Year: 2026
Type: article
Abstract: Background Stagnant government health expenditure (GHE) and declining development assistance for health (DAH) threaten universal health coverage (UHC) for women in low-income countries (LICs) and lower-middle-income countries (LMICs). Women's health financing remains under-resourced and vulnerable to fiscal austerity, debt distress, and donor withdrawal. This study quantifies the crowding-out effect of debt service on government expenditure for women's health (GHEW) and estimates the probability of closing women-specific UHC financing gaps under alternative donor withdrawal scenarios. Methods A balanced panel of 71 countries (32 LICs and 39 LMICs), comprising 497 country-years from 2018 to 2025, was constructed using WHO, IMF, World Bank, OECD, IHME, and DHS data. A fixed-effects instrumental-variable model estimated determinants of GHEW using lagged GHE and donor-alignment instruments (first-stage F = 41.2). A Cox survival model projected the probability of closing women's UHC financing gaps by 2030, defined as combined spending reaching ≥80% of sex-disaggregated benchmarks (US$62 for LICs and US$95 for LMICs). Projections incorporated announced donor reductions with probabilistic scenarios. Validation included out-of-sample forecasting, placebo tests, and patient-level DHS validation. Findings Median combined LIC spending increased only marginally, from US$15.90 in 2018 to US$16.40 in 2025. Each 1-percentage-point increase in debt service as a share of GDP reduced GHEW by 4.2% ( β =−0.042, p < 0.001), significantly exceeding its effect on general health expenditure ( β =−0.012, p = 0.032; difference p = 0.008). Under baseline projections, no LIC and 23.1% of LMICs were projected to close women's UHC financing gaps by 2030. Each 1% decline in DAH reduced gap-closure probability by 6.1% (HR = 0.939, p = 0.002), whereas fiscal-space expansion nearly tripled closure likelihood (HR = 2.947, p = 0.018). Patient-level validation showed that a US$10 increase in predicted spending was associated with a 4.2-percentage-point increase in skilled birth attendance (95% CI 2.8–5.6). Interpretation Debt service disproportionately crowds out women's health expenditure, highlighting gendered consequences of fiscal adjustment. Abrupt donor withdrawal makes UHC financing gaps virtually unattainable in aid-dependent LICs without domestic reprioritization. Debt-for-health swaps, phased donor transitions, and increased women's health expenditure shares are critical. Raising the women's health share by ≥2.5 percentage points could increase LIC gap-closure probability to approximately 31% by 2030 (range 22%–41%).
Author: Mayadhar Sethy
Institution: Centre For Development Studies
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,077
OpenAlex ID: W7223122818