Influence of public external debt on government health expenditure: A mixed-methods case study of Senegal

Public external debt burdens of low- and middle-income countries have grown substantially over the past decade linked to increased borrowing. Our empirical understanding of how external official loans and their ensuing debt burden may impact government health spending at the individual country level is limited. We aimed to better understand these relationships through a case study of Senegal. We conducted a mixed-methods case study using descriptive quantitative analyses of loan, debt and health financing statistics in Senegal from 1970-2023. We also used the Framework method to thematically analyse semi-structured interview data collected between October 2019 and January 2020 from 25 key informants from government ministries, development partners, academia, civil society and hospital management in Senegal. We triangulated these data with findings from a purposive document review of reports from government websites and academic literature discussing loan and debt effects on government health expenditure in Senegal. Debt obligations resulting from external loans appear to have had a constraining effect on the government budget including for health. Development loans have however also supported the health sector directly. We found less support for an indirect benefit to the health budget through loans to other sectors, due to substantial decreases in government health expenditure out of general government expenditure from 2000-2022. Overall, our findings indicate that Senegal's debt burden has constrained government health expenditure, serving as a possible co-determinant of the regression seen on the Abuja pledge since 2000. To mitigate the negative effect of debt repayment, official external creditors should consider more flexible debt repayment timelines and exploring options for debt relief including debt-to-health swaps. Supported by debt relief, increased government priority of the health sector working toward the Abuja pledge will be necessary to make progress on universal health coverage. We encourage further country level research documenting debt impacts on health financing.