Why politics matter: Aid effectiveness and domestic accountability in the health sector

Leni Wild, Pilar Domingo


This paper looks at the impact of different modalities of aid on domestic accountability, by focusing on the health sector in Zambia and Uganda. It examines how aid and mechanisms around aid have interacted with domestic accountability relationships, as well as with information flows between donors and governments and outwards to citizens. In particular, it compares and contrasts experiences of aid that is on budget with that which is off budget in both countries, and the implications across a range of actors and interests. It finds that aid can affect the capacity of domestic accountability actors and the scope for domestic accountability particularly where there is lack of transparency about aid.

Key findings:

  • There is a genuine need to take better account of context and of existing systems of domestic accountability when designing aid interventions. In both countries, there was evidence of a lack of attention to how different mechanisms around aid take account of and interact with domestic accountability dynamics and actors.
  • Moments of crisis can provide opportunities as well as additional challenges for domestic accountability.
  • Aid approaches which are seen as on budget and which use country systems do not always address existing domestic accountability weaknesses, whilst aid which is provided off budget and outside government planning and policy processes can reinforce existing weaknesses, and provide few incentives for strengthening domestic accountability systems.
  • Transparency and access to information remain cross-cutting issues for accountability, and are potentially key areas of linkage between domestic and mutual accountability debates. Lack of donor transparency as well as blockages in information flow between citizens and recipient governments remain key stumbling blocks to achieving greater accountability.
  • Donors’ own incentives and motivations need to be recognised as an important part of the picture.
  • Some of the mechanisms supported by the aid effectiveness agenda are not yet leading to meaningful shifts in the dynamics of domestic accountability.


  • The international community should ensure that weaknesses in domestic accountability are not exacerbated through their actions, and that the strengths are at best supported and at worst not undermined.
  • It is important to understand the different roles played by a range of accountability actors around policy and budget processes at the sectoral level. Unpacking the nature of the domestic accountability system around these cycles, and understanding where significant blockages exist and why, remain underexplored.
  • How domestic accountability systems evolve is essentially a reflection of the nature of the political system, the balance of power between different interests, and the quality and density of the institutions and processes – both formal and informal – that work to either support or undermine the prospects for the oversight and answerability of decision makers and holders of power.
  • Transparency should sit at the heart of both domestic and mutual accountability.
  • There is a need for donors to reflect on their own incentives within their aid relationships and within their own agencies. Donors’ choices regarding aid approaches can still be shaped by their own political considerations, which often trump consideration of the political context in the countries in which they operate.


Wild, L. and Domingo, P. (2012). Why politics matter: Aid effectiveness and domestic accountability in the health sector. Discussion Paper. Stockholm: International IDEA.