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Development assistance for health (DAH) rose to its highest levels during the COVID-19 pandemic but has since reduced amid rising global economic uncertainty and competing fiscal demands. In early 2025, major donors including the USA and the UK announced substantial reductions in aid, prompting concerns about the future of health financing in middle-income and low-income countries. To date, no comprehensive assessment has quantified the effects of these announced cuts on overall DAH levels or its future trajectories. We estimated DAH from 1990 to 2030, drawing from a wide range of data sources including the Organisation for Economic Co-operation and Development Creditor Reporting System database, online databases of agencies such as The Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization (Gavi), and financial reports from private philanthropies and non-governmental organisations. Disbursements were categorised by source, disbursing agency, health focus area, and recipient country using standardised keyword tagging methods developed over 15 years of Institute For Health Metrics and Evaluation Financing Global Health reports. For 2025, we incorporated budget cuts announced by major donors to develop preliminary estimates. Forecasts to 2030 used donor-specific funding targets and linear regression models. Additional refinements for this iteration of our DAH tracking included expanded donor coverage and disaggregation of health areas for additional disbursing entities. DAH peaked at US$80·3 billion in 2021 and fell to $49·6 billion in 2024. In 2025, announced budget cuts—particularly reductions in US bilateral aid—are expected to contribute to further declines in global DAH to $38·4 billion, amounts last seen in 2009. Key global health institutions (eg, Foreign, Commonwealth & Development Office and US Agency for International Development and Agence Française) providing DAH for key infectious diseases and childhood vaccines will contract their own disbursements. Because these key multilateral development banks have been protected from the major funding cuts, the World Bank has increased its relative share of total DAH disbursements. Forecasts indicate continued stagnation in DAH until 2030 under current policies, reaching $36·2 billion in 2030. Our sensitivity analyses suggest that our estimate for 2025 could range from $36·8 billion in a pessimistic scenario to $40·0 billion in an optimistic scenario, based on changes in US cuts. Similarly, in the next 5 years, total DAH is expected to reach $37·8 billion in 2030 under a positive scenario for US contribution and $34·5 billion under a negative scenario for US contribution. The global health financing landscape is entering a period of sustained cuts. Major reductions in DAH, particularly from historically leading donors, threaten to widen health disparities unless mitigated by increased domestic resource mobilisation or alternative financing mechanisms. This study highlights the urgent need for greater efficiency, strategic reprioritisation, and strengthened fiscal resilience in recipient countries to safeguard the substantial global health gains of the previous three decades. Gates Foundation.

Huge reductions, if enacted, could have ‘catastrophic’ effects on US competitiveness and the scientific pipeline, critics say. Huge reductions, if enacted, could have ‘catastrophic’ effects on US competitiveness and the scientific pipeline, critics say.

Letter to the Editor

Heads spun after warnings of budget cuts of up to 40% reached Nepal’s health ministry. Attempts to balance the books reveal the fragile nature of healthcare funding in lower income countries, reports Marty Logan

This article examines how fiscal stress shaped decision-making processes in the City of East Cleveland, Ohio, one of the most persistently distressed municipalities in the United States. Drawing on theories of bounded rationality, institutional failure, and austerity urbanism, it explores why decades of oversight and recovery planning have failed to restore fiscal stability. Using qualitative analysis of audit reports, public records, and media coverage, the study reveals how limited administrative capacity, political instability, and corruption constrain local governments’ ability to implement recovery plans, even under state supervision. East Cleveland’s experience challenges staged models of municipal recovery that assume a gradual transition from austerity to pragmatic municipalism. Instead, it illustrates how small, structurally disadvantaged cities can become trapped in perpetual fiscal emergency, where procedural oversight substitutes for effective governance. After decades in fiscal emergency, East Cleveland remained without consolidation or receivership until recent state action in 2025. The case contributes to the literature on emergency financial management and institutional theory by demonstrating that the most instructive lessons may come not from best practices, but from persistent failures. It highlights what not to do when navigating fiscal stress.

PurposeTo identify the changes of school burnout for Finnish adolescents in lower (grades 8–9) and upper secondary schools (grades 10–11) during years 2006–2019; and to examine the associations of personal—(gender, family socioeconomic, and immigrant status) and school-related (school level, urban–rural area) sociodemographic demands and resources in school burnout.MethodsWe used nationally representative data on 949,347 students in secondary school in Finland between 2006 and 2019. Generalized Linear Models were used to assess the effects of year, gender, school level, parental education, unemployment, immigrant status, and urban–rural area and the interactions of year, gender, and school level with each of the remaining sociodemographic variables on school burnout.ResultsSchool burnout increased among girls and slightly declined among boys. The increase intensified in girls and the decline in boys stagnated after 2011. The educational level of the parents had a constant protective impact over time, the gradient for boys slightly larger compared to girls. Urban areas contributed to the trend of increasing school burnout among girls but not among boys. Parental unemployment and immigration background were associated with the increasing trend of school burnout over time, although somewhat mitigated by parental education.ConclusionThe results showed the trends in school burnout are often gendered and appeared to worsen aligned with the school budget cuts after 2011. In addition to considering school burnout related to lower parental education and urbanization, it is important to support those students in families experiencing unemployment and/or immigration, especially when concurring with lower parental education.