Janet Ogundepo writes about the ordeals of patients and their relatives who were victims of detention in hospitals over their inability to pay their bills
The joy of reuniting with her second twin baby shone through the eyes and voice of 36 years old Akpesiri Ojiko.
Ojiko, a native of Warri in Delta State, delivered twin babies, a boy and a girl, at a public medical facility in the state on November 17, 2022.
After the delivery, Ojiko was informed that one of the twins, the girl, needed to be referred to another hospital, as there was no bed space to adequately attend to her.
She told Saturday PUNCH that the baby was then referred to a private clinic and attended to.
However, when she visited the new hospital where her daughter was kept, she was told that her daughter would not be released until the bill of N383,500 was paid.
This situation, Ojiko said, made her depressed as she was not allowed to see her baby whenever she went to the hospital to drop food and diapers.
“I felt depressed and sad,” she said while recounting how she felt during the period without her baby.
On January 3, 2023, after a month of being separated from her baby, Ojiko finally got back her child following the intervention of a philanthropist, who offered to pay the bills.
“I felt relieved from the depression. I felt as if I just gave birth to my baby. I gave birth to my babies on November 17 and I was reunited with my daughter on January 3rd. It was a great day for me,” Ojiko said.
The trader in edible starch and now mother of three, added, “It was my second birth; my first child is a girl before I had the twins.
“I delivered my babies in Central Hospital, Warri. I was still in the labour room when my sister came to inform me that one of the babies was upstairs and the other one was taken to a clinic in a particular place.
“I wondered why they didn’t tell me first. They didn’t ask whether I had the money for it. My sister and my husband were the ones who were told to go with the baby to the clinic.
“I didn’t see my baby after the delivery. I would just go to the hospital where she was and drop food, diapers and wipes for her. I am happy now and relieved.”
She called on the government to come to the rescue of other women in her condition.
“Other patients like me would be referred to private hospitals and would not have the funds to pay. The doctor told me he was going to take my baby to an orphanage home if I didn’t pay,” she added.
On medical detention
Hospital detention is refusing to release living patients after their discharge has been medically or clinically certified due to their inability to pay or balance their bills.
But hospital detention is an abuse of women’s and children’s rights and contravenes national and international laws.
It contravenes the United Nations Convention on the Rights of the Child.
Article 11 of the International Covenant on Civil and Political Rights prohibits arbitrary detention, especially for non-payment of a debt.
A paper titled, ‘Medial Hostages: Detention of Women and Babies in Hospitals,” by Delan Devakumar, et al, stated that detention of women was a common problem and practice in Burundi, Cameroon, the Democratic Republic of Congo, Ghana, Kenya, Nigeria, the Philippines and Zimbabwe.
The paper stated that though the practice was common with pregnant women with complications that required an emergency intervention, it was not limited to maternal health.
It described the process as detrimental to maternal and child health with short and long-term complications for the infant.
The study also emphasised that the physical and mental health of the patients was at risk.
The research said although hospitals that were complicit provided the required care for patients, the victims were detained for days or months without end until their bills were paid.
It emphasised that the practice was an enabler of pregnant mothers’ visits to traditional birth attendants and cheaper health facilities.
The paper stressed that the practice persisted due to a “shortage of government funding to public hospitals, poor governance within the hospitals and direct out-of-pocket payments.”
It added that in Nigeria, out-of-pocket expenditure accounted for 67 per cent of total health expenditure, while the median for Africa was 49 per cent.
Consequently, patients without health insurance and with difficulty accessing remote health services were mostly victims of this act.
Another paper, ‘Hospital Detention Practices: Position Statement of a SIOP PODC Global Taskforce’ by Saskia Mostert, et al, and published by the National Library of Medicine, stated that reports of hospital detention cut across patients of all ages with acute conditions and chronic diseases, among others.
It surmised that the practice violated international human rights laws and often reflected “mismanagement, corruption, dysfunctional health-care system structures, inadequate health-insurance coverage and unfair waiver procedures warranting urgent attention.”
Despite the National Health Insurance Scheme to ensure every Nigerian had access to reduced health care services, Ojiko stated that she did not know of the scheme.
Intervention by philanthropists, NGOs
The joy of returning home with her newborn eluded a 27-year-old nursing mother, Blessing Bassey, over her inability to pay outstanding N95,000 hospital bill.
For seven months, Bassey was said to have slept on the floor of one of the wards in the hospital where she gave birth.
The PUNCH reported in October 2020 that the hospital management ordered nurses and doctors to ensure she and her daughter did not leave the hospital.
Efforts by her husband, who worked as a mechanic, to raise funds to foot the bill, Bassey said, were unsuccessful.
Still carrying the burden of her inability to pay, coupled with sleeping on the hospital floor, Bassey said, “I had not spent one month on the hospital bed after the CS when I was told to move to the floor. I had to spread my wrapper on the floor so that my baby and I could sleep and that’s where we have been sleeping for the past seven months.
“I don’t have any money on me. I beg people that come to visit other patients for money to feed myself and the baby.”
The Administrative Officer of the hospital, Salami Akindayo, when contacted, told The PUNCH that Bassey was not released from the hospital because other patients that had been in such situations reneged on their promise to repay their bills.
He said, “We had released patients who promised to pay, but they never did. So, we decided that any patient that does not pay the hospital bill won’t be discharged. The hospital has written letters to some organisations to ask if they can assist her; we’re still waiting for their response. I have presented her matter to the Ohaneze group and they promised to get back to us.”
Following PUNCH’s report, several non-governmental organisations and individuals reached out to settle Bassey’s bills and she was freed from the hospital.
In June 2020, a petition to the Minister of Health, Dr Osagie Ehanire, by two non-governmental organisations led to the discharge of two patients detained in a health facility in Osun State over their inability to pay their bills.
After the intervention, they were released and their bills were written off.
Earlier in 2017, a new mother, Rashidat Oluokun, was for four months detained at the hospital where she was delivered of twins for not being able to completely pay her hospital bill.
Nineteen-year-old Blessing Abosede, another woman, had her baby through a caesarean section in a hospital in Osun State.
But because she could not afford to pay the N150,000 bills, she was detained in the hospital for about 20 days.
Her husband, who was said to be a mechanic, was her hope of settling the funds but he refused to show up at the hospital.
Abosede had said, “If I am unable to raise the money by this weekend, I will be moved to the gate. I am hoping help will come and I will leave here with my child very soon.”
She stated that she had been able to feed through the goodwill of her grandmother, who brought her food while in the hospital.
The dead not spared
Last year, the intervention of the Medical Social Welfare Unit of the Lagos State University Teaching Hospital led to the release of the corpse of one Fatima Olamide.
The PUNCH learnt that the hospital held on to the corpse over an outstanding bill of N860,000.
LASUTH Chief Medical Director, Prof. Adetokunbo Fabamwo, in a statement by the hospital’s Public Affairs Officer, Olutayo Irantiola, had advised the bereaved family to meet with the MSWU.
The statement read in part, “We need to inform the family as well as the general public that all fees in LASUTH, as well as other state hospitals, are collected by an agency appointed by the state government.
“No medical director has the authority to waive any hospital fees incurred by either the living or the dead. The family should have used the existing hospital avenues through the Medical Social Welfare Unit to upscale its challenge instead of running to the press, thereby scandalising the hospital for no just cause.”
The father of the deceased, Shamusideen Shobowale, later told The PUNCH that the matter had been resolved and the hospital had promised to release the body to the family.
Following the intervention, the family was asked to pay N300,000 out of the N860,000 and then the corpse was released to the family for burial.
Social workers needed in hospitals
A professor of social work at the University of Lagos, Lagos State, Chinwe Nwanna, stated that social workers or social welfare services were needed departments in hospitals.
She added that they played a vital role in ensuring that indigent patients unable to settle their bills were investigated.
Nwanna said, “Social workers will do what we call social inquiry to ascertain that the person is indigent and cannot pay the hospital bill. When it is confirmed that the person cannot pay, what I know some hospitals do is that they look into a purse where philanthropic deeds are gathered and such monies are used for such patients.
“The social worker must carry out their investigation which is called social enquiry and not just visit the patient in the ward and interview them. They would also visit the patient’s home, interview the members of the family, look around, access the type of area of residence and interview their neighbours. If the person is a worker, they would interview the colleagues and employer before they now conclude that this person is indigent and cannot afford to pay the hospital bills.”
When this is ascertained, the don stated that a discussion on how the bills would be paid would then be determined.
She added that private medical facilities faced this problem due to the lack of a social work unit or social workers.
Nwanna said, “In fact, some of them don’t even know that it is necessary to employ social workers and so they hold the patient back for some months and ask them to do some certain work until the money is realised.
“Also, some hospitals would not allow the situation to get to that extent because most of the time, the patients are being asked to deposit money frequently and when they cannot pay the deposit, the hospital will stop the treatment and discharge the patient. So, it may not get to the extent of having to work for the hospital for certain months.”
She clarified that patients under the National Health Insurance Scheme would not experience such because the scheme covered some aspects of their medication.
Another professor of social work at the University of Nigeria, Nsukka, Enugu State, Uzoma Okoye, said the situation was caused by some patients’ abuse of the privileges of the Hippocratic Oath, which compelled a doctor to administer treatment to a patient.
Okoye said, “If everyone comes to the hospital and does not pay, will the hospital remain there tomorrow? I know that a doctor must treat a sick person, the next job is now for the social workers to ensure that doctors get back their money after treatment.”
She explained that detained patients would be unhappy and experienced stigmatisation.
According to Okoye, “In Nigeria today, there are many resource systems that are available that people are not aware of. The social workers must direct the patients to where they can get some of these resources. They act as a support to clients who are not able to pay their bills.”
“There are immediate family resources; these are extended families. The social worker can act as a link and write to some of the family members informing them of their relative’s sickness and their inability to pay their bills. Most of the time, the extended family might not know of the situation and this step by the social worker will facilitate them coming around to pay,” she added.
She said social workers could also reach out to the patient’s immediate communities and helped in raising funds.
The don explained that the dearth of social workers in most private and some government hospitals contributed to the detention of indigent patients and relatives.
Okoye said, “In Nigeria today, only Federal Government-owned hospitals employ social workers. State and private hospitals do not employ social workers and it becomes a problem because the social workers cannot avail themselves of these types of services they can render.
“The time has come for state and privately owned hospitals to start to employ social workers in their medical teams. Apart from helping to raise funds to ensure people get treated, there are a thousand and one things social workers can do.
“Among the medical team, there can be conflicts and social workers can help to mediate such conflicts. They can as well counsel patients who might have psycho-social problems and this will help them in responding to treatment.”
Action illegal – Rights lawyer
A professor of Human Rights Law at the University of Calabar, Cross River State, Jacob Dada, stated that the practice of restraining a patient or family member on account of the inability of the patient to settle a hospital bill was “unlawful, illegal and reprehensible.”
He added that such actions violated the rights of the victims as enshrined in the constitution of the Federal Republic of Nigeria.
Dada said, “It is unconstitutional and it constitutes an actionable wrong. The Constitution unequivocally guarantees the right to personal liberty and bodily autonomy and integrity. It, therefore, amounts to a violation of this right to restrain or detain a patient on account of the inability of the patient to pay his bill. A lien can be imposed on goods to ensure payment of debt. Human beings not being chattels cannot be restrained to recover medical bills.”
He noted that hospitals could redeem their payments from defaulting patients through judicial proceedings, adding that detained patients or relatives could seek redress in a court of law.
‘Medical services not run on goodwill’
The President of the Healthcare Providers Association of Nigeria, Dr Austine Aipoh, stated that the tradition of holding patients hostage due to incomplete payment of bills was immoral and unconstitutional.
He recalled that before now, patients in Federal Government hospitals, who could not pay their bills, had social workers called to ascertain that the patient was indigent to pay their bills.
Aipoh further explained that since private medical practices were not run on goodwill and government subsidy, indigent patients should therefore seek medical care and attention at government hospitals and facilities where it was cheaper and with several interventions.
The HPAN president said, “The social work department carries out some surveys around the home of the patient to confirm that the patient is indigent. In this situation, the Federal Government rules out the bill. This is made possible because of the social workers going to confirm the patient as truly indigent.
“People should, however, understand that private hospitals are run by individuals. It is a business enterprise and every business enterprise will want to make a profit so people should have that at the back of their minds.”
Aipoh added that the NHIS Act which made it compulsory for Nigerians to have health insurance was a step in resolving the issue.
He urged the government to ensure the adequate implementation and adoption of the health insurance policy.
The doctor canvassed for a health bank where hospitals could have easy and low interest-rate access to loans.
“The government should help private health facilities by making sure that they can get loans from banks at low-digit interest rates. This will help hospitals to import equipment, buy drugs and other things that will make things easy for the populace. The man who goes to collect a loan at an astronomical interest rate will want to ensure he gets his money back because the bank will not listen that treated patients did not pay their bills,” Aipoh said.
He urged the government to strengthen the social work department in hospitals.
Hospitals do not detain patients – GMDs
Commenting on the issue, the National President of the Guild of Medical Directors, Dr Raymond Kuti, stated that it was illegal for hospitals to detain patients over bills.
He added that relatives of patients and an approved fund by the Federal Government could prevent such things from happening.
Kuti, however, decried the “bottlenecks and bureaucracy” that marred the process of accessing the fund.
The GMD president said, “Hospitals do not detain patients because it is illegal to do such. Most hospitals treat patients even without any financial commitments from the patients (that is the law).
“Unfortunately, some patients may not be able to offset the bills after the treatment. It is the duty of the family (extended and immediate) to help the patients out.
“There is even a Federal Government-approved fund for such cases. The government has not been forthcoming in helping hospitals access this fund due to bottlenecks and bureaucracy. The best way out is to form a public/private hospitals committee to see the proper disbursements of this fund as when needed.”
He called for the set-up of a proper implementation committee to ensure the process of emergency treatment of patients was flawless.
“Once an implementation committee is formed to agree on the format of bills presentations, vetting and payment processing, the emergency treatment for patients should be flawless,” Kuti said.
The GMD president tasked the government to invest in private health facilities for the provision of affordable medical services.
He said, “My take is that the government (both federal and state) should push more funds into the private practice sector. Seven out of 10 Nigerians use and patronise private hospitals and the funds channelled into the public hospitals have not made the populace go to the government hospitals.
“I believe the infrastructural and recurrent expenditure should be shifted to the private sector as single-digit syndicated loans under the auspices of selected commercial banks. This will help private practitioners to give cheaper and affordable medical services to the populace.”
Kuti further decried the overlap and lack of clear-cut function of the three tiers of the health sector.
“The functions of teaching hospitals have been usurped by medical needs in the country. Teaching hospitals are not created for treating basic medical needs of the populace (malaria, elective caesarean section); teaching hospitals are for complicated, super-specialised cases but their job descriptions have been eroded to general hospitals,” he said.