Vertical vs. horizontal programming: Which approach should you leverage to achieve your health improvement goals?

When in doubt, a vertical approach may be your best bet.

When in doubt, a vertical approach may be your best bet.

Vertical vs. horizontal programming: The individual perspective

Exactly how many measurable changes do you need to implement to improve your health? One, two, two dozen?  Only a few, really—fix your diet, get up and move, and quit the tobacco. You’ve heard all of this before. I’m not here to preach. 

I will, though, throw out a suggestion: consider whether taking your next step in the right direction will be part of a vertical or a horizontal approach. As an individual, the approach that nudges you toward making changes today, rather than tomorrow or next week, is the right approach for you.

Vertical programming emphasizes making changes in one area exclusively—such as using a pedometer and aiming for 10,000 steps each day—while modifying nothing else about your routine. In contrast, horizontal programming emphasizes a more comprehensive approach that requires altering multiple aspects of your routine simultaneously—maybe all three of the biggies listed above.

For many (if not most) of us, horizontal programming may be doomed to failure. In other words, is implementing multiple changes at one time simply too overwhelming? It’s likely. Horizontal programming is an ideal to work toward. How do you get there? Start with vertical programming, which provides a realistic starting point. Change one thing, stick with it for a while. Continue sticking with it. A little bit more. Still sticking with it. Okay. Make another change. Continue sticking with the first change. Stick with the second change. And so on.

The global perspective

On a global scale, public health officials continue to call for moving away from vertical approaches toward horizontal approaches. Understandable. What’s ideal is easy to strive for, but reality often dictates the methods we use to get there.

What does vertical vs. horizontal programming look like on a global scale?

From the age of colonialism to present day, the paradigm for addressing worldwide health issues has evolved from:

1) protecting imperial health (i.e., protecting the well-being of imperial populations for invading, conquering, and exploiting colonized populations), to

2) protecting international health (i.e., expanding local public health efforts to protect the well-being of colonial populations during increasing economic competition between empires, primarily to sustain trade and profits), to

3) protecting global health (i.e., promoting social and economic development to address the broader determinants of health, a notion first spearheaded on a large scale by the Rockefeller Foundation beginning in 1913 and more formally declared by the Declaration of Alma-Ata in 1978).

So, the paradigm for addressing worldwide health issues has shifted. It evolved from a paradigm based on “narrow self-interest” in which “the role of public health in human well-being was a low-order consideration” (Birn et al., 2009) to a paradigm emphasizing that “health…is a fundamental human right” (Declaration of Alma-Ata).

At the same time, however, the primary strategies and interventions deployed by major global health players failed to evolve at the same pace.

By way of example, the Declaration of Alma-Ata asserts that “governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures,” emphasizing the particular importance of a comprehensive primary health care approach. While some major global health players, such as the World Health Organization (WHO), support the primary health care approach in theory, the majority of global health activities and funding structures continue to emphasize “selective primary health care.”

In contrast to a comprehensive approach, the selective primary health care strategy pursues the fight against a limited number of diseases by concentrating on specific interventions that would be most cost-efficient (Italian Global Health Watch). Created in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) exemplifies the selective primary health care approach—it is a vertical, segmented program that targets specific, high-profile diseases in developing nations without also addressing the more systemic public health problems that these nations face, such as a limited infrastructure, an inadequate health care workforce, and lack of political will and leadership to prioritize health sector reform (Italian Global Health Watch; Garrett, 2007). One unintended outcome of the GF has been that the “large inflows of donor assistance targeted to these diseases have weakened the infrastructure [of nations] and drained the human resources required for preventing and treating common diseases that may kill many more people” (Italian Global Health Watch).

Does this mean we shouldn’t support the GF’s efforts? No. It’s a starting point.

It’s easy to argue that evidence of the limitations of the vertical approach to intervening in global health is growing. In “How Fight to Tame TB Made it Stronger,” published in the November 23, 2012 issue of the Wall Street Journal, authors Geeta Anand and Betsy McKay describe how the World Health Organization (WHO) and aid groups’ primary strategy for combating tuberculosis (TB) may have backfired in the very countries with populations most afflicted by the infectious disease.

Until recently, the collective WHO and aid group effort against TB entailed identifying the easiest-to-cure patients infected with traditional, treatable strains of the disease and prescribing a six-month course of standard medicines, an approach that sought to make diagnosing and treating TB “simple-to-understand” and “cheap enough to work in the world’s poorest places.”

In poorer countries across the world, though, an epidemic of new, multi-drug resistant (MDR) strains of TB emerged. Recent research shows that in India, where 2.2 million of 8.7 million new cases of TB in 2012 originated, anywhere from 7 to 25 percent of TB patients are drug-resistant. India began combating TB with the help of the WHO in 1997, relying primarily on the WHO’s simple approach to treating regular TB only. At the time, the “WHO decided that tackling MDR was unfeasible in places with poor infrastructure, little money, and millions of patients lacking even basic treatment.”

Even though the WHO’s simpler strategy to fight TB reduced the overall number of regular TB cases since the 1990’s, rates of drug-resistant TB—thought to be much more lethal—have climbed across 35 countries. In India, officials were unable to move quickly to address drug-resistant TB due, in large part, to a lack of basic infrastructure, including limited disease surveillance, lack of accredited laboratories for detecting and diagnosing diseases, and treatment delays.

The article is striking in that it highlights, as did the Global Fund effort, how idealistic views on the goals of global health do not align with the methods used to address global health concerns in practice. That is, the article highlights the shortcomings of vertical programming and, yet, vertical programming and selective primary health care continue to dominate how major global health players address worldwide health concerns.

Birn et al. (2009) point out that global health, as a form of development, raises central questions regarding the “hows of the field.” Specifically, how are activities of the field, such as disease campaigns, implemented and how do these activities lead to “path dependence?” In political science, the concept of “path dependence” refers to the notion that current policy and programmatic decisions—and, therefore, the structure of new policies and programs—are influenced and even constrained by past policy decisions, even if the context of policy decision-making has changed from one time period to the next.

In other words, there is a process of “policy feedback” through which policy builds on policy (Beland and Hacker, 2004). Path dependence may help explain our continued reliance on vertical global health interventions. If targeting low-hanging fruit—specific diseases for which evidence-based and cost-efficient treatments exist—has always been the norm, then switching gears to a more comprehensive approach may be all the more difficult. Again, though, it’s a start.

Back to you

In the end, what does this have to do with you and how you pursue your health improvement goals? If vertical programming offers a low-barrier “start strategy,” then choose one thing today and worry about everything else another day. Have you, in the past, attempted a comprehensive, horizontal overhaul of your routine only to hit a wall of resistance a few days or weeks later? Side-step your own sticky path dependence—shake it up and go with a vertical approach the next time around. It’s not ideal, but it’s a start.


Image: Jacob Valerio (via UNSPLASH)

From the literature:

Birn, A., Pillay, Y., & Holtz, T. H. (2009). Textbook of international health: Global health in a dynamic world. New York: Oxford University Press.

Beland, D. & Hacker, J. S. (2004). Ideas, private institutions, and American welfare state ‘exceptionalism’: The case of health and old-age insurance, 1915-1965. International Journal of Social Welfare, 13, 42-54.

Garrett, L. (2007). The challenge of global health. Foreign Affairs, 14-38.

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