Patients too poor to settle medical debts are chained to drain pipes, starved and abused in health centres across parts Africa.
Hospitals are detaining hundreds of thousands of people against their will every year - many of them mothers and their newborn babies - simply because they are too poor to pay their medical bills, a study has found.
The practice, which is widespread across parts of sub-Saharan Africa and Asia, sees patients chained to drainpipes, starved and abused, and forced to perform sexual acts in exchange for cash to pay off their bills, according to the paper published by Chatham House in December.
Campaigners are calling on the global health community to take immediate action against medical detentions.
"This is a systemic problem, and the number of rights abuses is quite profound: people are being detained without trial, they're being locked up with security guards, and women are giving birth to babies who are entering the world, in effect, as prisoners," said Robert Yates, project director at the Centre on Global Health Security, who co-authored the paper.
"Healthcare user fees are at the root of the problem, and this just shows how bad a privately financed health system can get. We need to do more research on this and the global health community needs to start taking this seriously."
While exact numbers of medical detentions are unknown, in some countries the practice is so common that patients consider it "normal" for hospitals to detain those who cannot pay their bills.
Politicians have used it to their advantage in the run-up to elections.
Recently in Nigeria, an aspiring governor paid off a number of patients' bills at a public hospital in Osun state, while the wife of a state governor in Abia showered nursing mothers with gifts, and paid off their bills after visiting them in a hospital presided over by her husband.
Those most at risk of being detained are the poorest people, according to the paper, among them those needing emergency treatment and pregnant women, with many of them resorting to desperate tactics in order to escape detention.
Over a six-week period in 2016 in one health facility in the Democratic Republic of the Congo, 54% of women who had given birth and were eligible for discharge were detained for nonpayment of user fees, according to the study, with many women and children held for months at a time.
In a Nairobi hospital in Kenya, women who had been detained post-childbirth for fees amounting to 210 000 shillings, were having sex with doctors for as little as 300 shillings in order to pay off their bills.
"Healthcare really needs to be free of charge to the patient, because this is the consequence of making patients pay, and it is the worst situation in a whole range of very difficult situations: they may get the medical care they need but then they, or their belongings or their ID papers, are kept hostage," said Mit Philips, health policy advisor at Doctors Without Borders (MSF).
"Unfortunately, because many of these health facilities don't receive sufficient funding to provide adequate care even when patients can afford to pay, this is the kind of economic logic that results. If we're serious about universal health coverage, then abolishing user fees would be a good place to start."
Campaigners have called for national leaders to ban medical detentions and prosecute the hospitals that imprison their patients, as well as reform their health financing systems towards publicly financed universal health coverage. The paper cites Burundi as a clear example of how the abolition of user fees can improve health services, as public finance to hospitals and the provision of free maternity services saw deliveries in health units quadruple and infant mortality decline by 43% within five years.
"The only countries that have achieved universal health coverage have done so through scaling up public financing, and a core part of universal health coverage is removing user fees," said Oxfam's health policy advisor Anna Marriott.
"But we're just seeing inaction around this across the world. This is the most grotesque violation of people's rights that you could imagine, and progress is far too slow for what is a very urgent need."
This feature was originally published as part of The Guardian's Global Development project.
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