Pakistan has received more than $20 billion in external development assistance but has made little evident improvement in its social indicators. So Much Aid, So Little Development offers a fresh explanation for this outcome.

The author, Samia Altaf, a physician and public health specialist, follows one major initiative, the Social Action Program developed by the Pakistani government in 1992 and funded by the World Bank to the tune of hundreds of millions of dollars. In an engrossing account that reads almost like a novel, at times hilarious, at others heartbreaking, she tells the story of the program’s shortcomings through a series of eyewitness vignettes. She begins with planning meetings in Islamabad, moves through layer after layer of the Pakistani bureaucracy down to the village health trainee, and then returns to Washington for the evaluation. At every stage, she finds skewed incentives, misplaced priorities, and inappropriate designs diverting the project from its original intentions and ambitions. In the process, Altaf introduces into the development conversation the human dimension that most frameworks have neglected to their detriment.

Samia Altaf, a physician and public health specialist, was formerly the senior advisor to the Office of Health in the USAID Mission in Islamabad, Pakistan. She was the 2007 Pakistan Scholar at the Woodrow Wilson Center.



Introduction: Why This Story Needs to Be Told

1. Meeting Lucymemsahib and Starting Our Project

2. The Organization of Our Project

3. The Pakistan Nursing Council: A Dead End

4. The Allama Iqbal Open University’s Bureau of University Extensions and Special Programs

5 The Women’s Division: A Brief Encounter of the Worst Kind

6. The Population Welfare Division: To Be or Not to Be…

7. Regional Training Institutes and Other Such Things

8. A Day in the Life of a Provincial Health Department

9. The UNICEF and UNDP Workshop and the Sindh SAP Proposal

10. The Punjab Proposal and the Firing of the Learned Dr. Sahiba: …And That’s the Way It Is…

11. The Immunization Program in the North-West Frontier Province

12. Bank’s World: Witches’ Oil and Lizards’ Tails

13. Packed, Sealed, and Delivered: Our Project Is Finished—in More Ways Than One

Epilogue: The Beat Goes On…


“This book highlights the well-documented problems with foreign assistance from within the system. It is a must-read for anyone working in development.”—Regional Studies

“Samia Altaf gives you hilarious accounts of how advisors from overseas go about implementing their ‘projects.’ How many at the World Bank, IMF and WHO have read this account of how aid actually works? How many high level bureaucrats with policy making powers at these agencies, will make the effort, or learn from these observations?”—Dawn, the leading English-language newspaper in Pakistan

“A must-read for anyone working in development.”—Claudia R. Williamson, Regional Studies

“Insightful and highly readable narrative.”—New Internationalist

“An engrossing account, at times hilarious, at others heartbreaking.”—Steve Goddard, History Wire - Where the Past Comes Alive

“This is a remarkable book. The author draws on her long experience in working on development programs in Pakistan to illuminate some of the major problems in the symbiotic relationships between providers of development assistance and the governments that receive the assistance.”—John W. Sewell, former president of the Overseas Development Council