March 27, 2020 Each year in low- and middle-income countries thousands of people are detained in hospitals for non-payment of medical bills, despite the fact that such detention is a violation of national and international law. Hospital detention for nonpayment of bills disproportionately affects the most vulnerable people, including post-partum women. In the US, medical debt manifests itself in other ways, including bankruptcy, litigation to garnish wages, and foregone care. In both contexts, these scandals are the result of failures of financing, priority-setting, and legal oversight. Without addressing these systemic issues, a "human right to health care" will remain a hollow slogan, as will political promises to achieve universal health coverage. This event will feature Robert Yates of Chatham House, which has conducted an in-depth investigation of the global phenomenon of hospital detentions. Additional panelists will address manifestations of predatory lending and surprise medical fees in the United States, the ethical imperatives of financing and priority setting for UHC in general, and the implications for thinking about health care as a human right. For more information, visit our website at: https://petrieflom.law.harvard.edu/events/details/debt-dignity-and-health-care

1. Debt, Dignity, and Health Care: Guaranteeing Health Rights and Universal Health Coverage
The Petrie-Flom Center, Harvard Law School
27th March 2020
Robert Yates, Executive Director, Centre for Universal Health, Chatham House
Hospital Detentions For Non-Payment of Fees-
A Denial of Rights and Dignity

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Health care user fees – a tax on the sick
Source: Yates R. Universal health care and the removal of user fees. The Lancet 2009; 373: 2078-81

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• Hundreds of poor patients had been
detained in hospitals because they could
not pay their bills
• Most detentions were a few weeks or
months but one patient detained for a
year
• Many victims were women who had had
caesarian section deliveries and their
babies
Human Rights Watch Report on Burundi 2005

4. I had to come to hospital because I
needed a caesarean delivery. When I
got the bill, the doctor said to me,
“Since you have not paid, we will keep
you here.” Life here is difficult. I don’t
have permission to leave with my
baby. We are often hungry here. I
cannot stand this situation any longer.
A Major Human Rights Issue
—Eighteen-year-old woman held with her
baby at Louis Rwagasore Clinic,
Bujumbura, Human Rights Watch 2005

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In Burundi in 2005 around one in five babies were born in health units, now the
majority are. How has the Government achieved this?
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008
%ofbabiesborninhealthunits
In May 2006 the President of Burundi announced that
maternity services would be provided free of charge
and since then additional public financing has been
allocated to meet the rising demand for services
146% increase since 2005

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But Burundi was not unique
Kenyan mothers too poor to pay for
treatment locked up in hospital - The
Guardian Aug 13 2009

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Hospital detentions were particularly a problem in DRC

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International Health Agencies Turn a Blind Eye

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Key Findings from our Report
• Difficult to research and quantify the scale of detentions
• 9 academic articles and 60 media articles 2003-17
• We estimate hundreds of thousands of detainees per year
• Occurs in public and private health facilities
• Wide societal acceptance in some countries of the
assumed right of providers to detain patients
• Often associated with emergency surgical procedures –
especially related to maternity services
• Detainees are often abused – unsanitary conditions, denied
food and medical treatment, forced to work in the hospital

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Key Findings from our Report
• High prevalence in countries with low levels of public financing,
high user fees and weak governance systems
• Large numbers of detainees in Nigeria, Democratic Republic of
Congo, Cameroon, Kenya and Zimbabwe
• Also reported in Ghana, Uganda, Liberia, Haiti, India, Indonesia
• Hospital detentions deter healthcare use and increase medical
impoverishment
• They are a denial of international human rights not to be
imprisoned as a debtor and the right to access medical care
• Fundamentally incompatible with the SDGs

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Politicians pay bills of detainees to increase their popularity

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In Ghana Vodafone paid to release patients

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The Consequences of Excluding the Poor Can be Worse

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Who is responsible for these human rights
abuses?
• Health workers and hospital authorities
• Local and national governments including
the head of state
• International development agencies

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Failed health financing policies
• Structural Adjustment pushed health
financing burden on to households
• Bamako Initiative
• Ineffective and inequitable health insurance
schemes

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Donors continue to be complicit in hospital detentions

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Policy Recommendations
• All hospital detentions should be banned
immediately by the head of state
• Presidents in Turkey and Burundi did this
• Implement Universal Health Coverage
reforms and in particular remove health
care user fees

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A simple definition of UHCA simple definition of UHC
All people receive the quality
health services they need without
suffering financial hardship

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Consensus on health financing for UHC
• Market-driven privately financed health systems do not result in UHC
• The state must force the healthy-wealthy to cross subsidise the sick
and the poor
• User fees are “unjust and unnecessary” : Jim Kim, President World
Bank , May 2013
• Private voluntary insurance including community based insurance is
ineffective, inefficient and inequitable
• Public financing (tax financing and social insurance) is the key to
UHC

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UNGA HLM a milestone on the route to UHC
“If there is one lesson the
world has learnt, it is that
you can only reach UHC
through PUBLIC
financing.”

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Campaigning and advocacy gets results

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Kenya is piloting universal FREE healthcare

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Hospital detentions in the era of COVID-19
• Beyond belief that scarce hospital beds can be
occupied by healthy detainees with COVID-19
patients requiring urgent hospital care
• Detained patients at risk of being infected
• COVID-19 is accelerating calls for publicly financed
UHC across the world – even in the US
• One action political leaders could take immediately to
respond to the crisis would be to ban all hospital
detentions for non-payment of fees

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