There is much discussion about the extent to which the volume of these additional funds creates multiple effects that positively and/or negatively impact both health systems and health outcomes for specific diseases. Assessing the direct impact of GHIs on specific diseases and health systems poses challenges pertaining to the issue of attributing particular effects to individual GHIs.[1] As such, a common response in evaluations of GHIs is to acknowledge the inherent limitations of establishing causal chains in what is a highly complex public health environment, and to base conclusions on adequacy statements resulting from trends that demonstrate substantial growth in process and impact indicators.[10]