Why women’s health financing collapses when donors retreat and interest payments rise
- 1Department of Development Studies, Nabakrushna Choudhury Centre for Development Studies, Bhubaneswar, India
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%).
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BibTeX
@article{sethy2026womens,
title = {{Why women’s health financing collapses when donors retreat and interest payments rise}},
author = {Mayadhar Sethy},
journal = {Frontiers in Global Women's Health},
year = {2026},
month = oct,
doi = {10.3389/fgwh.2026.1894105},
url = {https://doi.org/10.3389/fgwh.2026.1894105},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Why women’s health financing collapses when donors retreat and interest payments rise
AU - Mayadhar Sethy
PY - 2026
DA - 2026/10/21
JO - Frontiers in Global Women's Health
DO - 10.3389/fgwh.2026.1894105
UR - https://doi.org/10.3389/fgwh.2026.1894105
AB - 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%).
SN - 2673-5059
ER -