The ongoing debate about "vertical" versus "horizontal" approaches to health swings like a pendulum. My colleague Ruth Levine has previously pointed out the rhetorical tendency towards polarizing this debate in favor of practical solutions for resource allocation to health systems; more recently, Mead Over has commented on the alternative concept of â€œdiagonality.â€ But what does diagonality mean as an approach to health systems strengthening? As spelled out in a recent article by Gorik Ooms and others, this approach avoids the popular dichotomy by promoting harmonization and a focus on health infrastructure through which all vertical programs are ultimately delivered. In addressing this issue, the article looks largely at the role of key institutions such as the IMF, and explicitly recommends transforming the Global Fund to Fight AIDS, Tuberculosis and Malaria into a broader Global Health Fund. Indeed, the Board of the Global Fund has already moved in this direction by adopting diagonal interventions, where funds could be used to strengthen "public private or community health systems" using components of Global Fund grants. Although Ooms et al. laudably attempt to step out of the "either/or" orthogonality with this suggestion, they seem to advocate for diagonality as a means to fully horizontal integration, rather than as an end in and of itself as a type of sustainable financing. The long-term goal of foreign assistance for health is to achieve a functional and integrated health system at the country-level. However, there will always be vertical pieces that exist within these systems, ranging from the disease-specific programs du jour, to function or context-specific funding targets (read: vertical) such as laboratory capacity building that could serve as "islands of efficiency" around which the broader system could ultimately be strengthened.In that vein, the GAVI Alliance - the epitome of a vertical program - has already embraced diagonality through their traditional Immunization Services Support, and more recently through the broader Health System Strengthening window to dedicate non-discretionary type funding depending on country needs (ranging from activities like human resource capacity to building e-infrastructure). Embodying the diagonality debate with its potential for harmonization is the International Health Partnership (IHP+), a coalition of international health agencies, governments and donors (including both GAVI and the Global Fund) dedicated to a "country focused and country led" approach to the health-related Millennium Development Goals. While the Ooms article initially characterizes this program as a "rabbit in a hat trick, sans rabbit," because of its lack of commitment to new resources, IHP + has the potential to generate real symbiosis between donors, with short, medium and long term country goals accounted for through the formation of compacts: single "costed, results based national health plans" that take stock of current country health system status and build a roadmap for the future. However, the implementation of this lofty objective will extend beyond country level workplans and require addressing other concerns, including how compacts will mesh with existing national objectives and operations, implications for specific donors, their ability to reconcile the IHP+ principles with their current mandates, and the level of integration into their core functions. Planning will also need to include active and meaningful engagement between civil society and IHP+ which to foster true integration, will have to consider the broader private and traditional medicine sectors that often comprise large and functional parts of health systems in partner countries.As it is currently characterized, "health system strengthening" bears the risk of being just another nebulous approach unless activities are undertaken that look at how systems can be truly built from the bottom up. And like weaving a piece of cloth, we will need both the vertical and the horizontal threads to form a strong fabric (as poetically posited by a recent Lancet article (subscription required). IHP+ has the potential to start pulling the threads together, but we will have to wait and see whether ideas are translated to action. What we also need is a true realignment of our global health compasses to find a way to coordinate the new global health geometry, and a good definition of what the goals of diagonality really are.
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.