From polarisation to practice: puzzles and insights on integrated approaches from public health professionals

Much of the debate in the global health literature about vertical and horizontal programmatic approaches, between narrowly targeted interventions and those providing broader system-wide support, has taken place at the global level. Based on a comparative case study of international donors in the health sector in Peru that varied in their vertical-horizontal orientation, this article examines the extent to which health care practitioners and national policy-makers perceive and attempt to reconcile the tension between these approaches. Informants readily identified advantages and disadvantages of both approaches, but did not perceive a marked vertical-horizontal division, suggesting that tensions appear to be less pronounced in practice than academic debates suggest. A clear consensus did not emerge, and although more people spoke of a mixed approached, they too puzzled over how best to balance trade-offs. In practice, there were examples of more integrated approaches, targeted aspects of horizontal programmes and system-strengthening elements of vertical programmes; however, they were not explicitly identified as such. Practitioner perspectives reinforced the diverse and dynamic nature of disease, both epidemics and country profiles, and suggest that focusing on periods of transition and points of integration may be a fruitful path forward.