Accurately quantifying ecological compensation amounts is essential for alleviating the conflict between ecological conservation and economic development in the Huaihe River Basin. Using three phases of Landsat remote-sensing imagery for the Anhui and Henan sections of the basin over the period 2010-2020, ecosystem service value (ESV) is estimated using the equivalent factor method. In parallel, health loss values are quantified by integrating the potential years of life lost method, the revised human capital approach, and the morbidity and disability method, and both health losses and pollution control costs are incorporated into the accounting framework for ecological compensation. Building on the established framework, this study employs spatial autocorrelation models and the Grey Model (GM(1,1)) to investigate the historical evolutionary patterns and future developmental trends of ecological compensation. The results indicate that: (1) between 2010 and 2024, the average annual health-related damage across the basin reached 5.66 billion Yuan, with high-value clusters such as Zhengzhou and Hefei experiencing a continuous escalation in losses, while Xinyang alone recorded a significant 61.17% reduction in health damages; meanwhile, the average discrepancy between theoretical and actual environmental remediation investment was approximately 49 million Yuan, with this gap narrowing significantly after 2016. (2) Throughout the research period, Zhengzhou, Xuchang, and Luohe remained entrenched within the ecological deficit zone with their deficit scales continually expanding, whereas Kaifeng (in 2015) and Shangqiu (in 2022) sequentially surpassed the equilibrium threshold, transitioning from “ecological recipients” to “compensation payers”. (3) Ecological compensation metrics exhibit pronounced spatial clustering characteristics: in 2010, High-High (H-H) clusters were concentrated in Lu’an and Hefei, while Low-Low (L-L) clusters were limited to Zhengzhou and Xuchang; by 2016, Xinyang transitioned into an H-H cluster, while Zhoukou and Shangqiu shifted into L-L clusters; between 2016 and 2022, L-L clusters expanded into Northern Anhui Section, ultimately forming a distinct “high-in-the-south, low-in-the-north” configuration by 2024. (4) Prognostic simulations for the 2024-2034 period suggest that the basin will maintain a “stable south, declining north” trajectory, where municipalities in the Anhui section remain in the high-value recipient zone while the total compensation for the Henan section is projected to contract by 46.6%, leading to a further widening of the ecological profit-and-loss gap between the northern and southern regions of the study area.