In most developing countries, the majority of resources go to secondary and tertiary care hospitals, looking after a small part of the population. As in western countries, the attractiveness and the ‘power’ of hospitals in the healthcare system are quite strong. A hospital is more ‘visible’. Primary health care is much more dispersed in the community, under the form of clinics, community health centres, and district health hospitals. In the last 20 years, another ‘antagonism’ has become increasingly important: the antagonism between horizontal (person- and community-oriented care) and vertical (disease-oriented) care. Shortly after the Alma Ata Declaration, where the importance of comprehensive primary health care was pointed out by the WHO,2
the concept of selective primary health care underpinned the vertical ‘disease-oriented’ programmes. The AIDS epidemic in the 1980s gave a strong impetus to the development of vertical programmes. Organisations such as The World Bank, the International Monetary Fund (IMF), the Global Fund, Bill and Melinda Gates Foundation, and US-Aid, have concentrated on vertical programmes. Although enormous amounts of money are invested in those vertical programmes, the overall performance of disease control programmes is poor.23
For tuberculosis, HIV, and malaria, the Millennium Development Goals will not be met in Latin America, Sub-Saharan Africa, or South and South-East Asia. An overview of the literature on vertical versus horizontal programmes found very few studies providing empirical evidence in this area, and the overall quality of the studies was less than desirable. The authors conclude that vertical and horizontal approaches do not have to be seen as mutually exclusive but rather as complementary strategies, thus pointing to the need to discard the dichotomy of the one versus the other:
‘Given the capacity constraints of existing services, expansion of access to priority interventions which can feasibly be delivered independently of the health service infrastructure, may need to rely on vertically-delivered programmes in the first instance.’24
This contradicts other literature that demonstrates clearly that there is a need to integrate programmes into local health facilities to achieve reasonable prospects for successful disease control.25–27
These authors point to the merit of integrating curative and preventive care. Examples include the potential for detecting a patient with tuberculosis among those with cough, or suggesting vaccination to a patient or to a population with whom the practitioner (for example, a family physician or nurse clinician) has established trust. Ooms et al
even suggest a diagonal approach to decrease the polarisation in the discussion between horizontal versus vertical care programmes.28
The authors suggest that the the Global Fund should gradually and carefully be transformed into a ‘diagonal’ and ultimately perhaps ‘horizontal’ financing approach.
The problem with vertical programmes is that they address only a fraction of the demand or need for health care. Patients are likely to demand a range of treatments, spanning curative care, relief from suffering, reassurance, prevention, and advice on use of health services — not just a control of one single cause of ill-health. In contrast, vertical programmes focus on restricted objectives, largely ignoring the patient's demand for access to wider health care. This dialogue between ‘programme’, professional, and patient is limited to matters of education and information — one-way communication — to promote the campaign objectives.29
A report prepared for the Swiss Agency for Development and Cooperation identifies other disadvantages of vertical programmes: they create duplication (each single disease control programme requires its own bureaucracy), lead to inefficient facility utilisation by recipients, may lead to gaps in care, are incompatible with decent healthcare delivery and, where funded externally, undermine government capacity by reducing the responsibility of the state to improve health care in its own services.30
Recently, a new phenomenon is influencing the developments in a negative way: vertical disease-oriented programmes, funded by international donors, ‘extract’ the skilled local health personnel out of the local primary healthcare system in order to employ them, in much better financial conditions, in vertical programmes. This type of internal ‘brain-drain’ has devastating consequences.
To deal with these problems, a ‘code of best practice for disease control programmes to avoid damaging healthcare services in developing countries’ has been established:
- disease control activities should generally be integrated, with the exception of certain well-defined situations. They should be integrated in health centres, which offer patient-centred care;
- disease control programmes should be integrated in not-for-profit health facilities;
- disease control programmes should plan to avoid conflict with healthcare delivery; and
- the administration of disease control programmes should be designed and operated to strengthen health systems.29
In March 2008 the ‘15by2015’ campaign was started.31,32
The World Organization of Family Doctors (WONCA) in collaboration with Global Health through Education, Training and Service (GHETS), the Network Towards Unity for Health, and the European Forum for Primary Care (EFPC), called upon the new international health partnership and upon funding organisations, such as the Global Fund, the World Bank, the Bill and Melinda Gates Foundation, and the World Health Organization, to assign primary health care a pivotal role by investing, by 2015, 15% of the budget of vertical disease-oriented programmes in strengthening well-coordinated, integrated local healthcare systems and asking that this percentage would increase over time.
How could ‘15by2015’ work? Take the example of Mozambique. In 2005, the total health expenditure in the country was $356 million. Foreign assistance accounted for $243 million, from which $130 million was channelled through disease-specific vertical funds managed directly by donors.33
The ‘15by2015’ campaign proposes that 15% of the vertical funds from donor organisations (in this example, $19.5 million) should be diverted into the government's common health fund and be earmarked for strengthening primary health care through improvement of infrastructure, health education, and investment in human resources. This amount of money could support 65 health centres for a year. These centres could be staffed by primary healthcare teams including family physicians, mid-level care workers, primary care nurses, pharmacists, and health promoters.
If one primary healthcare centre covers a population of 20 000 people, then 65 health centres would give 1.3 million people access to improved primary health care. Part of the ‘15by2015’ fund could be allocated to support the training and upgrading of skills. It could also be used to provide better pay for health personnel to encourage them to stay in areas where they are needed, and to pay for community health workers, mid-level care workers, and ‘African family physicians’ who are a fledgling but emerging force.34,35
The Ministry of Health should monitor the accessibility and quality of this care in a transparent way to ensure that the ‘15by2015’ fund is used most effectively to improve community health.
This comprehensive, universal approach with primary health care as the hub of coordination and networking within the community, is exactly what the 2008 World Health Report Primary Health Care: Now More Than Ever
In the chapter ‘Primary Care: Putting People First’, there is a clear focus on person-centred care, comprehensive and integrated responses, continuity of care, and a regular and trusted provider as entry. This is exactly where these skills and competences of a family physician, operating in a primary healthcare team, are required.