The World Bank's internal watchdog group has given the poverty-fighting agency a mixed review for its efforts to improve health in poor countries and gave it low marks for its work in Africa.
The Independent Evaluation Group said while two-thirds of the bank's health projects between 1997 and 2007 achieved their development objectives, one-third, mostly in Africa, did not.
"Overly complicated project designs and weak government capacity contributed to low outcomes," said Martha Ainsworth, lead author of the report.
Although aiding the poor is the bank's main objective, the watchdog found that only half of the bank's support for health, nutrition and population (HNP) projects had a pro-poor focus, and fewer projects were explicitly committed to achieving better results for the poor.
"The evidence that HNP investments are reaching the poor is thin," Ms Ainsworth said.
The report also found that World Bank lending to reduce high fertility and promote family planning has dwindled, noting that in more than 30 developing countries, women have on average more than five children in their lifetime.
Bank lending to reduce malnutrition among the poor has also declined, it added.
The World Bank was once the globe's biggest financier of health projects, but its role has diminished over the past decade as new donors, including private philanthropic foundations, have emerged to fight disease around the world.
The report covers a decade of World Bank work in health sectors starting in 1997. Since then the bank has committed nearly $17 billion for projects that focus on health, nutrition and population.
Its private-sector lender, the International Financial Corp (IFC), has invested an additional $873 million in private health and pharmaceuticals sectors.
The Independent Evaluation Group attributed the problems to the "increasing complexity of (health) operations, particularly in Africa but also in health-reform support to middle-income countries, inadequate risk assessment and mitigation, and weak monitoring and evaluation."
It said investments in healthcare by IFC have improved but there are "important gaps in investing in activities that both make business sense and are likely to yield broader benefits for the poor."
The watchdog said the performance of IFC's health investments, mostly hospitals, has improved since 1999 and had good financial returns, although they have targeted wealthier income groups, contrary to the bank's mission to fight poverty.
It said accountability for results in projects has been weak and not always ensured the poorest were benefiting.
In its response, World Bank management broadly agreed with the watchdog's findings, saying the report was "consistent with the findings of the Bank's own self-assessment".
It said the bank had introduced a new health strategy in mid-2007 which sharpened its focus on results on the ground.
Emma Seery, head of essential services at development group Oxfam, questioned how the World Bank could claim to have a comparative advantage on health when many of its projects in Africa were unsatisfactory.
"If the World Bank wants to carry on having a role in health, they need to look at the evidence of what can deliver for all people, and question any increased investment in the private sector that does not reach the poorest people," Ms Seery said.
Reuters