Low-income and middle-income countries (LMICs) are facing an urgent and complex challenge: how to transition to greater self-sustainability in health financing amid declining donor support. While this shift is inevitable, the policy responses it elicits carry significant implications for health system equity and access. This commentary highlights four policy choices increasingly observed in LMICs that we 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. We 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. We 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.
Barasa et al. (2025) studied this question.