Mr. Malcolm Segall, Retired Fellow, Institute of Development Studies, University of Sussex chaired the symposium and presented a historical overview of the development of the vertical (or disease control) approach to health care and the horizontal (or comprehensive care) approach. He explored the main differences between the two approaches, emphasizing that the two do not attempt to arrive at different answers to the same question but are, at the outset, asking different questions. Such questions essentially pertain to the respective focus of each approach: the vertical approach is disease-centred, while the horizontal approach is patient-centred. The use of resources in a vertical approach is dictated by a centralized authority, while the horizontal approach encompasses area-wide planning at the centre with final decision-making devolved to the local or district level.
Two country models were presented where the initial use of the vertical approach failed and the horizontal, or sector-wide approach (SWA) was subsequently adopted. Mr. Bergis Schmidt-Ehry, who works in Tanzania for the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ), discussed the case of Tanzania. He presented a list of the various advantages of the SWA and the challenges currently faced by Tanzania in its implementation.
Mr. Francis Runumi, from the Ministry of Health in Uganda, presented the failure of the vertical approach in his country and the better results provided by the adoption of a horizontal approach. Prior to the adoption of the SWA in Uganda, a variety of health programmes existed, resulting in fragmentation and waste of resources, with a disproportionate amount of resources going to administrative expenses rather than on actual health care services. Quality of health care was also significantly lacking and health care workers were unnecessarily fatigued because of having to serve different managers in the same health care delivery system. Many problems had to be addressed with very limited resources. This scenario gave rise to health policy reforms in the late 1990s, which decentralized the health care system and brought about the adoption of a more integrated and sector-wide system.
The two country models demonstrated the positive results achieved with the implementation of the SWA. Inefficiencies were removed, and work was harmonized and coordinated. Pooled funding allowed resources to be better allocated to various health care needs, thus providing a more equitable and comprehensive health care system. This also allowed abolition of user fees, which widened health care access to the poor who would not otherwise have been able to afford it. Along with comprehensive care, disease control programmes were also implemented, proving that the two approaches do not have to be mutually exclusive. Health services have also been supplemented with health education and campaigns on specific targets such as improving immunization coverage. Uganda adopted the Child Days Plus (CDP) strategy which is implemented yearly. The CDP provides children with routine and catch-up immunization, de-worming, and vitamin supplementation. In Tanzania, infant mortality has been reduced by 30%. All of these efforts, which stem from the adoption of the SWA, have produced positive results in the overall health care services provided to local communities at the district level.
However, the SWA also raises certain challenges. In Tanzania, for instance, Global Health Initiatives (GHIs) interfere with existing local planning and attempt to influence the countries' health strategies. GHIs do not necessarily build on the country's decision-making process regarding resource allocation, but actually short-cut the systems in place. While GHIs provide additional sources of funds as well as lobbying efforts, they focus on providing funds only to selected diseases and health problems. Such select fund allocations distort the country's health budget planning. GHIs also introduce uncertainty regarding long-term sustainability because the serious commitment of such initiatives to future flow of funds is unpredictable. Moreover, the use of GHI funds requires monitoring, which is time and resource-consuming. Such monitoring activities necessitate additional administrative reporting duties on an already strained health care workforce. Interestingly, in Uganda, even with the implementation of the SWA, once the funds have been pooled and allocated to the various health needs and priorities of its population, the local districts manage the use of the funds such that the centralized authority, as well as the development partners, takes a 'hands-off' approach.
The SWA also necessitates additional skilled personnel who are versatile health workers able to provide a wide array of health services. With a shortage of trained health-care workers, existing health care providers are over-worked, resulting in inadequate service delivery. In Uganda, for instance, the abolition of user fees in 2001 saw an increase in the number of people seeking health services. But because an insufficient number of health workers had been recruited, such workers were not able to support the increase in services sought and, consequently, patient attendance dropped. Additionally, with more sophisticated equipment comes an increased need for equipment maintenance, as well as more qualified technicians to operate and service such equipment.
Despite the success of the SWA the issue of inadequate financing still remains. While the abolition of user fees has opened up access to the poor, it came with the risk of providing 'no services', said Mr. A. Hingora, Health Sector Reform Secretariat, Tanzanian Ministry of Health and Social Welfare. Thus, Tanzania is also exploring an insurance-type system to provide a more equitable health care delivery system.
In conclusion, despite certain negative consequences which the horizontal approach has had, tangible progress has been achieved with the implementation of such a sector-wide approach. Mr. Segall concluded that this progress is very encouraging for the future of health care and access, not only in Uganda and Tanzania, but in this region of Africa as a whole.
