Vertical vs horizontal health programmes in Africa: Idealism, pragmatism, resources and efficiency

Sec. Sn. Med. Vol. 17. No. 24, pp. 1971-1981. 1983 Printed in Great Britain

0?77-9536/83 $3.00 + 0.00 Pergamon Press Ltd

VERTICAL VS HORIZONTAL HEALTH PROGRAMMES IN AFRICA: IDEALISM, PRAGMATISM, RESOURCES AND

EFFICIENCY*

ANNE MILLS

Evaluation and Planning Centre. London School of Hygiene and Tropical Medicine. Keppel Street (Gower Street). London WC1 E 7HT. England

Abstract-Argument still rages over whether vertical health programmes-attacking one or a few health problems-should still be set up in developing countries. or whether all their efforts should be devoted to establishmg a horizontal multiproblem approach such as primary health care. This paper argues that the debatecan be made rather more informed firstly by a consideration ofthe technologies available to improve health and the methods of delivery to which thsy are most suited: secondly by a consideration of their effectiveness and the organisational feasibility of different strategies of delivery, and finally. by investigation of the total costs and cost-effectiveness of diHerent delivery systems. Particular attention is given to the contributton of economic analysis to elucidating these issues, and a variety of cost-effectiveness studies are reviewed to see w’hat informatlon is available on the way in which particular health programmes such as malaria control and immunisation activities can be organised in order to maximise their cost-effectiveness.

THE DEBATE

The debate over the relative merits of organising health programmes in wavs that go under the slogans of ‘vertical’ and ‘horizontai’ programmes has continued for at the least the lifetime of the World Health Organisation. Though condemned recently as ‘sterile polemics’ [I], the issue refuses to disappear, and raises its head at regular intervals. While the overwhelming philosophy at present favours horizontal systems, adherents of a (modified) vertical approach are still to be heard 12. 31.

This debate is closely linked to another slogan, that of ‘integration’. Integration can be sought at three levels, each of differing scope. At one level there is integration within health services. for instance of vertical immunisation programmes with horizontal health care programmes. At another level, there is integration within the broader health sector, of population control or sanitation programmes with health services. At a yet broader level. there is integration of all public sector activities affecting the goal of health improvement: this implies multi-sectoral strategies, programmes and activities, incorporating all sectors, such as agriculture. education. public utilities. which affect health. Such a philosophy is not new. and has clear antecedents in other fields. most notably in integrated rural development programmes which aim to raise the incomes and standard of living of rural populations by simultaneously providing a number of productive and social services [4].

One notable feature of most discussions on ‘integration’ is that the term is common11 used as an end in itself. that is integration as an ohjecti1.e. and not as a mwr~s to achieve objectives. While objectives are often implicit. for instance to improve service delivery or

* This paper was presented at a symposium on Healrh and D~~~/~pmwr irl .-I~m~r. Unlversit! of Baxreuth. Federal Republic of German) June 1982.

efficiency, they are usually assumed. as the sure consequence ofintegration.

This phenomenon is as apparent in developed countries as it is in developing countries. Thus the British NHS was re-organised in 1974 with the ‘objective’ of integrating hospital, community and general practitioner health services and integration was also for some time a catch phrase in the United States. Such integration often refers to achieving structural changes, which do not necessarily produce alterations in the way in which organisations behave [5].

The emphasis on integration of all activities affecting health is a fairly recent phenomenon. Historically, in the present developed countries. public health (water, sanitation, hygiene, etc.) was often kept separate from curative medical services. Indeed, in England public health care evolved with its own organisation and specialists. It is now argued that such separation is not relevant to the circumstances of developing countries. In particular, scientific advances mean that there is often a choice to be made, or balance to be struck, between strategies to improve health directed towards changing the environment, and those directed at the individual. Thus co-ordination between public health and curative services is more important, and this is further emphasised by the need to achieve greatest effect with often very limited resources. In recent years in developing countries the principle of the integrated health centre has been advocated. providing both curative and public health services, and now that of primary health care, extending the concept of integration to all health-affecting activities.

These developments have led many to suggest that there is no point contrasting horizontal, integrated programmes with vertical programmes since the two approaches are not mutuallq exclusive but comple- mentary. a judicious mix being required [6]. Nonethc- less. such soothing words do not remove the need fcr choice at the margin. given the health resources and infrastructure of a particular country. of how to tackle

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1972 AWE MILLS

a particular health problem. If measles is a major cause of infant mortality, should there be a vertical programme of immunisation. or should such an activity be included in the functions of basic or primary health care? Richer countries, with established infrastructures and adequate manpower, may not face such a choice but for many countries in Africa, it is clear that the existing infrastructure is inadequate in coverage and resources. and is likely to remain so for some time.

Health planners in Africa therefore face decisions in a number of areas. They must decide, within available manpower and financial resources. which health problems should be tackled, what activities are required. how much of each type of activity should be applied by whom and to whom, and what form of delivery system is needed. Such decisions can be evaluated in a variety of ways. This paper explores the contribution of economic analysis and evaluation to the types of choices on delivery systems facing many developing countries in Africa. The choice between a vertical and horizontal programme. given suitable technologies, can be considered in terms of which strategy is the most cost-effective to tackle known health problems in the circumstances of a particular country, given existing resource constraints and organisational capabilities.

DEFINITION OF TERMS

Before further developing some of these arguments, it is necessary to be clear on the meaning of the terms used. The terms ‘horizontal’, ‘vertical’ and ‘mass campaign’ are used here in the way defined by Gonzalez :

“the’horizontal approach’seeks to tackle the over-all health problems on a wide front and on a long-term basis through the creation of a system of permanent institutions commonly known as ‘general health services’ ” “The ‘vertical approach’ calls for the solution of a given health problem through the application of specific measures through single-purpose machinery” “a mass campaign will be taken to be a health programme that concentrates its efforts on the application, on a community-wide basis, of measures specifically designed for the control (in a broad sense, including eradication where feasible), of a particular communicable disease” [6].

Horizontal health services aim to provide promotive, preventive and curative services usually through multi-purpose workers. Vertical programmes in their traditional form are commonly thought of in connection with mass campaigns to control communicable diseases such as malaria, yaws, tuberculosis and onchocerciasis. Such programmes have tended to have limited, defined objectives concerned with the control or eradication of a single or limited number of diseases. They are often organised as a self-contained entity within the health system, often with strong central direction and control. A vertical programme of this type can have a number of phases, including an attack phase designed to break the epidemiological chain of transmission, a consolidation phase with more limited activity to prevent the re-emergence of transmission, and a maintenance phase with stress on surveillance.

Programmes concerned with less acute infectious diseases. for instance tuberculosis. trachoma or leprosy, have less clearly defined stages.

Vertical programmes are not necessarily confined. however. to communicable diseases or to a single disease. They may be based on a control strategy which affects several diseases. such as immunisation. or may provide a particular service, such as family planning or maternal and child health services. From the point of view of a particular geographical area. the title of vertical programmes may even be attached to the activities of different Government ministries. and horizontal programmes to those where there are local mechanisms. such as a co-ordinatine committee or chief officer with broad responsibilit;es. to link the various sectors.

Horizontal and vertical programmes may be organised in various ways and be centralised or decentralised to differing degrees. A vertical programme may have regional and local organisational units responstbie to the national level. m parallel with similar units responsible for general health services. On the other hand. an attempt at partial integration may be made by having all peripheral units formally responsible to a local chief officer, such as a District. Provincial or Regional Medical Officer. Such a medical officer would then control a number of units. some concerned with specific disease activities, and others with health service institutions. Even an integrated disease control programme will usually have to retain a limited vertical element for technical supervision and assistance.

While such organisational patterns appear to get away from the programme organised vertically up to national level, they do not necessarily mean that services are fully integrated locally. It is helpful to make a distinction between structural integration and functional integration [7]. The integration of various activities wtthin a single organisation does not always lead to functional integration, that is the integration of the various tasks to be done at the level of the patient or community. On the other hand. some degree of functional integration may be achieved without structural integration (for instance a team from a vertical vaccination programme visiting a static centre). The picture is further confused by considering the organisation of primary health care itself, for some countries have set up primary health care as a vertical programme, in parallel with other programmes for hospitals, immunisation, malaria control, etc.

The debate over vertical and horizontal programmes is thus extremely confused, not least by the diversity of practice and organisational structures and the potential gap between structural arrangements and what actually happens. In this paper, a distinction is drawn between a local programme which focuses on individuals and communities and attempts to meet all their health needs, and a local programme which has one, or at most a few. main activities. Both types of programme may be controlled by administrative hierarchies which come together at Regional or Provincial level. or may have vertical lines of responsibility up to one umbrella organisation (the Ministry of Health) at national level. The limited purpose programme which focuses on a few. defined health ‘needs’ is here termed ‘vertical’. and the programme which has broad objectives and

Vertical vs horizontal health programmes in Africa 1973

responds as much to individuals’ demands as to tech- health services required considerable financial assist- nically defined needs is termed horizontal. ante and logistical and organisational support.

A3 HISTORICAL PERSPECTIVE

Vertical campaigns have been used in the past to attack a number of diseases. In Africa these have included trypanosomiasis. smallpox, cerebrospinal fever. plague, hookworm. venereal disease and yaws [8]. The attitudes of international organisations such as

WHO and participating countries were particularly influenced by scientific discoveries, of insecticides such as DDT. of penicillin and vaccines. Moreover, in- creased knowledge of the epidemiology of certain diseases initially promised to make control and even eradication of diseases such as malaria and smallpox feasible. Enthusiasm was strengthened by initial success, notabl) in malaria control, and subsequently in the eradication of smallpox. In the light of present pessimism. it is instructive to read that as late as 1975. it M’as being argued that:

The type of activities that general health services were expected to cover included basic medical care, detection and prevention of disease. maternal and child health. sanitation, health education and the reporting and collection of statistics. In addition. in order to assist mass campaigns, they should cover school hygiene through simple surveillance and protec- tion measures, geographical reconnaissance. determining the location of people and dwellings. and the collection of vital statistics [12]. Continuing surveillance and treatment of residual cases were considered particularly important, as such activities were usually prohibitively expensive for a mass campaign to undertake, but were vital to maintenance of control.

“It is lil\ely that the use of mass campaigns for a wide range of health problems will he stimulated as improved technical tools and hetter operational procedures result from applied research already under way. In consequence. the lastmg control of important diseases such as bilhaziarsis, onchocerciasis and trypanosomlasis may reasonably be anticipated as a practical possibillty”[h].

Considerable stress was laid on the likely economic benefits of disease control (though with very few detailed explorations of the impact of disease on economic activity or of the economic effect of disease control or eradication). Such arguments undoubtedly encouraged the foreign assistance for disease control which has been a strong Influence on tlie nature and organisation of these programmes [9]. In certain cases, such as onchocerciasis and leprosy, external donors appear to have been more concerned. and to have given greater priorit), to these diseases, than the countries themselves.

Given this long list of activities, it is not surprising that few general health service systems in Africa were sufficiently well-developed to take them on satisfac- torily, especially since outreach activities of basic health services have proved difficult to organise and sustain. Some countries have therefore had programmes of strengthening basic health services phased with disease control programmes. In Malawi. for instance, the strengthening of health centreh was undertaken at the same time as a leprosy and tuberculosis case-finding and control programme. and the identified cases handed over to the strengthened sub- centres. Such programmes, however, can have considerable continuing financial costs for national governments. In Togo, for example, the pre-eradication programme to strengthen basic health services prior to a malaria eradication campaign implied an increase in recurrent costs of two and a half times the existing expenditure on dispensaries [6].

External assistance, inadequate coverage of basic health services. the nature of the technology, and the weakness of existing organisations (such as Ministries of Health) were all factors that encouraged the or_panisation of programmes as distinct entities, not reliant to an! significant degree on existing institutions [lo]. Moreover. disease ‘eradication’ programmes \vere attractive to donors. promising not only significant economic benefits but also a time-limited commitment.

The experience of Francophone and Anglophone countries with regard to vertical and horizontal programmes has been rather different. stemming from the different colonial traditions. In Francophone countries the functions of dispensaries were curative and did not include preventive services and public hygiene. Instead, vertical programmes (campagnes contre les grandes enditmies) provided preventive services by mobile units (itquipes de prospection et des vaccinations) which were vertically organised and responsible for surveillance of the major endemic diseases and for vaccination programmes [13].

It had been recognised from early on that in the long term. general health services were required if control or eradication was to be maintained:

“more authorities are becoming aware thai many campaigns for the eradication 6f diseases will have only temporary results if the! are not followed b> the establishment of

permanent health services in those areas. to deal with the day to da) worh In the control and prevention of disease and promonon of health” [I I].

While mass campaigns have been carried out in Anglophone countries, the basic health services have usually had preventive and promotive tasks in addition to curative functions. In Kenya. for example. the concept of health centres covering preventive and curative care was established by the 1950s. although even by the ‘1970s the original concept of community orientated care was not being practised and preventive services, especially immunisation, were predominant11 delivered through intermittent mass mobile opera- tions [14].

The implications of such statements were not clearly thought through and permanent services were developed onl! slowly. lt became apparent that while mass campaigns could be mounted quite quickly. general

The disillusionment with basic health services al- luded to above was mirrored in other African countries. In Ghana, for instance, a detailed study indicated that a third to a half of the population of the Districts investigated lived outside the effective reach of the health units providing basic health care and that the ser<ices provided were generally of low quality [15]. In brief. in many countries the effective coverage of

1974 ANNE MILLS

basic health services has been low, and prospects for remedying it not good. In addition. by the mid 1970s there was increasing pessimism about the likely success of vertical disease control programmes in the light of the resurgence of malaria in certain countries of South-East Asia, increasing problems of resistance to drugs and insecticides, awareness that not enough was known about the epidemiology of certain diseases for the success of control to be sure, and inadequacies of the basic health infrastructure to assist with disease control [16].

On the other hand, the legacy of the vertical control programmes should not be underestimated. particularly in terms of the knowledge and experience that has been carried over into, for instance, the Expanded Programme on Immunisation. Moreover, some vertical campaigns have continued, most notably the large onchocerciasis control programme in West Africa, perhaps the ultimate vertical programme in terms of technology used and pattern of organisation [17]. In addition, another type of vertical programme has been established, that for family planning, though there is an increasing tendency to incorporate this into general health services[l8].

Primary health care is now seen by most international commentators as the only viable way of attacking the health problems of poor countries. A basic PHC package is considered to include aspects of personal health services, maternal and child health, family planning, nutrition, environmental health, health promotion. disease surveillance and vital registration. and links with agriculture. education and other development activities [191-a list comparable to that of the tasks of basic health services given above, but with a stress on intersectoral activities. community participation, appropriate technology, and essential drugs. PHC thus represents an integrated-holistic- horizontal approach to health, in contrast to what is seen as the technical approach of vertical programmes [20].

While PHC programmes have been shown to be successful in reducing mortality and morbidity on a small scale [21], it is not clear to what extent they can be successful on a national scale. as part of a widespread programme, organised within existing institutional constraints [22]. Nor is it clear to what extent they can participate successfully in disease control activities, whether integration of existing vertical programmes is feasible. and whether countries can aford complete coverage of their populations. These two issues, of the relationship of vertical programmes to PHC, and the cost of PHC, are considered in subsequent sections.

FACTORS INFLUENCING THE ORGANISATION OF HEALTH PROCRAMMES

A number of factors can be identified which should be borne in mind by health planners when considering whether health programmes should be organised vertically or horizontally. These are the available technology, the etTectiveness of alternative organisation patterns, total resource availability (including external resources), the cost-efiectiveness of the various options, and organisational capabilities. While the measure of cost-etfectiveness should take account of

all these factors (since technologies and organisational efficiency, for instance. will affect costs and effectiveness) it is useful to consider them separately here. since they have a considerable etTect on the feasibility of horizontal and vertical programmes.

Technology

A number of methods of intervention. aimed at improving health status, can be identified [23]. These are first, diagnostic, therapeutic and preventive actions directed at individuals; second. interventions aimed at changing the behaviour of individuals; third. those aimed at the community, to help them change their patterns of living and conditions of life: and finally. direct interventions to change hazardous environmental situations or improve hving conditions.

These methods can be related to, for instance. control of a specific disease and the interruption of the epidemiological cycle. This can be attempted by intercepting the vector (where relevant) for instance by residual spraying. reducing as rapidly as possible the human reservoir’ of infection (by treatment) or increasing the resistance to the disease of susceptible individuals (vaccination). In addition. continuing control may require change in the behaviour of individuals and communities.

Horizontal programmes will clearly be at an advantage where continuing contact is required with the community, for instance for long-term treatment of tuberculosis, and especially where behavioural change is required. Their success in mass chemotherapy, however, will depend‘crucially on coverage of the population, and on the availability of suitable drugs,

Vector controls, which will include the identification of breeding sites, preparation of insecticide. larvicide or molluscicide schedules, spraying and surveillance of the success rate and for resistance, will usually demand expert supervision and technical knowledge. This is particularly so where a concentrated and well-timed programme is required to interrupt transmission, for instance of malaria or onchocerciasis.

Any technology intended for widespread use by relatively unskilled personnel, whether in PHC or a vertical campaign, must satisfy certain criteria including simplicity, effectiveness and safety. cheapness. well- defined methods of application and ease of use. maintenance and replacement [23]. While PHC should provide means of easy access to a population. it is less clear that many of the technologies available for disease control satisfy all these criteria, and consideration has to be given to problems of drug resistance. adverse reactions, and vaccine effectiveness. For instance. while mass chemotherapy for malaria has been shown to be feasible, it is not clear that drugs for the treatment of onchocerciasis [17], schistosomiasis [24] or leprosy [25] are yet safe enough for widescale use by relatively unskilled primary health workers. In the case of leprosy, it is argued that there are important medical reasons concerned with diagnosis, treatment and adverse immunological reactions why leprosy may be a particularly difficult disease to control in the context of PHC. Thus in the case of a disease which has traditionally been handled by vertical. specialised programmes. there are doubts whether integration with PHC is feasible. Similar concerns arise where the widespread and poorly supervised and controlled use

Vertical vs horizontal health programmes in Africa I975

of drugs or insecticides may lead to problems of resistance.

Moreover. a- vertical campaign with a well-defined aim, clear and precise schedules of work, well-defined techniques and frequent, expert supervision is likely to be able to undertake control activities more efficiently than a primary health care worker, with short training covering a number of skills and often poor supervision and back-up. However, the traditional type of vertical campaign is best suited to control those diseases such as smallpox which require a concerted attack through a limited number of applications. Such diseases are difficult to find. though measles has been mentioned as the next candidate for eradication on a country-wide basis [26].

Available technologies thus affect the extent to which communicable disease activities at least can be undertaken by PHC or by vertical programmes. In conclusion. the extent to which integration with primary) health care is feasible will depend on :

what technical tasks are necessary; whether they can be divided into different levels of

complexity; what type of health worker is most appropriate for

these tasks : what support they need ; how this is best organised; whether public acceptance and success is dependent

on close rapport with the community and related to other health problems ;

whether evaluation of the success of the programme depends on data collected from individuals and communities and the best way of organising this;

the extent of the provision of basic health services.

The effectiveness of alternative organisational patterns will depend partly on the technology, discussed above, but also on factors such as the coverage of PHC. the quality of PHC workers, the amount of time they can devote to their various activities, and the amount of back-up and supervision they get. Ensuring that patients requiring continuing treatment take their drugs. or organising mass chemotherapy, will require considerable time. and little attention seems to have been given to exploring what it is realistic to expect a PHC worker to do (though see Cumper (271 on the time needed for household visiting in Bangladesh). It is interesting to note that in China, curative medicine takes up about 90”” of the time of barefoot doctors, and drugs and traditional medicines may consume two-thirds of overall health expenditure [28]. There is clearly a danger that the demands of curative care may hamper preventive and promotive activities. On the other hand. PHC workers may lack status and thus influence in comparison with traditional practitioners, a problem encountered in. for instance, Upper Volta [13]. Yet even if they, possess the status, they may not possess the commitment necessary to ensure the active promotion of disease control, or family planning, when their activities are so numerous and their role ill-defined [ 181.

The debate on the effectiveness of PHC is still unresolved. with some observers pointing to the

effectiveness of particular programmes [21] and others remaining sceptical in view of the uncertainty sur- rounding the nature of the link between programme inputs and health impact, and the extent to which the experience of small projects is capable of transference to national programmes. An important factor here is the organisational capabilities of countries. As WHO has recognised, PHC requires extensive back-up from the rest of the health system, regular supervision, and assured drug supplies. Yet this has often not been forthcoming in the past for the more limited network of basic health services.

Organisational considerations have led O’Connor. from his experiences in Afghanistan, to argue strongly against integration [2]. He concluded that those health programmes that have had any success in affecting levels of health in the rural areas have had at the least training and supervision organised vertically and provided from Regional or national levels rather than from the basic health services, even if their activities were integrated into health centres. This was true, for instance, of dai training and a village health worker programme. while smallpox, malaria and mass immunisation programmes were entirely vertical opera- tions. The advantage of vertical programmes was that workers could have clear. discrete tasks, morale and enthusiasm could be sustained more easily and stores and supplies organised more efficiently.

Cost considerations

In devising alternative strategies, cost considerations need to be taken into account in two different ways. Firstly, the total costs of a programme determine what proportion of national resources is needed to attain a given objective, and whether this is feasible. Secondly, methods of economic evaluation can help planners decide whether a particular objective is worth attaining (cost-benefit analysis) or determine the best way to attain a’ given objective (cost-effectiveness analysis). In theory, therefore, the problem of whether to adopt a vertical or horizontal approach to tackling a particular health problem can be defined in terms of which is the most cost-effective approach, given available technologies. In practice. the economist faces a number of difficulties in applying this technique [29], only a few of which can be discussed here.

Firstly, in order to compare the effects of different programmes on mortality and morbidity, these measures need to be expressed in a common form and quantified. Many studies simplify this, by using either number of deaths or cases averted and ignoring other aspects of impact. Moreover, using such measures demands that the link between intervention and health impact besusceptible at the least to a reliable prediction. Where this connection is vague. studies may use indicators that are more measures of activities or quantity of services provided, such as number of vaccinated children.

Secondly. these problems are usually minimised where the choice is between different ways of tackling one disease (for instance by chemotherapy or vector control) and at their greatest where the cost- effectiveness of a variety of interventions, attacking a number of health problems. is being investigated.

1916 ANNE MILLS

This is seen most acutely in attempts to assess the cost- effectiveness of PHC. where in the first place knowledge of its health impact is incomplete, and in the second place, PHC is likely to have a number of different effects, not all of which can be quantified, or put into comparable measures. Thus a cost-benefit analysis of three methods of tackling xerophthalmia in the Philippines, which looked at the comparative costs and benefits of two different methods of Vitamin A supplementation and of a public health programme, found that the public health intervention using paraprofessionals was most expensive, but would probably have both other beneficial effects on health and a long-term impact, even if the programme were to cease. Thus comparisons of the three intervention methods were complicated by differences in the nature of their benefits [30]. In contrast, the development of epidemiological models for a number of tropical diseases means that the effectiveness of different intervention methods aimed at a single disease can be simulated with some degree of accuracy [3 I].

Thirdly, the measurement of programme costs needs considerably more attention than it has received in the past. As illustrated in the following section, a number of studies of different interventions have used largely hypothetical costs in their calculations, and very few have looked at the cost implications of organising a programme in different ways (the Philippines study referred to above being one of the few exceptions). Furthermore, few have taken account of social costs (as opposed to private costs to the programme agency) although different interventions and strategies of delivery might be expected to have different implications for individual, household and community expenditures. Finally, studies of the cost-effectiveness of alternative technologies or strategies need to recognise that they are not implemented in countries where no services exist, but rather that they may be able to build on any infrastructure already in existence. Thus the cost of, for instance, a new vaccination programme will need to compare the cost of adding on that activity to any existing horizontal units (and extending them if necessary) vs alternative methods of delivery. Costs will necessarily be specific to the particular circumstances of countries.

The importance of cost analysis has been underlined by the work of Grosse et al. in investigating the costs and effectiveness of alternative strategies for improving mortality and disability rates in rural Java [32]. Sensitivity analysis of the robustness of their conclus- ions to changes in their variables indicated that while the results were usually robust to uncertainty or variations in the underlying epidemiological data (attack rates and case fatality rates), the relative ranking of programmes was considerably affected by variations in estimates of their costs (and of the effect of specific interventions).

In order to investigate these economic issues in more depth, the following section looks at work that has been done firstly on the costs of the control of malaria, secondly on incorporating economic considerations into epidemiological models, and thirdly on the delivery of immunisations, to see what information is available on the way in which such control activities and health programmes can be organised in order to minimise costs and maximise effectiveness.

THE ORGANISATION OF SERVICES FOR

SELECTED DISEASES AUD .ACTIVITIES

Malaria

The importance of the involvement of general health services in malaria control activities. and the relative capabilities of general health services and mass campaigns have been well recognised [33]. Despite the scale of the malaria problem in Africa. or perhaps because of it. there have been no full scale malaria eradication programmes on the African mainland. but only pilot projects of different control methods. As in other parts of the world, opinions are changing on the most appropriate means of control. For Instance. a recent paper has pointed out that during the last 20 years, technical and financial constraints have considerably reduced the use of residual insecticides for the control of malaria in tropical Africa and argued that the extension of mass chemotherapy is the only feasible means of control in most countries [34]. A primary health care system is potentially an ideal vehicle for mass chemotherapy, if a sufficiently high coverage of the population can be achieved. and drug supplies assured. However, it is clear that there are also dangers with mass chemotherapy which require that control of the use of the drugs and surveillance of possible resistance be maintained.

This very brief mention of techniques serves to indicate that choices of intervention method and delivery strategy do exist for malaria. However. while malaria control and eradication have been the subject of a number of economic studies in other parts of the world, it is notable that virtually all of them concentrate on prospective or retrospective assessment of the benefits, and very few look at the costs of programmes (see Prescott [35] for an extensive review of such studies). Moreover, the studies usually ignore issues of thechoiceofcontrol technique and of the scale ofopera- tions. A recent survey of research has pointed out that investigation of organisational patterns for malaria control is also rare[36]. It is difficult to hnd examples of studies where epidemiologists and economists have worked together, looking at the costs and benefits of alternative methods and scale of control, in contrast to an economic element being added to an already conceived control programme. The potential for such an approach is indicated by a study of schistosomiasis control which developed a model to predict the impact of water resource projects on schistosomiasis transmission [37]. This was then used to compare the costs and effectiveness of different control strategies. While potentially a very useful method. knowledge of the epidemiology of schistosomiasis is still too limited to predict with reasonable certainty the effect of control measures, and thus the most cost-elective intervention methods [24].

Epidemiological models

In general, the development of epidemiological models of diseases and their linking with cost-benefit and cost-effectiveness calculations represent an important advance in determining the most appropriate means of disease control. Epidemiological models attempt to set up a system whose behaviour resembles the natural course of a disease [31]. They can be used to simulate the natural evolution of an epidemic or

Vertical vs horikntal health programmes in Africa 1977

endemic situation, and the effect of interventions on transmission and thus on the incidence of the disease (as in the schistosomiasis model discussed above). The costs of different intervention methods can be included in the models, and the information the models provide on the impact of methods can be used to assess the benefits.

Cvjetanovic EI a/. have set up models and explored cost-benefit and cost-effectiveness for a number of acute bacterial diseases [31]. Their cost data is illus- trative. and represents the cost to the government only. For instance, estimation of the costs of the strategies of immunisation and latrine construction for the control of typhoid fever leads to a misleadingly low cost for latrines. because the cost to the individual of materials and labour is excluded. Moreover, benefits are defined as savings in treatment costs to the govem- ment and exclude, for instance, the value of lives saved.

The most .elaborate application of this type of approach has been undertaken for tuberculosis control [38]. Alternative strategies were defined for TB control, such as case-finding. prevention, treatment etc., and the resource requirements for each were calculated. A resource allocation model was then used to determine the levels at which different activities should be implemented, given available resources, in order to maximise benefits (specified in various ways such as lives saved and disability reduced). Data from Korea was used to demonstrate the model but the authors recognised that it needed further development to be a practical planning device.

While the detail of such approaches can be challenged they do potentially provide a useful way of assessing which are the most cost-effective strategies and in the context of a particular country, could indicate how best to tackle a given health problem.

Immunisation represents an activity where there has been rather more investigation of the most efficient mode of delivery than for some of the activities discussed above. One advantage that immunisation has over some other preventive interventions is that it is a technical intervention which for success doesnot rely on changing people’s behaviour or their environment. It has also been organised in the past in different ways, ranging from national immunisation teams, through District teams. to total integration in basic health services.

The success of immunisation as a disease control activity capable of reducing transmission is dependent on achieving a sufficiently high coverage of susceptible individuals with an effecttve vaccine. Achieving adequate coverage has proved difficult for mass campaigns to sustain after the initial attack phase [39]. For instance. an evaluation of a measles-smallpox campaign in the Ivory Coast. where mobile vaccination teams visited each village every 12-18 months, showed 54”,, coverage of children 6-24 months. Poor publicity \vas considered the main problem here [40]. A measles campaign in Senegal achieved about 607, coverage [4l]. and a mobile mass campaign in Yaounde was highly effectivae for smallpox, but achieved inadequate coverage to control measles [42].

An evaluation of this particular programme indicates the technical problems of providing an effective measles

vaccine [43]. 60% of children vaccinated were already immune because immunisation occurred after an epidemic; only 51”/, of the target population received vaccination because of poor attendance and errors in selecting children to be vaccinated; the sero-conversion rate was only 40%. probably because of suboptimal vaccine and deterioration in storage as a result of heat and delays in utilisation. Indeed, the maintenance of a cold chain represents one of the major problems. especially for measles vaccination [44].

A new strategy of delivery was devised in Yaounde to increase coverage by a campaign that focused on maintenance rather than intermittent mass campaigns [45]. It also combined the advantages of a vertical, mass campaign, where staff could be trained to do selective tasks well, methods of mass vaccination could be used for economy and speed, and technical control of quality could be maintained, with those of a fixed centre where vaccination could be integrated with maternal and child health care, and children brought at the optimal age. The strategy adopted was for a mobile team to visit static centres at regular intervals. Coverage, however, was disappointing, and the cost relatively high in relation to per capita health expenditure in Africa.

Another strategy for the delivery of vaccinations employed in a number of countries is that of vaccinations in a fixed centre. with outreach activities where necessary to increase coverage. A study in Thailand shows that such a strategy can achieve high coverage of DPT and BCG (461.

While the trend of immunisation strategies is generally towards their incorporation in basic health services whenever possible, two cautionary points can be made. Firstly, a recent study on oral polio vaccine indicated that the protective effects of vaccination are likely to be greatest when large groups are vaccinated in a short time because the vaccine virus infection appears to spread amongst the community for a while and enhances the overall infection rate [47]. Such spreadis likely to be minimal with sporadic vaccination. Secondly, new immunisation strategies may be developed which are more selective than mass immunisation. For instance the surveillance and containment approach of the later stages of the smallpox campaign has been suggested for measles ’ (481 and has organisational implications. In addition, if mass immunisation leads to a decline in the incidence of certain diseases, alternative strategies may become most cost- effective [49].

It is thus clear that health planners wishing to introduce or expand immunisation face choices on the mode of delivery. Mass campaigns can be used. or separate mobile units visiting static centres, or static centres can immunise at the centre and/or through intermittent or regular mobile clinics. Thus immunisation can be integrated to differing degrees with basic health services. Clearly no one mode guarantees that an effective vaccination is delivered. However, such choices are susceptible to economic evaluation to determine the most cost-effective mode of delivery in the circumstances of a particular country.

A considerable amount of work has already been done. sponsored by the Expanded Programme on Immunisation, on its economic aspects [50, 511. and a costing manual has been produced, to help managers

1978 ANNE MILLS

make the sort of decisions discussed here [52]. An economic study of the EPI was carried out in two districts in Thailand which provided the opportunity to compare different immunisation strategies [46]. In one. immunisation was always available at health centres and in addition about half of the health centres provided immunisation predominantly by outreach activities: in the other, immunisations weregiven in two mobile campaigns each year. The study found that the more children vaccinated by a health unit, the lower was the cost per fully immunised child because fixed costs accounted for a large proportion of total costs. Health centres appeared to be offering immunisation to populations of sub-optimal size from the viewpoint of economic efficiency and it was concluded that potential savings might be available from organising immunisation (and other outreach activities) on a district basis. Such arrangements would economise on the fixed costs of buildings, refrigerators, motor cycles and supervision.

In contrast, a study of MCH services in Kenya, which included a brief analysis of costs, concluded that in areas of medium population density it was cheaper to immunise children through static health units than through mobile teams in mass campaigns [14]. Thecost estimates used, however, were not strictly comparable, the estimates of the cost at fixed centres omitting immunisation’s share of capital costs and depreciation.

It is thus apparent that under certain circumstances, and particularly depending on population density and utilisation rates, a vertical, limited activity campaign organisedon a district, or even regional basis may be the most efficient way of delivering immunisations. It may also be the only one where vaccine effectiveness cannot be maintained in basic health centres. Unfor- tunately, other economic studies of immunisation have not explored the implications of different delivery patterns for covering the same geographical area, but rather have costed one particular pattern [53, 541. The study by Ponnighaus [53], however, indicates that vaccinating against measles by mobile campaign from the District hospital in a rural area of Zambia was considerably more expensive than vaccinating from a fixed centre in the nearby town. (Using rural dispensaries to deliver measles was ruled out because it was considered impossible to maintain a cold chain.) How- ever. the delivery of only one vaccine was considered; studies elsewhere have shown that the incremental costs of adding a new vaccine to an existing programme is less than the initial cost of setting up the programme

[551. In summary, there is very little evidence of the

relative costs of different strategies for health interventions, or of adopting a vertical or horizontal pattern for, for instance, disease control activities or immunisation. While there are good reasons for assuming that adding on activities to an existing infrastructure should be cheaper than setting up a limited purpose campaign (where such a choice is technically feasible), any con- clusions will depend on such factors as population density, accessibility, utilisation rates, and available technologies.

This section has discussed the cost-effectiveness of different delivery strategies and organisational patterns. There is also the issue, however. of total costs.

Can all countries afford the extension of a horizontal programme; that is primary health care, to their entire populations or can selected activities only be afforded? In other words, not only relative costs but also absolute costs may influence planning. This issue is considered further in the next section.

THE COST OF PRIMARY HEALTH CARE

If the extension of primary health care to whole populations is to be the overriding ,objective of international and national health pohcies. what prospect is there of this being financially feasible? A number of estimates are available, based on reported costs of ‘successful’ programmes [3], on best guesses of the likely per capita cost [l] and on extrapolations based on thecost ofdrugs and supplies for specified conditions [28]. These estimates, however, consider only the cost of primary health care activities at the periphery: the necessary infrastructure for referrals and support is usually excluded, sometimes on the assumption that it already exists. Indeed, two studies argue that there is considerable potential to finance primary health care by shifting resources from existing patterns of expenditure without increasing overall government health expenditure [21] and by tapping private health expenditure on, for instance, traditional practitioners. or on transport to far-off health centres which will be replaced by primary health care close at hand [56].

Whether the political circumstances of countries or the preferences of individuals will permit such a trans- fer is, however, questionable. Moreover, the prospects for growth in GNP per capita in low income countries in the next decade are not good. The World Bank has estimated an increase of the order of only 0.7-1.8’,,, and even possibly a reduction in per capita income in sub-Saharan countries [57]. Therefore the prospects for financing primary health care in these countries cannot be optimistic, as the World Bank has recognised [58].

Two further studies are worth mention for their attempts to assess the cost of extending health care to whole populations. One of them. similar to those mentioned above in its international focus on aggregate, rather than country Specific costs. estimates the cost of attaining an infant mortality rate of 50/1000 by assessing what level of inputs. for health services, water supply, excreta disposal and education is associ- ated with the level of GNP per capita which, on an international scale, corresponds with the target IMR [59]. Such calculations can be used to estimate the volume of inputs needed to attain the target IMR by the year 2000. A clear conclusion is that the poorest countries of sub-Saharan Africa and Asia will find it very difficult to finance the recurrent costs of health development, although capital costs could probably be financed with external assistance.

The second study is exceptional in that it looks at the costs of achieving ‘health for all’ in the circumstances of one particular country, Upper Volta [l3]. Upper Volta is one of the poorest countries in Africa. with a per capita GNP in 1977 of $130, a negative real growth rate per annum between 1970 and I977 of ~~ I”;,, and annual government health expenditure of about $1 per capita. The existing health service network is inadequate, and severely handicapped by chronic shortagesofdrugs, materials and transport. In contrast

Vertical vs horizontal health programmes in Africa 1979

the traditional medicine sector is very strong, and the primary health care worker not always respected by the community.

A projection of the costs of providing ‘health for all’, in terms of setting up a basic infrastructure of health facilities and hospitals by 1990, implied a 5.5 timesincreasein recurrentcosts,anda4.6 increasein per capita recurrent costs. The primary care programme took up only I .7”;, of the total development (capital and new recurrent) cost. This however is misleading the author argues, since a crucial condition for its survival is a functioning basic health care system, technical and organisational help and practical support in preventive and promotive measures. Moreover, the rural population expect the provision of certain hospital services.

While such estimates may represent more of a con- ventional approach to a health care delivery system than PHC is intended to be, it does emphasise the difficult choices that the poorest countries of Africa face. PHC can be made to appear more economical than it actually is, firstly by neglecting the costs of supervision. support and referral, and secondly by assumine that countries can avoid the costs of a health service mfrastructure where this does not already exist. Moreover. in this study as in others, PHC activities appear inexpensive partly because only costs that fall on the government are counted. Costing of PHC programmes should take account of the opportunity cost of all inputs. including volunteer labour. materials for construction, and voluntary health workers; of hidden costs to the community, for instance profit made by the health worker on the sale of drugs: and of the costs of high turnover resulting from the use of volunteer workers.

CONCLUDING REMARKS

Concern on the cost and complexity of primary health care has led Walsh and Warren to propose ‘selective primary health care’ based on the ‘categorical model’, i.e. the vertical, selective system of disease control [3]. However. they propose such a model not for one disease but for prevention and treatment of a group of diseases through immunisation. chloroquine for small children. and oral rehydration. Such services would be provided either by fixed or mobile units, depending on resource availability.

Such a proposal brings back the debate of horizontal vs vertical programmes, which shows no sign of dis- appearing [60. 611. This paper has argued that this debate can be made rather more informed firstly by a consideration of available technologies and the methods of delivery to which they are most suited, secondly by a consideration of their effectiveness and the organisational feasibility of different strategies of delivery, and finally. by investigation of the total costs and cost-effectiveness of different methods of delivery of health activities.

These are still those who argue that discoveries of new technologies in the foreseeable future may make disease eradication by vertical campaigns aimed at single conditions worthwhile [62. 631. However, it is clearly important that such programmes should not repeat the experience of the onchocerciasis control project. where despite the success of the programme in reducing transmission. an anticipated time-limited

commitment has turned into continuing high expenditure.

Moreover, given the limited resources at the disposal of governments, limited purpose campaigns should not absorb a very large proportion of total health expenditure, and pre-empt even a minimal horizontal approach. However, it nonetheless may be the case that the vertical pattern, whether organised as a district, regional or national programme and aimed at controlling diseases or providing a limited number of health activities, may under certain circumstances be a cost-effective means of delivery. The most difficult choices will be faced by those countries with poor health delivery systems and few resources, for whom there are likely to be no easy answers to tackling their major health problems.

In conclusion, considerably more attention needs to be given to organisational considerations. While the literature goes into detail on what activities should be undertaken, the ways in which the delivery of services can be organised, and especially their cost implications, are neglected. Those studies that have estimated costs have done so on the basis of limited information, heroic extrapolations from data up to ten or twenty yearsold, and even from different continents. What is badly needed are detailed cost analyses of the total costs of different programmes, vertical as well as horizontal, and analyses of their cost-effectiveness.

Acknowledgemenfs-The author would like to acknow- ledge the assistance she has received in drafting this paper from her colleagues at the Evaluation and Planning Centre. and particularly from Godfrey Walker.

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Vertical vs horizontal health programmes in Africa: Idealism, pragmatism, resources and efficiency