NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Friday, April 17, 2015

In low-income and middle-income countries (LMICs), systematic research regarding the prevalence and personal consequences of patients who are unable to pay their medical bills has been scarce. However, news headlines frequently tell a simple story of detention—eg, “Kenyan mothers too poor to pay for treatment locked up in hospital”. Similar reports are found in Burundi, Ghana, India, Liberia, Nigeria, the Philippines, and Zimbabwe.

In the 1970s and early 1980s the governments of many LMICs provided free basic health-care services to their citizens. With the introduction of structural adjustment programmes in the 1980s, the World Bank recommended that LMICs reduce public spending for health and social programmes. Cost recovery mechanisms such as user fees for basic health services were introduced. The Bamako Initiative, developed by the WHO and UNICEF and endorsed by African governments in 1987, reinforced this strategy. To address potential negative outcomes on patients, community health-insurance schemes were also promoted, and governments were expected to establish mechanisms to assure access to health care for people with no means to pay.

The goals of these reforms were to increase health sector revenue, promote efficiency and equity, and improve quality of care. The results are contested, and thousands of peer-reviewed journal articles have been published on the effect of user fees and community health-insurance schemes on health care in LMIC. What is clear is that although user fees were widely adopted, more complex community health-insurance schemes were introduced less frequently, and, when introduced, often failed. Overall, user fees raised less revenue than expected, and, arguably, promoted inequity, negatively affected demand for health care, and contributed towards household poverty.

The detention of patients by health facilities can be seen as a direct consequence of the imposition of user fees and and inadequate social welfare protections. But how does the experience of this policy decision affect the citizens of a low-income country such as Uganda?

In the documentary film Twero: The Road to Health (2012), the practice of patient detention in northern Uganda is seen through the eyes of Esther Ayugi. After being turned away from public providers, Ayugi turns to care offered by a gynecological surgeon in private practice, but she is unable to pay the entire bill. The surgeon’s response to the $65 shortfall was to lock up Esther, and her son, in his clinic. Esther would be released only when her family paid the difference, or when her son worked it off. Esther’s son was also put in charge of guarding his mother and other detained patients; if any patients escaped, he was charged a day’s wage.