Global intercourse.

1596 www.thelancet.com Vol 374 November 7, 2009 direct engagement with countries, and weak design and assessment mechanisms. GAVI relies on in-country WHO and UNICEF staff , both better versed in immunisation than in health systems, and the Global Fund relies on country coordinating mechanisms whose members have disease-specifi c interests, mostly HIV. Both use panels in Geneva—the Independent Review Committee (GAVI) and the Technical Review Panel (Global Fund)—to assess projects about which they know little. Whereas GAVI promotes good aid principles, the Global Fund requires complex applications and reporting, produces unpredictable funding, and weakens country planning and budgeting processes by bypassing them. Potential donors should ask how a joint funding partnership could: (1) Develop in-house technical capacity and in-country engagement to reduce risk, build capacity in countries, and resolve tensions in favour of system strengthening rather than the status quo of vertical programmes. (2) Replace “rounds-based” funding with processes supporting countries’ mechanisms and cycles, resulting in predictable funding. (3) Reduce the burden of complex application and reporting (joint assessment will not help while participants require disease-specifi c strategies too). (4) Use monitoring indicators relevant to systems strengthening rather than disease outcomes, and tailored to countries’ capacities, not to a common global framework. The case for joint funding is overwhelming. But it always has been, and it is unclear how the Global Fund particularly can do this now when it has been unable to participate eff ectively in sector-wide approaches (eg, in Mozambique). As conceived, a joint funding partnership risks doing little more than coordinating disease-specifi c funding. Although desirable, this leaves the glaring global gap of reforming the systems through which services are fi nanced, produced, and delivered— the foundations for improving health for all. Without structural reform themselves, participants in a joint funding partnership are in no position to do this.