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Robert Yates, "Hospital Detentions For Non-Payment of Fees A Denial of Rights and Dignity"

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Robert Yates, "Hospital Detentions For Non-Payment of Fees A Denial of Rights and Dignity"

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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

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

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Robert Yates, "Hospital Detentions For Non-Payment of Fees A Denial of Rights and Dignity"

  1. 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
  2. 2. Chatham House | The Royal Institute of International Affairs 2 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
  3. 3. Chatham House | The Royal Institute of International Affairs 3 • 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. 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
  5. 5. 5 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
  6. 6. 6 But Burundi was not unique Kenyan mothers too poor to pay for treatment locked up in hospital - The Guardian Aug 13 2009
  7. 7. Chatham House | The Royal Institute of International Affairs 7 Hospital detentions were particularly a problem in DRC
  8. 8. Chatham House | The Royal Institute of International Affairs 8 International Health Agencies Turn a Blind Eye
  9. 9. 9
  10. 10. Chatham House | The Royal Institute of International Affairs 10 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
  11. 11. Chatham House | The Royal Institute of International Affairs 11 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
  12. 12. 12 Politicians pay bills of detainees to increase their popularity
  13. 13. 13 In Ghana Vodafone paid to release patients
  14. 14. 14
  15. 15. 15 The Consequences of Excluding the Poor Can be Worse
  16. 16. Chatham House | The Royal Institute of International Affairs 16 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
  17. 17. Chatham House | The Royal Institute of International Affairs 17 Failed health financing policies • Structural Adjustment pushed health financing burden on to households • Bamako Initiative • Ineffective and inequitable health insurance schemes
  18. 18. 18 Donors continue to be complicit in hospital detentions
  19. 19. Chatham House | The Royal Institute of International Affairs 19 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
  20. 20. Chatham House | The Royal Institute of International Affairs 20 A simple definition of UHCA simple definition of UHC All people receive the quality health services they need without suffering financial hardship
  21. 21. Chatham House | The Royal Institute of International Affairs 21 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
  22. 22. Chatham House | The Royal Institute of International Affairs 22 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.”
  23. 23. Chatham House | The Royal Institute of International Affairs 23 Campaigning and advocacy gets results
  24. 24. 24 Kenya is piloting universal FREE healthcare
  25. 25. Chatham House | The Royal Institute of International Affairs 25 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
  26. 26. 26 For daily updates on UHC Follow @yates_rob

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