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Development aid for health increased dramatically during the past two decades, raising concerns about inefficiency and lack of coherence among the growing number of global health donors. However, we lack a framework for how donor proliferation affects health program performance to inform theory-based evaluation of aid effectiveness policies. A review of academic and gray literature was conducted. Data were extracted from the literature sample on study design and evidence for hypothesized effects of donor proliferation on health program performance, which were iteratively grouped into categories and mapped into a new conceptual framework. In the framework, increases in the number of donors are hypothesized to increase inter-donor competition, transaction costs, donor poaching of recipient staff, recipient control over aid, and donor fragmentation, and to decrease donors' sense of accountability for overall development outcomes. There is mixed evidence on whether donor proliferation increases or decreases aid volume. These primary effects in turn affect donor innovation, information hoarding, and aid disbursement volatility, as well as recipient country health budget levels, human resource capacity, and corruption, and the determinants of health program performance. The net effect of donor proliferation on health will vary depending on the magnitude of the framework's competing effects in specific country settings. The conceptual framework provides a foundation for improving design of aid effectiveness practices to mitigate negative effects from donor proliferation while preserving its potential benefits., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The study objective was to identify how donors and government agencies in Vietnam responded to donor proliferation in health sector aid between 1995 and 2012. Interviews were conducted with key informants from donor agencies, central government, and civil society in Hanoi in 2012 (n = 34 interviews), identified through OECD Creditor Reporting System data, internet research, and snowball sampling. Interview transcripts were coded for key themes using the constant comparative method. Documentary materials were used in triangulation and validation of key informant accounts. The study identified a timeline of key events and key themes. The number of donors providing health sector aid to Vietnam increased sharply during the late 1990s and early 2000s, then leveled off and declined between 2008 and 2012. Reasons for donor entry included Vietnam's health needs, perceptions of health as less politically sensitive, and donor interests in facilitating market access. Reasons for donor withdrawal included Vietnam's achievement of middle-income status, the global financial crisis, and donors' shifting global priorities. Key themes included high competition among donors, strategic actions by government to increase its control over aid, and the multiplicity of government units involved with health sector aid. The study concludes that central government and donor agencies in Vietnam responded to donor proliferation in health sector aid by endorsing aid effectiveness policies but implementing these policies inconsistently in practice. Whereas previous literature has emphasized donor proliferation's transaction costs, this study finds that the benefits of a large number of less coordinated donors may outweigh the increased administrative costs under certain conditions. In Vietnam, these conditions included relatively high capacity within government, low government dependence on aid, and government interest in receiving diverse donor recommendations. Vietnam's experience of donor proliferation followed by donor withdrawal illustrates a trajectory that other countries may experience as they transition from low-to middle-income status., (Copyright © 2015 Elsevier Ltd. All rights reserved.)