International Monetary Fund and World Bank influence on domestic health financing sources: A mixed-methods case study of Senegal

Federspiel, F., Borghi, J. ORCID: https://orcid.org/0000-0002-0482-5451, Tarp Jensen, H., Mbaye, E.M., & Martinez-Alvarez, M. (2026). International Monetary Fund and World Bank influence on domestic health financing sources: A mixed-methods case study of Senegal. SSM - Health Systems 6 e100179. 10.1016/j.ssmhs.2026.100179.

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Abstract

Background
International Monetary Fund (IMF) and World Bank (WB) influence on domestic health financing has been heavily debated. In this debate, in-depth country case studies are lacking. We conducted a mixed-methods case study of IMF and WB policy recommendations and conditionality in Senegal to better understand their influence on the mix of domestic health financing sources at the country level.

Methods
We performed a purposive document review of reports from IMF, WB and government websites and academic literature from 1966 to 2024, semi-structured interviews between October 2019 and January 2020 with 25 key informants, and descriptive quantitative analysis of health financing sources from 2000 to 2022.

Results
Before 2002, IMF/WB policy recommendations and conditionalities promoted public sector austerity, health sector user fees, hospital autonomisation and private health service delivery. After 2002, more targets and safeguards were introduced to protect and increase government health spending within general public sector austerity, expand community-based health insurance, while still building the role of the private health sector. These efforts failed to achieve real-term increases in domestic government health spending between 2006 and 2019, and user fees have prevailed.

Conclusions
Instead of broad social sector spending floors at 40 % of government expenditure, a specific health expenditure floor at 10–15 % of government expenditure could support progress toward the Abuja pledge. Other policy options include a relaxation of general fiscal austerity measures and improved terms of lending to support expansion of government health spending, provided this sector receives government priority. We encourage further in-depth country-level studies into IMF/WB influence on domestic health financing.

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