Post-Accra: is there space for country ownership in global health?

On 4 September 2008 the Accra Agenda for Action, which emphasised that country ownership over health must be strengthened, was agreed upon. While the Agenda for Action, which builds on the 2005 Paris Declaration, is a major step forward, there are still structural factors that impede developing country ownership in health. This paper outlines the key issues in the governance and resourcing of public health in low- and middle-income countries focusing on three major structural challenges for developing countries: the proliferation of initiatives, donor influence on priority setting and donors' lack of accountability, and the sustainability of current levels and types of external financing. How can these structural obstacles be overcome? Three avenues hold considerable promise: creating new mechanisms to hold donors to account, developing national plans and strengthening national leadership in health, and building South-South collaborative networks through bilateral, multilateral and plurilateral relations.