On December 22, 2022, Sakaja Arthur Johnson, the Governor of Nairobi County, Kenya’s capital, partnered with Cooperative Bank to release patients who had been detained in hospitals due to accrued medical bills. We congratulate Governor Sakaja for such a humanitarian gesture. However, prior to this public good, the rights of these patients were infringed upon. This is unacceptable.
Sadly, detaining people for inability to pay for healthcare is an epidemic across Africa. A study by Chatham House shows this disturbing trend in Kenya, Nigeria, South Africa, Cameron, Democratic Republic of the Congo, Ghana, Zimbabwe and Uganda. Detaining patients is dehumanising and comes with other traumas.
Another Chatham House study summarises abusive experiences women face when detained:
In one case, 60 women were held next to an overflowing toilet in a Kenyan hospital; and one victim reported being told by nurses that she was ‘stupid’ for not having known she was pregnant after being raped.
In another, a Nigerian woman was chained to a urinal pipe during her detention.
A Kenyan woman who was forced to leave her bed and lie on the floor a day after her Caesarean operation spoke of being berated by staff who asked her: "Why do you open your legs and give birth every time?"
These abuses are atrocious and despicable. The right to health is a fundamental right without which other rights are indispensable. Kenya has safeguarded the right to health by anchoring it in the Constitution of 2010, which provides that all Kenyans have a right to the highest attainable standard of health, including reproductive health .
Exhaustion of family resources to cater for medical bills leads to patients being detained in hospitals. While hospitals have to recover costs of treating patients, the reality is that detention of patients due to medical bills violates the right to liberty, dignity and non-discrimination. Further, it can impact the mental health of patients negatively, and also increase their risk of contracting hospital acquired infections.
So, who pays for healthcare in Africa? A major challenge with healthcare financing across Africa is that it is mostly out of pocket - people pay for healthcare at the point of need. For instance, out of pocket expenditure in Kenya is 24% of total health expenditure. In contrast, it is a whopping 77% in Nigeria (3 times that of Kenya). Across Sub Saharan Africa , the average out of pocket expenditure for healthcare is 30%. To this end, reliance on out of pocket expenditure to finance access to health invariably affects quality and is inequitable. Vulnerable households are often exposed to poverty as medical bills exhaust their savings, reduce quality of life, and interfere with patients' adherence to medication and follow up.
In fact, public financing of healthcare across Africa is poor; much of it is donor-driven. Only three countries in Africa have allocated 15% of their annual budgets to healthcare as per the Abuja Declaration; and a number have reduced their annual health budgets. The reality of not funding public health became evident during the peak of the COVID-19 pandemic. Patients who contracted COVID and needed hospitalisation had to incur very expensive medical bills , many of them ending up in hospital detention due to debts.
Africans paying for healthcare at the point of need is inequitable and unsustainable. Consequently, these are five ways that Governor Sakaja, other leaders and politicians across Africa can stop detention of patients and ensure equity in healthcare.
First, improve healthcare financing by channelling the high out of pocket expenditure towards health insurance to ensure a publicly-led universal health coverage for all Africans. African politicians must show that it is better to pre-pay for healthcare than wait until one is sick to do so. This must involve education of Africans on the importance of health insurance. It must be for the long haul because behaviour change takes time. The message, messenger and medium must be well defined in targeting different groups of people.
Second, focus on addressing social determinants of health. These determinants of health are diverse and interconnected, including poverty, levels of education, economic and gender inequalities, place of residence, access to water, sanitation and hygiene. The external environments including climate change and pollution, food insecurity, also affect the health of many. For example, giving communities living in informal settlement areas improved access to clean water can increase survival in children aged five years and below who often succumb to diarrhoeal diseases.
Third, as part of expanding domestic resource mobilisation for healthcare, establish equity funds to cater for health insurance for the poorest of the poor. Surely, if private sector organisations such as Kenya’s Cooperative Bank can pay for detained patients to be released from hospitals, they can also afford to contribute to a fund that prevents this inhumane act of denying people of their rights. A classical lesson is the Road Accident Fund in South Africa that is funded by levy from fuel proceeds which pays for hospital bills for victims of road traffic accidents.
Fourth, mainstream healthcare in all policies. COVID-19 has shown that without health, we have nothing. In developing policies, policymakers must ensure that they are geared towards improving health and wellbeing. For instance, mainstreaming health in road construction should ensure there are walkways and bicycle paths to encourage exercise and fitness among the populace. This would help in reducing the incidence of hypertension, obesity and other non communicable diseases.
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Lastly, develop legislation which criminalises the detention of patients in hospitals. We need laws that criminalise this practice and protect the rights of patients. Such laws should also protect hospitals and compensate them via equity funds and other sources.
Health is a fundamental human right that creates an obligation for States to ensure availability, accessibility, affordability, acceptability and quality.
Indeed, the State has a responsibility to ensure that no one is pushed into poverty because they cannot afford the cost of healthcare; and no one is detained for inability to pay for healthcare. African States have to renew their commitments to at least allocate 15% of their budgets to healthcare.
Dr. Stellah Bosire is a Senior New Voices Fellow at the Aspen Institute. She is the Executive Director and Founder - Africa Center for Health Systems and Gender Justice, and Dr. Ifeanyi M. Nsofor is a Senior New Voices Fellow at the Aspen Institute and a Global Health Equity Advocate.
