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

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. We performed a purposive document review of reports from IMF, WB and government websites and academic literature from 1966-2024, semi-structured interviews between October 2019 and January 2020 with 25 key informants, and descriptive quantitative analysis of health financing sources from 2000-2022. 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 2006-19, and user fees have prevailed. 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. • IMF/WB influence on health financing policy in Senegal has evolved from promoting cost sharing before 2002 to expanding government health spending and community-based health insurance after 2002. • General public sector austerity and promotion of private health service delivery has however been maintained over time. • Within this mixed IMF/WB influence, domestic government health spending has not increased in real terms between 2006-19, and user fees remain the predominant source of health financing. • Broad IMF social sector spending floors have been ineffective at raising real-term government health spending levels, and a specific government health expenditure floor at 10-15% of general government expenditure could be considered.