The African Development Bank commissioned four case studies on Debt Relief Initiatives, Development Assistance and Service Delivery in Ghana, Malawi, Senegal, and Uganda from the last quarter of 2006 to mid 2007. The objective of the study was to appraise the extent to which debt relief resources are being used to improve social service delivery. There is strong agreement from all four case studies that debt relief created flexibility in governments spending by playing the role of flexible and predictable budget support. In this context, governments acquired more degrees of freedom to allocate debt relief resources in line with their own objectives. In all four countries debt relief resources were more easily transformed into MDG-related spending than tied aid. The case studies had a consensus in identifying the accountability of public institutions to civil society, through community monitoring or execution of expenditures, as the most effective means of enhancing spending effectiveness. This formed the basis for the success observed in program implementation. From the findings of the case studies it is clear that debt relief can lead to enhanced service delivery provided certain conditions prevail. These conditions can be influenced by donors as well as the willingness of beneficiary governments to undertake reforms. The general observation across the case studies is that debt relief has a major positive impact on service delivery, and progress towards the MDGs, when beneficiaries: (i) have high capacity in MDG spending, (ii) are highly accountable, and (iii) receive stable and high-quality aid.