expect a magic pill to resolve most issues, the reality is pretty farfetched. Donors and international agencies come with stipulated funding for certain diseases and begin implementation, often overlooking the structural challenges that the health system faces especially in developing countries. So the vertical program can be used as a short term strategy alongside the efforts to strengthen the health care system with a more integrated approach. There is no evidence on why a vertical and horizontal program cannot co-exist.  Studies have shown that it’s not necessary all the time for a program to be completely vertical or completely horizontal.

A mixed method approach could be used, making use of the policies from vertical programs under the leadership and management of horizontal programs for a more sustainable outcome. There is no standard golden rule to the application of a particular program for a disease intervention. In the absence of evidence on which are the most effective models, countries could have their own tailored and custom made models incorporating the administrative expertise of a horizontal model and operational expertise of a vertical program. There needs to be a system in place that can combine and utilize the expertise of both the programs. This system also should have a mechanism such that the donors also help in building a stronger yet sustainable health system saving a maximum number of lives.

[1] Tkatchenko-Schmidt E, Renton A, Gevorgyan R, Davydenko L, Atun R. Prevention of HIV/AIDS among injecting drug users in Russia: Opportunities and barriers to scaling-up of harm reduction programmes. Health Policy. 2008 Feb 1;85(2):162–71.

[2] Tkatchenko-Schmidt E, Atun R, Wall M, Tobi P, Schmidt J, Renton A. Why do health systems matter? Exploring links between health systems and HIV response: a case study from Russia. Health Policy Plan. 2010 Jul 1;25(4):283–91.

[3] Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008 Mar 1;23(2):95–100.

[4] Berer M. HIV/AIDS, sexual and reproductive health: intersections and implications for national programmes. Health Policy Plan. 2004 Oct 1;19(suppl 1):i62–70.

[5] Crossette B. Reproductive Health and the Millennium Development Goals: The Missing Link. Stud Fam Plann. 2005 Mar 1;36(1):71–9

[6] Pushing the Pace: Progress and Challenges in Fighting Childhood Pneumonia [Internet]. [cited 2015 Oct 6]. Available from:

[7] Vaccines to prevent pneumonia deaths reaching poor countries in record time – Gavi, the Vaccine Alliance [Internet]. [cited 2015 Oct 11]. Available from:

[8] GAVI Alliance partners to tackle childhood killer in Ethiopia – Gavi, the Vaccine Alliance [Internet]. [cited 2015 Oct 11]. Available from:

[9] LSHTM. New vaccine introductions: decision‐making & impact on health systems [Internet]. Health Systems. 2013 [cited 2015 Oct 11]. Available from:

[10] Unger J-P, De Paepe P, Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countries. Int J Health Plann Manage. 2003 Dec;18 Suppl 1:S27–39.

[11] De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N. Strengthening primary care: addressing the disparity between vertical and horizontal investment. Br J Gen Pract. 2008 Jan 1;58(546):3–4.

[12] Levine R. Should All Vertical Programs Just Lie Down? [Internet]. Center For Global Development. 2007 [cited 2015 Sep 30]. Available from:

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