The Health Record
Health Sector Analysis · April 2026 · mdbreform.com
$8.4 Billion Committed to Health in Africa. 71% of Committed Resources Below Satisfactory.
Health Works Without Accountability — What the IEG Record Shows. What Health Works Must Fix.
Parminder Brar · Former World Bank Country Manager and Lead Governance Specialist · mdbreform.com · April 2026
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| 29% S+ by commitment — 29 cents on the dollar |
$5.9bn Below Satisfactory in a decade |
$1.3bn Tanzania: zero Satisfactory |
84.6% MS+ — the number the Bank reports |
The World Bank has committed $8.4 billion to 78 IEG-rated Health, Nutrition and Population projects in Sub-Saharan Africa between FY2015 and FY2026. Of this, $5.9 billion — 71 percent — went to projects that did not achieve Satisfactory development outcomes. By project count, 27 of 78 achieved Satisfactory — 34.6 percent. By commitment, only $2.4 billion of $8.4 billion went to Satisfactory projects — 29.2 percent. The commitment-weighted rate is lower because the largest health projects fail: Tanzania’s Basic Health Services ($1.062 billion, MU), Nigeria’s SOML PforR ($500 million, MS). The global HNP rate is 43.8 percent by count. South Asia achieves 46.2 percent.
The headline MS+ rate is 84.6 percent — one of the highest in the Africa portfolio. The gap between 84.6 percent (the Bank’s headline) and 29.2 percent (the commitment-weighted honest bar) is 55 percentage points. The health portfolio is where the MS+ metric does the most damage to accountability.
Health Works and the 1.5 Billion Target
The Bank’s Health Works initiative — launched in April 2024 — commits the Bank to reaching 1.5 billion people with quality, affordable health services by 2030. $27 billion global portfolio across 160 projects. Fifteen National Health Compacts launched in Tokyo, December 2025. $2 billion in co-financing with each of the Global Fund and Gavi. $410 million in philanthropic mobilisation. The Bank reports 375 million people already reached.
The Bank’s own promotional material cites Mozambique as a Health Works success — community health workers doubled from 3,380 to 8,300, household access rose from 1.7 million to 3.6 million. Mozambique’s IEG record for health in Africa: 2 projects, zero Satisfactory, $150 million. The gap between the marketing and the evaluation is the accountability problem this paper documents.
The $1.3 Billion Tanzania Question
Tanzania is the single largest health commitment in Africa at $1.3 billion — and has zero Satisfactory outcomes. The Basic Health Services Project ($1.062 billion) was rated Moderately Unsatisfactory by IEG — the largest single health project failure in Africa. The successor project improved to Moderately Satisfactory but did not reach the Satisfactory threshold. Tanzania will repay both loans in full.
Ten Countries, Zero Satisfactory
Ten countries with two or more HNP projects returned zero percent Satisfactory: Tanzania ($1.3 billion), DRC ($880 million, 3 projects), Kenya ($291 million), Burkina Faso ($189 million, 3 projects), Cameroon ($188 million), Mozambique ($150 million), Africa regional ($129 million, 3 projects), Central African Republic ($81 million), Sierra Leone ($36 million), Lesotho ($21 million). Combined: 23 projects, $3.3 billion, zero Satisfactory.
What the 2018 IEG Evaluation Found
The IEG evaluation — World Bank Group Support to Health Services: Achievements and Challenges (2018) — found that access to health services improved in 70 percent of evaluated projects but quality improved in only 46 percent. The Bank can get people to clinics. It cannot ensure that what happens inside is adequate. Health systems strengthening objectives fell from 42 percent of closed projects to 27 percent of open projects — the Bank is retreating from the hard institutional work. The health sector was the second-most-vulnerable to corruption — 191 Integrity VP cases (18 percent of all cases). IFC investee companies failed to integrate with public financing. DPF in health: zero Satisfactory on $300 million. Health worker constraints cited in only 12 percent of IEG lessons.
The Structural Finding
The Bank’s health portfolio succeeds when it does specific things — eradicate a disease, respond to an outbreak, distribute a commodity. It fails when it tries to build the systems that would allow countries to do these things for themselves. Projects with bounded operational objectives succeed (REDISSE I–III all Satisfactory, Ebola Emergency HS, Polio Eradication HS). System-strengthening projects fail at rates that have not improved in a decade. The 2009 IEG evaluation documented this. The 2018 IEG evaluation confirmed it. The design model has not changed. The 15 National Health Compacts should each carry an annex: what does the IEG record show for this country’s health portfolio, and what specifically will be different this time?
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