The unintended consequences of vertical health programs on health systems in lower and middle-income countries
1
Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1790
ABSTRACT
BACKGROUND:
Vertical, disease-specific interventions are widely implemented in low- and middle-income countries (LMICs) to address high-burden diseases. Despite notable disease-specific gains, these programs are often not integrated into broader health systems, triggering unintended consequences (UCs)—both favorable and adverse—that can paradoxically weaken fragile systems. As resilient health systems are essential for universal health coverage, understanding these systemic effects is critical. However, system-wide UCs remain under-examined and are inconsistently incorporated into evidence-informed decision-making.
METHODS:
This study was conducted as a desk-based, two-phase mixed-methods systematic review (MMSR). Phase 1 involved a rapid scoping review to map literature, refine search terms, and develop an analytical framework based on the WHO health system building blocks. In Phase 2, a systematic search was executed across electronic databases and institutional repositories to identify published and grey literature. Two reviewers screened records, appraised methodological quality, and extracted qualitative and quantitative data. A convergent integrative approach was used to synthesize findings into key thematic categories.
RESULTS:
There were 50 included studies from 2000-2025. Findings indicated that vertical programs frequently resulted in systemic impacts, such as skewed health worker distribution and the depletion of government funds for non-targeted services. While some favorable UCs were identified, such as strengthened surveillance and coordination, a crucial finding was that evaluators and implementers do not appear to be considering effects on the greater health system. Most evaluations remained hyper-focused on disease-specific indicators, neglecting broader system-wide synergies or potential long-term systemic harms.
CONCLUSIONS:
Identifying UCs is essential for robust decision-making. This research highlights an urgent need for a "whole-system" approach in evaluation to ensure that vertical programs contribute to sustainable health system strengthening rather than further fragmentation.
Vertical, disease-specific interventions are widely implemented in low- and middle-income countries (LMICs) to address high-burden diseases. Despite notable disease-specific gains, these programs are often not integrated into broader health systems, triggering unintended consequences (UCs)—both favorable and adverse—that can paradoxically weaken fragile systems. As resilient health systems are essential for universal health coverage, understanding these systemic effects is critical. However, system-wide UCs remain under-examined and are inconsistently incorporated into evidence-informed decision-making.
METHODS:
This study was conducted as a desk-based, two-phase mixed-methods systematic review (MMSR). Phase 1 involved a rapid scoping review to map literature, refine search terms, and develop an analytical framework based on the WHO health system building blocks. In Phase 2, a systematic search was executed across electronic databases and institutional repositories to identify published and grey literature. Two reviewers screened records, appraised methodological quality, and extracted qualitative and quantitative data. A convergent integrative approach was used to synthesize findings into key thematic categories.
RESULTS:
There were 50 included studies from 2000-2025. Findings indicated that vertical programs frequently resulted in systemic impacts, such as skewed health worker distribution and the depletion of government funds for non-targeted services. While some favorable UCs were identified, such as strengthened surveillance and coordination, a crucial finding was that evaluators and implementers do not appear to be considering effects on the greater health system. Most evaluations remained hyper-focused on disease-specific indicators, neglecting broader system-wide synergies or potential long-term systemic harms.
CONCLUSIONS:
Identifying UCs is essential for robust decision-making. This research highlights an urgent need for a "whole-system" approach in evaluation to ensure that vertical programs contribute to sustainable health system strengthening rather than further fragmentation.
| eISSN: | 2654-1459 |
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