{
  "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.\n\nMethods: 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.\n\nFindings: 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).\n\nInterpretation: 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%).",
  "abstract_shown": true,
  "affiliations": [
    "Department of Development Studies, Nabakrushna Choudhury Centre for Development Studies, Bhubaneswar, India"
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 1,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Mayadhar Sethy"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/44c5d4n53tccp.bib",
  "cited_by": 0,
  "doi": "10.3389/fgwh.2026.1894105",
  "fulltext_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC13731282/",
  "id": "44c5d4n53tccp",
  "issns": [
    "2673-5059"
  ],
  "landing_url": "https://doi.org/10.3389/fgwh.2026.1894105",
  "language": "en",
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "heading",
      "Original Research"
    ],
    [
      "openalex",
      "2739|Healthcare Systems and Reforms"
    ]
  ],
  "openalex": "W7223122818",
  "pdf_url": "https://www.frontiersin.org/journals/global-womens-health/articles/10.3389/fgwh.2026.1894105/pdf",
  "pmcid": "PMC13731282",
  "pmid": "42984594",
  "published": "2026-10-21",
  "publisher": "Frontiers Media SA",
  "ris": "https://research.draconitic.com/paper/44c5d4n53tccp.ris",
  "sources": [
    {
      "first_seen": "2026-11-08T12:21:30Z",
      "native_id": "PMC13731282",
      "source": "pmc",
      "url": "https://doi.org/10.3389/fgwh.2026.1894105"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2739|Healthcare Systems and Reforms",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "Why women’s health financing collapses when donors retreat and interest payments rise",
  "title_text": "Why women’s health financing collapses when donors retreat and interest payments rise",
  "type": "peer-reviewed",
  "updated_at": "2026-11-08T12:21:30Z",
  "url": "https://research.draconitic.com/paper/44c5d4n53tccp",
  "venue": "Frontiers in Global Women's Health",
  "versions": []
}