The Pacific islands is one of the most aid-dependent regions in the world. This article examines developments in the delivery of foreign aid to the region since the year 2000, a period in which there has been considerable change in both the amount and way in which aid is delivered internationally. Although Pacific island countries have seen a scale-up in development assistance, it has been modest relative to that enjoyed by other developing countries. Improvement has been mixed in areas identified as a concern by the aid effectiveness agenda, with high levels of volatility and lack of predictability particularly problematic.