We need cooperation to get this epidemic global affair i apprecaite your welcome and share aprtnership global Orphan/Hiv/Aids Focus we vision gaol with intelligence all is collective measure to achive the goal of global health focus then diagonal approach" is needed with consideration and evidence-based alternatives solution How we can solve this epidemic campaign keeping the record straight global health emergency response plan NRP/EOG/JFO /MAC Etc Decission maker and debate focus 2008/10 Women and Children not left out from Cordinator Margret Spellings Foundation Rep of Guinea Conakry

I agree with you totally; planning has to be done in a comprehensive manner and should be done through national planning and not when it is time to draft another proposal or just to get the numbers, results and performance that will only deliver very basic services and products to under-fives and pregnant women in the short term. Disease specific programmes can enhance broader service delivery beyond their primary focus.

 

I equally agree with you that well-needed resources should be seen to catalyze HSS and I will add, also indirectly influence policies.

 

On the issue of countries that have been able to negotiate substantial support for horizontal programming, it may have been due to the availability of strong structures in their health systems, which makes it possible for them to absorb the pressure of the ‘push’ factors. It will be good for us to look closely at why these countries succeeded. Can give you give a few examples of such countries? I think Ghana is one of such countries.  In other words, these countries already have structures that have ‘pull’ factors that are able to absorb the funds from the GFATM.

 

And I must then add that the GFATM ‘angle of approach’ should remain vertical but rather than ‘push’, the recipient countries should establish strong health systems that will have the capacity to absorb the funds, in other words ‘pull’ the funds, create a ‘good demand’ for the funds, which the GFATM is doing anyway but they are just ‘pushing’ the funds for ‘quick wins’ as you will call it. Though we may want to say that from the proposals that recipients countries send shows demand but considering the fact that they do not have absorptive capacities for the funds, it amounts to ‘pushing’ of funds and not ‘pulling’ of funds from the recipient countries.

 

The GFATM should make a demand on these nations to establish such structures and not just ‘push’ the funds. This will serve as a very clear signal, rather than trying to implement programmes both vertically and horizontally. This is the reason why we are having what you called the ‘mixed signals’. The GFATM cannot just do it both ways and not even diagonally. In that way, the GFATM will be catalyzing the HSS in countries where that is not being done adequately.

 

Already because of the varied realities in countries, the GFATM may not find very easy to have a one-size-fits-all type of strategy to tackle the HSS issues. I will refer you to a WHO document that was developed for the GFATM on HSS issues. Makes a case for diagonal approach, which I disagree with but let’s see how far we can go with it. This vertical vs horizontal debate, they say, is stale.

 

I think it is a result of trying to avoid the problems that will be caused by the short time frames of funding that the GFATM established the Rolling Continuation Channel. Countries in this class of recipients definitely have very good and strong structures in their health systems that are able to serve the interest of GFATM in the short term (that is these countries are ‘spending it and proving it’) but actually serve their own interest (the recipient countries) in the long term. Even if they do not have such structures on ground, I seriously believe that if we observe the health systems closely, we may see a situation where these countries have made substantial efforts at establishing such strong structures. I think the GFATM is actually asking for such efforts to be made, which will definitely and gradually lead to the establishment of such strong health systems.

 

The ‘bottomless pit issue’, that the GFATM is trying to avoid, I believe, is to avoid a situation where the funds are diverted towards building infrastructure, etc. (which recipient countries are meant to set up themselves), at the expense of directly benefiting the end users. If the GFATM had not taken those steps from the beginning, I can assure you that most countries by now would have diverted funds away from health and then will wait for the GFATM to provide the entire budget for health. Reason why, I guess the GFATM demands countries show that the GFATM funds are only part of the budget for health in these countries. The funds would have gone into establishing structures at the expense of delivering the very basic, direly needed services into the hands of under-fives and pregnant women, and all those who need these services and products.

 

In summary, what I am trying to say is that the GFATM should focus on monitoring and implementing vertical programmes while demanding from the nations to create the enabling environment for the absorption of the funds made available. It will be very difficult to make an attempt at supporting HSS. Even with the GFATM’s attempt at adopting the diagonal approach, the governments of recipient countries should be made play their own role. The diagonal approach will still encourage ‘quick wins’.

 

It has been interesting brainstorming on this issue with you and it is my desire that all this will translates to the sustainability of GF sponsored programmes and will ultimately continually deliver very basic and direly needed services into the hands of those who need them.

Hi, I admire your tenacity for keeping this discussion alive so in the spirit, I would like to respond. While, I acknowledge that governments do have ultimate responsibility for the state of their health systems, the Global Fund, other GHIs and development partners more generally also have responsibility for ensuring that the programmes that they fund will not undermine or overwhelm fragile health systems.  Balance can and should be struck between horizontal support for health systems and the vertical delivery of specialised products and services for disease specific programmes.  If planning is done in a comprehensive manner (ie: through national health, not disease specific plans), disease specific programmes can enhance broader service delivery beyond their primary focus. The Global Fund has, over its evolution and through the various funding rounds, acknowledged the need for HSS (or more horizontal approaches) however it has also sent mixed signals to countries in terms of what is permissible under this.  For example, some earlier round 1 proposals included large components on HSS as this was a felt need by many countries.  Some of these proposals were rejected (ie: Uganda) or requested to re-submit (ie: Malawi).  This sent an early signal to countries that HSS was not considered ‘fundable’.  Since round 1, some countries have been able to successfully negotiate substantial support for horizontal programming/HSS and for integrating GFATM support both financially and programmatically into health SWAPs but these examples are few in sub-Saharan Africa.  The ‘angle of approach’ for the delivery of GFATM programmes in countries with fragile health systems remains more towards vertical implementation due to various ‘push’ factors such as:

• Short timeframes of GFATM funding
• Weak health system (your reference, the ‘bottom less pit’)
• Weak absorptive capacity
• ‘Spend it, prove it’ rhetoric which requires quick wins and demonstrable results

It is important that the well-needed resources provided by the Global Fund catalyse HSS in countries where this is not being adequately addressed.  In countries where this is being addressed, the GFATM can support this by ensuring that their funding is ‘joined up’ with HSS strategies articulated in national health plans and supported by other development partners (ie: World Bank). For this to happen, would require a different approach to that currently taken in many countries when it comes time for the next GFATM funding round. It may also require clearer signals from the Global Fund.

While we wait for other contributions to issue of Vertical vs. Horizontal approaches to global health challenges, I will like to bring our attention again to the LA Times article "Unintended victims of Gates Foundation generosity". The GFATM released a statement on that issue on her website but that I strongly believe that the article was able to raise issues that will guide our discussions on the matter. I have as well included my comments in response to another response to the LA Times article in a blog by April Harding, a staff of the Center for Global Development.

The LA article has succeeded in bringing to fore a very important matter but has failed to proffer holistic solutions to dilemma caused by vertically implemented health programs. Dominic and Michael have really touched the same views that I have about the matter and I really recommend that who reads through April's blog should as well hear what these gentlemen have to say. But I just wanted to add this. The regulation and management of health systems is primarily the responsibility of the government of the recipient developing countries. If not for any other reason, at least for the fact that any attempt at HSS or horizontal approach to implementation of public health programs will definitely have to deal with the prevailing political realities of these countries or else they would not just succeed. I guess that may be one of the reasons why the GFATM from the onset avoided creating what it referred to as a "bottom less pit" where the funds will just go down the drain if they have started by trying to tackle these diseases horizontally.

Another wisdom in that decision is that it ensures that government of the recipient countries do not run away from their responsibilities in ensuring that the health systems of their respective countries are working. One of the major problems we have in Africa is poor leadership and the "failure" of vertically implemented public health programs lies squarely on the shoulders of the government of these countries. It is the government's responsibility to provide a platform that can sustain or contain the pressure or distraction caused by vertically implemented programs. It has nothing to do with the good intentions of donor agencies, of which Gates Foundation and the GFTAM are just a few of them. Public health programs have been implemented vertically long before the establishment of the GFATM.

The picture of the dilapidated primary health care center painted by the LA article brings to fore the failure of the government of these countries and not that of the good gestures of development partners and donor agencies. And it is not even as issue of scarce resource but fundamentally an issue of poor leadership and poor management. At least, that is exactly the case for an oil-rich country like my own country, Nigeria.

The GFATM has succeeded so far, so have other agencies. Though I do not agree with its emphasis on performance but they may be excused because it may not be fair to judge the GFATM's impact from what they have been able to achieve within a short period of its establishment. But it may as well not be too early to evaluate for impact. The GFATM already has been able to wield her powers well to extent that she is indirectly influencing policy formulation and implementation in the recipient countries. What I will call a "carrot-and-big stick" kind of powers. Health systems is primarily the responsibility of the recipient countries and these countries should work out modalities to develop programs that will be implemented horizontally or provide a platform that will be very conducive for the implementation and success of the vertically implemented programs. The GFATM should use its powers to set some set of rules that will require potential recipient countries show visible, tangible and concrete evidence that they have health systems that are working before they are qualified to get more grants. Other development agencies and donor should also toe such a line. Rather than continually pumping in funds that will continue cause a diversion of attention, both in terms of resources and manpower, from other components of the health systems that need as much attention as the three diseases.

It would have been worse if these funds have not been poured into Africa and we cannot afford to stop now. When my organization started receiving ARVs from the GFATM-sponsored National ARV program in Nigeria, we had our fears that with time these programs will stop. But for the program to still be running, two years down the road, it is a miracle in Nigeria where things are just beginning to work.

I think that the diagonal approach will still have the same effect of 'quick wins', 'JUST spend the money, prove it' as the vertical approach. But the truth which I have been trying to run away from is the fact that the issue of Health Systems Strengthenineg to a large extent is the rsponsibilty of the government of the recipient countries to a very large extent. They must be made to account for failures of programs that fail to impact the lives of their subjects, and not the Global Fund. Though the GF has good opportunity to actually influence the health policies, more than they are doing at the moment

While we deliberate on which approach is best in the design, planning, development and implementation of health interventions and programs, let us have the two persons at the back of our minds; an under-five at risk of not growing up to five years of age because of the threat of these three diseases and a person living with HIV, at risk as well of not surviving another five years because the ARVs may not be available because the programs providnig these drugs are not sustained. Obviuosly, the hope for survival for these two lies in the assurance that whatever health program or intervention targeted at them will be sustained for another five years or even beyond.

 

Now while we think about the next thing to contribute to this discussion, which of the approaches to public health program implementation and other global health challenges (Vertical, Horizontal or Diagonal Approach) will assure our two friends that there is hope for survival, at least for another five years of life?

and yes i agree totally  t that a 'diagonal' approach is most likely a better description  and more evidently sounding of how GF programmes should be conceptualised.

and beside the opinion that vertical approach may solve the urgent needs in the our community (Iraq) ,but we found that horizontal approach is more vital on the long run and thats make me believe  (and as you did confirmed) that the  Long term plans should inform proposals  using an modular approach.

As Dr. Inyang pointed out politics and bureaucracy plays a very important role in public health programming, reason why the host countries should be held accountable.

The host countries should be made to provide the enabling platform to ensure that programs that are vertically implemented succeed.

The next round of grants should use this as a criteria for judging the eligibilty of potential recipient countries for more grants, maybe retropsectively.

Donor countries should also demand such from their recipients to ensure their programs have greater impact.

There are many advantages and benefits for either parties, if the each will take on these roles as I have suggested here here.

This is a very important and timely debate and one which, in my opinion, GF recipient countries need to engage with especially as subsequent rounds of funding are awarded and multiple grants are being implemented in-country.

In my experience of GF programmes (as a CCM member, sub recipient, and consultant for proposal preparation), it is far easier for countries to approach programming from a vertical perspective for many reasons:  

• greater control over spending as there is less dispersion (both laterally at national level and through the various health service delivery points);
• greater control over data and information for reporting against targets;
• greater control of resources (power, prestige, etc) and less 'hassle' in filling in the application (R7 is a good case in point as the HSS sections were very complicated).

This tendancy is partly in response to the 'quick wins' and 'spend it, prove it' rhetoric of the Global Fund--it is far easier to spend quickly and 'prove' results if you have more control over the inputs and outputs.

As rounds accumulate however, there will be fewer opportunities for quick wins and a greater emphasis on impact. Without a functioning health system, this will be difficult to achieve and sustain.

I think that a 'diagonal' approach is likely a good description of how GF programmes should be conceptualised. Long term plans should inform proposals even if all parts of the plan are not incorporated into individual rounds using an almost modular approach.

I am currently doing research on this using a historical perspective so I would love to hear what others have to say.

Dear ALL,

My experience in Nigeria is that, there is no one correct option to approaching Global Health. It is generally agreed that Health in itself is a political subject; there is no one option as to political governance. It is largely related to the socio-cultural affiliations of the society in question.

Back to health! Public Health program implementation in recent times has shown that where there is a strong solidarity in the society, vertical programs may succeed. There is hardly any donor country that gives without considering the political linkages with the host country. In such cases, a vertical programme may serve the interest of the donor in the short term only to show little or no impact in the long term. A horizontal programme on the other hand may attempt to solve ALL the teething problems of host nation and thus show only infinitesimal progress. A mix of vertical and horizontal protocols may serve to improve the status of compliance and also succeed in creating accountability.

These are personal views!!

The resurgence of the age-old debate over vertical or horizontal approaches are best suited to meet the challenges of the future global health needs will have important conseqences for allocating limited resources. Others have argued that the choice need not be either vertical or horizontal, rather that something resembling a "diagonal approach" is needed.

I would be interested to learn about the views of Forum members on this "debate," and particularly to learn about what if any evidence-based alternatives are worthy of serious consideration.