A large portion of Kenya’s youth work as “Boda-Bodas,” or motorbike taxis. It’s a dangerous job that earns them around $1 a day. This was how Patrick Maina used to earn a living before his accident in 2021, when he broke his spine. Five years later, Patrick has the potential to walk again, but can’t afford the physiotherapy and other medical costs he needs to make that a reality.

Much like other African countries, Kenya has taken on massive amounts of debt and is regarded as in “debt distress” by the International Monetary Fund (IMF), the same institution that Kenya owes a portion of its debt to. Unfortunately, this gives the IMF and the World Bank, known together as the Bretton Woods institutions, substantial leverage over domestic policy.

The institutions push neoliberal policies, requiring governments to enforce harsh austerity measures that hurt the working class. Although there is little evidence that the Bretton Woods institutions directly ask governments to cut health care spending, these cuts usually are an outcome of IMF and World Bank lending. This is because the conditions attached to loans require African governments to make cuts to the public sector, or to privatize public assets, so they can allocate more money to paying off their creditors. Yet their conditions are rarely successful and typically result in more debt and poverty.

Kenya’s president, William Ruto, has recently reformed the country’s health care system in an attempt to institute a form of universal health care. However, the results are anything but universal.

The new system, called the “Social Health Authority,” or SHA, requires all Kenyans to pay into it, including people who earn less than $1 a day or can’t work. For Ruto, this shores up the budget, as the IMF requires, so that Kenya can pay back its Western creditors more quickly. However, this means many like Patrick are now forced to pay into the system, yet do not receive any health care or medical treatment in return.

“Despite being sick (PWD [person with disability]) for five years, I am required to pay Ksh. 500 per month [$4] for medical coverage, which is a bit high considering I can’t do any work,” Patrick told me over WhatsApp. “But when I get sick, no assistance from the SHA.”

On top of this, many of the public hospitals are still underfunded and lack sufficient medical equipment. Meanwhile private hospitals, some of which are funded by the World Bank, are too expensive for most Kenyans. Some hospitals, as has been reported, are even too expensive for their own doctors and nurses.

There are similarities in this system and others across Africa, the result of decades of privatization and austerity at the hands of the IMF and World Bank.

According to most analysts and historians, IMF and World Bank conditionality took a turn in the early 1980s, after oil price surges in the 1970s and the Volcker Shock in the United States led to a debt crisis in Africa. For years, and despite repeated warnings, the IMF, World Bank, and Western banks encouraged African nations to continue borrowing because interest rates were low. This was a cheap and easy source of income for these banks. However, that changed in 1983, when Paul Volcker, as head of the Federal Reserve, arbitrarily hiked interest rates. This turned Africa’s already high level of sustainable debt into a full-blown crisis.

As a result, institutions like the IMF and World Bank gained enormous leverage and used it to require strict neoliberal reforms, resulting in massive cuts to health care. Early evidence from a 1987 UNICEF study suggested that the scale and speed of public spending cuts imposed through IMF and World Bank adjustment programs contributed to harmful effects on maternal and child health.

Due to debt owed to the Bretton Woods organizations, many African nations were forced to prioritize debt servicing over essential social spending. Howard Stein, a professor of Afroamerican and African Studies at the University of Michigan, told Jacobin that the resulting “impact on health care and the poor was particularly acute.”

Stein points to a drastic decline in per capita health expenditure during the late twentieth century to illustrate this shift. He highlights that between 1976 and the 1995–2000 period, Ghana’s spending dropped from $10 to just $6 per person annually, while “Zambia [fell] from $14 to $11, and Nigeria from nearly $3 to $1.81.”

By the turn of the century, the neoliberal model had permeated nearly every facet of public health. According to Stein, the introduction of user fees in Kenyan sexually transmitted infections clinics led to a “drastic decline in attendance” just as the HIV pandemic began to accelerate. Ultimately, he argues, “there is little doubt that neoliberal health care contributed to the deterioration of the health of the population in the ’80s and ’90s, including the fall in life expectancy from fifty to forty-six years from 1980 to 2002.”

By the late 1990s and early 2000s, public opinion turned heavily against the Bretton Woods institutions, as activists called for debt relief across the developing world. This forced the IMF and World Bank to launch the Highly Indebted Poor Countries (HIPC) Initiative, in an attempt to offset the calls for total debt relief. However, in order to receive debt relief, the institutions forced countries once again to accept a slew of new and far-reaching neoliberal policies.

Due to these detrimental outcomes from their policies, the Bretton Woods institutions claimed to have reformed. However, an in-depth study of IMF-imposed conditionality by Alexandros Kentikelenis and Thomas Stubbs shows that their policies still result in cuts to health care. On top of that, their study found that “regardless of how much a government spent on health,” IMF conditionality still led to negative health consequences. This was because, the authors argue, IMF conditionality related to public health required “privatisation . . . and price liberalisation of basic needs goods.”

Their study concluded IMF conditionality had a negative effect on a range of health indicators, from “maternal mortality, under-five mortality, malaria cases, hepatitis B incidence, vaccination coverage, health worker density (nurses and midwives, physicians, and summed across cadres), deaths from poisoning, and death attributed to unsafe water sanitation, and hygiene.”

They found that IMF policies had — inadvertently — improved only one health indicator, as it pushed down “daily smoking prevalence.” This was due to the increase in taxation on everyday items, making smoking too expensive.

Patrick Maina, after his motorbike accident in 2021, needed urgent spinal surgery. However, the public hospitals near his home in Karatina, just north of Nairobi, didn’t have the equipment or staff required to perform such a surgery. So he was transported to a private hospital. In almost all Western countries, you would have had spinal surgery within twelve to twenty-four hours. However, Patrick had to wait for three weeks before his family could come up with the money just to pay for this.

“If the amount was available, the surgery would have been done immediately,” he told me. “We had to organise a fundraiser event from churches, well wishers and friends.” And this was just to raise enough money for the deposit for the surgery. On top of that, his father “had to sell his cow, a goat and also [Patrick’s] motorbike . . . to raise the amount.”

Following the surgery, Patrick was detained in the hospital for a further six months while his family found the rest of the money to cover the full cost of the surgery.

Sadly, Patrick’s story is not an anomaly. Last year, Caroline Tito was receiving treatment at Mater Hospital, a private hospital in Nairobi, when she passed away. As a result, her two sons, in college at the time, were orphaned. Upon her death, the hospital presented the sons a medical bill of Ksh. 3,315,784 (around $25,000), which they could not afford. As a result, the hospital detained their mother’s body for nearly two months, with the medical bill further accumulating every day. Eventually the High Court stepped in and ordered the release of the body.

A report from Oxfam also found another private hospital, Nairobi Women’s Hospital, “regularly imprisoned patients until their bills were paid. One newborn baby was reportedly held for at least three months, and a schoolboy for eleven months. Bodies of those who have died have been held for up to two years.” The Nairobi Women’s Hospital receives funding from the World Bank through its funding arm, the International Finance Corporation (IFC).

“From our perspective, the profit drive is taking priority over patient well-being,” Linda Oduor-Noah, health policy lead at Oxfam International, told Jacobin. “The research we and others have produced shows IFC client hospitals, particularly those funded via financial intermediaries, involved in a range of egregious practices and human rights violations, including patient detentions, overcharging or price rigging, unnecessary treatments, labor concerns, denial of emergency care, fraud and failures of corporate governance, among other concerns.”

Unfortunately, expensive private health care is common across the continent. In Morocco, the World Bank supported the creation of a private cancer hospital, which it claims “mostly benefits Morocco’s salaried middle class.” The lack of public funding for health care was a contributing factor in the “Gen-Z” protests in Morocco in 2025. With some protesters saying “We want hospitals, not stadiums.”

In Nigeria, IFC-funded hospitals have been set up in “exclusive districts of Lagos,” according to Oduor-Noah. One of these hospitals, Hygeia’s Lagoon hospitals, is “charging birthing costs that start at the equivalent of nine months’ income for the poorest 50 percent of Nigerians.”

“The World Bank’s argument is that something must be done to meet the large demand for health care, but rather than focus all efforts on improving the public health care system, they invest in expensive private hospitals.”

This system has left ordinary Africans like Patrick Maina stranded. Today he is wheelchair-bound and can barely work. He occasionally sells everyday items from the front of his house. Four years after his accident, he could have the possibility to walk again, although he cannot afford the physiotherapy sessions and other medical costs he needs to make that happen. The only hospitals that could provide this kind of care are private and extremely unaffordable.

The 2023 Oxfam report Sick Development called for the World Bank, as well as “rich country governments,” to “Stop all future direct and indirect funding from development finance institutions to for-profit private healthcare” and to “take action to remedy any harms resulting from these investments.”

“We have not seen tangible evidence of any of these changes, nor seen findings from any review,” Linda Oduor-Noah told me. “Unfortunately, despite engaging the World Bank Board, IFC, and even the Bank’s accountability mechanisms on several occasions; and despite snowballing evidence from multiple sources corroborating and adding to our findings; we find an institution that appears to have no desire to change or engage seriously with the evidence.”