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At a recent conference on eHealth/telemedicine in Nairobi one speaker mentioned the fact that there are many pilots running at any one time. Sometimes these pilots (within the health systems context) are duplicates of project pilots being run by other donors in the same region. Aid fragmentation is not only shrinking the size of projects but resulting in duplication and ineffectiveness in terms of impact per dollar spent. Ringfencing creates silos making it impossible for everyone to benefit from a knowledge commons and exacerbating the negative effect of shrinking aid fragments. It seems to me that even a highly fragmented aid sector could achieve great gains if the different actors collaborated better. It would mean putting aside 'monumental' ambitions and political interests which is unfortunately no mean feat. That is definitely one way aid could be delivered better. However, it does go beyond funding fragmentation and fences to funding the right sustainable projects. As Caitlin has mentioned, there are too few instances of aid recipients being asked what they need or want. The same tools commercial enterprises use to determine where new opportunities lie or what pain the market is feeling can be used to identify needs and design projects that run into less cultural problems and barriers to adoption. For instance, design thinking has shown great promise as an approach that can result in better targeting of aid money and better outcomes for all.