Jacob Njagi\u2019s 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 \u2014 COVID-19 cases were surging \u2014 and Njagi and his family had spent hours searching for an available bed. When they finally pulled up to the hospital in Parklands \u2014 a leafy neighborhood that felt a million miles away from the poverty around their home on the edge of the city \u2014 Njagi was exhausted. His infant, Jason, was in peril, his lungs clogged.<\/p>\n
But Njagi said that administrators at the hospital \u2014 which is backed by the International Finance Corp. (IFC), a member of the World Bank Group that works to relieve poverty \u2014 demanded a deposit. \u201cWe had to beg them to at least give us oxygen, because the oxygen in the ambulance was almost out,\u201d Njagi recently told the International Consortium of Investigative Journalists (ICIJ).<\/p>\n
Admission, he learned, required a deposit of 100,000 Kenyan shillings (about $850 at the time) \u2014 more than a month\u2019s income from the wholesale foods business he\u2019d 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.<\/p>\n
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 \u2014 already more than 400,000 shillings (about $3,600) \u2014 so he asked for his son to be discharged. Jason\u2019s care had come at an almost unbearable cost: the financial stability Njagi had built for his family.<\/p>\n
![\"\"](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Jacob-1-760x427.jpg\")
\n Jacob Njagi said he has \u201cnothing left\u201d 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\u2019uru, north-east of Nairobi. Image: Micah Reddy \/ ICIJ <\/p>\n
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\u2019s son was supposed to be different.<\/p>\n
One of five institutions that make up the World Bank Group, the IFC\u2019s 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\u2019s son was treated, was intended to advance the World Bank Group\u2019s health care strategy, which includes helping families in the developing world avoid \u201cpoverty due to illness.\u201d<\/p>\n
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\u2019s operator, the Evercare Group, said that its hospitals and clinics provide \u201caccess to quality care for many poor and lower income Kenyans\u201d and that it does not make emergency care contingent on a patient\u2019s ability to pay upfront.<\/p>\n
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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
The model was \u201cprofit before life. It was profit before health care. It was profit first,\u201d 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.<\/p>\n
\nIt was profit before health care. It was profit first.<\/strong><\/p>\n
\u2014 former executive at an IFC-backed hospital in East Africa<\/p>\n<\/blockquote>\n
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 \u201cadvocates for improved financial protection for citizens,\u201d adding that its client hospitals try to help low-income patients but people still struggle because many countries\u2019 public health care systems aren\u2019t 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.<\/p>\n
\u201cWe can and must do better in our oversight and supervision,\u201d the IFC said in its statement, adding that, going forward, it \u201cwill not work with new clients who do not commit to \u2014 and follow \u2014 our standards, and ethical principles and practices for patient care.\u201d Bloomberg News<\/a> and the anti-poverty organization Oxfam<\/a> have both also recently reported on the high cost of care and problematic practices at IFC-financed hospitals.<\/p>\n
Evercare, Avenue Group\u2019s operator, also said that \u201cit is not our policy to detain patients for non-payment.\u201d It noted the \u201crobust financial counselling programs\u201d and \u201cflexible payment solutions\u201d it provides to patients and also said it has introduced care protocols that include an express prohibition on detentions.<\/p>\n
But the concerns shared with ICIJ about the IFC\u2019s investments cannot be reduced to individual acts of wrongdoing; they go to the very core of the organization\u2019s approach to investing in health care \u2014 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 \u201cemphasizing robust health systems and ensuring accessible, affordable quality services for all.\u201d<\/p>\n
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.<\/p>\n
\n Jacob and Josephine Njagi with their two children at their home in Wang\u2019uru, an agricultural center. Image: Micah Reddy \/ ICIJ <\/p>\nFor some, however, those services have come at an almost unbearable cost. Njagi is grateful to the IFC-backed Avenue Group hospital that saved his son, but the bill put him in a financial spiral, he said. His family was homeless at one point and has at times lived with relatives, he said, adding that the strain nearly ended his marriage.<\/p>\n
Before his encounter with Avenue Group, Njagi\u2019s finances were \u201cstable,\u201d and he was \u201cable to provide,\u201d he said. But now, he works as a day laborer in the rice fields near his home \u2014 a single room with a communal toilet. Financially, he said, \u201cI have nothing left.\u201d<\/p>\n
The business of health in Africa<\/p>\n
Founded in 1956 and headquartered in Washington, D.C., the International Finance Corp. is tasked with promoting private enterprise in the developing world and with helping to create global prosperity. But in its first four decades, it largely stayed away from health care, an area that many at its parent organization, the World Bank Group, believed was better left to governments.<\/p>\n
In the 1990s, however, as a wave of enthusiasm for the privatization of government services swept the Western world, the World Bank Group reevaluated the private sector\u2019s role in providing health care. In 1997, it released a comprehensive health strategy that pledged to use its vast resources and influence to improve health outcomes for the poor and protect them from \u201cthe impoverishing effects of illness.\u201d Responding to the call, the IFC began pouring money into the health care sector, and by 2001 it had approved dozens<\/a> of projects.<\/p>\n
Still, some at the IFC weren\u2019t sure that financing private hospitals would advance its anti-poverty mandate. They worried about how patients would afford the care at these new facilities: Private hospitals \u201care less open to poor people unless there are some financial mechanisms,\u201d such as universal health coverage, to pay the costs of their care, Guy Ellena, the IFC\u2019s then-director of health and education, told a 2002 meeting of its board.<\/p>\n
\n The World Bank Group headquarters in Washington, D.C. <\/p>\nBy 2007, however, such concerns had faded. In a report titled \u201cThe Business of Health in Africa,\u201d the IFC described how investors could, through strategies like increasing patient volume, profit from hospitals tending to the continent\u2019s poor.<\/p>\n
Seeking to set an example for other investors, the IFC announced plans to launch the Africa Health Fund \u2014 a $100 million investment vehicle for \u201chelping low-income Africans gain access to affordable, high-quality health services.\u201d<\/p>\n
To manage the undertaking, the IFC and several co-investors selected Aureos Capital, a private equity firm focused on small-scale investments in the developing world. In a 2008 fund proposal obtained by ICIJ, Aureos told prospective shareholders that it saw \u201cno conflict in the goals of improving Africans\u2019 livelihoods through better healthcare provision, and generating 15-20% gross annual returns to investors.\u201d<\/p>\n
Aureos would collect an industry standard 2.5% management fee, according to an appointment letter from the IFC. And the firm would earn millions more if it met the fund\u2019s goal of serving the \u201cbottom of the pyramid\u201d \u2014 people earning less than $3,000 per year. Additional rewards would kick in if the investments reached those making under $1,000. (Nearly 40% of Kenyans live on less than 8,006 Kenyan shillings a month, equivalent to about $730 a year, according to the most recent government survey.)<\/p>\n
For its first investment, Aureos selected a company that looked like a perfect fit for the fund\u2019s objectives: a private hospital in Nairobi founded by Sam Thenya, a charismatic, young doctor who used his profits to subsidize charitable work.<\/p>\n
Thenya founded Nairobi Women\u2019s Hospital in 2001, driven by his anger after administrators at his previous job insisted that a sexual assault survivor pay for emergency care out of pocket. The hospital tended to Nairobi\u2019s middle class and poor while offering free care to survivors of sexual and domestic violence.<\/p>\n
\u201cI told the [Nairobi Women\u2019s Hospital] board that we had to provide free services even though we were struggling financially,\u201d Thenya said in a 2014 interview<\/a>. When the board told him that the work was unaffordable, he refused to listen: \u201cI told them, \u2018Over my dead body!\u2019 \u201d<\/p>\n
Thenya\u2019s story was compelling for IFC\u2019s fund manager Aureos, and by early 2010 it had acquired over 20% of Nairobi Women\u2019s for $2.7 million; two Aureos staff members joined the company\u2019s board of directors.<\/p>\n
Finding other investments that fulfilled the IFC\u2019s ambitious goals was a slow task. More than a year later, Aureos invested in two more private health care providers. One was Avenue Group, which ran the hospital that would one day treat Jacob Njagi\u2019s infant son.<\/p>\n
Soon the Africa Health Fund attracted partners from around the world, including the development finance institutions of France, Norway and South Africa. But there were already concerns that the money was failing to reach those it was intended to serve.<\/p>\n
In 2012, an independent advisory firm hired by the IFC and its partners to evaluate their health initiative in Africa noted that private investments focused on helping the underserved \u201cmay not be viable on a commercial scale.\u201d<\/p>\n
That didn\u2019t seem to deter Abraaj Capital, a Dubai, United Arab Emirates-based private equity firm focused on emerging economies. The firm acquired Aureos later that year, taking over management of the IFC-backed Africa Health Fund.<\/p>\n
The fund\u2019s portfolio of companies epitomized the kind of \u201cimpact investing\u201d that Abraaj\u2019s founder, Arif Naqvi, had championed in settings like the billionaire-studded World Economic Forum in Davos, Switzerland: businesses that promised to make large profits while improving lives in the developing world.<\/p>\n
With the Aureos deal, Abraaj gained control of around $7.5 billion worth of investments in a variety of industries worldwide. That same year, an industry publication ranked Abraaj the largest private equity firm specializing in emerging markets. Abraaj had previously invested in hospitals and other health care businesses in the Middle East and Asia, and it quickly increased the Africa Health Fund\u2019s stake in Nairobi Women\u2019s.<\/p>\n
With the fund as a backer, the chain had rapidly expanded its operations, opening new hospitals and clinics. Avenue Group had also grown quickly \u2014 doubling its clinics and adding a hospital. Bolstered by this apparent success, Abraaj began approaching investors about a new fund: a billion-dollar \u201cecosystem\u201d of health businesses serving developing countries.<\/p>\n
The IFC decided to invest $150 million in the project. The organization\u2019s involvement signaled to other potential backers that their money would be well spent, a portfolio manager at the pension fund of the United Church of Christ, a socially liberal Protestant denomination, said during a 2017 forum co-hosted by Abraaj. For those interested in social change, he said, the power of the IFC\u2019s imprimatur \u201cliterally cannot be overstated.\u201d<\/p>\n
Altogether, investors piled $850 million into the new fund, allowing Abraaj to make major acquisitions in India, Pakistan, and elsewhere. The fund also dramatically increased its presence in Kenya: It took controlling stakes in Nairobi Women\u2019s and two other hospitals and acquired Avenue Group.<\/p>\n
\n A ward at one of the Nairobi Women\u2019s Hospital branches. <\/p>\nIn a disclosure, the IFC said the new fund would contribute to its anti-poverty mission by targeting \u201cimprovement in access, quality and affordability of healthcare for low-income and middle-income populations in Africa\u201d and elsewhere.<\/p>\n
During meetings at a public hospital in Kenya, however, Khawar Mann, the head of Abraaj\u2019s health investments, provided a less optimistic analysis to a medical student who questioned how the fund would help the poor.<\/p>\n
\u201cWe can\u2019t go to that part of the population,\u201d Mann replied, according to a description of the encounter<\/a> in The New York Times. \u201cThe business is just not sustainable.\u201d<\/p>\n
\u2018Like prisoners\u2019<\/p>\n
By the third quarter of 2017, Abraaj had collected $37.6 million in management fees from the new health care fund \u2014 enough to cover the cost of a routine birth for over 77,000 women at an Avenue Group hospital.<\/p>\n
Meanwhile, administrators at IFC-backed hospitals required uninsured patients \u2014 more than 75% of the population in Kenya and nearly everyone in Uganda lacks insurance \u2014 to pay large upfront deposits for admission, occasionally causing delays in critical care, according to interviews with current and former hospital staff and patients\u2019 families. (Evercare denied making emergency care contingent on a patient\u2019s ability to pay upfront.)<\/p>\n
Once admitted, patients without the ability to pay their bill could be stuck indefinitely. Even transfer to a cheaper facility could depend on a patient\u2019s financial resources: One man interviewed by ICIJ was hit by a car in late 2024 and lay in Avenue Group\u2019s Parklands hospital in Nairobi for a week with two broken legs and a broken jaw while family and friends solicited donations for his treatment. His family asked for a transfer after a doctor estimated it would cost 700,000 Kenyan shillings ($5,400 at the time) to fix just one leg, according to a supporter and medical bills reviewed by ICIJ. Management agreed to move him, a friend said, but only after the family paid the bill for his ICU care and other services, which by then had risen to more than 1.3 million Kenyan shillings ($10,263). When he eventually went to a public hospital, treatment costs were a fraction of what Avenue charged.<\/p>\n
\n The Avenue Group\u2019s Parklands hospital in Nairobi. Image: Ben Dooley \/ ICIJ <\/p>\nHospital administrators, including at Avenue Group, sometimes asked patients in arrears to turn over the deed to their land or their car as collateral, according to doctors, nurses, staff, and patients interviewed by ICIJ, as well as a legal agreement and internal documents from Avenue.<\/p>\n
Those without assets to turn over sometimes faced a bleaker scenario: remaining in the hospital while they \u2014 or their friends and family \u2014 collected funds. Public and private hospitals throughout the region were notorious for the practice of holding patients until they settled their bill, sometimes known as \u201cdischarge-in.\u201d This most often happened to uninsured people who had come in for a serious emergency.<\/p>\n
The problem was particularly acute at Nairobi Women\u2019s. The hospital group, which had received its first IFC-backed investments by early 2010, had been under scrutiny by the news media and local authorities for holding patients and even bodies over unpaid bills since at least 2014, the year a man reportedly sued the group for allegedly refusing to transfer his ailing wife to another facility because of an outstanding bill.<\/p>\n
Thenya, the hospital group\u2019s founder and current CEO, freely admitted to the practice. In a 2016 interview<\/a>, he told the Kenyan newspaper Business Daily that his \u201cbiggest problem\u201d was \u201cpoliticians calling for release of patients who have not paid their bills.\u201d<\/p>\n
\n Founder of the Nairobi Women\u2019s Hospital Dr. Sam Thenya. Image: Nairobi Women’s Hospital <\/p>\nAs the years went by, examples of abuses at Nairobi Women\u2019s piled up: Patient \u201cdetentions\u201d were noted in court cases and chronicled in newspaper articles<\/a> and two television expos\u00e9s in 2017 and 2019 that found 16 people being held at the company\u2019s hospitals. One woman had been there for nearly 230 days.<\/p>\n
\u201cWe just became sick like any other person can get sick,\u201d one of the patients told a reporter in 2017 \u2014 as Abraaj piled up its management fees. \u201cAnd now we\u2019ve been detained in here like prisoners.\u201d<\/p>\n
In an interview with a television reporter about the detentions, Thenya said that \u201cCheap does not exist in health care.\u201d Nairobi Women\u2019s was owed over 430 million Kenyan shillings ($4.2 million) in outstanding bills, the report noted, but did not explain why.<\/p>\n
Following a news report, a Kenyan parliamentary committee ordered an investigation into the months-long detention of the body of a young woman whose kidneys had failed after she received treatment at a Nairobi Women\u2019s hospital. Before she died, her family had requested a transfer to a cheaper, public facility. But Nairobi Women\u2019s moved her instead to a different branch, where she died several weeks later, the committee found, adding that the family consent form that the hospital shared with the committee \u201cappeared to be a forgery.\u201d The administrators\u2019 actions, the committee noted, seemed to have been \u201cmotivated by the need to keep the patient in the hospital\u2019s custody to ensure payment of the bill already incurred\u201d \u2014 nearly 2.6 million Kenyan shillings (about $25,000).<\/p>\n
The board of Nairobi Women\u2019s, which at the time included at least one representative from Abraaj, had met to discuss the case, the hospital group\u2019s chief operating officer told the committee, adding that the board was empowered to forgive debts after 12 months. But it was only after the committee began its investigation that the hospital agreed to release the woman\u2019s body and waive the bill. The committee took no further action, and detentions at Nairobi Women\u2019s hospitals continued: Two years later, in 2019, the Kenya Ministry of Health reportedly<\/a> found 15 bodies and 12 discharged patients being held there.<\/p>\n
Even rulings from Kenya\u2019s High Court, which heard at least three civil suits by patients detained unlawfully at Nairobi Women\u2019s, did little to stop the practice. In 2016, a judge ordered<\/a> the company to pay a million Kenyan shillings ($9,600) to a woman it had held for more than three months over an outstanding bill of 173,000 Kenyan shillings ($1,700). Two years later, the court ordered<\/a> Nairobi Women\u2019s to release a man it had held for months after a traffic accident. And in 2021, it awarded<\/a> damages to a young mom, Emmah Njeri, whom Nairobi Women\u2019s had held for more than five months in 2018 over unpaid bills exceeding 2.7 million Kenyan shillings (about $27,000).<\/p>\n
When Njeri finally went home, her 9-month-old son no longer recognized her, she told ICIJ: \u201cThe bond has never been as before.\u201d<\/p>\n
In a statement to ICIJ, Thenya wrote that the practice of \u201cdelayed discharges\u201d was never meant to be punitive. Rather, they were merely \u201ca reflection of systemic challenges in healthcare financing.\u201d<\/p>\n
The board, he wrote, had been aware that Nairobi Women\u2019s was holding patients over unpaid bills, and \u2014 after the first High Court ruling \u2014 the company took steps to end the practice. Still, the hospital \u201ccontinues to face difficulties\u201d with uninsured patients, \u201cwhich sometimes complicates discharge logistics,\u201d Thenya added. \u201cNevertheless, we remain committed to patient dignity and legal compliance.\u201d<\/p>\n
It\u2019s unclear what the IFC knew about the detentions at Nairobi Women\u2019s and other hospitals, and it has not been named in any of the publicly available court documents involving former patients reviewed by ICIJ. But representatives from multiple IFC-backed private equity funds \u2014 not just Abraaj \u2014 knew of detentions, according to interviews with five people familiar with the situation.<\/p>\n
\u2018Priorities have changed\u2019<\/p>\n
By the end of 2017, investors had begun raising questions about Abraaj and its global health fund. According to allegations in court filings by the U.S. Securities and Exchange Commission, hundreds of millions of dollars earmarked for health care investments had been flowing into the firm\u2019s other accounts \u201cto cover cash shortfalls.\u201d The following year, Abraaj returned part of the IFC-backed fund\u2019s capital under pressure from its investors, who soon began a search for a new firm to take over its assets.<\/p>\n
It had been a decade since the IFC had begun its private health care push into Africa, but a report by the World Bank\u2019s independent evaluation group found there was still \u201climited evidence\u201d that the IFC\u2019s health care investments had benefited the poor.<\/p>\n
Meanwhile, staff at Avenue Group hospitals were increasingly concerned about their employers\u2019 direction since their purchase by Abraaj. Dissatisfaction with wages and conditions had led nurses and other staff to unionize. A petition reportedly signed by more than 100 employees decried Avenue\u2019s focus on profit over patient care: \u201cPriorities have changed from provision of high quality health care for a reasonable price to one in which staff have been encouraged to over test, over prescribe and generally overcharge our valuable patients to increase profits.\u201d<\/p>\n
\n Abraaj founder Arif Naqvi. Image: World Economic Forum <\/p>\nIn April 2019, Abraaj\u2019s founder, Arif Naqvi, was arrested in the United Kingdom on fraud charges, including the alleged misappropriation of approximately $100 million of the health fund\u2019s assets. Shortly after, TPG, one of the world\u2019s largest private equity funds, took over Abraaj\u2019s health portfolio, including its IFC-backed investments in Kenya,\u00a0 renamed it the Evercare Health Fund, and wrapped it into its own impact investment portfolio, the Rise Fund. (Naqvi is currently awaiting extradition to the United States to stand trial. Naqvi has denied wrongdoing and could not be reached for comment.)<\/p>\n
On its new website, in an echo of the Abraaj fund\u2019s founding logic, Evercare stated that its mission was \u201cto build a legacy of accessible, high quality, safe private healthcare for low and middle-income patients in emerging markets.\u201d<\/p>\n
But by the end of 2020, the reference to low- and middle-income patients had disappeared. (In a statement to ICIJ, the company said that it \u201ccontinues to focus on access to high quality care for patients across the socio-economic spectrum, particularly in underserved markets.\u201d)<\/p>\n
That same year, local media reported on leaked messages from a WhatsApp group made up of Nairobi Women\u2019s employees. The messages, from before TPG took over, showed the CEO of Nairobi Women\u2019s at the time, Felix Wanjala, pushing doctors to meet daily admissions targets and apparently urging them to extend patients\u2019 hospital stays. Progress updates posted to the group included a category for \u201cdischarge-ins.\u201d<\/p>\n
In an email to the hospital group\u2019s board after the leak, Wanjala denied accusations that he was trying to raise revenue unfairly. But he wrote that, under TPG, the need to boost returns was only growing more urgent: Profits were the \u201cnumber one issue that every one of our directors keep an eye on,\u201d he wrote, adding, \u201cwe rarely discuss patient care in our meetings \u2014 [it\u2019s] a side issue.\u201d TPG, he said, \u201cwants EBITDA X3 in three years,\u201d using an abbreviation for a common measure of profitability.<\/p>\n
Two days later, Nairobi Women\u2019s announced that Wanjala would step aside from his post. Instead, a three-person committee from TPG\u2019s Evercare would lead the hospital group and report to the board.<\/p>\n
The Kenya Medical Practitioners and Dentists Council subsequently admonished the company\u2019s management for overruling doctors\u2019 decisions to medically discharge patients. But, the council noted, it had seen no evidence of overcharging for services. In response to questions from ICIJ, Evercare wrote that after the leak, the board of Nairobi Women\u2019s hired an outside firm to recommend ways to improve patient care and established better reporting and monitoring of admissions and discharges.<\/p>\n
Speaking to ICIJ, Wanjala said that the WhatsApp messages were taken out of context and that there was no evidence that patients had been overcharged. Additionally, he said that during his time as CEO, Nairobi Women\u2019s never received specific profit targets from investors and that his email was only in regards to initial conversations he had had with TPG.<\/p>\n
For some executives at Evercare and Avenue Group, the scandal confirmed long-held suspicions about Nairobi Women\u2019s. For years, fund managers had viewed it as the most successful of the IFC-backed hospital businesses in Kenya, an example for the others to emulate, according to four former executives at Avenue Group and Evercare.<\/p>\n
But few investors questioned how the business achieved its results. The focus on \u201cfinancials and nothing else\u201d had stopped investors from seeing what was happening right in front of their eyes, a former Avenue Group executive said. When a hospital is overly focused on generating substantial returns, that means \u201cthere\u2019s a patient who\u2019s suffering. There\u2019s a patient who\u2019s losing in terms of either losing quality of life [or] quality of care.\u201d<\/p>\n
In 2023, Evercare sold Nairobi Women\u2019s back to its founder, ending IFC\u2019s involvement with the chain. But Nairobi Women\u2019s never fully recovered from the WhatsApp leak about patient discharges. Its Rongai branch closed in October 2024, and employees across the company quit as it fell months behind on paychecks.<\/p>\n
In a Facebook post addressing the situation, Thenya, the Nairobi Women\u2019s founder, attributed the shortfall to delayed payments from government-run health insurance plans. Nairobi Women\u2019s performance is improving, he told ICIJ.<\/p>\n
\n An aerial view of Nairobi in Kenya. Image: shutterstock.com <\/p>\nNew scandals \u2014 and a new direction<\/p>\n
In summer of 2020 after the WhatsApp leak, as COVID-19 spread, the IFC launched an initiative to promote ethical principles in the private health sector.<\/p>\n
A guide<\/a> to the initiative provided examples of unethical practices, including \u201cincarcerating patients for non-payment,\u201d in what appeared to be the first public acknowledgement by an IFC-affiliated organization of the widespread practice of holding patients with unpaid bills.<\/p>\n
The IFC encouraged private health care investors and providers to commit to a set of 10 ethical principles, including one calling on hospitals to deal \u201chumanely\u201d with patients unable to pay their bills. But there was no built-in enforcement: Organizations that pledged their commitment to these standards would not be held accountable to them.<\/p>\n
For instance: One of the ethics initiative\u2019s founding signatories, Hospital Holdings Investment (HHI), managed a Ugandan hospital that in 2021 drew national condemnation after it reportedly refused to release the body of a doctor who had died of COVID-19. In 2019, the IFC had provided $27 million in financing to the business \u2014 including a $22 million equity investment that made it one of the company\u2019s largest shareholders \u2014 pledging to \u201censure that the Company adheres to high environmental, safety and social standards.\u201d A 2018 proposal for the venture told potential investors that they could expect a \u201cminimum\u201d 25% return over a five-year period, according to documents reviewed by ICIJ.<\/p>\n
In a statement to ICIJ, the Investment Fund for Health in Africa (IFHA), the private equity fund managing HHI, wrote that the case of the detained doctor\u2019s body occurred at the height of the pandemic when health care providers globally were strained, that it has since strengthened care and that it \u201chas policies in place to avoid detention of patients or corpses over unpaid medical bills.\u201d It also said that ICIJ\u2019s email asking about IFHA\u2019s operations contained \u201cmultiple statements which are incorrect and taken out of context,\u201d but did not provide examples.<\/p>\n
GIVE TO HELP US INVESTIGATE!<\/p>\n
Help us fight corruption, injustice and inequality with just $25\/month.<\/p>\n
Evercare signed on to the ethics pledge in September 2021. But at some hospitals in its portfolio, pressure from management to increase revenue in ways that might run afoul of that pledge was still present, according to people familiar with the situation and documents reviewed by ICIJ. In a meeting with representatives from TPG in early 2021, Avenue Group\u2019s chief operating officer accused the medical group\u2019s then CEO of instructing doctors \u201cto contravene medical policy and ethics by referring patients for admission to treatment who do not fit that medical criteria,\u201d according to a witness statement submitted to the Kenyan High Court in relation to a labor dispute.<\/p>\n
The witness also claimed that staff repeatedly raised concerns through an employer-provided whistleblower platform. Avenue Group\u2019s board, Evercare and TPG ignored them and even took disciplinary actions against \u201cthose who oppose unethical or illegal instructions,\u201d the person wrote in the statement.<\/p>\n
Evercare told ICIJ that it had conducted an extensive investigation in response to the allegations and found \u201cno evidence or indications of misconduct.\u201d<\/p>\n
In early 2024, managers at Avenue Group\u2019s hospital in Parklands told medical officers that they would be evaluated in part on their ability to \u201cincrease revenue.\u201d Targets included meeting an average \u201cticket price\u201d per patient, performing lab work on 78% of patients, and sending 85% of patients to radiology, according to a document reviewed by ICIJ.<\/p>\n
In its statement, Evercare said that the doctors \u201care not evaluated based on revenue generation or commercial targets but solely on quality patient care, clinical safety, and adherence to internationally accepted evidence-based medicine guidelines.\u201d<\/p>\n
Today, Avenue\u2019s hospitals display signs telling patients that they are free to leave against medical advice, but also that they have an obligation to settle debts: Discharge and financial consent policies, last updated in September 2024, do not mention detention or how staff should handle patients who cannot pay their bills.<\/p>\n
\n Signs on display at an Avenue Group facility spell out patients\u2019 rights and responsibilities. <\/p>\nFormer and current Avenue Group staff interviewed by ICIJ continue to question its direction. While there was wide agreement that health care resources had benefited from the investments by the IFC, almost all felt patients had been ill-served by the fundamental misalignment between the goals of private equity and the goals of health care providers. The hospitals provide high-quality care, one former executive told ICIJ. But, he added, if receiving treatment means \u201cyou\u2019re in debt for the rest of your life, what\u2019s the point?\u201d<\/p>\n
Left with \u2018less than nothing\u2019<\/p>\n
In recent years, despite court cases and news coverage, IFC-backed hospitals have continued to put patients in financial distress. (A new national health insurance program introduced last year in Kenya has aimed to make health care more accessible.) ICIJ found dozens of posts on social media and the fundraising site GoFundMe, published from 2020 to 2025, pleading for friends, family and community members to contribute money toward bills at Avenue Group and other IFC-backed hospitals. ICIJ spoke with 12 people who, since 2020, have received treatment at Avenue Group hospitals for themselves or family members only to come under severe financial strain.<\/p>\n
Among them was Siamah Shabaan, who in March 2024 fell ill while pregnant and was taken to a public hospital in Kisumu. But doctors at government facilities nationwide were on strike, so she was moved to an Avenue Group hospital. The hospital admitted her without a deposit, but her baby died shortly after birth. The family soon took out a private loan to pay part of the baby\u2019s bill.<\/p>\n
\n Siamah Shabaan, left, with her mother Asha Salim at their home in Muhoroni. Image: ICIJ \/ Micah Reddy <\/p>\nShabaan only needed a few days to recover from her illness, she said, but she remained in the hospital for almost two weeks as her mother, Asha Salim, begged the village chief and local imam to each send the hospital a letter explaining that the family had no money. She hand-delivered them to the hospital to ask for leniency.<\/p>\n
Not long after, Shabaan returned to her home in Muhoroni, where she lives with her mother in a shack with a tin roof and no electricity. When Shabaan was discharged, there were two bills: around $1,200 for her and around $600 for her baby, far more than she could pay. Even before Shabaan was treated at an Avenue Group hospital, she and her family had nearly nothing. Now they have less, Shabaan said. The hospital regularly calls her mother, urging her to make payments toward the debt. The family says they have been told to pay any amount, even as little as 1,000 Kenyan shillings ($7.68). But her mother has no job, and the family can\u2019t afford to.<\/p>\n
\n Siamah Shabaan, right, with her mother in the colorful living room of their sparsely appointed home. Image: Micah Reddy \/ ICIJ <\/p>\nShabaan is not bitter about the situation \u2014 she is thankful to the hospital for saving her life. She hopes to someday have the resources to pay the bill. She\u2019s just not sure how that will ever happen.<\/p>\n
\n Siamah Shabaan hopes to one day pay her hospital bill. Image: Micah Reddy \/ ICIJ <\/p>\nIn the meantime, the creditors that Shabaan\u2019s mother turned to when her daughter was hospitalized have threatened to have her arrested, Shabaan said during a visit with an ICIJ reporter. The women were sitting on a pair of old wooden chairs, the only decorations in their nearly empty home. The chairs had belonged to her grandfather, Shabaan said. Just a few days before, the creditors had come to take them.<\/p>\n
The family had to plead with them not to, she said. But she doesn\u2019t know how much longer they will wait.<\/p>\n
Contributors: Denise Ajiri, Jelena Cosic, Miguel Fiandor Guti\u00e9rrez, Karrie Kehoe, Delphine Reuter, David Rowell, Annys Shin, Joanna Robin, Kathleen Cahill, Davi Sherman (ICIJ), Hannah Levintova (Mother Jones<\/a>), Frederic Musisi (Daily Monitor)<\/p>\n
![\"\"](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Njago-family-760x427.jpg\")
![\"Man](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/World-Bank-Group-GettyImages-2171754701-1138x640.jpg\")
![\"Photo](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/NWH-ward-via-Facebook-1280-1138x640.jpg\")
![\"\"](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Avenue-hospital-crop-569x427.jpg\")
![\"Sam](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Sam-Thenya-via-Facebook-Nairobi-Womens-Hospital-1280-1138x640.jpg\")
![\"Arif](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Arif-Naqvi-WEF-Flickr-23912919174_3dcbe28021_k-1138x640.jpg\")
![\"Aerial](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Nairobi-shutterstock_2436207273-1138x640.jpg\")
![\"Photos](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Avenue-Group-patient-rights-and-responsibilities.jpg\")
![\"Two](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Siamah-Shabaan-ICIJ-Micah-Reddy.jpg\")
![\"\"](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Siamah-760x427.jpg\")
![\"\"](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/07\/Siamah-doorwat-760x427.jpg\")