INTRODUCTION:
Public health systems face increasing pressure to deliver equitable and resilient outcomes under conditions of fiscal constraint, competing priorities, and recurrent shocks. Economic evidence is widely produced through costing, cost-effectiveness, and value-for-money analyses, yet its contribution to strategic public health financing decisions remains uneven. This study examines how economic evidence can support transparent prioritization and resource allocation across public health portfolios in low- and middle-income countries.

METHODS:
This analysis synthesizes findings from multi-country economic evaluations and portfolio-level assessments conducted between 2015 and 2025 across infectious disease prevention, nutrition, HIV and TB, health supply chains, and pandemic preparedness. Methods included cost-of-illness studies, program costing, allocative efficiency analysis, and synthesis of expenditure and outcome data across national and global health portfolios. Comparative case analysis was used to assess how economic evidence informed financing decisions, budget negotiations, and sustainability planning across diverse institutional and fiscal contexts.

RESULTS:
Across settings, economic evidence was most influential when it explicitly clarified trade-offs between prevention and treatment, short-term response and long-term system resilience, and efficiency and equity objectives. Portfolio-level analyses enabled decision-makers to identify key cost drivers, assess affordability, and reallocate resources toward higher-impact interventions. However, evidence use was constrained by fragmented financing structures, rigid budget classifications, and limited fiscal space, particularly in contexts experiencing donor transition or crisis-related expenditure pressures. Economic analyses that incorporated equity considerations and system-wide implications were more likely to inform prioritization decisions than narrowly defined project-level assessments.

CONCLUSIONS:
Economic evidence plays a critical role in making public health trade-offs visible and supporting more transparent, equitable, and resilient financing decisions. Strengthening the integration of economic analysis into public financial management and health system planning can enhance the capacity of public health systems to sustain preventive and equity-oriented investments under fiscal constraint.