Health-care providers' perspectives on health-insurance access, waiving procedures, and hospital detention practices in Kenya

Hospital Detention for the Inability to Pay: A Qualitative Study of Patient Experiences in Cameroon

INTRODUCTION

Equitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills.

METHODS

In-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants.

RESULTS

Living in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts.

CONCLUSIONS

The experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study

BACKGROUND

Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

METHODS

An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

RESULTS

Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

CONCLUSION

While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

Determinants of delayed childhood cancer care in low- and middle-income countries: A systematic review

Early access to care is essential to improve survival rates for childhood cancer. This study evaluates the determinants of delays in childhood cancer care in low- and middle-income countries (LMICs) through a systematic review of the literature. We proposed a novel Three-Delay framework specific to childhood cancer in LMICs by summarizing 43 determinants and 24 risk factors of delayed cancer care from 95 studies. Traditional medicine, household income, lack of transportation, rural population, parental education, and travel distance influenced most domains of our framework. Our novel framework can be used as a policy tool toward improving cancer care and outcomes for children in LMICs.

Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background

Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.

Methods

A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.

Results

346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office.

Conclusions

Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

Global Problem of Hospital Detention Practices

Although an official definition by the World Health Organization (WHO) or any other authority is currently lacking, hospital detention practices (HDP) can be described as: "refusing release of either living patients after medical discharge is clinically indicated or refusing release of bodies of deceased patients if families are unable to pay their hospital bills." Reports of HDP are very scarce and lack consistent terminology. Consequently, the problem’s scale is unknown. This study aimed to find evidence of HDP worldwide, explore characteristics of HDP reports, and compare countries with or without reports. PubMed and Google were examined for relevant English, Spanish, and French publications up to January 2019. Of 195 countries, HDP reports were found in 46 countries (24%) in Africa, Asia, South-America, Europe, and North-America. Most reports were published by journalists in newspapers. In most countries reports concern living adults and children who are imprisoned in public hospitals. A majority (52%) of reports were of individuals detained for at least a month. Almost all countries, with or without HDP reports, have signed the Universal Declaration of Human Rights. Countries with reported HDP have larger population size (P <.001), worse Corruption Perception Index score (P=.025), higher out-of-pocket expenditure (P =.024), lower Universal Health Coverage Index score (P =.015), and worse Press Freedom Index score (P =.012). We conclude that HDP are more widespread than currently acknowledged. Urgent intervention by stakeholders is required to stop HDP.