The 1978 Declaration of Alma-Ata1 advocated primary health care (PHC) as the main strategy to achieve the goal of health for all.2 The principles underlying PHC systems continue to be recognised as essential to the achievement of universal health coverage (UHC).3, 4 However, the debate between advocates of comprehensive PHC approaches and those of more targeted strategies represents an ongoing challenge.5, 6 Some have argued that comprehensive PHC is too idealistic and expensive, and that UHC should be pursued with a more selective model that focuses on diseases with cost-effective interventions.7, 8
As a result, during the past two decades, there has been an increase in the number of disease control programmes (DCPs) and disease-specific global-health initiatives (GHIs) that leverage additional resources for targeted health interventions.9 Estimates suggest that The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank have contributed more than two-thirds of all development assistance for health (DAH) to prevent and control HIV/AIDS, tuberculosis, and malaria in resource-poor settings.10, 11
Since 2005, GHIs have provided Ethiopia with substantial resources to support DCPs. However, the implementation of these DCPs was soon found to be compromised by underlying weaknesses in the Ethiopian health system, and the strategy of targeted funding was found to undermine efforts to strengthen the health system.12 Criticisms have also been raised by the global health community that weak health systems hinder progress towards DCP targets and that GHIs overburden already fragile health systems.13 Acknowledging these issues, key GHIs—ie, PEPFAR, The Global Fund, and Gavi, the Vaccine Alliance (Gavi)—have collaborated with other donors to increase their financial support towards health-systems strengthening,13 in what has been called the diagonal investment approach.14, 15
A diagonal investment approach is a proactive and balanced approach that concurrently strengthens PHC systems and scales up DCPs. The diagonal investment approach addresses the requirements of specific priorities while providing opportunities for strengthening health systems.16, 17, 18 The approach has been employed in Mexico, where specific intervention priorities (such as immunisation services) were used to drive improvements to the health system.14, 15 Other resource-poor countries, such as Rwanda and Malawi, have also benefited from this approach as HIV/AIDS investments have been channelled to strengthen health systems.13, 19
Key messages
- •
Weak primary health-care (PHC) systems have hindered progress in meeting the targets of programmes in resource-poor settings
- •
Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and scale up disease control programmes (DCPs); this approach has led to increased PHC-system capacity and has improved programme coverage and health status
- •
Despite the decrease in development assistance for health, Ethiopia has sustained its financial support for health and has promoted PHC systems' capacity with increased domestic resources (such as public, private, and out-of-pocket funds)
- •
The lessons from Ethiopia have implications for future investments on DCPs so that effective, sustainable, and resilient PHC systems can be built to progressively realise universal health coverage in resource-poor settings
With this Review, we aim to present the experience of Ethiopia as a case study of how diagonal investments from key GHIs can be used to broaden funding effectiveness (ie, the degree to which the objectives of targeted and complementary health systems are achieved) and sustainability (ie, the ability to maintain achievements at the desired standard after the intervention is completed). Our manuscript combines a narrative review of both published and grey literature and a quantitative analysis of national programmes and health-account data from government offices and financial-disbursement data from GHIs.