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Ruth Wanjala, KEMRI Wellcome Trust, Kenya
BMJ Global Health commentary by Edwine Barasa, Jane Chuma, Justice Nonvignon and Olusoji O Adeyi.
LMICs are confronting a new fiscal reality in the wake of declining external assistance for health. Recent reductions in donor funding have created what has been referred to as funding cliffs. These sudden and significant drops in aid threaten the delivery of critical health services, risking the reversal of decades of progress in the fight against HIV, tuberculosis, malaria and in reproductive, maternal, newborn, child and adolescent health.
In this BMJ Global Health commentary, the authors highlight four policy choices increasingly observed in LMICs that they argue are unacceptable in the pursuit of sustainability. These include: (1) shifting the financial burden to out-of-pocket payments; (2) over-reliance on contributory health insurance schemes; (3) displacement of basic primary healthcare services; and (4) abandoning community-based service delivery in favour of facility-centric models, undermining the integrity of people-centred health systems.
The authors argue that while short-term fiscal pressures may push countries towards these decisions, they ultimately erode health gains, exacerbate inequities and threaten progress towards universal health coverage. They call on policymakers to adopt evidence-informed approaches that enhance efficiency, protect the most vulnerable, prioritise public financing and preserve the core values of inclusive and equitable health systems during this critical transition.