The steep global gradient between rich highly developed countries (HDL) and the poor least developed countries (LDC) is well known. With a few exceptions the low GDP per capita goes hand in hand with limited access to food and water, low housing standards, incomplete educational coverage, high levels of (hidden) unemployment and high emigration. Not surprisingly also limited access to and low quality of health care services and population health measured as (healthy) life expectancy are running in parallel. Aid to developing countries is therefore perceived as a moral obligation, which however more often is declared in speeches and resolutions than in deeds. A target of 0.7 percent of the GDP of economically developed countries for Official Development Assistance (ODA) has been first pledged 35 years ago but never been reached by the big donor countries. However, private foundations and NGOs shift the paradigm of global health aid away from governments and agencies like the World Bank and the United Nations and make up by now a large piece of health assistance. Although Development Assistance for Health (DAH) has quadrupled since 1990 for the last decade obviously it has not been given according to the highest disease burdens. One of the obvious reasons for imbalances is the extreme fragmentation and therefore ineffectiveness of international: Globally: 280 agencies, 242 multilateral funds, 24 Development Banks, 40 UN Organisations, and thousands of NGOs can be identified. For under-resourced ministries in developing countries, the transaction costs can be unbearably high and reduce the value of the aid they receive to almost none. Furthermore the temptation to accept international aid without conditions on the side of the beneficiary often disrupts national priorities as is the case if money comes too easily as in some EU funded programmes. Loans for example of the World Bank - though at low interest rates – often put an underestimated burden on later years. Finally it seems that the Paris indicators for aid effectiveness (2005) with a few exceptions have not been reached sofar, i.e. up to 2010. New indicators are expected from the Busan High Level Forum on Aid Effectiveness (end of 2011).