History and Current Themes
Efforts to improve health in low- and middle-income countries over the past 50 years can be divided into a number of periods, with pendulum swings between focused, disease-specific support and broader health service or health system support. The 1950s, 1960s, and 1970s witnessed a number of successful disease control efforts, often termed mass campaigns—notably smallpox eradication, but also, for example, malaria and yaws control (Walt 2001). These mass campaigns built on earlier efforts, including those of the Rockefeller Foundation from the 1920s in controlling hookworm, yellow fever, and malaria. Despite regional differences in the degree of progress—for example, malaria control was not attempted in most of Sub-Saharan Africa—successes in regional and global control of diseases such as Chagas disease and measles in Latin America and the Caribbean and, more recently, polio worldwide have continued since the 1960s.
From early in the history of mass campaigns, the terminology used was of vertical and horizontal approaches (Gonzalez 1965), referring essentially to two key dimensions in program organization (Mills 2005): the extent to which program management was integrated into general health systems management, especially at lower management levels, as opposed to kept strictly separate, and the extent to which health workers had one function as opposed to many functions. Vertical programs (also known as categorical programs) had their own financing, management structures, and staff, even down to the service delivery level, instead of relying on existing systems. In contrast, horizontal programs delivered a number of services through the general health service structure.
In malaria control, for example, the World Health Organization defined a process whereby an initial vertical approach would evolve into a horizontal approach as the incidence of malaria fell. Initially, the effort required to detect and treat cases demanded dedicated and mobile workers. As transmission was reduced, these workers would detect fewer and fewer cases, so on efficiency grounds, detection and treatment activities needed to be handed over to the general health service infrastructure. However, this approach faced the dilemma that such services were often not strong enough to carry the control efforts forward.
The Alma Ata Declaration of 1978 was a turning point. The increasing emphasis on building networks of peripheral health services in a number of post independence Sub-Saharan African countries and the health successes of countries such as China and Cuba influenced a new international emphasis on a broadly based definition of primary health care. Quickly, however, the advocates of more focused disease-specific efforts responded with the notion of selective primary health care (Walsh and Warren 1980), focused on a limited number of presumed cost-effective interventions.
Since 1980, this tension in international health policy has persisted, with four main strands, namely:
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The health care reform movement of the 1990s, which has continued into the new millennium in a somewhat attenuated form, has focused almost exclusively on financing and organizational changes, largely neglecting the question of whether improved health outcomes have been achieved.
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The definition and development of cost-effective packages of care has progressed, as reviewed in chapter 64, with some attention given to their implications for services and systems.
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The emphasis on specific disease-focused international programs, as reflected in the Global Fund for AIDS, Tuberculosis, and Malaria, has been increasing, and resources for such programs have been expanding.
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The effort to encourage investment in integrated health services has continued.
Recent events indicate that these tensions remain unresolved. For example, Molyneux and Nantulya (2004) call for combining community-driven, global health initiatives (including drug distribution for schistosomiasis, filariasis, and onchocerciasis; trachoma control; bednet distribution for malaria control; and immunization), with little mention of how community-based efforts might link with the general health infrastructure. In contrast, Unger, de Paepe, and Green (2003) examine how best to implement disease control programs so as to strengthen existing health systems and propose a code of best practice for such programs.
This debate is being given a new urgency by the introduction of treatment for HIV/AIDS. Immunization can be delivered using either a vertical or a horizontal approach. HIV/AIDS treatment, which requires continuing care, calls for strong health service backup. Nonetheless, such treatment services could be organized so that they isolate themselves from the broader health system—say, through separate clinics with their own workers and separate laboratories—or they could contribute to a greater degree of integration by sharing resources.
The implications of these different approaches for health system change are not purely academic. Table 3.1 compares the responses to health system constraints that derive from a disease-specific focus as opposed to a health systems focus. A disease-specific focus leads to solutions for the specific program, whereas a health systems focus identifies a somewhat different set of reform priorities that relate to system-level changes and affect disease management across multiple diseases and conditions. The disease-focused responses can generally be implemented relatively quickly, whereas the systems-focused actions take longer. However, numerous, separate disease-specific responses can rapidly overwhelm frontline workers and managers.
[Table .]
