The present article proposes an analysis of the USA–Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives—decentralization, fertility and disease control, and maternal and child health—may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti‐drugs, political, and economic US interests in Bolivia. Copyright © 2012 John Wiley & Sons, Ltd.