When do vertical (stand-alone) programmes have a place in health systems?

Key messages

• The available evidence on the relative benefits of vertical versus integrated delivery of health services is limited and too weak to allow for clear conclusions about when vertical approaches are desirable.
• The limited evidence available suggests that integrated approaches to delivering health services, compared with vertical approaches, improve outcomes in selected areas including HIV, mental health and certain communicable diseases. In several countries in the eastern part of the WHO European Region, for example, vertical programmes appear to have impaired the effective management of HIV, tuberculosis, substance abuse and mental health.
• Nevertheless, vertical programmes may be desirable as a temporary measure if the health system (and primary care) is weak; if a rapid response is needed; to gain economies of scale; to address the needs of target groups that are difficult to reach; to deliver certain very complex services when a highly skilled workforce is needed. In practice, most health services combine vertical and integrated elements, with varying degrees of balance between them.
• When vertical programmes may be desirable, policy-makers could consider two policy options: (1) time-limited vertical programmes with clear strategies to avoid negative spillover effects for the health system and non-targeted populations; and (2) indefinite programmes, with mechanisms at both the strategic and operational levels to enhance links between the vertical and horizontal elements of the health system.
• Political economy within a particular context and technical factors related to the health system will influence the extent of integration. As powerful interest groups are likely to oppose the integration of vertical programmes, policy-makers should develop strategies to offset such resistance.
• Where vertical governance, funding and service delivery systems exist, integration will be difficult and changes in service delivery must be underpinned by legal and regulatory adjustments aimed at linking the governance, organization and funding of vertical programmes with mainstream health systems.