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Exploring Vertical and Horizontal Integration for Multiple Intervention Programs: An Overview Print E-mail

Moving Beyond the Rhetoric: Incorporating Horizontal and Vertical Integration into Multiple Intervention Programs

Speaker: Nancy Edwards

Incorporating vertical and horizontal integration into multiple intervention programs (MIPs) holds great promise for tackling pressing health issues. MIPs are comprehensive programs distinguishable by their deliberately coordinated multi-strategy and multi-level interventions. Edwards suggested that immunization, tobacco control, and injury prevention programs are testament to the success of using a set of strategies to target multiple system levels. However, while the use of multiple strategies is routine in complex programs, targeting local to global systems remains less common. Thus, understanding how to achieve and study vertical and horizontal integration was a fitting theme for this year’s symposium.

Edwards set the stage for symposium discussions by sharing her insights about vertical and horizontal integration and the challenges these approaches face. Verticality reflects a service delivery mode of thinking that considers how all levels of the system must work together to achieve objectives, often to address a specific disease. Vertical programs are effective when rapid responses and time-limited approaches are required for integration of programs into mainstream health services. The eradication of smallpox illustrates the success of a vertical approach. Horizontality refers how to work across sectors, or across departments and organizations.

Despite its merits, arguments against a vertical approach to delivery include: a limited chance for sustainability; neglect of some of the underlying determinants; negative spinoff effects for health systems and non-targeted populations; potential duplication of services; and lack of pooling of funding or resources. Horizontal approaches are similarly criticized, as discussions remain at the policy level (intersectoral action) or at the service delivery sector without attention to differing levels of jurisdiction. Edwards suggested that governance structures and funding arrangements are two key program elements that we must bear in mind as we think about the relative strengths and weaknesses of vertical and horizontal integration. This is because they tend to lock us into particular ways of working that are not necessarily intersectoral. So a question is presented: How do we work within these existing structures that cannot be easily dismantled?

The MIP framework offers a way to move forward in understanding how we might work towards vertical and horizontal integration. The success of using an intersectoral approach begins with naming the ‘problematique’ and ensuring both a vertical and horizontal view of the problem. Defining the ‘problematique’ includes considering: 1) how a health sector driven entrance to issues frames our understanding of problems; 2) how existing formalized documentation and surveillance systems may narrow definitions of problems; 3) how data on social structures and resource distribution are required to understand inequities; and 4) how health and equity impact assessments can be used to facilitate integration. At the second stage of the MIP framework, the selection of intervention options also has implications for how we can work intersectorally. Edwards suggested that selecting interventions requires consideration of organizational mandates, accountability frameworks, existing partnerships and capacities that may narrow the range of intervention options, potential policy levers, time-scales for change at different system levels, and sustainability, spread of innovations, and scaling-up strategies.

Ending the introductory session to the symposium, Edwards acknowledged the shifting state of science around population and public health and movement from understanding complex interventions to understanding complex interventions within complex adaptive systems. Moving beyond the rhetoric to incorporating horizontal and vertical integration in MIPs requires that we:

  • Purposefully extend assessment of problems beyond the health sector and across jurisdictional levels;
  • Capture the experience of those working on the front-lines and those who are experiencing inequalities;
  • Systematically examine the shorter and longer term trade-offs between horizontally-directed and vertically-oriented approaches;
  • Consider what policy levers might be used at all system levels and within a range of sectors to impact the health of populations and to reduce inequities; and
  • Build a new research agenda and funding mechanisms that fit with new directions in horizontal and vertical integration of programs.

Discussants: Barbara Riley and Bernard Lamontagne

Following Edwards’ presentation, Barbara Riley and Bernard Lamontagne offered insights about incorporating horizontal and vertical integration gained from their experiences. Riley recalled her interest in horizontal and vertical integration, which began over twenty years ago as she led the evaluation of the Heart Health Action Program in Ontario. This initiative engaged communities across the province in the development of comprehensive programs that linked a number of different sectors and crossed local, provincial, and national jurisdictions. According to Riley, by many accounts the programs had all the ingredients of success for horizontal and vertical integration. Yet, in many ways they also had the ingredients for failure. Expectations for demonstrable changes in behaviours and decreased cardiovascular disease fell short.

Since then Riley has been committed to establishing an evaluation and research approach to create realistic expectations for these programs and how they can work more effectively. As she thinks about the challenges for developing programs that involve many sectors and systems, Riley has learned that we need to develop a systems lens to guide the examination of situations and the complex forces operating at different levels and across different sectors. Riley echoed that public health does not necessarily need to lead and suggested a ‘Jujitsu’ approach whereby public health considers how to best position itself in order to strategically influence and infiltrate thinking and action across levels and systems. In closing, Riley described how a new science for public health research should not only be asking new questions and exploring new methodologies, but shifting its mindset to one that is less about proving and more about improving.

Bernard Lamontagne provided insights about horizontal and vertical integration gained through his experiences with the introduction of Local Health Integration Networks (LHINs) in Ontario. The development of a strategic plan for LHINs required and exemplified many layers of horizontal and vertical integration. Arriving at a strategic plan to improve the health of citizens, client experience with health services, and health system sustainability involved: 1) working with a number of partners across various system levels to re-conceptualize the population (inclusive of age, health conditions, and geographic location); 2) integrating ministerial and regional mission and vision statements; and 3) engaging health service providers and community of care advisories.

According to Lamontagne, a number of dis-incentives to integration persist. Physicians, primary health care, and public health are essential partners for successful integration. Yet, they are not part of LHIN funding and resistance exists to move dollars to other parts of the health system. However, improving population health, enhancing the quality and effectiveness of services, and meeting the growing demands for services are key drivers to find ways to make integration work. Lamontagne ended with a humorous but important message: ‘Ready; Aim; Fire’: We need to fire in the approximate range (be willing to experiment); then aim (give efforts a chance to fail and then improve upon), and then we will be ready to shoot for real (with forethought).

Last Updated on Sunday, 11 October 2009 22:31