Strengthening primary care: addressing the disparity between vertical and horizontal investment

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Abstract
Recently we have seen an unprecedented increase of financial support to improve health care in developing countries estimated at 26% between 1997 and 2002, from $6.4 billion to $8.1 billion.1 While the magnitude of such an investment is a positive development, the vast majority of aid has been allocated towards disease-specific projects (termed ‘vertical programming’) rather than towards more broad-based improvements in population health, such as preventive measures, primary care services, and health workforce development (termed ‘horizontal programming’). For instance, the initiatives of the Bill and Melinda Gates and Clinton Foundations usually focus on specific communicable diseases: 60% address ‘big diseases’ (HIV/AIDS, malaria, and tuberculosis). Rwanda, for example, with an HIV prevalence rate of 3.1 %2 and an annual health budget of $37 million,3 received $187 million since 2003 exclusively for HIV/AIDS. Thirty years ago, in 1978, the Alma-Ata Declaration pointed to the importance of community-oriented comprehensive primary health care for all nations. Improving health required changes in economic, social, and political structures, in addition to access to health care. In this comprehensive or ‘horizontal’ healthcare concept, health care is also a basic human right that requires community participation. Some have argued that the Alma-Ata concepts were unattainable because of the costs and numbers of trained personnel required. From this perspective, a selective disease-oriented approach could address the greatest disease burden in the community in less developed countries.4 The two positions differ both …