In an era of shrinking development assistance for health, is 'spending better' a more viable strategy than 'spending more' for LMICs? Discuss.

Development Assistance for Health (DAH) peaked in 2021 and has since reversed sharply, with the OECD projecting net ODA to fall 9–17% in 2025 and health ODA by up to 40% against the 2023 baseline [1]. For LMICs facing simultaneous donor retrenchment and tight fiscal space, "spending better" is the immediate imperative — but it substitutes for higher outlays only partially.

Why 'spending better' has become the viable near-term strategy

• Donor retrenchment is structural, not cyclical: for the first time, France, Germany, the UK and the US are cutting ODA in two consecutive years, with bilateral aid to LDCs and Sub-Saharan Africa projected to fall 13–25% and 16–28% respectively [1].
• Efficiency yields quick gains: allocative shifts toward primary and preventive care, plus public financial management reform to cut leakages, expand coverage without new money.
• Concentrated donor risk: a handful of donors account for a majority of WHO and WFP funding, making aid-dependent budgets fragile [1].
• Proven domestic gains: India's out-of-pocket expenditure fell from 64.2% (2013-14) to 39.4% (2021-22) of total health spending as public provisioning and purchasing improved [2].

Why 'spending more' remains indispensable

• LMIC public health spending is around half the UHC benchmark, and the gap with high-income countries has widened over three-fold in per-capita terms even while narrowing as a share of GDP — efficiency cannot close an absolute resource deficit.
• India's own Government Health Expenditure rose from 1.13% (2014-15) to 1.84% of GDP (2021-22) [2], still short of the National Health Policy 2017 target of 2.5% by 2025 [3].
• Health systems require lumpy investment in workforce, diagnostics and pandemic preparedness that no efficiency gain can generate.

The two strategies are sequential, not rival: efficiency buys credibility and time, while domestic resource mobilisation supplies the durable base. LMICs should institutionalise outcome-linked budgeting and pooled procurement while steadily raising tax-financed health outlays toward the UHC benchmark — the surest route to SDG-3 and to health as a substantive dimension of the right to life.