Correspondence Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ www.thelancet.com Vol 374 October 10, 2009 1237 The review of the effect of global health initiatives on health systems by WHO’s Maximizing Positive Synergies Collaborative Group 1 is welcome. Unfortunately, it also contains many shortcomings. First is the general lack of quality evidence. Second, data of good, moderate, and mediocre quality seem to have been treated equally in the review, including potentially biased information provided by global health initiatives themselves. Third, the paper only examines four global health initiatives and fails to consider the effects of more than 100 others. Finally, most of the findings and conclusions are lumped together instead of being specific to each initiative, leading to a set of weak and non-specific recommendations. There is therefore still little evidence on the effect of global health initiatives on health systems. There is stronger evidence that they have positively affected some health outcomes and outputs, but even here it is hard to adjust for the confounding effect of a four-fold increase in development assistance for health since 1990. 2 Nonetheless, the review is important because it points to Global health initiatives and country health systems We agree with the WHO Maximizing Positive Synergies Collaborative Group (June 20, p 2137) 1 that global health initiatives have contributed to an increase in total resources for global health. However, we question the statement that global health initiatives “have contributed to some improve- ments in health aid effectiveness, particularly in the area of predictable financing”. Data from Zambia point to little improvement in both predictability of resources and donor alignment to country financial management systems. 2 Zambian national health accounts show that an increasing proportion of resources in the health sector is unaccounted for in govern- ment budgets. In 2003, 63% of donor resources went through government mechanisms, whereas in 2006 this figure was down to 29%. Further, national health accounts show that the share of donor funds that could not be related to any health-care provider rose from 13% in 2003 to 26% in 2006. Most of these constitute funds from global health initiatives. 2 Four of us have studied the Paris Declaration in practice in three districts in Zambia. 3 On the basis of the declaration’s indicators 3, 6, 7, and 9, we measured progress of the aid effectiveness agenda. Results indicated poor predictability of global health initiative resources and low involvement of district health directors’ managers in planning for these resources. All indicators illustrated persisting problems of aid coordination. 3 We acknowledge the uniqueness of each context, but the findings from Zambia show that global health initia- tives are still struggling to align with national systems and make funding more predictable. In this case the trend was for the worse, not the better. Your Editorial of June 20 (p 2083) 1 makes valid points about the effects of global health initiatives on country health systems. 2 Many points are also applicable to other donors, such as: “misalignment [with] country health needs”, “distraction of government officials”, “the creation of expensive parallel bureaucracies to manage [donors]”, and “increased burdens on already fragile health workforces”. The channelling of large amounts of funds by global health initiatives to non-governmental organisations (NGOs) has indeed raised complex questions around accountability— and not just of NGOs to governments but of governments to their people. On the plus side is the 550 000 life-years gained across 14 African countries due to HIV interventions, 3 for which most of the external funds and urgency at the global level have come from global health initiatives. We declare that we have no conflicts of interest. *Jesper Sundewall, Collins Chansa, Göran Tomson, Birger C Forsberg, Dale Mudenda jesper.sundewall@ki.se Division of International Health, Karolinska Institutet, 17177 Stockholm, Sweden (JS, GT, BCF); Ministry of Health, Lusaka, Zambia (CC); and Department of Economics, University of Zambia, Lusaka, Zambia (DM) 1 World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet 2009; 373: 2137–69. 2 Ministry of Health. Zambia national health accounts 2003 to 2006: general accounts with HIV/AIDS, TB and Malaria sub-accounts. Final Report. Lusaka: Ministry of Health, 2009. 3 Sundewall J, Forsberg BC, Jonsson K, Chansa C, Tomson G. The Paris Declaration in practice: challenges of health-sector aid coordination at the district level in Zambia. Health Res Policy Syst 2009; 7: 14. three aspects of global health that need urgent attention. First, the inadequate funding and support for rigorous and independent studies of the effect of global health initiatives on health systems. Second, the existence of an overpopulated, fragmented, and competitive global health architecture. And third, the different and detailed health systems strengthening policies and strategies of different global health actors. The Positive Synergies review must therefore mark the beginning of a process, not the end. WHO must now take things forward. I declare that I have no conflicts of interest. David McCoy rmjddmc@ucl.ac.uk Centre for International Health and Development, University College London, London WC1N 1EH, UK 1 World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet 2009; 373: 2137–69. 2 Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 2009; 373: 2113–24. USAID