This article surveys the recent literature relating to the rationale for scaling up aid and improving its effectiveness. Modalities such as general budget support (GBS) are being introduced to increase country ownership and strengthen budget systems and domestic accountability. However, recent assessments of GBS programs and public financial management (PFM) reforms highlight a number of shortcomings which call into question the role of donors in supporting institutional change. Political economy factors are often overlooked. Moreover, in a number of countries, donors are closely involved in core policy processes, undermining their capacity to play a more constructive role. As a result, the objective of strengthening domestic accountability remains difficult to achieve.