The World Bank set out to transform health care for the poor in Africa. It drove patients deeper into poverty. - ICIJ

Jacob Njagi’s newborn son could barely breathe when he arrived in an ambulance at the emergency ward of an Avenue Group hospital in Nairobi, Kenya, in the early hours of the morning. It was June 2022 — COVID-19 cases were surging — and Njagi and his family had spent hours searching for an available bed. When they finally pulled up to the hospital in Parklands — a leafy neighborhood that felt a million miles away from the poverty around their home on the edge of the city — Njagi was exhausted. His infant, Jason, was in peril, his lungs clogged.

But Njagi said that administrators at the hospital — which is backed by the International Finance Corp. (IFC), a member of the World Bank Group that works to relieve poverty — demanded a deposit. “We had to beg them to at least give us oxygen, because the oxygen in the ambulance was almost out,” Njagi recently told the International Consortium of Investigative Journalists (ICIJ).

Admission, he learned, required a deposit of 100,000 Kenyan shillings (about $850 at the time) — more than a month’s income from the wholesale foods business he’d built. Njagi scrambled for funds, begging his sister for assistance. Her friends helped scrape together enough to cover a deposit for the baby, he said.

Nearly a week later, Jason was well enough to go home, but he had spent three days on a ventilator in the neonatal intensive care unit and needed further treatment, the doctors warned. Njagi, who is 34, was concerned that he could never pay the bill — already more than 400,000 shillings (about $3,600) — so he asked for his son to be discharged. Jason’s care had come at an almost unbearable cost: the financial stability Njagi had built for his family.

Jacob Njagi said he has “nothing left” financially after paying for lifesaving treatment for his son at an IFC-backed hospital in Nairobi, Kenya. Above: Njagi with his wife, Josephine, and their two children at their home in Wang’uru, north-east of Nairobi.

In Kenya, where only about a quarter of the population was insured in 2023, health care is scarce and often ruinously expensive. But the IFC-backed hospital that treated Njagi’s son was supposed to be different.

One of five institutions that make up the World Bank Group, the IFC’s mission is to fight poverty in developing nations by investing in the private sector, a task supported with funds from its more than 180 member countries. Its investment in Avenue Group, the company that runs the hospital where Njagi’s son was treated, was intended to advance the World Bank Group’s health care strategy, which includes helping families in the developing world avoid “poverty due to illness.”

Instead, IFC-backed, for-profit hospitals like those run by Avenue Group have destabilized the finances of families across East Africa, a year-long investigation by ICIJ has found. Avenue Group’s operator, the Evercare Group, said that its hospitals and clinics provide “access to quality care for many poor and lower income Kenyans” and that it does not make emergency care contingent on a patient’s ability to pay upfront.

Since 2009, the IFC has partnered with at least four private equity firms that have invested its money in for-profit hospitals in Kenya and Uganda. While the IFC has made public promises to improve health care for everyone, its financing for private hospitals in East Africa has instead deepened inequality. It has also contributed to the tens of millions of dollars in management fees and financial performance bonuses paid to private equity firms for their work managing investments in hospitals on behalf of the IFC and others.

In over 70 interviews, former and current doctors, nurses and executives from IFC-backed facilities in Kenya and Uganda and from the private equity firms managing them described how pressures to improve returns for investors contributed to increased treatment costs and reduced accessibility. This saddled some patients with crushing debt and diverted resources originally intended to help the poor toward making medical facilities more profitable. These accounts are supported by court records, internal corporate communications and documents, and patient records reviewed by ICIJ.

To collect unpaid bills, some of the hospitals unlawfully detained patients up to months at a time, ICIJ found. Some of these incidents were widely reported in the media and were the subject of high-profile court cases and government inquiries. But the IFC failed to prevent problematic practices from continuing at hospitals it helped finance. And the organization has continued backing private hospitals even as it has remained unclear whether the investments increase accessibility or affordability for the poor in any meaningful way.

The model was “profit before life. It was profit before health care. It was profit first,” according to one former executive who requested anonymity to discuss his experience leading a hospital in East Africa managed by an IFC-backed company. Care at some of the hospitals was so expensive that their own doctors and nurses could not afford it, ICIJ learned. In interviews about more than a dozen patients at these hospitals, their relatives and friends described how they solicited money for medical care from churches, mosques, workplaces and even their home villages, effectively draining wealth from entire communities.

It was profit before health care. It was profit first.

— former executive at an IFC-backed hospital in East Africa

The IFC did not answer detailed questions from ICIJ about allegations of patient mistreatment or aggressive efforts to collect payments at the hospitals it funds. It said that the IFC “advocates for improved financial protection for citizens,” adding that its client hospitals try to help low-income patients but people still struggle because many countries’ public health care systems aren’t sufficiently funded. The organization also said that it expects the hospitals to inform the IFC and other relevant authorities of credible allegations of wrongdoing, and that when necessary the hospitals should strengthen internal controls.

“We can and must do better in our oversight and supervision,” the IFC said in its statement, adding that, going forward, it “will not work with new clients who do not commit to — and follow — our standards, and ethical principles and practices for patient care.” Bloomberg News and the anti-poverty organization Oxfam have both also recently reported on the high cost of care and problematic practices at IFC-financed hospitals.

Evercare, Avenue Group’s operator, also said that “it is not our policy to detain patients for non-payment.” It noted the “robust financial counselling programs” and “flexible payment solutions” it provides to patients and also said it has introduced care protocols that include an express prohibition on detentions.

But the concerns shared with ICIJ about the IFC’s investments cannot be reduced to individual acts of wrongdoing; they go to the very core of the organization’s approach to investing in health care — one based on trust in private equity firms and for-profit corporations to protect the most vulnerable. Since 1999, the IFC has put more than $9 billion into backing private health care companies in countries such as Kenya and Uganda, kicking off a surge in financing from taxpayer-funded development institutions into private hospitals across the developing world. It has set the bar for other players investing in international development, promising that its health care investments will work toward “emphasizing robust health systems and ensuring accessible, affordable quality services for all.”

The IFC has delivered on part of that promise: Its financing has helped underwrite the construction or acquisition of hospitals and outpatient clinics in Africa, Asia, Latin America and the Middle East. And it has, among other things, helped providers secure loans to buy equipment and set up operating theaters that enable hospitals to offer life-saving care.

Jacob and Josephine Njagi with their two children at their home in Wang’uru, an agricultural center. Image: Micah Reddy / ICIJ

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