When hospitals become debtors' prisons

Robert Yates and Eloise Whitaker on the scandal of detaining patients who cannot afford medical fees

In 2009, Kenyatta National Hospital was forced to release 44 detained patients

Hospitals should be places that improve well-being, where people feel safe and are free to leave at the end of their treatment. Sadly, this is often not always the case. In some parts of the world, people are detained for months for not being able to pay their medical bills or are refused care when they can no longer pay. 

This practice is particularly prevalent in some sub-Saharan countries, but also occurs in Asian countries where there is poor access to affordable healthcare. Hospital detentions contravene several international laws and represent a gross violation of human rights, especially as many detainees suffer abuse during their enforced hospital stay.

In Kenya, hospital detentions have been receiving a lot of media coverage. Due to low levels of public health spending, many patients are charged high fees for their care, which leads some people to delay seeking treatment when unwell, while others amass high medical bills that they cannot afford. Hospitals are often faced with a decision of whether or not to provide life-saving care or not and having to find ways to recoup unpaid bills. Somtimes this results in detaining patients. 

For example, in 2009, Kenyatta National Hospital was pressured into releasing 44 detained patients after a TV station used a hidden camera to show them being held in a padlocked room. More recently, in 2017, a grieving mother who had lost four children in an accident was detained in a Migori County Hospital, and in another case, the body of a 73-year-old woman was not released to her family for over a year.

This practice has become so widespread that Kenyan politicians routinely use what are known as ‘set aside allowances’ to secure the release of detained patients. In June 2017, one senator in Nairobi entered a hospital with a large sum of cash to release patients. He paid the outstanding medical bills of at least 10 patients, including an 89-year-old woman. 

The detention of patients is not exclusive to Kenya but is widespread in sub-Saharan Africa, most notably in Nigeria, the Democratic Republic of Congo, Ghana, Cameroon, Zimbabwe and Uganda, but there is also evidence of the practice in India and Indonesia. 

A recent research paper by Chatham House, Hospital Detentions for Non-payment of Fees: A Denial of Rights and Dignity, shows that hospital detentions result in patients being forcibly separated from their families and becoming unable to maintain their livelihoods. There are reports of families having to sell land and cattle to clear hospital debts. This is not only psychologically distressing, but can result in the poorest people sliding into greater poverty.

There is limited research into the scale of detentions, with most reports coming from local media sources. A recent study in the Democratic Republic of Congo found in one hospital over a six-week period in 2016 that 54 per cent of women who had given birth and were eligible for discharge were detained for the non-payment of user fees. At one hospital in Kenya, 53 per cent of uninsured parents of children whose cancer treatment had been withdrawn said they had been detained for non-payment.

Patients, who are medically fit for discharge and who cannot meet medical expenses may be held in squalid conditions. Those most likely to be detained are new mothers who have had complicated deliveries that required emergency surgery, often not met by government funding. 

Another common group of detainees are people admitted to hospital requiring emergency care, after severe burns or car crashes for example. The abuse these people have to endure can be shocking. In 2015, it was reported that a new mother was chained to a urinal pipe in Lagos,
Nigeria, when unable to pay her hospital bill after receiving treatment following complications during the birth. Reports from Kenya into similar practices showed that 60 women were kept next to an overflowing toilet. Women from another facility
reported being pressured into having sex with hospital staff to pay their bills. 

There are two approaches that governments could take to end hospital detentions. One would be for countries to simply outlaw the practice, with sanctions for hospitals that continue it. However that alone may not be sufficient, as those needing emergency care may simply be denied treatment if they appear unable to pay. For example in 2016 in Cameroon, a country with high numbers of medical detainees, a relative tried to perform a caesarean section on the steps of a hospital that had denied access to a woman who had not been able to pay in advance for her care. The mother and her unborn twins died leading to demonstrations. This case shows that simply banning the practice without reforming the health system may not enough to ensure that rights to treatment are met.

The second strategy would be the introduction of a publicly financed health system that achieves universal health coverage. This would ensure that people were able to get the care they need without suffering financial hardship. Universal health coverage is a specific target in the UN’s Sustainable Development Goals and is an established way to improve health outcomes, increase economic growth and lower health-related impoverishment. Countries with a high level of publicly financed health coverage do not experience hospital detentions. Universal health coverage would not only reduce financial hardship for patients but negate the need for hospitals to detain patients for non-payment. Political pressure at the highest level is needed to ensure these reforms are effective. Political leaders need to be made aware that it is unacceptable to allow hospitals to lock up vulnerable people and it would be in their interest to outlaw the practice. 

There have been two examples of this pressure working in recent years. In Burundi in 2005, after a damning Human Rights Watch report about hospital detentions, President Pierre Nkurunziza released new mothers, their babies and children from the country’s hospitals. Within six months, he announced that all health services for these groups would be provided for free. Similarly in 2003, in response to political pressure, Turkey’s newly elected Justice and Development Party government outlawed medical detentions and launched major health financing reforms that helped bring the country close to universal health coverage within a decade.

It would appear that similar pressures are building in Kenya as well, with Chatham House’s report generating considerable media coverage there. Esther Passaris, a prominent MP and activist for women’s rights, called on President Uhuru Kenyatta to scrap New Year celebrations and use the money to fund the release of medical detainees. She has been posting video clips on social media of her confronting hospital staff detaining patients. With President Kenyatta announcing in his New Year message that ‘the days of hospital costs bankrupting families will end’, might Kenya be the next country to outlaw hospital detentions and in the process take a significant step towards universal health coverage?