Aid agencies work in some of the most dangerous environments in the world, often facing hostility and harassment, extortion and attack.
Now a new report has detailed how aid groups in Somalia had to pay armed fighters for access to areas under their control.
This report reveals the extent that aid agencies are willing to compromise and work with groups that are considered sometimes as rebel organisations like al-Shabab, to deliver much needed humanitarian assistance and actually save lives …. [If it were not the case] more people would have died in the 2011 famine which killed about 260,000 people already.
The joint study by the Humanitarian Policy Group, the Overseas Development Institute and the Heritage Institute for Policy Studies, looked at the demands made on aid groups by al-Shabab during the 2011 famine in Somalia, which killed more than 250,000 people.
The report found that al-Shabab, considered a "terrorist" group by the US, sought to control aid agencies through a system of regulation, taxation and surveillance.
Aid groups were forced to pay as much as $10,000 to 'register' their work. They would then have to disclose project details, their budgets and even staff members' names.
They were sometimes forced to pay so-called additional 'taxes', and in many cases al-Shabab insisted on distributing aid, and kept much of it for themselves.
But is that how aid agencies survive in conflict zones?
“It is never clear cut in conflict zones. Aid agencies have to make deals and accept unpalatable conditions from all sides just to function, and at times simply to survive. That means they sometimes end up paying the ransom that armed groups demand. But the alternative is to do nothing, and see many more people suffer and die," says Al Jazeera’s Peter Greste.
Aid groups have come under fire before, for inadvertently picking sides.
Millions of dollars were sent to help Ethiopia's famine in the 1980s but critics say some money ended up in the hands of rebels who used it to buy weapons.
The al-Shabab group had set up a government, they had policies around there. They had a humanitarian coordinating office. They are acting as a local authority. And we negotiate with them.
And aid agencies were accused of getting it wrong following the Rwandan genocide, when their efforts focused on helping Hutus who had been involved in the killing of Tutsis.
Even now, concerns are being raised about Syria, where aid groups must cooperate with either the government or rebels. It can mean supplies and medicines can be used to help only certain groups.
This fine line means that aid work can be viewed with suspicion.
Agencies point to one particular case that caused immeasurable damage to their reputation in Pakistan, involving the CIA's hunt for Osama bin Laden.
In the weeks before the al-Qaeda leader was killed, the CIA told a Pakistani doctor to set up a fake vaccination scheme in the town of Abbottabad so they could try to gain access to Bin Laden's house.
When news got out it cast doubt on the integrity of aid workers in general, 200 US aid groups wrote to the CIA blaming the ploy for a polio crisis in Pakistan.
Since then at least one aid group, Save the Children, has had to pull out their staff because of concerns over their safety.
So, what are the moral consequences and implications for aid agencies operating in areas of conflict? Are aid workers being forced to pay a bigger price to carry out their work? How fine a line are they treading between cooperation and compromise?
Inside Story, with presenter Jane Dutton, discusses with guests: Abdi Aynte, director of the Heritage Institute for Policy Studies, and co-author of this latest report; Marc Dubois, executive director of Doctors Without Borders; and Richard Dowden, director at the Royal African Society.
|"These famines, particularly war-caused famines, are amazingly good opportunities for fundraising. If you [as an aid agency] can get your logo there and say we are helping out, your funds will just go through the roof ...
"I am just very suspicious about aid agencies who make huge claims for what they are doing without mentioning this dark side, the difficult side, where they know may be 20 to 30 percent or 40 percent or more perhaps is actually being siphoned off - may be spent on guns, will be spent on war - and they have to accept that. I think the only option is to be completely open about it."
Richard Dowden, director at the Royal African Society