Collins points out the lack of capacity at local levels in almost all of the developing world and the United States to implement prevention services. We were unclear in our presentation. While we argue that services need to be delivered locally in one site, we endorse the need for service packages, training systems, and infrastructure to be designed centrally, where the capacity is the greatest. Diagonal integration (Frenk 2006
; Ooms et al. 2008
; Uplekar and Raviglione 2007
) is the correct description for such a system. The diagonal approach intends to leverage disease-specific program funding to build capacity in local health systems that generalize to a variety health challenges. from Ooms et al. (2008)
outlines the benefits and costs of horizontal, vertical, and diagonal approaches to strengthening health systems. We intended to communicate the importance of integrated delivery at the local level, particularly in rural sites. However, we share with Dr. Collins and the work of previous public health providers that recognizes the lack of local capacity. There have been global examples of such successful integration: the system of barefoot doctors in China; the health monitoring system in Thailand; and the prevention services in Australia for high risk youth.
Fig. 1 Comparison of vertical, horizontal, and diagonal integration in health expenditure and capacity (from Ooms and Bestgen 2008 in Ooms et al. 2008)
Typically, diagonal integration is discussed in the context of macro-structural funding for global health infrastructure. However, we believe these principles generalize to dissemination of evidence-based prevention, as well. Our proposals for disseminating EBI based on common elements (i.e. factors, processes, principles) found across EBI, is congruent with a diagonal approach. If EBI were disseminated and adapted based on a common language and framework that reflects the common elements of all effective programs or practice, then the local capacities that are built while disseminating disease-specific EBI could be more easily generalized and translated to a variety of local health challenges.
Currently, we are trying to assess whether EBI for preventing obesity, heart disease, substance abuse, and HIV share the same common elements. Riggs et al. (2007)
has demonstrated that a program originally designed for violence and substance abuse prevention for adolescents could be adapted into an efficacious obesity prevention program: impulse control, decision-making, and social competence were the key proximal intervention targets for improvements in HIV, diet and physical activity. The intervention elements were common across the adaptations, only the disease-specific focus and content was different. From our HIV prevention experience, we recognize that the same intervention elements can be efficaciously applied to sexual behaviors, substance use, medical adherence, and quality of life. Thus, it seems feasible to build or adapt EBI using a common framework that is adaptable to multiple disease behavioral targets. Whether or not this can be done effectively in practice with local providers remains to be determined.
Recently the World Health Organisation (2008)
has recommended “task shifting” HIV prevention services away from highly trained healthcare workers to paraprofessional workers with less training and fewer qualifications in order to meet the increasing demands put on stressed healthcare human resources. The CDC’s DEBI initiative is consistent with this recommendation by supporting local CBOs and their staff to deliver prevention, rather than medical providers. This approach has been extended outside of the U.S. through international partnerships.
However, we believe the global needs for rapid and broad expansion of prevention services, and the human resources needed to deliver them, will require a new model for intervention development, dissemination, training, and adaptation. We need a disruptive innovation (Christensen et al. 2000
; Christensen 2007
) in global prevention for HIV and other local priorities where good enough solutions can reach much larger populations, faster, with increased potential for sustainability, and more easily adaptable to changing conditions and priorities over time.
We suggest that using a common elements framework for adapting and developing prevention programs, applied to a community’s top three health prevention priorities, holds strong potential to be a disruptive innovation in effective prevention dissemination. Most communities have only a few big-ticket prevention priorities. Three prevention priorities are likely to be trainable to paraprofessionals in CBOs using a common elements framework. Information and communication technologies, such as mobile phones and the internet, can support such an approach by extending reach and lowering the costs to train, deliver, and sustain programs. Again, as Collins suggests, with reference to horizontally integrated community participation models generally, research is needed to identify if our proposals can help overcome challenges to maintaining efficacy. Collins’ recognition that both horizontal and vertical approaches exist and are needed suggests that a diagonal integration perspective can support innovative solutions to these challenges.