Josip Car[1], Tapio Paljärvi1, Mate Car1, Ayodele Kazeem1, Azeem Majeed1, Rifat Atun[2]

Objectives By using the Global Fund as a case example, we aim to critically evaluate the evidence generated from 2002 to 2009 for potential negative health system effects of Global Health Initiatives (GHI).

Design Systematic review of research literature.

Setting Developing Countries.

Participants All interventions potentially affecting health systems that were funded by the Global Fund.

Main outcomemeasures Negative health system effects of Global Fund investments as reported by study authors.

Results We identified 24 studies commenting on adverse effects on health systems arising from Global Fund investments. Sixteen were quantitative studies, six were qualitative and two used both quantitative and qualitative methods, but none explicitly stated that the studies were originally designed to capture or to assess health system effects (positive or negative). Only seemingly anecdotal evidence or authors' perceptions/interpretations of circumstances could be extracted from the included

studies.

Conclusions This study shows that much of the currently available evidence generated between 2002 and 2009 on GHIs potential negative health system effects is not of the quality expected or needed to best serve the academic or broader community. The majority of the reviewed research did not fulfil the requirements of rigorous scientific evidence.