Inside health aid: personal reflections of a former bureaucrat

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Abstract
The health projects which are funded by national development agencies are shaped by a variety of forces arising from the agency's environment and structure. The domestic political and commercial environment ensures that an agency's aid programme conforms to the country's foreign policy and is responsive to domestic commercial interests, most notably through tied aid. Special interest groups also influence governments to change funding targets and levels, as, for example, the pro-life movement. Political considerations in developing countries tend to give sectors other than health a priority for aid funding, or to request assistance for health projects the greatest impact of which is not on the most unhealthy. A third aspect of the environment of aid agencies which affects health programmes is the current state of development theory, a new and immature field which gives little guidance on the role of health in development. Finally, the structure of the aid bureaucracy is shown to affect programming, because of the demands for accountability of aid moneys, the staffing patterns and the way in which planning is carried out. Most examples of these points are from the Canadian International Development Agency and the UK Overseas Development Agency.

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