This study modelled government and donor spending on women's health in 32 low-income and 39 lower-middle-income countries, 2018 to 2025. A fixed-effects instrumental-variable model estimated drivers of spending, and a Cox survival model projected closure of the financing gap. Median combined low-income spending rose only from US$15.90 to US$16.40 per capita, against a US$62 benchmark. A 1-point rise in debt service relative to GDP cut women's health spending 4.2%, and general health spending 1.2%. On simulated spending paths, no low-income and 23.1% of lower-middle-income countries reached 80% of benchmark by 2030. Most 2024–25 spending figures were model estimates (nowcasts), and 2030 gap closure is simulated, not observed.
Why it is interesting: It separates women's health spending from health spending overall and finds debt service is linked to sharper falls in it. It also links predicted spending to skilled birth attendance in survey data.
Abstract — the authors' own words, CC BY
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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