Strategies to end hospital detentions

Financial strategies have been proposed to end the practice of detaining patients in health facilities for failure to pay their health bills. Many of these strategies have been implemented in various countries with a considerable degree of success. These include both medium and long term measures and may involve a combination of several options.

Immediate measures 
An immediate measure that health units can implement for patients who have failed to clear their hospital bills is to offer a delayed payment schedule after discharging the patient. 

Social workers or community health workers should support patients in this process or act as negotiators in a delayed payment plan.

This is a painful option for both the health units and families of the patient as it not a solution in itself; the patient or the family of the patient, who are already financially constrained, must still pay the accrued bill.

Funding health units 
Additional funding needs to be mobilised for the health units that chronically face the challenge of detaining patients to recover funds to support the operations thereof.

Additional funding may be from the central government or from donors. Health units should also be allowed to use their funds flexibly; some hospitals that have been known to detain patients receive donor funding earmarked for specific activities. 

Donor funding 
Increased flexibility in allocating donor funding could allow these hospitals to shift these resources to exempt patients who cannot fully meet the costs of their treatment. 

Donors should also be encouraged to make funding conditional upon hospital detention not being practiced. These measures, however, do not address the root causes of hospital detentions.

Budgets 
Health facilities should be encouraged to set aside a designated budget for covering the treatment costs of patients who are unable to settle their bills.

A budget line may also be created to manage the bills of patients who cannot afford their health bills, including a specific claims mechanism through which health providers can be compensated for exempting patients. This budget line should be designed to cater for emergency care and should be managed on a case by case basis.

User fee exemption
It is important that user fee exemption mechanisms should be introduced for vulnerable patients, with a clear definition of who is vulnerable and hence eligible. And there should be a clear mechanism in the society to identify such people. 

In many countries free health care services have also been introduced with particular focus on maternal and child health services, including immunization services.

And to make these free services feasible adequate and specific financial resources need to be provided to the health units, more so to avoid stock-outs.

It is also prudent to provide funds to cater for high-cost treatments such as cancer treatment and management of disasters. These funds need to be managed by specific and specialised bodies and these funds should be sustainable.

The main disadvantage here is that such specific funds potentially increase fragmentation in pooling, which will lead to higher administrative costs.

Insurance schemes 
Insurance schemes are excellent to minimise the challenges of detaining patients. Awareness about such schemes and the benefits should be explained to the potential beneficiaries. 

These schemes should be properly managed from the time of enrolment and management of funds. It is important that payments to the health providers should be timely.

Insurance schemes need the full backing and support of the central and local governments and are profitable when adequate facilities and personnel are in place for the provision of quality health services.

For these schemes to be effective, health insurance should be made compulsory or automatic for everybody. The schemes should be merged so that everybody is in the same pool. People in the informal sector should be in the same pool as formal sector employees.

These schemes have the potential to increase the redistributive capacity in health. This is the potential to redistribute funds from individuals with lower health needs and lower health risks to individuals with higher health needs and risks.

Insurance schemes are however prone to abuse by the managers as well as service providers hen there are inadequate checks and balances. In countries with comprehensive health insurance schemes, detention of patients for failure to clear their health bills is unheard of.

Insurance schemes should be operated in such a way that the payment methods and rates should be the same for all people regardless of their contributions. The benefits of the insurance policy must be explicitly defined and aligned with the patients’ needs. 

Fixed schedules 
Fixed, transparent and published fee schedules inform patients of the cost of treatment. It may be important to provide a cap on the billing; patients should not be billed above the agreed rate of reimbursement by the Insurance Company.

Governments need to address the health financing challenges and causes of poor performance in the health sector and provide financial protection and equity in access to health. 

Health services need to be adequately and sustainably funded. Health financing must consider the vulnerable population right from the planning stage.

Health financing cannot be considered in isolation; it is necessary to improve revenue collection especially in form of taxes. Higher government spending on health is generally associated with fewer incidences of detention of patients for failure to clear their health bills.    

To be continued
   
Patients’ needs must be aligned 

Dr Sylvester Onzivua
Medicine,  Law & You