6 December 2017

Congo-Kinshasa: Hospitals That Act As Modern-Day Debtor Prisons Deny Rights and Dignity

analysis

Hundreds of thousands of people are detained in hospitals against their will each year. Their crime? Being too poor to pay their medical bills. Robert Yates examines two practical steps that countries can take to eliminate this practice.

Around the world, human-rights activists fight on behalf of people imprisoned in unsanitary jails and denied a fair trial. These victims often suffer the double indignity of being mistreated by their captors and deprived of basic services. In many countries, these abuses are not only taking places in prisons, but in hospitals, too.

A new Chatham House paper that I co-authored with Tom Brookes and Eloise Whitaker shows that up to hundreds of thousands of people are detained in hospitals against their will each year. Their crime? Being too poor to pay their medical bills. This phenomenon is particularly prevalent in several sub-Saharan African countries, notably Nigeria, Democratic Republic of Congo, Ghana, Cameroon, Zimbabwe, and Kenya, but there is also evidence of it in India and Indonesia.

The practice of medical detentions is particularly rife in Democratic Republic of Congo. In one study of a health facility over a six-week period in 2016, 54 per cent of women who had given birth and were eligible for discharge were detained for the nonpayment of user fees. In many cases, women and babies are held for months and are denied ongoing health care until their bills can be settled.

In Nigeria, there are frequent reports of hospitals detaining poor and vulnerable patients, including newborn babies. Two stories were recently reported in local media. One involved a mother and baby being detained for four months at the God Cures Hospital in Lagos after a caesarean section. Another story involved an aspiring politician visiting a public hospital in Osun State in the run-up to a local election and paying the bills of elated patients who had been detained for many months.

Hospital detentions are so common in Nigeria and Ghana that there are many stories of politicians releasing medical detainees in the run-up to elections -- a gesture which provides an excellent public relations opportunity. In one bizarre example, the wife of a state governor in Nigeria was heralded as a savior for releasing patients from a hospital governed by her spouse.

Our research shows that in addition to depriving victims of their liberty, these detentions are often accompanied by the denial of medical care and food, and sometimes also by physical and sexual abuse. In another example from Nigeria, a woman spent her hospital detention chained to a urinal pipe. In Nairobi, Kenya, patients at Kenyatta National Hospital claimed in 2015 that they had been pressured into having sex with hospital staff in exchange for cash to help pay their bills.

These detentions and associated abuses contravene many international laws and represent a gross violation of human rights. What is particularly shocking is that they take place in health facilities, which are supposed to protect and improve the welfare of vulnerable people.

There are two practical steps that every country can take to eliminate this abhorrent practice.

The first is straightforward and should be taken immediately by national leaders: ensure that the practice is banned by domestic law, and prosecute hospitals that continue to imprison their patients. There is no legal or moral justification for health facilities to detain people on their premises, in effect holding them hostage until their families settle their bills. A United Nations or World Health Assembly resolution might prove an effective way for countries to outlaw this practice.

The second action is more long term and addresses the root cause of this problem: reforming health financing systems so people are not presented with unaffordable medical bills. This requires reducing the use of direct charges to pay for health services and instead moving towards prepaid financing mechanisms that pool contributions from across society. In essence, that means launching publicly financed universal health coverage reforms that ensure everyone can access the services they need without financial hardship.

Although this plan may seem utopian, in the last decade Turkey and Burundi have succeeded in implementing this dual strategy of banning medical detentions and simultaneously launching successful health financing reforms that have removed user fees for vital services.

The example of Burundi, one of the poorest countries in the world, is particularly striking. Following a damning Human Rights Watch report in 2005, President Pierre Nkurunziza realized that the nation's hospitals had become debtor prisons and released all mothers and babies from detention. But Nkurunziza's government also recognized the importance of reforming the health financing system. By channeling public funding, including aid, to hospitals, the government was able to remove fees and provide free maternity services. As a result, deliveries in health units quadrupled and, in the following five years, infant mortality declined by 43 per cent.

If Burundi's neighbors, Democratic Republic of Congo and Nigeria, which together represent 20 per cent of Africa's population, followed this strategy, the impact on the continent's maternal and infant mortality rates would be immense. Moreover, tens of millions of women would be free of the fear that their lifesaving hospital maternity care might condemn them and their babies to months of incarceration in a debtor prison.

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