How Can We Move Away from Vertical to Horizontal Health Programs?

Master's Thesis, 2016

35 Pages, Grade: Merit





Introduction and Background
Politics of AIDS

Results and Discussion.



Abbildung in dieser Leseprobe nicht enthalten


This paper examines how governments and health organizations can successfully transit from vertical programming into a broad-based and inclusive community based Primary Health Care that responds to the needs of the local community. Using HIV/AIDS in Uganda as a case study, this paper finds that though these programs are important in combatting some of the biggest pandemics affecting the largest percentage of most populations in the developing world, enhancing the efficacy of vertical programs requires its integration into the more inclusive Primary Health Care system.


Introduction and Background

The course of human history has been deeply affected by infectious diseases. The extent of impact of HIV/AIDS on sub-Saharan African countries has been devastating failing social patterns, healthcare systems and government foundations. HIV/AIDS has over the past 25 years become a part of the modern world with every country reporting and acknowledging the infection amongst its population (Merson, O'Malley, Serwadda, & Apisuk, 2008). This has therefore led to an unprecedented global response that has been termed ‘AIDS exceptionalism’ where the disease has been seen as requiring a response that is way beyond any normal health intervention (Smith & Whiteside, 2010), thereby attracting a number of stand-alone programs aimed at curbing it. Though some studies link the pandemic to the five cases of pneumonia in gay men in Los Angeles reported by the US Centers for Disease Control and Prevention (Anon, 1981), Faria et al (2014) traces the epidemic way back to the colonial times of the 1920s when the pandemic crisscrossed from the chimpanzees to the humans through hunting and was later fast spread by an active transport network that linked Kinshasa to the rest of sub-Saharan Africa. The CDC initially thought that this disease was confined to homosexual men but this premise was nullified towards the end of 1981 when cases of the disease was reported among non-homosexual injecting drug users in the UK (Merson, O'Malley, Serwadda, & Apisuk, 2008).

The ability of different policy makers in different divisions to network are reduced by vertical programs. This is because health workers and managers are made to remain specialized and isolated because of the competition for limited resources (Lush , 2002). Delivery of HIV/AIDS services is usually done through vertical health programmes. Fragile public health services in resource poor countries are undermined by vertical health programs simply because they divert Health Care Workers (HCW) and other resources away from other programs (Dambisya et al., 2009). The enthusiasim of addressing the AIDS pandemic has created various negtive effects due to vertical programming such as wage distortions, dramatic escalation, unsustainable demands on the health workforce, thereby dwarfing national health budgets because of external funding (Levine, 2007). In a study done in Mozambique, it was noted that excessive funding caused by external funding starved the ministry of support of administrative functions as there was a massive movement of workers from the public sector to private international and private organisations, because funding was channeled through the non-profit organisations (Mussa et al., 2013).

The concept of Primary Health Care has had a massive impact on health practitioners in various developing countries with many not understanding the origins of the term. As cold war was coming to an end (late 1960s and early 1970s), the political context of the US being entangled in a crisis of its own world hegemony, gave rise to the concept of Primary Health Care, keeping in mind that this was a time when the vertical approach used by the US and WHO in combatting malaria in the late 1950s, was under heavy criticism(Cueto, 2004). In 1975, a joint WHO-UNICEF report titled ‘Alternative Approaches to Meeting Basic Health Needs in Developing Countries’ was released with the term ‘Alternative’ meaning the shortcomings of traditional vertical programs’ concentration on specific diseases (ibid). In 1978, the Alma-Ata Declaration noted the importance of a comprehensive community-oriented comprehensive PHC for all states. WHO launched an initiative of ‘Health for All by 2000’ after Alma-Ata and it based on the principle of a horizontal mode of delivery of basic health services (WHO, Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata 1978, 1978). Termed as comprehensive or horizontal generally means that healthcare is seen as a basic human right that involves the community as community participation is needed for it to become a reality.

Some critiques like Walsh and Warren were skeptical of the concept of comprehensive healthcare arguing that this was a concept not meant for developing countries, as it was unattainable because of the high costs needed to run it such as large numbers of trained personnel and prohibitive costs, thereby initiating a new appealing concept of ‘selective PHC’, an approach aimed at concentrating on the greatest disease burden of the country (Walsh & Warren, 1980). Vertical programs therefore aim at solving a specific health problem with the application of selective measures but it should be noted that this type of approach is based on the short-term look. Vertical health programs move around the premise that in resource limited settings, health planners are better off prioritizing their interventions (Msuya, 2003). This differs from the comprehensive approach that aims at constructing permanent institutional infrastructure to handle general health services thus tackling overall health problems with a long term process (Maeseneer, et al., 2008).

To move away from the vertical health programs, we need to integrate these programs hence making them comprehensive (horizontal) thereby improving Primary Health Care in general. Integration as a concept in health has various meanings such as training of personnel to provide multiple services, provision of tools, processes and training to better link separate services, harmonization of logistics systems such as data collection, transport and supervision across services, drug and maternal distribution (Pfeiffer, et al., 2010). World Health Organization defines it as “The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.” (WHO, 2008). However, for the purpose of this research paper, I will look at integration as the provision of HIV services and programs with other health services at a single point of access or by using referrals within a single health region.

The study uses HIV/AIDS in Uganda as a case study because Uganda has often stood out in the world as one of the earliest, convincing and success models in the fight against HIV/AIDS. Since the early 1980s, HIV has had a stern impact on Uganda. Starting in Rakai district located in the South Western part of the country, HIV eventually spread to the whole country. A strange ‘wasting disease’ started to claim the lives of people in Rakai district and by 1982 became known as ‘slim’ though no one had associated the evidence with what would later be known as HIV. It was not until the late 1983 and early 1984 that a team of Ugandan and foreign doctors including Dr. David Serwadda working at the Uganda Cancer Institute in Mulago Hospital National Referral Hospital and Dr. J. Wilson Carsell, a British surgeon observed repeated evidence of Karposi’s Sarcoma among young patients all from Rakai district who sent blood samples to Robert Downing at the Centre for Applied Microbiological Research, at Portion Down in the UK who confirmed it was HIV-1 as originally labelled (Putzel, 2004). Major urban areas and along highways necessitated the quick spread of HIV infection to all districts in the country by 1986, acquiring the term generalized epidemic that left many families annihilated, necessitating the rise to a wave of AIDS as an increased number of people were succumbing to infections rising out of their weak immune system (MOH & ORC Macro, Uganda HIV/AIDS Sero-behavioural Survey 2004-2005, 2006). Because of the economic collapse and social dislocation existent at the time, new economic activities materialized. Young women turned to sex trade situating themselves on highways.

This was because at the time, disposable income was with long distance truckers who were often away from home and this gave rise to brothels and bars along the routes in search of income generating activities, and so the unregulated commercial sex work and multiple sexual partners along the routes facilitated the rise and spread of AIDS (Putzel, 2004). Putzel (2004), goes on to note that warfare and social movement also played a role in the spread of HIV and so the combined effects of the social, political and economic disruption and war necessitated the spread of the virus from high risk groups like soldiers, truckers and commercial sex workers to the general population. After the capturing of power by Y.K Museveni’s NRM, a national open minded and aggressive stand that involved international, local, national and individuals coming together to fight AIDS was deployed which saw a massive decline in prevalence rates i.e. a reported drop in HIV-1 infection rates from 30% in the early 1990s to 10% in 1996 and 6.5% in 2006 played a major role in Uganda’s labelled success story (Kiweewa, 2008). However, it should be noted that HIV prevalence of the general population in Uganda increased from 6.4% in 2004/5 to approximately 7.4% in 2012/13 which strongly undermines the earlier interventions that reduced the prevalence rates in the earlier years (Uganda Aids Commission, 2015). But this can be attributed to the over reliance of ART that has reduced on the number of deaths ie ART increased from 330,000 in 2011 to approximately 750,896 in 2014 hence reducing HIV related deaths from 67000 in 2011 to 31000 in 2014 (ibid).

An unprecedented increase of financial support over the years has been noted to go into developing countries. Only disadvantage is that regardless of the positive development, allocation of these funds tends to focus on disease-specific projects dubbed ‘vertical programs’ as opposed to more broad based improvements in population health such as primary care services, preventive measures and health workforce development known as ‘horizontal programming,’ for instance Clinton foundations and Bill and Melinda Gates initiatives that deal with particular communicable diseases (Maeseneer, et al., 2008). Already wrestling with huge inflows of foreign money to fund programs such as AIDS, is Uganda with an estimation of over $100 million each year entering the country to run AIDS projects (Fawzia, 2005). This is because the funding for HIV/AIDS in Uganda remains predominantly donor funded, with the government contributing 12%, private sources only 20% and development partners 68% (Uganda Aids Commission, National AIDS Spending Assesment Uganda 2008/9-2009/10, 2012). This therefore signifies the fact that Uganda will have to adhere to the donors’ preferences hence initiation of vertical programs.

In Uganda, the PHC concept was seen as a timely innovation and adopted by Uganda after the Alma-Ata conference as the basis of the development of its health system from the establishment of an extensive network of health units and hospitals with health inspectors running the home hygiene and preventive programmes to that of a more community-oriented health service. However, during the period of sensitization of health workers (1980-1983), a debate between comprehensive PHC and selective PHC ensued with selective PHC coming up as a preferred strategy and so vertical projects came up defeating the idea of horizontal holistic implementation of PHC programmes (Tashobya & Ogwal).

Uganda has a number of programs which are categorized under prevention, care & support and treatment aimed at dealing with the HIV/AIDS pandemic. These programs are run by the Uganda government and assisted by some NGOs. These programs are PMTCT, HCT, ART, ABC, OBULAMU campaign program, Mango Tree Program, THETA. Prevention has been the principal reaction in Uganda till to date with a call for a combined prevention approach that includes biomedical interventions (condoms, treatment, needle exchanges, testing and PMTCT), behavioral interventions (sex education, counselling, programs to reduce stigma & discrimination and cash transfer programs) and structural interventions (interventions to address inequality, decriminalization of sex work, homosexuality, drug use, increasing access to school education for young girls, laws protecting the rights of PLWHIV) (AVERT, 2016).

There has been increasing debate on the importance of vertical programming on the improvement of developing weak health systems. This debate hasn’t excluded HIV/AIDS as it attracts a lot of vertical attention thereby leading to debates centering on the premise of whether the over concentration on HIV programs strengthens or weakens fragile health systems. Due to major global health initiatives, increased resources have been brought into countries for HIV programs (Yu, Souteyrand, Banda, Kaufman, & Perriëns, 2008). This has come with advantages such as the heightened consciousness of public health by individual governments, improved and expanded services to PLWHIV and ART provision has enhanced the health of the workforce however, this has led to some very negative impacts such as the stagnation and detoriation of SRH services and general health services (ibid, 2008).

Politics of AIDS

The impact of HIV/AIDS in the world today can be clearly seen as a reflection of the Bubonic plague that hit Europe many years ago. By the closure of 2015, UNAIDS estimations of PLWHIV globally stood at 36.7 million (UNAIDS, Global AIDS Update, 2016) with the majority of infections coming from sub-Saharan Africa standing at 25.5 million. This has led to the rise of responses that have a sort of predominant pattern. This thereby has led to a number of responses that have been inadequate in Africa and this can be attributed to the weak fragile states and the infliction of prevention strategies that are unfamiliar with the cultures and traditions of Africa.

The eradication of AIDS has been separated into three main lines notably politics, economics and weak fragile states. The political dimension which has been propagated by Van der Vliet sees the best way of dealing with the disease as promoting sex education and behavioral change but this may affect some political groupings which would de-campaign this initiative in favor of their own goals (Van der Vliet, 1994). The economics argument is raised by Poku & Whiteside who blame the insufficiency of HIV response in Africa on the various socio-economic crises affecting African countries such as poverty, famine and weak fiscal policies (Poku & Whiteside, 2004). Nevertheless, Patterson looks at the nature of the African state being weak as the reason behind the inadequacy of the programs noting that the state lacks leadership, resources and associations that will enable it fend off the disease (Patterson, 2005).

The most striking argument is the political dimension because it resonates the rights based approach and the principle of paternalism which portrays vulnerability mixed with control (Barnett, 2012). This kind of outlook is a manifestation of the creation of Western knowledge that portrays other huge regions of the world as being disease-prone & poor, inferior & incapable thereby giving Western medicines and pre-emptive structures the capability to deal with these epidemics (Bankoff, 2001). This has therefore led to the transfer of Western models that ignore the African cultures and traditions. This thereby portrays the over-reliance on implementation of drugs and policies as the reason for the inadequacy of HIV response in Africa as a cover-up to the bigger picture of the realm of power politics. This thereby acknowledges the fact that responses to the pandemic shouldn’t be separated from the socio-political economic history and structure of the African state.

However, regardless of the fact that the problems concerning the eradication of HIV/AIDS are way beyond vertical programming and policies, this research carries importance into adding to our understanding of the importance of integrating vertical health systems into Primary and comprehensive Health Care system using the case study of HIV/AIDS in Uganda.

This dissertation gathers incentive from the need to scrutinize how governments of developing countries can shift away from vertical programming and programs answering the questions: Has Uganda started to integrate the vertical programs? If it has integrated some of these programs, why has it done so and how can it improve the integration based on evidence? If it hasn’t integrated some of these programs, what can be done to integrate these programs based on evidence? To answer these questions, this dissertation will use three standard HIV programs notably PMTCT, HCT and ART.

In order to articulately answer these research questions, this dissertation is further structured as follows. Chapter Two lays emphasis on the methodology used in this dissertation, Chapter Three undertakes an analysis of the three chosen programs of PMTCT, HCT, and ART which will then take this research to its final Chapter Four that will contain the conclusion.



This research will adopt a case study investigative approach to scrutinize and elucidate how the concept of vertical programs can be transformed into a more beneficial comprehensive health care system approach. In order to gain a thorough appreciation of an issue, event or phenomenon of interest in its natural real-life context, a case study approach is of salient importance (Crowe, et al., 2011).

For the purposes of this study, a wide-ranging examination of peer reviewed academic articles, policy documents, reports and grey literature were used. The search approach used necessitated the usage of a mixed approach which involved the use of search terms such as “HIV/AIDS in Uganda”, “HIV programs in Uganda”, “Vertical programs”, Primary Health Care or Comprehensive Health Systems”, “Integration”, and the non-use of search terms because at times these search terms could have been used inversely. This therefore required the scrutiny of service provision so as to find out if it fulfilled the criteria of this paper’s definition of integration.

Various databases were searched such as PubMed, The Lancet, Google Scholar, Ministry of Health Uganda library, World Health Organization library, UNAIDS library, POPLINE, BioMed central, AEGIS as well as books, non-academic articles and internet sources. The bibliography of the relevant included studies were also vetted in order to get more articles that were relevant to the study.


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How Can We Move Away from Vertical to Horizontal Health Programs?
London School of Economics  (International Development)
MSc Development Studies
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move, away, vertical, horizontal, health, programs
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Jenkins Tanga (Author), 2016, How Can We Move Away from Vertical to Horizontal Health Programs?, Munich, GRIN Verlag,


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