Smaller donors in HeaLth: Influence, Effectiveness and Development

External development assistance remains a central pillar of global health financing but is undergoing significant changes due to slowing aid growth, fiscal pressures on donor countries, and evolving multilateral dynamics. In this context, smaller bilateral donor countries are becoming more prominent within the aid landscape yet remain empirically understudied. This interdisciplinary project examines how smaller donors operate within the global health financing landscape and how variation in their institutional practices relates to health outcomes. The project investigates the relationship between donor size, aid practices and health outcomes, using a conceptual framework that combines evidence from the global aid effectiveness literature and small state theory. It tests two inter-related hypotheses: (a) smaller donors vary systematically in their aid practices, and (b) higher-quality practices among donors are associated with improved health outcomes at recipient country level, beyond funding volume. The study is structured around three Work Packages and employs a mixed-methods design drawing on publicly available datasets on development finance, aid quality and population health outcomes. Work Package 1 develops a data-driven typology of donors, empirically assessing whether donors cluster into distinct configurations of size and aid practices, and whether smaller donors occupy specific positions within this landscape. A sequential multivariate clustering approach based on size and aid practices will be used. This will lay the empirical ground for subsequent analyses in this project. Work Package 2 uses a structured comparative case study to examine why smaller donors adopt different aid practices. Two smaller donors with contrasting practice types will be selected using the WP1 donor typology to identify the underlying institutional and political mechanisms that shape aid delivery. Thematic analysis on public donor peer review assessments will be combined with semi-structured interviews conducted with a purposive sample of individuals with relevant institutional roles. Work Package 3 assesses whether variation in aid practices among smaller donors – and between smaller-donor and other donor configurations – is associated with differences in subnational health outcomes. A geo-coded panel dataset will be constructed by linking project-level aid data with subnational health and demographic indicators across low- and middle-income countries. The primary empirical strategy will be a difference-in-differences design with region and year fixed effects to assess whether regions exposed to different smaller donor practice configurations exhibit systematically different outcome trajectories. The research will provide novel empirical evidence on how aid practices among smaller donors shape global health financing and outcomes. It will hence contribute to the ongoing international debates on improving aid effectiveness in resource-constrained settings.