From polarisation to practice: Puzzles and insights on integrated approaches from public health professionals

Abstract

Much of the debate in the global health literature about vertical and horizontal programmatic approaches, between narrowly targeted interventions and those providing broader system-wide support, has taken place at the global level. Based on a comparative case study of international donors in the health sector in Peru that varied in their vertical–horizontal orientation, this article examines the extent to which health care practitioners and national policy-makers perceive and attempt to reconcile the tension between these approaches. Informants readily identified advantages and disadvantages of both approaches, but did not perceive a marked vertical–horizontal division, suggesting that tensions appear to be less pronounced in practice than academic debates suggest. A clear consensus did not emerge, and although more people spoke of a mixed approached, they too puzzled over how best to balance trade-offs. In practice, there were examples of more integrated approaches, targeted aspects of horizontal programmes and system-strengthening elements of vertical programmes; however, they were not explicitly identified as such. Practitioner perspectives reinforced the diverse and dynamic nature of disease, both epidemics and country profiles, and suggest that focusing on periods of transition and points of integration may be a fruitful path forward.

Keywords:

• health system strengthening
• vertical approach
• horizontal approach
• practitioner
• international donor

Acknowledgements

This research was supported by a Thomas Francis, Jr. Global Health Fellowship from the University of Washington. The author would like to thank Mary Kay Gugerty, Sanjeev Khagram, Peter May, Joe Zunt, the School of Public Health and Administration Unit of Epidemiology, STI and HIV at Universidad Peruana Cayetano Heredia, Ministry of Health General Office of International Collaboration, Peruvian Agency for International Cooperation and each of the interviewees for sharing their insights and expertise.

Notes

1. As part of the High Level Fora on Aid Effectiveness in Rome (2003), Paris (2005), Accra (2008) and Busan (2011), multilateral institutions, private foundations, and government officials from more than 100 countries committed to five core principles of development cooperation (ownership, alignment, harmonisation, results and mutual accountability) and identified specific indicators to assess progress towards each (Organisation for Economic Cooperation and Development, Development Cooperation Directorate, n. d.).