摘要：Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs. Debates about vertical versus horizontal approaches to health improvement have a lengthy unresolved history in public health. 1 Vertical approaches are generally disease specific and promote targeted clinical interventions delivered by a specialized service. Horizontal approaches, by contrast, tackle several interrelated health issues by strengthening health systems and developing integrated delivery systems. 1 – 3 Despite prolonged efforts to combine vertical and horizontal approaches, vertical programs have dominated and are often found competing with one another for funds and professional recognition. 1 , 4 , 5 Authors have warned that disproportionately concentrating funds into disease-based initiatives in developing countries may compromise health systems and fragment complex interventions. 6 , 7 An increasingly popular compromise approach is to devote general health resources to a limited package of interventions prioritized on the basis of cost-effectiveness. This approach has thus far failed to enable synergy between vertical and horizontal approaches. 1 One reason for continuing tensions relates to the difficulty of producing evidence of effectiveness for evidence-based policymaking in a wide array of social, political, and health system contexts. 8 Critics claim experimental research, originally developed to assess the effect of targeted clinical interventions on a measurable outcome, is unsuitable for investigating the population-level, nonclinical, and context-specific health system domains. 9 – 12 In response, authors have begun calling for non-experimental epidemiological methods and an interdisciplinary approach. 13 – 17 Professionals in the international maternal health subfield are currently grappling with how to improve vertical and horizontal synergy. 18 – 20 This has lead to lively debate on the role of evidence production. Whereas some call for the scientific rigor of randomized controlled trails, 21 – 24 others claim that using randomized controlled trials is misplaced because of the complex health systems needs of maternal health interventions. 25 – 28 Using the subfield of maternal health as a case study, we explore 2 questions: What are the main challenges faced in bringing vertical and horizontal approaches together? What are the social and epistemological factors that constrain researchers from producing evidence for synergistic vertical and horizontal policymaking?
