VI. Consequences of Hospital Detention
Economic pressure
Large hospital bills often have disastrous economic and social consequences for the recipients and their families. If patients are detained, the pressure to pay the bill increases and their ability to earn the money to pay the bills decreases. A study by Save the Children found that if poorer households managed to pay for health care, more than half of them did so by selling assets. Another 20 percent borrowed money from a friend or relative. The study concluded that these are “risky, irreversible strategies” that are “potentially catastrophic” for households that are already poor.106 A larger study by Médecins Sans Frontières Belgium reached similar conclusions, finding that more than 80 percent of the households surveyed paid for healthcare by incurring a debt, selling a possession (cattle, land or harvest) or by taking on additional work, for example agricultural labor.107
In seeking release of themselves or family members from detention by selling such resources as land or cattle even though they need them for their livelihood, people are drawn deeper into poverty.108 The situation is particularly difficult for those who have few social networks, such as orphans, widows or returnees, and hence few possibilities of getting help. Gabriel N., the man who suffered two road accidents, told our research team,
I had a wife, but since my accident, she went back to her parents. I am an only child and an orphan. My parents died when I was very young. My wife tried to help me with the medical bills, but when she had nothing remaining, she left me. I am just a farmer and I have only once piece of land. I do intend to pay these bills and if I could leave here, I might be able to start to pay things back. I think that my best option would be to sell my land, because otherwise, I will never be able to pay the hospital bills. If I could work, I could earn money, but I need to be in good health. This is my dilemma, I am not sure if I should sell my land and abandon my parcel or if I should stay here and wait for a benefactor.109
The father of Noah B., the boy detained following surgery on his foot, also faced serious economic hardship:
My land is all I have. Even if I sell the land, it won’t cover the cost of the medical expenses. I had a cow, but it was stolen during the war. If I still had the cow, maybe I would have others now and we would have more money. My nephew used to help me work on the land and lend us money, but he was killed three weeks ago by bandits in Bukeye. My wife is trying to manage. I sell bananas sometimes and occasionally manioc flour to make a little money.110
Women and children often do not have legal access to property and cannot take decisions about the sale of land or other property without the approval of a male family member. Male heads of household control family resources, and women and children may have no information about the family’s financial situation, including whether there is in fact the means to pay the hospital bills. This helps explain the case of Félix M., described above, whose father stole the money that had been supplied by ONUB and that was meant to pay his hospital bill.
Detained children such as Noah B. and Félix N. miss out on schooling. For some, their forced stay at the hospital is likely to have a negative long-term effect on their education and consequently their livelihood prospects.
A boy detained at Roi Khaled Hospital. His father, who is a farmer and cannot pay the bill for surgery, is staying with him. © 2006 Jehad Nga
Fear to seek access to health care
In addition to economic consequences, detention shatters the trust of individuals detained, and others, in the health system. As knowledge of the practice becomes generally known, fear of detention may result in individuals delaying seeking care or avoiding it altogether, or going instead to a traditional healer. Josephine C., whose baby was sick, initially avoided going to hospital because she expected to be detained:
I would be kept there for a long time because I wouldn’t be able to pay the bills. But I didn’t have a choice in the end. I was already here in Bujumbura when the baby got really sick and so I finally came to the hospital here.111
Olivia N., who suffered from long-term birth complications, also delayed her trip to the hospital as long as possible:
I had complications after having a baby in June 2004. I gave birth by caesarean section and that is when my problems started. The baby died. I went to the hospital in Bururi but they could not help me. They told me only Roi Khaled Hospital could help me. I had so many health problems for a year, but I didn’t have the money to get better. Finally I decided to come here, even without money. I have two other children and it was too hard because I was so sick all the time. Since I have been here, I have had two operations and I am not totally healed now, but it is better…. Now, I would prefer to go back home to finish healing but I cannot leave here.112
Gabriel N., from Cibitoke, spent five months in the hospital following an automobile accident. He was fortunate to find a benefactor who paid his bill and he went home, even though he was not yet completely healed. He said, “The bill was too high for me to ever be able to pay myself.”113 Three months later, Gabriel N. fractured his leg and severely injured his mouth in a motorcycle accident. He stayed at home, hoping to heal on his own, but went back to the hospital after his wounds became infected. He had surgery to repair the fractured leg. “After that surgery, I told the doctor not to treat me too much,” he said, “because I knew I wouldn’t be able to pay for the costs of the treatment.” At that time his bill amounted to about U.S.$275. Doctors suggested surgery to repair the damage to his mouth, where several of his front teeth had been crushed into his lip and gums, making talking and eating difficult. Gabriel N. refused, reluctant to complicate his situation further. He remained detained, however, because he could not pay the $275.114
Delaying treatment can lead to further complications and the need for more extensive—and expensive—care. This ultimately increases the likelihood of detention once care is sought. For others, care is simply not sought at all, leading potentially to disability and even death.
106 Save the Children, “The Cost of Coping with Illness,” p. 3. The study was based on surveys done in households and at health facilities, focus group discussions, and interviews with key informants.
107 MSF, “Access to Health Care in Burundi,” p .46.
108 Ibid.
109 Human Rights Watch/APRODH interview with Gabriel N., Roi Khaled Hospital, Bujumbura, February 11, 2006.
110 Human Rights Watch/APRODH interview with father of Noah B., Roi Khaled Hospital, Bujumbura, February 11, 2006.
111 Human Rights Watch/APRODH interview with Josephine C., Prince Régent Charles Hospital, Bujumbura, February 13, 2006.
112 Human Rights Watch/APRODH interview with Olivia N., Roi Khaled hospital, Bujumbura, February 11, 2006.
113 Human Rights Watch/APRODH interview with Gabriel N., Roi Khaled Hospital, Bujumbura, February 11, 2006.
114 Ibid.