A High Price to Pay

Detention of Poor Patients in Burundian Hospitals

Acronyms

APRODHAssociation for the Promotion of Human Rights and Detained Persons CAMIllness insurance card

CEDAWConvention on the Elimination of all Forms of Discrimination against

Women

CNDD-FDDNational Council for the Defense of Democracy-Forces for the Defense

of Democracy

CNRSNational Commission for the Reintegration of the Displaced

ECEuropean Commission

ECHOEuropean Commission Humanitarian Office

EDFEuropean Development Fund

FBUBurundian francs

FNLNational Liberation Forces

ICCPRInternational Covenant on Civil and Political Rights

ICESCRInternational Covenant on Economic, Social and Cultural Rights

MSFMdecins Sans Frontires

ONUBUnited Nations Operation in Burundi

PARESIProject for the Support of the Repatriation and Reintegration of War Affected Persons

PRSPPoverty Reduction Strategy Paper

UNDPUnited Nations Development Programme

UNICEFUnited Nations Childrens' Fund

WHOWorld Health Organisation

Map of Burundi

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.

-Eighteen-year-old woman held with her baby at Louis Rwagasore Clinic, Bujumbura

One day, I tried to get out of the hospital and I was stopped because I had not paid my bill yet. When I see a doctor, I always ask to leave, since I am not getting any medical treatment. The guards threaten me. Whenever I come near the exit, they tell me that I cannot leave because I have not settled the bill.

-Twenty-two-year-old man who had a car accident, held at Prince RegentCharlesHospital, Bujumbura

Hospital managers have to ensure financial stability. If the directors don't pay attention, they have to shut down the hospital.

-Dr. Julien Kamyo, chef de cabinet in the Ministry of Health

I. Summary

Over the past few years, public hospitals in Burundi have detained hundreds of patients who were unable to pay their hospital bills. Patients were routinely held for several weeks or months, and in one case for over a year. They were kept on the wards, guarded by security staff of the hospital, or were held in a separate room. Detained patients without money often went hungry if not fed by the charity of others. Some were forced to vacate their beds and sleep on the floor to make space for paying patients. Often, indigent patients did not receive further medical treatment once the bill had reached a large amount, even if they needed additional medical care, including basic follow-up care such as removing stitches after a caesarean delivery.

The detention of patients unable to pay their bills both results from and draws attention to broader problems of health care in Burundi. Although one of the poorest nations in the world, Burundi implemented in 2002 a cost recovery system as part of its delivery of health care services. The aim was to make the system more financially efficient. Patients must pay all medical costs, such as medical consultations, tests, medicines, supplies, and their stay at a hospital. There is a health insurance and a waiver system for the destitute, meant to assist the poorest in meeting medical expenses, but both function badly and in some places not at all. Public hospitals do not receive enough income from patient fees, direct donations and funds from the government to allow proper functioning, and they lack well-trained medical staff, equipment, and medicine. The Burundian health sector is plagued not just by huge funding shortfalls, but by inconsistent state funding, and by fraud and corruption that shrinks an already small pie. Hospital staff, who have been typically grossly underpaid, are among those involved in the financial mismanagement and corruption.

Most detained patients have had surgery, such as following an accident or as a result of birth complications, while others suffer from chronic diseases, including HIV/AIDS. The patients are very poor, often belong to vulnerable groups like orphans, widows, single mothers, or those displaced by Burundi's civil war, and lack family or larger networks of social support. Some of those detained are obliged to sell their last belongings in order to pay their bills and get released. Others find a benefactor (bienfaiteur), a wealthy individual or charity, to pay their expenses and allow them to return home.

On May 1, 2006, President Pierre Nkurunziza announced that maternal health care and health care for children under the age of five would henceforth be free of charge. If sustainable, this measure should end hospital detentions of some women and young children. However, it provides no relief for other patients unable to pay their bills who constitute more than half the persons typically detained.

Official responses to hospital detentions have been confused and contradictory, vacillating between denial, justification, and misrepresentation. Hospital managers and government officials often minimize the problem, claiming that those who cannot pay their bills are released after a few days. Most refuse to use the term "detention" to describe the practice. At the same time they justify the detentions as necessary, saying hospitals would be forced to close their doors if they could not use such means to oblige patients to pay their bills. Because government officials do not consider detention of patients to be a human rights violation, they take no measures to make hospital staff halt the practice, nor do they punish them for continuing it.

International human rights law provides that everyone has the right to liberty and security of person. Arbitrary detention of any kind is a violation of article 9 of the International Covenant on Civil and Political Rights (ICCPR), to which Burundi is a party. The detention of anyone for non-payment of a debt specifically violates ICCPR article 11, which states: "No one shall be imprisoned merely on the ground of inability to fulfill a contractual obligation." The detention in crowded conditions with scarce food violates the right of persons not to be detained under inhumane conditions.

Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR), to which Burundi is a party, requires states to progressively realize the right to the highest attainable standard of health. The detention of hospital patients who cannot pay their bills has important implications for health care in Burundi. Hospital detention discourages indigent people from seeking health care in the first place, subjects patients to having their treatment curtailed or ended when it is apparent to doctors and hospital staff that the patient cannot pay, and incarcerates recovering patients in conditions that may exacerbate their health problems.

The issue of hospital detentions also reflects the broader problem of access to health care for all members of Burundian society. While recent steps to end fees for maternity care and young children are welcome, the government should urgently provide health structures with the means to respond to the increased demands. More broadly, the government must ensure that funding for health care reaches the population most at risk, and take steps to reduce corruption in the health care system.

With the Millennium Development Goals, the international community has committed itself to reaching ambitious targets in the area of health, such as reducing child mortality, improving maternal health, and combating HIV/AIDS and malaria. In Burundi, international donors fund a large proportion of Burundi's health sector, and directly influence health policy decisions. Despite these commitments, donors have not pressed effectively for an end to the detention of patients, and for improved access to health care for the poor.

The Heavily Indebted Poor Countries Initiative might bring some change. Under this initiative, Burundi got debt relief on an interim basis during 2005, and the government has been able to almost triple the health budget as a result. The country is currently completing several economic measures, with a view to finalizing the debt relief agreement in late 2006. International financial institutions and other donors should ensure that such funds are used to improve access to health care and to end hospital detentions.

II. Recommendations

To the Government of Burundi

• Immediately effect the release of all current hospital detainees.
• Order an end to the practice of detaining insolvent patients in hospitals, and monitor hospitals to ensure that the practice does not continue. Take disciplinary or legal action as appropriate against persons responsible for hospital detentions.
• Propose legislation to make the detention of debtors, including insolvent patients in hospitals, illegal and punishable by law.
• Progressively implement the right to health by adopting measures to improve access to health care for the poor. Existing systems of cost exemption for the poor are inadequate and should either be reformed, or replaced with a new health care system.Reforms that should be considered include abolishing user fees for basic health care or the introduction of mutuelles, a community-based health insurance system. Any health policy reform should focus on access to basic health care for the poor and focus on the four essential elements regarding the right to health- availability, accessibility, acceptability and quality. In particular consider making health policy changes in the following areas:

• Urgently take measures to implement the new policy of free maternal health care and health care for children under the age of five. Ensure that primary health care systems are strengthened to respond to the increased demands, with access to staff, medicine, and equipment made available to all on an equitable basis. Develop a long-term plan on how to make this policy effective and link it with the broader health policy.
• Any future reform to abolish user fees should be prepared carefully as part of a larger policy, should rely on sufficient funding that is sought in advance, and should inform and involve stakeholders at all levels during the planning phase.
• Clarify plans to introduce a community-based health insurance and, if they are pursued, develop a strategy on how to include the poor in this scheme and ensure high levels of enrollment.
• Clarify plans to subsidize health care for the poor, as announced in the government health policy plan. Any cost exemption mechanism should be well publicized with clear criteria, administered in a transparent way, and include a patient's right to appeal decisions.
• Inform the public about ways to obtain assistance from the Support Project for Returnees (Projet d'Appui au Rapatriement et la Rintgration des Sinistrs, PARESI) and from the Fund for the Displaced at the National Commission for the Reintegration of the Displaced (Commission Nationale pour la Rintegration des Sinistrs, CNRS), and any other cost exemption systems established.

• In the Poverty Reduction Strategy Paper (PRSP), lay out specific plans on how to end hospital detentions and reform the health system to improve access to basic health care for the poor.

To the newly established Government Anti-Corruption Brigade

• Investigate corruption in the health sector, including in hospitals and illegal sales of medicine, and ensure that those accused of crimes be promptly brought to trial according to international standards of due process.

To Donor Countries

• Urge the government of Burundi to end the detention of poor patients in hospitals immediately.
• Provide technical expertise to reform or replace existing cost exemption mechanisms and assist the government to develop health policy reforms that would better ensure access to health care for the poor, as outlined above.
• Provide positive incentives to the government of Burundi to dedicate a greater portion of debt relief funds to the health sector, particularly to improve access to health care for the poor.
• Ensure that development assistance for Burundi's health care system specifically addresses the problems of access to health care by the poor, which previously was funded through humanitarian assistance programs.

To The World Bank

• Urge that funds made available to the health sector through debt relief are used to end the detention of poor patients in hospital and to improve access to health services for the poor, including through health policy reforms, as those outlined above.
• Urge the government of Burundi to enforce laws on corruption and fraud and make use of the newly established government Anti-Corruption Brigade specifically to address misuse of funds in the health sector.
• Urge that development assistance for Burundi's health care system specifically addresses the problems of access to health care by the poor, which previously was funded through humanitarian assistance programs.
• Ensure that the PRSP and any future Poverty Reduction Support Credit (PRSC) for Burundi contain detailed plans for improving access to health care for the poor and fighting corruption in the health sector.

To the International Monetary Fund (IMF)

• Urge that funds made available to the health sector through debt relief are used to end hospital detentions and to improve access to health services for the poor, including through health policy reforms, as those outlined above.
• Ensure that the PRSP and any future Poverty Reduction Growth Facility for Burundi contain detailed plans for improving access to health care for the poor and fighting corruption in the health sector.

To the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health

• Investigate the issue of detention of poor patients in hospitals in Burundi and other parts of Africa, and make recommendations to governments on how to end the practice.

III. Methodology

Researchers from Human Rights Watch and the Burundian Association for the Promotion of Human Rights and Detained Persons (Association pour la Protection des Droits Humains et des Personnes Dtenues, APRODH) planned and carried out the research for this report. They interviewed 41 victims of hospital detention in six public hospitals: Prince RgentCharlesHospital in Bujumbura; Prince Louis Rwagasore Clinic in Bujumbura; RoiKhaledHospital (the Centre Hospitalo-Universitaire de Kamenge) in Bujumbura; GitegaHospital (Gitega province, central Burundi); NgoziHospital (Ngozi province, northern Burundi) and MuramvyaHospital (Muramvya province, central Burundi). They also interviewed hospital staff, including hospital directors, financial and administrative directors, doctors, nurses, and social workers. In addition, they interviewed representatives of local and international organizations working in the healthcare sector, public health experts, representatives of donor governments and agencies, and officials of the Ministry of Public Health and the Ministry of National Solidarity, Human Rights and Gender. APRODH observers interviewed hospital managers and others in five other hospitals in three other provinces (KaruziHospital, MuyingaHospital, and Bururi, Rumonge and MatanaHospitals in Bururi province).[1]

We interviewed most patients when they were still in hospital detention, in February 2006.When citing the length of detention we generally refer to the amount of time the patient had been held at the time of the interview; we were not in a position comprehensively to monitor how much longer they may have subsequently spent in detention. Pseudonyms are used in this report for all hospital patients, to protect the identities.

Researchers also used quantitative data provided by the hospitals about the loss of income from insolvent patients. Although the format and detail of the reports varied significantly, researchers were able to analyze statistics from eight hospitals to determine changes over time, including, for example, the number of detained patients and the groups most commonly affected by detention.

IV. Background: Health, Poverty and Conflict

Political and socio-economic situation in Burundi: Moving from conflict to post-conflict

The current Burundian government under President Pierre Nkurunziza was elected in August 2005, following a decade of civil war and a long process of political transition. The dominant force in the government was formerly the country's largest rebel group, the National Council for the Defense of Democracy-Forces for the Defense of Democracy (Conseil national pour la dfense de la dmocratie-Forces pour la dfense de la dmocratie, CNDD-FDD). The CNDD-FDD portrays itself as a popular movement addressing the needs of the poor.

Another rebel movement, the National Liberation Forces (Forces de libration nationale, FNL), continued its war against the government, particularly in areas near the national capital Bujumbura. Both FNL and government forces continue to commit serious violations of international humanitarian law (the laws of war), including attacks on civilians.[2] As of July 2006 the FNL and the government were engaged in peace talks.[3]

The long and violent conflict has had a destructive impact on society, the economy and the health sector. Burundi is now one of the least developed countries (LDC) in the world, ranking at 169 of 177 on the 2005 United Nations Development Programme's Human Development Index.[4] The yearly gross national income per capita is at U.S.$90.[5]

The health sector in Burundi

During the period of armed conflict, health care deteriorated as shown by such key indicators as maternal mortality, infant mortality, vaccination rate and medical staff per inhabitant. Maternal mortality is at 1,000 deaths per 100,000 live births, and constitutes one of the most acute public health problems in the country, according to the World Health Organization (WHO).[6] Infant mortality is at 114 per 1,000 live births (11.4 percent), and mortality of children under five is at 190 per 1,000 live births (19 percent)-these are among the highest in the world. The adult prevalence of HIV is 6 percent.[7] The health system is plagued by a lack of trained staff and resources to pay them, as well as by a lack of medications and modern equipment.[8] Many skilled medical staff leave the public sector in Burundi for better-paid jobs in international nongovernmental organizations (NGOs) or private health institutions, or in neighboring Rwanda.[9]

Access to health care was made more difficult for poor Burundians by the adoption of a cost recovery system in February 2002. Patients, regardless of their means, must pay all medical costs, such as medical consultations, tests, medicines, supplies, and their stay at a hospital.[10] Only five of seventeen provinces operate alternative models of health financing.[11]

The cost recovery system revived a health policy from before the war that had not been properly put into practice. Before the 1980s, health care services were free of charge in Burundi. In 1988, the government started a policy of reform and decentralization: It introduced a pre-payment system at the community level and established management autonomy in the health structures at the provincial level, which meant that hospitals were running their operations with a degree of independence (autonomie de gestion) and were obliged to raise some of their funds themselves, while still receiving some state subsidy.[12] The 1988 reform also aimed to gradually implement a cost recovery scheme in all health structures, but was halted during the following decade of armed conflict.[13]

Health policies in Burundi are partly the result of the government's own priorities: the government devotes only a small fraction of the budget to health-in 2005 just 2.7 percent.[14] They are also the result of the World Bank's policies across Africa during the 1980s and 1990s, which intended to bridge a "health sector resource gap" through user fees. The strategy was given added weight by the Bamako Initiative, developed by the WHO and UNICEF and adopted by African governments in 1987.[15] The Bamako Initiative aimed at improving access to primary health care through involving communities in managing and financing health care. It was hoped that cost recovery at the community level would increase the revenue of the health sector, promote an efficient use of resources, and increase equity-that is, overcome differences in access to health care.[16] The introduction of user fees was seen as a step towards rebuilding a sustainable health care system, including in countries wrecked by armed conflict.[17]

Studies show that the cost-recovery initiatives for health financing rarely had the desired impact. Cost recovery systems in Africa raised less revenue than expected, and there is little evidence that they improved the efficiency of health care systems.[18] In Burundi, access to the health system is limited, with about one million people-17 percent of the population-being excluded from health care altogether.[19] Because of this limited access, hospitals have a low occupancy rate, despite the enormous needs of the population.[20] The World Bank no longer promotes cost recovery as the sole option, and donors have moved to a more nuanced position.[21] Yet, cost recovery is still the most common health financing model in Africa.

Several mechanisms were meant to ease the pressure on the poor in Burundi, but have failed to do so: the indigence card (carte d'indigence),which waives health fees for the very poor; a voucher that waives health fees for displaced people; and the illness insurance card (carte d'assurance maladie, CAM), which can be bought for the equivalent of about $0.50[22] and reduces the medical bill by 80 percent. Both in Burundi and elsewhere in Africa, such programs have rarely been effective in expanding access to health care.[23]

Availability and access to health care

Burundi is a relatively small country and 80 percent of the population lives within five kilometers of a health center.[24] Still, transport-particularly prompt transport-to a health facility poses a problem for those lacking money. For example, 39-year-old Michelle N. could not get transport when she went into labor at night. She lives in Gatumba, about six miles from Bujumbura. She was able to reach the hospital only at 5 a.m. the next morning, by which point her baby had died. She was then unconscious for two days.[25]

Some patients seeking help find that the nearest facility lacks the staff or equipment needed for appropriate care, and must move on to another hospital.This was the case of 13-year-old Noah B., who injured his ankle while playing football. His father took him to the nearest hospital, at Kayanza, only to be told that the hospital could not perform the surgery Noah needed. They borrowed money for a taxi to RoiKhaledHospital in the capital.[26] Many women in labor whom we interviewed during or following hospital detention were also sent from one hospital to another. Researchers interviewed one woman who while in labor had gone to four health facilities before being admitted.[27]

The poor may confront the further obstacle of lacking money to pay the fee for admission to a hospital. Most hospitals require patients to pay fees before receiving care. Fees vary according to hospital and according to the evaluation of the case, with large hospitals in Bujumbura charging the equivalent of approximately $10 for simple cases and up to $100 for more complicated cases or ones where surgery will be required.[28] Outside the capital the admission fees are lower. At Ngozi hospital, for example, the regular admission fee is approximately $5.[29] Anne K. is a woman who could not pay the admission fee at Prince RgentCharlesHospital in Bujumbura at the birth of her second child:

For medical reasons, I cannot give birth normally, so I must have a caesarean delivery. At the birth of my first child, I found a benefactor who took me to the MSF [Mdecins Sans Frontires] clinic and I had a caesarean delivery there. This time there was no benefactor. I went to RoiKhaledHospital but they refused to admit me because I had no money to pay the admission fee. They sent me to Prince Louis Rwagasore Clinic. There, they were reluctant to do the caesarean delivery so soon after the first one. So I went to Prince RgentCharlesHospital. They, too, refused me because I had no money. I thought to myself, "There is nothing else I can do. If I have to die, I will die." I left, but then the doctor ran after me and said, "I will do it."[30]

As the example of Anne K. shows, some persons needing care were admitted even if they lacked money to pay the admission fee. Such decisions, however, were the exceptions to the usual rule.Gabriel N., a man who suffered two road accidents, was also rejected because he could not pay the admission fee:

On November 22, 2005, I came here to the hospital [Roi Khaled]. The doctors refused to treat me because I could not pay the admission fee. I stayed outside the hospital for a few days, trying to get treatment. One day a man passed by and asked me why I had been there so long. I explained my problem and showed him my injury and he paid the admission fee of 100,000 francs [FBU, $100].[31]

Getting admitted to a hospital is by no means the same as getting medical treatment. Burundi's hospitals are poorly equipped and staffed, and medical care is often insufficient or inappropriate.[32]

Hospital detentions in Africa

The detention of poor patients by hospitals is found in numerous other African countries where the health system is based on a cost recovery system and hospitals try to force insolvent patients to pay their bills. The practice is found in countries including Kenya, Ghana, the Democratic Republic of Congo (DRC), and there has been at least one instance in Zimbabwe, affecting multiple patients.

Wealthy patients in Kenya can get private health insurance, high quality medical treatment and hospital accommodation, but most Kenyans cannot afford such insurance and are relegated to substandard hospitals where they have to pay for services and end up detained if they fail to do so.[33] In Ghana, women who have delivered babies are frequently kept in the hospital until they pay the costs for childbirth. The country is in the process of introducing a flat fee for poor and vulnerable patients but this will not cover high-cost surgery including caesarean deliveries.[34] In the DRC, a local human rights organization focused on the situation of young mothers in hospital on International Women's Day 2006, showing both the growing frequency of detentions of women in hospitals and their rejection by family members who do not want to be forced to pay for them. Among the detained women are rape victims who are completely isolated and unlikely to find anyone to pay for them.[35] The detention of patients is not the rule in Zimbabwe, but in one case, 28 mothers and their newborn babies were detained at HarareHospital. The charges for maternal health care had just risen and the women were unable to pay the bills for childbirth.[36]

A young mother and her newborn baby, detained at Prince Louis Rwagasore Clinic following a caesarean section. 2006 Jehad Nga

V. Detention in Public Hospitals for Lack of Payment

Numbers of hospital detainees

Statistics kept by Burundian hospitals show that they have been struggling with the problem of unpaid bills for years, and that the detention of patients is not a new or ad-hoc measure.[37] Hospitals short on funds began detaining patients unable to pay their bills in the 1990s,[38] when cost recovery was already practiced in some health facilities, and have done so with increasing frequency since the wholesale introduction of the cost recovery system in 2002.

During 2005 hundreds of patients were detained in Burundian hospitals. Data from seven of the thirty-five public hospitals in Burundi combined show 1,076 cases of patients who were unable to pay their bills in 2005 (see table 1). This figure includes both those who were detained and those who managed to leave without paying their bills. Given that this sample represents only a fifth of the public hospitals in Burundi, the total number of patients unable to pay their bills was certainly far higher. At the Prince RgentCharlesHospital alone, 621 patients were detained during 2005. Of those, 354 patients had their bills eventually paid by benefactors, and the other 267 found a way to leave the hospital without paying.

Figures on unpaid bills at RoiKhaledHospital show varying numbers since 2001 (see table 2), with an average shortfall of about U.S.$39,000 per year. At other hospitals, similar figures are not available, but there are statistics documenting the loss of income in 2005 (see table 3). At Prince RgentCharlesHospital, staff have also documented a steep rise in the number of bills paid by benefactors: a total of 44 for the three years 2001-03; 85 in 2004 alone, and 352 in 2005.[39] It can be assumed that in most cases benefactors paid bills of patients who were unable to pay their bills and had been detained. It is likely that the rise represents a real increase in the number of hospital detainees, though other factors-such as increased media attention to the problem-might have exaggerated this trend. [40] Statistics of the much smaller Prince Louis Rwagasore Clinic show an increase in the number of indigent persons listed in their books: 11 in 2001, 18 in 2002, 16 in 2003, 16 in 2004, 39 in 2005 (table 4).

Table 1

Number of patients who did not pay their bills

at seven Burundian hospitals in 2005

Table 2

Unpaid bills at RoiKhaledHospital, Bujumbura, 2001-2005 (FBU)

(1,000,000 FBU = approximately U.S.$1,000)[43]

2001	2002	2003	2004	2005
23,334,446	64,150,549	34,297,612	25,666,425	47,769,382

Table 3

Unpaid bills at seven hospitals[44] in 2005 (FBU)

Table 4

Indigent[46] patients and their bills at Prince Louis Rwangasore Clinic, Bujumbura, 2001-2005 (FBU)

2001	2002	2003	2004	2005
Number of indigent patients	11	18	16	16	39
Bills by indigent patients	1,716,744	1,753,456	2,568,408	2,586,682	7,629,331

Medical problems leading to detention

Data from four hospitals show that during 2005, surgical patients represented about two-thirds of all indigent patients. The remaining one-third of indigent patients were mostly from two types of ward: internal medicine (16 percent) and pediatrics (10 percent). Of indigent patients overall, 35 percent were women who had delivered their babies by caesarean section.[47]

Surgery

It is not surprising that many victims of hospital detention were patients who had undergone surgery, given that surgery is often more expensive than ordinary medical care. In addition to women undergoing caesarean deliveries (discussed below), we interviewed several men who had suffered bad road accidents, a woman with breast cancer, and the mother of a baby who needed urgent surgery on the intestines.

-

Flix M. has been in detained in Prince RgentCharlesHospital for over one year, after having already spent a year there for treatment. The thirteen-year-old boy was hit by a vehicle when he was playing with other children. He suffered a serious leg injury and underwent surgery. His father allegedly embezzled the insurance funds destined for his hospital care, and his mother had been unable to find a way to pay for the treatment. As of August 2006, Flix M. continued to be detained. 2006 Jehad Nga

Patients suffering from long-term or chronic diseases, including HIV/AIDS

Patients with long-term or chronic diseases also incurred high hospital costs that they could not pay and that resulted in their detention. People with chronic conditions are often unable to work and therefore depend on others to pay their hospital bills. One such example was Christian B., an 18-year-old young man who suffered from a serious skin disease. He was an orphan, and the uncle who was looking after him could not pay his hospital bill. He said local authorities refused to issue an indigence card for him, saying the card was not being used any more.[48] Christian B. told us,

I have had a skin disease for about two years now. I went to Bujumbura for treatment but they refused to treat me, so I came here. I was given medicine at the hospital and it got better. I was put in an isolated room. I could not pay the bill but around Christmas 2005 I was released along with other people. I had a bill of over 240,000 FBU [$240]. Now the illness has come back. I came back to the hospital.[49]

There are about 220,000 people[50] living with HIV/AIDS and 46,000 people in need of AIDS treatment in Burundi, and many of them also face detention in hospital.[51] The Global Fund to Fight AIDS, Tuberculosis and Malaria is currently providing about $21 million to the Burundian government for treatment and prevention. Under this program, antiretroviral drugs are provided for free.[52] The World Bank runs a multi-sector program on HIV/AIDS in Burundi of $36 million over a period of four years.[53]But even with this level of international assistance, only about 6,400 persons received the life-saving drugs without cost in 2005, while about 40,000 more needed the drugs but were unable to benefit from them due to the inaccessibility of treatment sites and other reasons.[54] Many of those without antiretroviral drugs seek medical care for opportunistic diseases such as tuberculosis, pneumonia, fungal infections or other diseases, and they usually have to pay for treatment.[55] According to the medical director in the Ministry in Charge of the Fight against AIDS, around 70 percent of internal medicine patients have HIV/AIDS.[56] Records of four hospitals show that about 15 percent of all indigent patients in 2005 were internal medicine patients (see table 5).

Because of reluctance to discuss AIDS and absence of any indication on hospital records, we collected no data on the frequency with which AIDS patients were detained for unpaid bills.

We spoke to one patient who identified herself as suffering from AIDS. She was detained for two months for failing to pay for treatment for a fractured arm and leg.[57]

Table 5

Number of patients unable to pay their bills[58] by ward

(medical department) in 2005

RoiKhaledHospital, Bujumbura	Prince Louis Rwagasore Clinic, Bujumbura	Prince Rgent Charles Hospital, Bujumbura	MuramvyaHospital, Muramvya province
Total	422	39	267	47
Gynecology/ Obstetrics	91	24	137	15
Surgery	100	6	47	13
Internal Medicine	64	1	42	14
Pediatry	48	4	22	3
Intensive Careand Emergency	46	1	6	0
Operating theatre (anaesthetics etc.)	64	3	5	2
Other	9	0	8	0

This newborn boy urgently needed surgery after birth. As the mother could not pay for it, she and the baby got detained at Roi Khaled Hospital. 2006 Jehad Nga

Maternal health problems before May 1, 2006

Before the presidential order on maternal and child health care on May 1, 2006, a significant proportion of hospital detainees were women who had suffered complications in connection with the birth of a child, such as those who delivered by caesarean section.

While 35 percent of indigent patients unable to pay their bills were women who had recently given birth, the situation varied considerably by hospital.[59] At the time of one visit to Prince Louis Rwagasore Clinic to research this report, in February 2006, all the detainees were women who had delivered by caesarean section, and according to the guards, this was often the situation.[60]

At 1,000 deaths per 100,000 live births, the maternal mortality rate in Burundi is alarming. About 80 percent of deliveries take place at home without the assistance of a trained health professional.[61] There is no functioning referral system that ensures timely access to hospitals in case of complications. Emergency obstetric equipment is not available as widely as it should be. Research has shown that lack of access to emergency obstetric care is one of the main causes of maternal mortality worldwide.[62]

Infant and child health problems

Another important group among those detained-about 10 percent-were infants and children. As mentioned above, infant and child mortality rates in Burundi are among the highest in the world. This is due in large part to malaria, diarrhea, pneumonia, and HIV/AIDS.

Malaria is responsible for 50 percent of hospital deaths of children under age five. Acute respiratory illness and diarrhea are also frequent causes of death in young children, mostly due to the lack of potable water, inadequate sanitation, and poor housing conditions. About 44 percent of children are malnourished or stunted, and 56 percent suffer from anemia. Approximately 27,000 children under the age of fifteen have HIV/AIDS. Immunization rates for the deadliest childhood diseases have declined in recent years.[63] Experts have found that about two-thirds of child deaths could be averted if proven existing health interventions could be made available.[64]

The introduction of free health care for women giving birth and children under five constitutes an important step towards improving maternal and infant health, and ending detention among patients of this vulnerable group.

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A young mother and her newborn baby, detained at Prince Louis Rwagasore Clinic following a caesarean section. 2006 Jehad Nga

"Since you have not paid, we will imprison you": Experiences of patients

The moment when hospital staff hand patients their bill can mark the transition from hospital treatment to hospital detention. Hospital staff-mostly nurses and doctors-impose the detention and attempt to justify it to the patients. Hospital managers-medical doctors as well as administrators-also justified the detention to Human Rights Watch researchers.[65] Hospital staff may detain patients because they believe it is necessary in order to keep the hospital functioning. Nonetheless, in doing so they violate their own ethics[66] and their conduct leads to a breach of trust in a privileged relationship. They also become agents of a human rights abuse.

Christine K., an 18-year-old who gave birth by caesarean section, recounted her experience. At the time of the interview she had been three weeks in detention. She said,

When I got the bill, the doctor said to me, "Since you have not paid, we will imprison you." 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.[67]

Pierre B. is a middle-aged man who was hit by a car when walking home after church service in November 2005, and held for one month at Prince RgentCharlesHospital when we spoke to him. He explained,

My leg and face were crushed. I was unconscious for one day. In January, I was given a bill of 205,445 [FBU, $205]. When I said that I cannot pay this, I was told to stay.[68]

Josephine C., whose baby was sick, tried to plead with the hospital director for her release but he only confirmed her detention:

I spoke with the director of the hospital and I told him that I couldn't pay. He said that I cannot leave the hospital, that I have no right to leave the hospital until I paid the bills.[69]

A young mother and her newborn baby, detained at RoiKhaledHospital following a caesarean section.

2006 Jehad Nga

Some patients, such as Josephine C., knew about the risk of detention. Other patients were caught off guard by the high costs of their treatment. Claudine N., an 18-year-old mother of two, did not expect a high bill for the delivery of her baby. At the time of the interview, she had been held for six weeks:

I got the bill on December 28, 2006, and it was over 116,000 FBU [$116]. I did not expect that because Roi Khaled is a public hospital. The doctor said to me, "We cannot do this differently, you have to stay here."[70]

The length of detention of patients varied greatly, depending in part on whether the patient can find a benefactor to pay the bill or find a way to evade surveillance and leave.Most patients interviewed were detained for a period of several weeks or months, but a few were kept for about a year.

Surveillance

In most hospitals, detained patients are able to move around the building but are prevented from leaving the premises by security guards from private security companies contracted by the hospitals.[71] According to several patients, security guards on the grounds generally knew the names and faces of those detained, often because they had been pointed out to them by hospital staff. Several detainees said guards followed them around even within the hospital premises.[72] As a consequence, patients could not leave even for a moment, unless they got express permission to do so. As one victim put it, "I am detained because I cannot pack up my things and leave. To leave means to escape."[73]

Thodore N. was detained for two weeks in Prince RgentCharlesHospital after he received treatment for an accident injury. He told us,

I am really imprisoned here. One day, I tried to get out of the hospital and I was stopped because I have not paid my bill yet. When I see a doctor, I always ask to leave, since I am not getting any medical treatment. The guards threaten me. Whenever I come near the exit, they tell me that I cannot leave because I have not settled the bill.[74]

Patients in other hospitals had similar experiences. A patient who was held for three months in GitegaHospital complained that whenever he would leave his bed to sit in the sunshine, guards or other hospital staff would come and ask him where he was going.[75]

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A patient detained at Prince RgentCharlesHospital. 2006 Jehad Nga

At Ngozi Hospital, the director of finance and administration explained how surveillance by a private security company is essential. Either patients stay until they find someone who pays, or-if they flee-the company pays a fine. Because of the large numbers of people escaping, the hospital has negotiated a modus vivendi with the security company, reducing the fine to a sum that is acceptable to them:

We have come to an arrangement with the security company. For us, [using the security company] is a way of cutting down on the costs. Otherwise the hospital would have to be shut down.[76]

Seventeen-year-old Flicit G. had been held for two weeks at Ngozi hospital when she spoke to us. She described what surveillance meant for her:

I am detained because I cannot gather the money to pay the bill. I cannot leave or move around. I am watched everywhere because they always think I want to escape. But it is not good to run away. When they catch you, you cannot go back for treatment. I would be punished for that.[77]

Other detainees in Ngozi and elsewhere confirmed that they did not escape because they feared that they or their children might fall ill at some future time and be refused treatment.[78] They preferred to stay detained in the hospital than to risk having no possibility of hospitalization during the next illness.

Nevertheless, some patients found ways to leave hospital. At Prince RgentCharlesHospital, 191 did so between January and August 2005. Many left at night, and one person had left disguised in the clothes of a Muslim woman.[79] According to one patient, two persons caught trying to leave surreptitiously were mocked and insulted by nurses.[80]

Prince Louis Rwagasore Clinic: Detention in a lock-up

Detainees at Prince Louis Rwagasore Clinic are held in a separate room with a guard at the door and are not allowed out of the room. When visited by researchers on February 14, 2006, about 20 people were in the room, about a dozen mothers with newborn babies who were confined there, plus some family members who were assisting or visiting them. A filthy toilet and shower constituted the sanitary facilities for all the detainees and visitors.

AgnsI., a 23-year-old woman who delivered her baby by caesarean section on January 17, 2006, could not pay her bill equivalent to $235 and so was moved to the lock-up, where she had stayed for one month when we spoke to her. She said she was told to stay in the room until she found money or a benefactor. She continued, "I have tried to get the money together but I have not managed. I stay here, I cannot get out. I cannot even go out to dry the clothes I have washed."[81]

According to those guarding the room, most detainees were women who had had birth complications. Many were held until the babies were able to hold up their heads, meaning two or three months. When patients left without paying, the guards sometimes followed them home.[82]

At Prince Louis Rwagasore Clinic, detainees are held in a separate room with a guard at the door. At the time of our visit, the room held about twenty people. The sanitary conditions in the room were deplorable: there was a filthy toilet and a shower, and they could not be used in private because they belonged to the room. One person who had been held for a month, said: "After I got the bill I was directly taken here and told 'Stay here. When you have money or there is a benefactor, you can leave.'" 2006 Jehad Nga

Size of bills

Bills vary in size according to the services received by the patients. Even amounts that seem relatively small may exceed the monthly income of a poor Burundian. Flicit G., a 17-year-old mother, was held at NgoziHospital because she could not pay the equivalent of $9 for the treatment of her baby, who was sick with malaria.[83] At the opposite extreme, David S. from Rutana province was hospitalized after he had a bicycle accident, and now faced a bill equivalent to $1,750, an enormous sum by the standards of ordinary Burundians. He said,

We arrived in Gitega hospital on June 15, 2004. At that moment I had nothing because the rebels had come to my house and looted almost everything. I was operated [on] here, but there was no improvement. Three months ago, they came to see me and told me to pay 1,750,000 FBU [$1,750]. I don't see how I can pay this bill, because I do not even have a plot of land that I can sell.[84]

When the bills are very high, it is harder to find benefactors. Therefore, patients who have had costly surgery or other expensive treatment are likely to be held for longer.

Conditions of detention

Lack of medical treatment

Hospital officials sometimes refuse further treatment to patients who have shown themselves unable to pay the cost of their medical care. At Prince Louis Rwagasore Clinic two young mothers who were detained following caesarean deliveries asked medical staff to treat their newborn babies, who had respiratory problems and were vomiting. According to the women, the staff refused. They said that doctors and nurses never entered the lock-up at Prince Louis Rwagasore Clinic.[85]

Michelle N., whose case was mentioned earlier, gave birth to a stillborn baby at Prince RgentCharlesHospital and was unconscious for two days after the birth. When she could not pay the bill she was moved to ward nine where many detainees were kept, and where she stayed for about ten weeks. There was no assistance from medical staff:

I got a fever and asked for treatment, but it was refused. The nurse said that I would have to pay the 10,000 FBU [$10] admission fee to obtain the registration form. Luckily the fever went away.[86]

At GitegaHospital, nurses allegedly went one step further and refused to remove the stitches that closed the incisions from caesarean deliveries. If stitches are not removed, the incision may get infected. Emrite N., a poor farmer from Mwaro province, gave birth at Gitega hospital to a child who died after two weeks. In addition to coping with her grief, she was overwhelmed by a bill equivalent to $45 that she was unable to pay. She said, "I was told that they cannot remove the stitches until I have paid the bill. The stitches are now hurting. I worry that I will get an infection, and I feel trapped here."[87]

Sometimes hospitals also refuse to carry out treatments on patients who will be unable to pay the costs, probably because they want to avoid expenditures which they will not be able to recover. Dorothe H., a widow who had recently returned from living as a refugee in Tanzania, was taken in by a family in Bujumbura and survived by selling tomatoes. She had the misfortune to fall and break her hip but did not seek treatment immediately. When her condition worsened, she said she went to two private clinics where she was refused, at the second one because she lacked the equivalent of roughly $100 needed for the admission fee. She entered a public hospital where doctors did some tests and advised surgery to replace her hip. Since the cost would be $400, clearly beyond her means, the surgery did not take place. Unable to pay her bill, even without the surgery, she remains in the hospital where she can hobble only a few steps at a time with the help of a cane.[88]

Lack of food

Almost all detainees complained of hunger. Hospitals in Burundi generally do not provide meals to patients, who depend on family members, charities or benefactors to give them food and drink. Human Rights Watch observed that those detained were particularly affected, due to their indigence and the length of their stay at the hospital, and those who had no family members nearby and willing to help or who did not find assistance elsewhere just went hungry. AgnsI., a young mother who had undergone a caesarean delivery, said that her relatives only rarely brought food and that patients had to buy even the water needed to make coffee or tea.[89] Another young mother who had been detained for two months at a different hospital said, "For me it is difficult to get food. My family is tired of bringing food here. I have not even had tea today. I am waiting for God's help."[90]

In some hospitals, nuns provided food once a day to detainees who were grateful but pointed out that the food was of poor quality and insufficient in quantity, in particular for patients recovering from illness or surgery.

Losing the bed

Sometimes detained patients had to vacate their beds for patients who could pay. Gabriel N., mentioned above, told us after five weeks of detention at RoiKhaledHospital:

I feel like I am in a prison here. I lost my bed last night to a sick person who could pay. So I slept on the floor. I don't know when I will have another bed. They promised me that when a sick person leaves, I will get a bed.[91]

Several detained persons in NgoziHospital complained of the same practice.[92] Christian B., the young man with a serious skin disease, mentioned above, who was hospitalized at Nogzi for about six months in 2005, was detained for non-payment of a bill of over $240. He reported having to sleep on the cement floor when paying patients arrived needing a bed.[93] Also in NgoziHospital in March 2006, four other detained patients had been obliged to vacate their beds. One was a 65-year old widow. Two others were 17-year-old Flicit G. and 20-year-old Valentine Z., both of whom were sleeping on thin mats on the cement ground with their babies.[94]

Children in hospital detention

Children are not spared from hospital detention. Mothers stay with babies and small children while older children are sometimes held by themselves, with little or no support from the hospital.[95]

Mohamed S.

Three-year-old Mohamed S. was burnt badly all over his body when he was playing with other children and they accidentally tipped over a pot of boiling beans. At the time he was visiting his grandmother, who took him to hospital and had stayed with him since. They arrived at the hospital on November 16, 2005, and were detained for about six weeks when they spoke to us. Mohamed's grandmother told us,

I received a first, incomplete bill at the end of December. It was not complete because they continued treatment. I was afraid of seeing it. It was more than 400,000 FBU [$400]. I have asked for the final bill because I am worried about the amount of money. We have been told we are not allowed to leave, even though the boy is now healed.[96]

The situation has been particularly difficult for the grandmother because her son, the child's father, holds her responsible for the accident and refuses to provide money for the hospital costs.

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Three-year-old Mohamed S. was burnt badly all over his body when he was playing with other children and they accidentally tipped over a pot of boiling beans. At the time he was visiting his grandmother, who took him to the hospital and stayed with him since. When we met them, they had been detained in Roi Khaled Hospital for six weeks. Mohamed's grandmother, who can be seen in the background, explained: "We have been told we are not allowed to leave, even though the boy is now healed." 2006 Jehad Nga

Noah B.

Thirteen-year-old Noah B. was injured while playing football with his friends. He broke some bones in his ankle and needed surgery. He is one of eleven children and his parents are farmers. His mother and siblings stayed in their home province of Muramvya while Noah's father accompanied him to RoiKhaledHospital in Bujumbura and took care of him there during the treatment and the detention that followed. At the time of the interview, Noah B. had been held for about six weeks. His father told us,

We owe 438,785 FBU [$438] for Noah's surgery. We are waiting for abenefactor because we will never have that much money. The situation now is very hard. I have pretty much abandoned my house because I have spent all my time here. I have two younger children at school but I had to abandon everything and leave it all behind to be in the hospital with Noah.

I am free, I can come and go from this hospital, but my son cannot leave. He cannot escape. The doctors threaten us, telling us that soon Noah will lose his bed and will have to sleep on the floor so that a paying person can have the bed.[97]

Noah told us that he was in his first year of school when the injury happened, and that he wants to return to school as soon as possible.[98]

Flix M.

Flix M., aged 13, has been detained at Prince RegentCharlesHospital for over a year, after having already spent a year there for treatment for injuries suffered when a vehicle belonging to the African Union mission in Burundi struck him in July 2004. His father spent or used the money provided by the United Nations Operation in Burundi (ONUB), the successor agency to the African Union, for the boy's care. His mother, who struggled to find the money necessary to pay just for Felix's medicine, was unable to find a way to pay the rest of the hospital charges. Felix said,

I was in seventh grade in school but now I am not going to school any more. Now I am healed, there is just one small injury left. My family cannot pay the bill. I have been told that I cannot leave unless the bill is paid. I am detained here because I cannot go past the exit. The nuns give me food twice a day.[99]

The truth of Felix's predicament emerged as a result of research done for this report.[100] Although Felix's father admitted to taking the money, he had nothing left of it.[101] As of August 2006, Felix was still detained at the hospital.

Adle A.

Twelve-year-old Adle A. from Cibitoke province suffered a broken leg in an automobile accident in January 2006 when returning home from school. Following surgery, she had been detained for over four months at Prince RgentCharlesHospital when we interviewed her. She said,

I have no father and my mother is a farmer. My mother stays with me in the hospital here and tries to find things for us to eat. It is very hard. We have no family here, everyone is back in Cibitoke. We have no land so we cannot sell anything to pay the bills. Even to cultivate crops, we rent a plot. Right now, I have my bed but I am afraid that I will lose it. The conditions here in the hospital are very difficult. Sometimes I go for two weeks without soap No one told me that if I couldn't pay, I would have to stay in the hospital. It's just accepted as normal that you just cannot leave if you haven't paid the bill.[102]

Refusal to release dead bodies

When patients die and medical bills have not been settled, hospitals frequently refuse to hand over the bodies to family members. As a burial according to Burundian tradition becomes impossible, it is hard for mourners to express their grief in culturally acceptable ways. Francine U. died in December 2005 of malaria during pregnancy. The nurse at RoiKhaledHospital who cared for her said:

She came too late, and she died. Her brother was with her but he left when she died. He did not pay her bill so her body stayed in the morgue. She is still there.[103]

The nurse confirmed that bodies are often held in the morgue for long periods if relatives cannot pay the bills, but said that if there are bodies at the morgue for a very long time, eventually "the hospital management will deal with it and bury them."[104] According to research by APRODH, there were seven bodies held at the morgue of RoiKhaledHospital in August 2005. The relatives of the deceased had not paid the bills, which totaled more than $1,400.[105]

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 Mdecins Sans Frontires 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 Flix 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 Flix 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 RoiKhaledHospital 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.

VII. The Government Response

The government has an immediate duty to end the detention of poor patients for non-payment of their medical bills, and a longer-range responsibility to progressively realize the right to health of its citizens. Senior government officials and hospital staff alike often deny or minimize the problem of hospital detentions. The chef de cabinet in the Ministry of Health told us,

In my opinion, this is not detention or imprisonment. It is a long waiting period. If people cannot pay at all, they are allowed to go. They might overstay two to three days or a week.[115]

The director of Prince Louis Rwagasore Clinic said,

We have a small hospital so we let people [who cannot pay] leave because we realize they cannot pay, or because they find a benefactor. As soon as people have recovered, they are released. We just keep the bills. One speaks about prisoners but in reality there are no prisoners. They themselves say tomorrow, the day after tomorrow a person will come and pay for me.[116]

The director of RoiKhaledHospital declared that "this is not a prison," and said that people who cannot pay their bills are released.[117] Several hospital managers questioned the use of the word "detention."[118]

The reality was different, as shown above. In nine of the eleven hospitals we visited, patients were detained, and many of them for far longer than one week. While denying or minimizing the problem, government and hospital officials contradicted themselves by attempting to justify hospital detentions. According to the chef de cabinet in the Ministry of Health:

Hospitals managers have to ensure financial stability. If the directors don't pay attention, they have to shut down the hospital.[119]

The chef de cabinet in the Ministry of National Solidarity, as well as several hospital managers, echoed this argument, pointing out that hospitals would have to close if they lacked the funds to operate. Others suggested the alternative was to refuse treatment.[120] Government and hospital officials alike presented the issue as deplorable but refused to take responsibility for it.

In December 2005, the Ministry of National Solidarity-apparently at the initiative of the president-ordered the release of patients and announced it would pay for their bills. The move was widely reported in the press, and one formerly detained patient we spoke to expressed her gratitude to the president for this initiative. The minister's chef de cabinet reportedly told hospitals that they should release their detainees and send the bills to her Ministry. But when asked by the press whether detentions in hospitals would now end, she replied evasively,

There is no reason to believe that the problem of insolvability will be resolved if the majority of the population continues to live in conditions of extreme poverty. To eradicate this phenomenon completely, one needs a series of projects that allow people to pay for their medical treatment.[121]

To the dismay of hospital officials, the government did not reimburse the bills as promised. By May 2006, the government owed the four major hospitals over U.S.$50,000.[122] According to the chef de cabinet, the responsibility for the non-payment lay not with her Ministry, but with the Crdit de Relance Economique, a World Bank-financed fund for reconstruction activities.[123]

Ad-hoc measures such as the December 2005 "charitable" release of detainees in hospitals may bring the government good publicity but do nothing to solve the real problem. Shortly after Christmas 2005, hospitals were again filling up with insolvent patients in detention.

VIII. Government Measures Aimed to Improve Access to Health Care

The failure of health insurance

The Burundian health system uses mechanisms that are supposed to increase access to health care for the poor. If functioning effectively, these mechanisms could allow some of the poor to pay their medical expenses and avoid hospital detention. An illness insurance card (carte d'assurance maladie, CAM) costs U.S.$0.50 per year and covers 80 percent of some, but not all medical, costs.[124] The CAM is a voluntary, community-based prepayment scheme that is open to all. It is particularly meant for the poor, and complements a compulsory insurance scheme for civil servants.[125]

In practice, health insurance rarely, if ever, works well enough to keep poor people from detention in hospitals. Recognized as ineffective, the card is little used in most of the country and has been abolished in five of seventeen provinces. The 2005 National Plan for Health Development says that "the population does not have confidence in the illness insurance card (CAM) any more This card is in the process of disappearing in most parts of the country."[126] Only 1 percent of patients surveyed by the MSF study mentioned above had the insurance card.[127]

In our own interviews, we spoke with over 20 hospital detainees who had the insurance card but still ended up in hospital detention. Many patients did not have insurance when they entered the hospital, but obtained it with the help of their family on the day they were hospitalized, or later. Hospitals sometimes rejected the illness insurance card when it was bought at this late date. Claudine N., whose newborn baby needed lifesaving surgery, told us,

I obtained the insurance card after I came to hospital. My husband got it for me at the commune, and it cost 500 FBU [$0.50]. But they did not accept it at the hospital. You are supposed to get it before you come.[128]

Large hospitals like RoiKhaledHospital and Prince RgentHospital also excluded medical equipment and supplies from the costs covered by insurance. Dorothe H., mentioned above, needed a hip replacement but was told that her insurance did not cover the $400 cost.[129] Other hospitals, like Prince Louis Rwagasore Clinic, do not accept the insurance at all.[130]

Some provincial hospitals, like those at Gitega and Ngozi,[131] accepted the insurance and Gitega Hospital even promoted it. Yet even in these hospitals patients were detained if they could not pay the remaining 20 percent of the costs. Such was the case of two women detained at Gitega Hospital after having had surgery for birth complications.[132]

The failure of the exemption system for the poor

In Burundi, people with no financial means at their disposal, defined as "indigent" by their local administrators, may receive an indigence card (carte d'indigence) that makes them exempt from paying health care costs, as well as from educational and other fees. Since 2003, those who have been displaced by the war may also qualify for a voucher that exempts them from health care costs.

However, criteria for receiving both the indigence card and the vouchers are not officially defined, leaving the process lacking in transparency and open to arbitrary decisions. According to MSF, "the exemption system has become a sectoral and clientelistic practice."[133] These faults in the procedure make it even more likely that the systems meant to provide relief to the poor actually deliver little but token help to a few.

The indigence card

When poor people receive the indigence card, the commune of residence of such persons is then required to pay their medical bills. The government points to the system as proof of its will to assist the needy, but the system rarely provides exemptions for the poor, and simply hides lack of effective government action. A local administrator in Bujumbura-rural province explained to us,

We as communal administrators are charged with handing out the indigence card. We know who is vulnerable: orphans, very old people, people without land, people who live from begging, sometimes people without children to support them. If someone like this gets sick, neighbors take them to the commune. For small things, we can take them to the health center run by GVC and ECHO [Gruppo Voluntariato Civile and the European Commission's Humanitarian Aid Office, both humanitarian agencies]. But for big things, like an operation, we cannot help them now. Even if I gave them the necessary document, it does not have any meaning. The commune is responsible for paying these bills and we do not have a budget for that.[134]

In its recent National Plan for Health Development (Plan national de dveloppement sanitaire), the government itself admits that most communes do not provide indigence cards any more.[135]

Most hospital detainees we interviewed did not have an indigence card and had not even heard about it. The study by Save the Children, mentioned above, found that only about 10 percent of all people surveyed knew there was a system to exempt the poor from health care costs, and only 4 percent of the poorest households interviewed knew about it.[136] Our research found that those who did have the indigence card, or tried to get it, encountered difficulties. As noted above, Christian B., an orphan suffering from a chronic skin disease, was told by his local administrator that the card was no longer in use.[137]

Other patients who had the card had it rejected by the hospital. For example, Dsire N., a woman from Bubanza province who came to Roi Khaled Hospital because she was pregnant and had a tumour, gave birth prematurely and the child needed an incubator. As she was destitute, she was detained-four weeks at the time of the interview-and did not get the tumour treated. She said that she had an indigence card but that the hospital had rejected it.[138] The director of Roi Khaled hospital told us that "the hospital does not accept the indigence card because the state does not reimburse its expenses." He added that displaced people and returnees could get vouchers until the end of 2005, but not any more.[139] A nurse at the same hospital confirmed that staff had been instructed not to accept the indigence card.[140] This is also the case for other hospitals.[141]

The voucher for displaced people

In recent years displaced people and returnees with an indigence card were eligible for vouchers at the National Commission for the Reintegration of the Displaced (Commission Nationale pour la Rintegration des Sinistrs,CNRS).[142] The CNRS was an agency established under the Arusha Accords to aid "all displaced, regrouped and dispersed persons and returnees."[143] Funded by the government and donors, it functioned from mid-2003 to December 2005.[144]

Local administrators sometimes handed out indigence cards when they were confident that the CNRS would reimburse them. However, this was not often the case, as a local administrator criticized:

For a while, the CNRS was able to pay some bills. But you had to find someone who could "do gymnastics" to ever get any money there. If I thought a family had someone who could manage to get help from CNRS, I would give them the indigence card and sometimes they could get some money, but often not.[145]

Other officials familiar with the process echoed his concern about the "management and money problems" at the agency.[146]

The procedure for obtaining vouchers was such a burdensome and complex process that few potential recipients pursued it to the end.[147]If they did obtain a voucher, it could be used at only three hospitals, all in Bujumbura. For a patient to be permitted to leave the hospital at the conclusion of treatment, the hospitals would have to agree to accept the voucher and then transmit the bills to the office of the CNRS to be reimbursed.[148] Poorly designed, the system was also badly managed and some funds, according to officials involved, were misused.[149]

The CNRS, a structure of the transitional government, ended when the newly elected government took power, but a government body called PARESI has been created to succeed it, and the Fund for Victims continues to exist, reassigned to the Ministry of National Solidarity, Human Rights, and Gender. According to the chef de cabinet of the Ministry, the fund held 500 million FBU in 2006 ($500,000).[150] The criteria for receiving assistance are unclear, in particular whether only displaced people and returnees are eligible for help or whether other needy persons may also apply. According to an official charged with distributing vouchers, displaced and repatriated people are often better treated and have better access to free medical care than other indigent people. When there is a lot of media attention on a certain case, for example if a woman has triplets, the Ministry will help her, but in general other needy people will be turned away.[151]

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A patient detained at Prince RgentCharlesHospital. 2006 Jehad Nga

Alternatives to hospital detention

Some hospitals have found ways other than detention to assure payment of bills, though these alternatives can create other problems for patients. Hospitals in Muyinga (northeastern Burundi) and Matana (southern Burundi) keep the identity cards of patients who are unable pay.[152]Such former patients then feel pressure to pay because security forces frequently ask to see identity cards, and anyone without one may be considered suspicious and even taken as a possible supporter of the FNL rebels. When an indebted patient has a bicycle, the hospital in Muyinga also retains this essential means of transport in order to increase pressure to discharge the debt.[153]

In some health centers staff get former patients to work off their debt by cultivating fields belonging to the health center.[154] Staff of the Prince Louis Rwagasore Clinic allow patients with stable employment to leave once they agree to have the money owed deducted from their salaries and paid directly to the hospital by their employers.[155] This strategy is useful only in urban settings where patients are salaried workers.

Some facilities supported by international NGOs operate a different model of health financing: the patients pay a percentage of the costs, as in Makamba province where they pay 50 percent of the medicine plus cost of treatment, or a flat fee, as in Karuzi, Cankuzo, Bujumbura-rural and Ruyigi provinces, where patients pay an all-inclusive charge ranging from 50 to 500 FBU ($0.05 to $0.50).[156] As a result, detention of patients is unusual in these hospitals. At Buhiga Hospital in Karuzi, where patients pay 300 FBU [$0.30] for out-patient treatment and 500 FBU [$0.50] for hospitalization, there were no detainees at the time of a visit by some of our research team to the hospital in March 2006. According to the financial and administrative director, there were patients who could not pay the flat fee, but they are treated at Karuzi nevertheless.[157] In Bururi province, the Dutch agency Cordaid started a new scheme for indigent patients in January 2006, sponsoring medicine and consultations, and soon after there were no hospital detainees there.[158]

Free care for women giving birth and small children: The May 1 presidential directive

On Labor Day, May 1, 2006, President Nkurunziza declared that all maternal health care and treatment for children under five years old would henceforth be free of charge.He also announced pay rises for public service employees, and the creation of an anti-corruption brigade.[159]

The ruling CNDD-FDD portrays itself as a popular movement addressing the needs of the poor. Shortly after coming to power, the new government abolished primary school fees and introduced free and compulsory primary education.[160] The government health plan of December 2005 focused on improving maternal and infant health through improved obstetric care at health centers and hospitals; the creation of a fund for caesarean deliveries and complicated births; improved antenatal care; subsidies for medicine for the poor; and health care for children under five years old.[161]

The introduction of free health care for pregnant women, mothers and small children is part of the government's self-proclaimed effort to reach out to the poor.[162] Perhaps more importantly, it also aims to show donors the government's willingness and ability to use funds well. It constitutes concrete progress towards two Millennium Development Goals-reducing child and maternal mortality.Under the Heavily Indebted Poor Countries Initiative, a country's debt can be reduced if certain economic and social conditions are fulfilled. Burundi is currently getting debt relief on an interim basis, and it is striving to qualify for permanent debt relief. According to one hospital manager, "The government has received debt relief funds, and now they need to be used."[163]

Some observers have also noted that increased pressure regarding the detention of hospital patients might have played into the decision.[164] Prior to the announcement of the reform, the Burundian government and the World Bank were discussing how to best use the $10 million gained from debt relief, and the release of detained patients was one of the issues that arose.[165]

While the directive on free maternal and child health appears to be a very good idea, in practice it has caused serious problems.

An increased burden on the health system

During the first days of May 2006, thousands of pregnant women and parents of sick children made their way to the nearest hospital to benefit from the reform. According to a manager at Prince Louis Rwagasore Clinic in Bujumbura:

Our hospital is overwhelmed with patients, and we have insufficient capacity. We have four tables for delivery and sometimes ten women arrive at the same moment, so you can imagine the problem. We have sometimes run out of sterilization equipment and sent women elsewhere.[166]

At Bururi Hospital, the number of patients in the maternity ward rose from a daily average of 14 a day to at least 40.At KayanzaHospital, where there was already an acute lack of medical staff, the single doctor able to perform caesarean deliveries was overwhelmed.[167]RumongeHospital ran out of medicine or supplies only days after the presidential directive.[168]RoiKhaledHospital ran out of essential materials and had to ask suppliers to fill their orders without immediate payment.[169] As hospitals were overstretched, some patients were denied treatment. A woman with a miscarriage died at Roi Khaled Hospital, after medical staff in this and other locations reportedly turned her away.[170]

Many ordinary Burundians have expressed enthusiasm for the initiative. However patients have also criticized that hospitals do not always pay for the medicine for beneficiaries.[171] The reform foresees free medicine only for those future mothers and small children who are hospitalized; outpatients-those who do not stay at the hospital-have to pay for their medicine themselves.[172]

One of the main problems of the May 1 presidential directive was the lack of preparation for the reform. Hospitals learned of the change on the radio, which meant that they had no chance to prepare in advance for the influx of new patients.[173] Even the chef de cabinet in the Ministry of Health recognized this problem:"When the President declared free health care [for women giving birth and children under five], the hospitals were not ready in terms of medicine, equipment, staff numbers and housing capacity. Now we are dealing with these problems."[174] Many health administrators and hospital managers also criticized the way the reform was launched so suddenly, a sentiment shared by representatives of donor nations as well.[175]

According to the World Health Organization, the government and donors decided that about $3 million of the $10 million to be made available in the context of debt relief were to go to essential medicines and health care for children and costs of childbirth. Some of these funds could be used to pay for maternal and child health care[176] and other funds might have an indirect impact on access to health care. But funds would still be insufficient to pay for the new initiative, which were not covered in the regular budget.[177] The Ministry of Health may ask donors for more support but first, said one official, "we have to negotiate with the government itself to show the gap in funding."[178] By early August 2006, the Ministry had managed to get some additional government funds, but these "are not sufficient at all" and the government continued to seek further funds.[179] In late June hospitals began sending their bills for the costs of the new program to the government, anxious to see whether they would be reimbursed as promised. Bills at Prince Louis Rwagasore Clinic and Roi Khaled Hospital were roughly $20,000 each.[180] By early August they had not been reimbursed.[181]

The introduction of free maternal and child health care constitutes an important step towards the progressive realization of the right to health, in particular achieving the reduction of the stillbirth rate and infant mortality.[182] But the policy will fail if the government does not urgently take the measures to ensure the program's sustainability and increase staff, equipment and medicine throughout the country. Furthermore, the government must embed the new, badly prepared change in the context of a larger health policy.

Impact on hospital detentions

The May 1 reform meant that women giving birth and children under five years old are no longer detained in hospitals, thus significantly reducing (by about one third) the number of persons suffering from this abuse. In June 2006, for example, there were no women with birth complications or children under five detained at Roi Khaled and Prince Rgent Charles Hospitals.

The presidential directive also spurred other initiatives. The Ministry of National Solidarity, Human Rights and Gender paid about $13,000 to free women with birth complications and children under five who had been detained at Roi Khaled Hospital between January and May 2006.[183]

Yet the majority of detainees have not benefited from the reform as it does not apply to them. Women with problems unrelated to childbirth, children over the age of five, and men continue to be detained. In late June 2006, 36 patients were held at Roi Khaled Hospital and 41 at Prince Rgent Charles Hospital.[184] A staff member at Prince Louis Rwagasore Clinic also confirmed that the practice continued at his hospital.[185]

Among those held at RoiKhaledHospital was Jerme N., a 17-year-old boy who suffered a serious leg infection, and who could not walk. He was detained for almost one month at the time of the interview, and told us,

My mother left here and sold a piece of our land to help pay for the medicine. We had to pay for the medicine up-front before the surgery could even be done, so she sold the land for 300,000 FBU [$300] to pay for the medicine. By the end of March, I felt much better. I have now been completely healed for a month but I cannot leave the hospital because I have the bill of more than 700,000 FBU [$700] for the operation. The doctor came and told me that I am healed but that I cannot leave because I cannot pay. Yesterday they told me to leave my bed so a paying patient could have it, so I slept on the floor on a mat that someone lent me. I tried to escape once but the guards at the gate said that I couldn't leave and I didn't have an authorization to leave.[186]

Among those held at Prince RgentCharlesHospital was Augustin M., a 26-year old man from Muyinga province who had a car accident. He told a Human Rights Watch researcher,

Two weeks ago, the doctors told me that I was healed, but I could not pay the bill, so I had to stay here. I have no money and no land and no work, and I need another operation to take the metal rod out of my leg. The nurse told me that they might not take out the metal rod if I cannot pay for the first surgery. I feel like a prisoner here because I cannot leave. I am afraid I will have the metal rod in my leg forever.

The [government] declaration is good but I think that other people should be covered, like those who have no father. He died when I was young and my mother has no money.[187]

Not surprisingly these and other victims detained expressed hope that the government would extend the reform to their cases as well.[188]

Twenty-year-old Albert H. was hurt in a car accident when he went to check on his family's farm, which they had fled a year earlier. He sustained injuries to his eye and left arm. When he could not pay the bill, he was detained at Prince Rgent Charles Hospital in Bujumbura. 2006 Jehad Nga

Further government plans for health reform

In its National Plan for Health Development, the Ministry of Health says it intends to raise the health budget to about 15 percent of the total annual budget (from about 2.7 percent in 2005[189]), in line with a commitment made by African countries in 2001.[190]

The plan also acknowledges that the current medical insurance system is not working properly and proposes abolishing it and replacing it with a system of mutuelles. These are voluntary community-based health insurance schemes that function somewhat like a cooperative. The Burundian government proposes to promote these for the population that is active in the informal urban or rural sectors of the economy-that is, large parts of the population. While community-based health insurance is traditionally created and funded totally through a local community, the Burundian government gives the state a more important role, as it is planning to subsidize them.[191] Studies have shown that low enrollment is a frequent problem of community-based health insurance. Should the government go ahead with its plan to create mutuelles, it will need to develop a strategy for how to address this problem and make mutuelles viable for the poor who are active in the rural or urban informal economy.

In its national health plan, the government makes a somewhat artificial distinction between those who work in the informal sector and those who are poor. It suggests that there might be difficulties in extending community-based health insurance schemes to the poor and proposes state subsidies to "protect the most vulnerable groups such as pregnant women (all), children under five years of age and indigents."[192] While the government has, as already discussed, taken steps to improve access to health care for pregnant women and small children, it has not done so for indigents. The Ministry of Health has attempted to create a fund for poor patients but this was rejected during the budget debate in December 2005.[193] The plan remains vague and does not mention the problem of hospital detentions. In August 2006 the Burundian government was working on the final touches of the country's Poverty Reduction Strategy Paper (PRSP), the draft of which repeats the same health policy priorities but does not provide any additional detail. It also does not mention hospital detentions.[194]

IX. Government Failure to Address Other Structural Problems of the Health System

Starving the hospitals: The downside of hospital autonomy

When hospitals were made autonomous beginning in 1988, they had to assume responsibility for financing most of their activities. If they fail to recover past costs, they must cut future expenses; in many cases this includes staff salaries.

The state owes hospitals large sums of money under the medical insurance system. According to management staff at the Prince RgentCharlesHospital, insurance bills from 2004 and 2005 are still outstanding.[195] The Ministry of Finance, responsible for paying bills, pays them with less and less regularity as the year goes on and, according to one hospital official, "by June the payments stop."[196] The overall budget for medical insurance was 180 million FBU (U.S.$180,000) in 2005 and 300 million FBU ($300,000) in 2006.[197]

The government pays a subsidy to public hospitals, but this support covers only a fraction of their costs. Prince Louis Rwagasore Clinic, for example, receives about 10 percent of its annual budget from the state[198] and Prince Rgent Charles Hospital about 30 percent.[199]Salaries of health personnel are very low, in part because state assistance to hospitals is so limited. The starting salary of a general practitioner in 2004 was 62,980 FBU ($62) per month.[200]

Lack of transparency in health sector finance

The Burundian health sector is plagued not just by lack of funds but by lack of clear guidelines, as well as fraud and corruption, in how they are used.

Hospital staff are uncertain when and how much of their institution's expenses will be reimbursed by the state because the medical insurance and indigence card systems do not work properly.Poor patients are unsure what costs they will have to pay.

Hospital staff have themselves been involved in financial mismanagement and corruption. In October 2005, officials at the CNRS found Roi Khaled staff submitting false vouchers and fabricating and selling documents attesting to poverty or returnee status. The supposed organizer of the fraud, an employee of the CNRS based in the hospital, was suspended.[201]According to an official in the Ministry of National Solidarity, Human Rights and Gender, cheating and fraud remain a problem at the Fund for Victims.[202]International agencies that pay hospital bills for some of their beneficiaries have complained of cases of false or inflated bills prepared by hospital staff.[203]

On February 24, 2006, the finance minister acknowledged in a radio broadcast that one billion FBU ($1 million) had come through the treasury, supposedly for the purchase of medicine, but that he could not account for its use.[204] Shortly after, health officials deplored the disappearances of medicine from health centers and expressed concern that there might be "deliberate speculating by health center managers" in the sale of medicine.[205]

Among past indications of corruption in the health sector was the 2001 murder of Kassi Manlan, head of the World Health Organization in Burundi, reportedly killed because he had uncovered embezzlement by important Burundian officials of money meant to buy medicines.[206]

Following the president's announcement of anti-corruption measures, parliament voted in July 2006 for the creation of an Anti-Corruption Brigade with police powers, despite worries about the constitutionality of the body.[207]

X. Keeping the System Alive: The Dilemma of Being a Benefactor

As shown above benefactors in the form of private individuals, churches or organizations sometimes paid off the debts of patients so they could go home.

The number of benefactors has risen in the last few years, according to statistics and observations by hospital staff. At Prince Rgent Charles Hospital, the figure has more than quadrupled between 2004 and 2005, as mentioned above. Like similar interventions by the government, freeing individuals renders them immediate assistance but provides no permanent solution to the problem of hospital shortfalls. Such acts of generosity may have even encouraged the practice by in effect rewarding hospitals that detained people.

In at least one facility, the Roi Khaled hospital, the presidential directive on maternal and child health has led to a decline in the number of benefactors, presumably because they believe private charity is no longer so necessary.[208] It is too soon to say whether the recent decrease in one institution will continue and will be replicated in other hospitals.

XI. The Role of the International Community in the Health Sector

Donor aid

In 2000, the international community set itself ambitious development targets, the Millennium Development Goals, including major progress on combating child and maternal mortality, HIV/AIDS, and malaria. The Millennium Project report on goals four and five (reducing child and maternal mortality) recommends that "bilateral donors and international financial institutions should substantially increase aid" to the health sector. It also recommends that user fees for basic health services be abolished.[209] Donors committed themselves, at the 2002 Monterrey Conference[210] and subsequently, to funding the initiative; in particular rich countries pledged to devote 0.7 percent of their gross national product to official development assistance. However, to date, only a few countries have done so,[211] and attaining the health-related Millennium Development Goals remains a distant prospect.

In Burundi, aid flows have been heavily affected by the political crisis and armed conflict. Following Pierre Buyoya's 1996 military coup, countries in Central Africa imposed economic sanctions on Burundi, and international aid was reduced by two-thirds.[212] With the Arusha Peace Agreement at least partly implemented and the political transition moving ahead, many donors recently renewed aid. In late February 2006, the government held a donor conference to request funds for improved health care, aid to drought-stricken regions, and other programs needed to help rehabilitate the damaged country.[213] In the coming period, donors are expected to shift their aid from humanitarian assistance to development aid. As already noted above, in August 2006 the Burundian government was working on the final touches of the country's Poverty Reduction Strategy Paper. The PRSP offers a long-term development plan and forms the basis for decisions about future donor funding, debt relief and loans from the international financial institutions.[214] The completed PRSP will be presented to the World Bank and made public.

At present, the European Commission (EC) is the most significant multilateral donor, currently providing about 72 million (U.S.$92 million) through various channels including the European Development Fund (EDF) and the European Commission Humanitarian Office (ECHO). It provides about 31 million ($39 million) in budgetary support.[215] Belgium and France are the two largest bilateral donors: they support the government budget and fund particular projects in the areas of rule of law, health and education. The United States is providing approximately $30 million per year in non-food humanitarian and development assistance.[216] Germany is supporting the government with about 44.5 million ($57 million), primarily in the area of improving water supply.[217] The UK government provides about 10m ($19 million) to Burundi for 2006-07, of which about one-third is destined for the health sector.[218] In addition, nongovernmental agencies such as Cordaid, MSF and ActionAid fund particular areas of the health sector.

Despite the commitments of international donors to assisting Burundi in the area of health, donors have not pressed effectively for an end to the detention of patients, and improved access to health care for the poor.

Debt relief

Under the Heavily Indebted Poor Countries Initiative, Burundi has qualified for the initial phase of interim debt relief, subject to meeting certain conditions. During this period, the World Bank and the International Monetary Fund have imposed a limitation on the use of the funds and determined that they must go towards education, health and agriculture.[219] As a result, the government has almost tripled the health budget from about $5 million to about $15 million. Burundi is currently completing the economic measures essential to finalizing the debt relief agreement in 2006. Once Burundi has permanent status, the government is in theory free to set its own spending priorities and is not required to fund key social sectors.[220]

Nonetheless, the government has pledged to spend the debt relief funds on health, education, infrastructure, agriculture, the settlement and reintegration of victims of civil strife, and judicial reform. It has also promised to set up an independent oversight committee composed of international and national representatives, to monitor expenditures.[221]

XII. Human Rights Standards

The detention of patients who are unable to pay their medical bills at public hospitals in Burundi raises a number of concerns under international human rights law.This includes the right not to be arbitrarily detained, detained as a debtor or mistreated in detention as protected in the International Covenant on Civil and Political Rights (ICCPR).The impact of the policy on individuals seeking health care implicates the state's progressive realization of the right to the highest attainable standard of health under the International Covenant on Economic, Social and Cultural Rights (ICESCR) and other human rights instruments.Burundi became a party to both covenants in 1990.

Detention

The detention of debtors-such as persons who are unable to settle their hospital bill-is unlawful under international human rights law.Article 9 of the ICCPR provides that everyone has the right to liberty and security of person and "[n]o one shall be subjected to arbitrary arrest or detention."Detention is considered arbitrary if it is illegal or if manifestly disproportionate, unjust, discriminatory or unpredictable.[222]

More specifically, article 11 of the ICCPR states: "No one shall be imprisoned merely on the ground of inability to fulfill a contractual obligation." This provision prohibits the deprivation of personal liberty for failure to pay a debt either by a creditor or by the state. States have an obligation to enact laws and other measures to prevent the state and private creditors from limiting the personal liberty of their debtors who cannot fulfill their contracts.[223]

The ICCPR lays out the right to humane treatment in detention. Article 10 states that all persons deprived of their liberty shall be treated with humanity and with respect for the inherent dignity of the human person. In its General Comment, the Human Rights Committee, the international body of experts that monitors compliance with the ICCPR, has made clear that this article applies to:

[A]ny one deprived of liberty under the laws and authority of the State who is held in prisons, hospitals - particularly psychiatric hospitals - detention camps or correctional institutions or elsewhere. States parties should ensure that the principle stipulated therein is observed in all institutions and establishments within their jurisdiction where persons are being held.[224]

Patients who are held in state hospitals come within the protection of article 10.

Health

Health is a fundamental human right enshrined in numerous international human rights instruments, including the Universal Declaration of Human Rights, the ICESCR, the African Charter for Human and People's Rights, the Convention on the Rights of the Child, and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). The ICESCR specifies that everyone has a right "to the enjoyment of the highest attainable standard of physical and mental health."[225]

Because states have different levels of resources, international law does not mandate the kind of health care to be provided, beyond certain minimum standards.The right to health is considered a right of "progressive realization." By becoming party to the international agreements, a state agrees "to take steps to the maximum of its available resources" to achieve the full realization of the right to health. States are obliged to create conditions that would assure access to all medical service and medical attention in the event of sickness.[226]

The Committee on Economic, Social and Cultural Rights provides examples of what constitutes a failure of a government to fulfill its obligations with respect to the right to health. The examples include failing to adopt or implement a national health policy designed to ensure the right to health for everyone; insufficient expenditure or misallocation of public resources which results in the non-enjoyment of the right to health by individuals or groups, particularly the vulnerable or marginalized, and the failure to reduce infant and maternal mortality rates.[227]

International law describes essential elements of the right to health (availability, accessibility, acceptability and quality), as well as minimum "core obligations" of governments. The basic elements of this right and the minimum core obligations are described in detail in General Comment No. 14 of the Committee on Economic, Social and Cultural Rights. That General Comment emphasizes the minimum core obligations of a government in terms of health care, which includes, for example, "the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups" and that governments must "ensure equitable distribution of all health facilities, goods, and services."[228] With regard to economic access, the Committee states:

Health facilities, goods and services must be affordable for all. Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households.[229]

In this perspective, the recent decision by the Burundian government to make maternal and child health care free of charge constitutes an important advance in progressively realizing the right to health.

Under international law on the right to health, priority is given to children and women. The ICESCR stipulates that efforts must focus on child and maternal health, that is by taking measures to reduce the stillbirth rate and infant mortality and to provide for the healthy development of the child.[230] The Committee on Economic, Social and Cultural Rights states that ensuring "reproductive, maternal (pre-natal as well as post-natal) and child health care" is of comparable priority to the core obligations. Lowering of maternal mortality is defined as a "major goal" for governments.

Building upon the provisions of the ICESCR, the Convention on the Rights of the Childhas specified the particular rights of children with regards to health, and states that governments must act in the areas of child health and pre-and post-natal health care, in particular primary health care.[231] Similarly, the CEDAW defines the right of women to access health care without discrimination and to get "appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation."[232]

XIII. Acknowledgements

This report was written by Juliane Kippenberg, NGO liaison in the Africa division of Human Rights Watch. It is based on field research conducted by Juliane Kippenberg, Maria Burnett, Burundi researcher at Human Rights Watch, Jean-Baptiste Sahokwasama, legal representative of APRODH, Ladislas Gahungu, assistant psychologist at APRODH and APRODH observers based in the provinces of Burundi. Batrice Nicitegetse provided research assistance and translated the interviews.

The report was edited by Maria Burnett. It was reviewed at Human Rights Watch by Alison Des Forges, senior advisor on the Great Lakes; Joseph Amon, director of the HIV/AIDS and Human Rights division; Tony Tate, researcher in the Children's Rights division; Janet Walsh, acting director of the Women's Rights division; James Ross, senior legal advisor; and Ian Gorvin, consultant to the Program Office. At APRODH, it was reviewed by Jean-Baptiste Sahokwasama and Ladislas Gahungu.

Production assistance was provided by Lizzie Parsons, associate in the Africa division, Veronica Matushaj, photo editor, Andrea Holley, productions director, Juliette Le Dor, press associate, Ella Moran, creative associate, and Fitzroy Hepkins. Isabelle Thomas translated the report into French.

Jehad Nga, photojournalist, took all the photographs in this report, and generously donated them to Human Rights Watch.

We would like to thank all patients who agreed to speak to us while in hospital. We would also like to thank directors, financial directors, doctors, nurses, social workers and other staff at Roi Khaled Hospital, Prince Rgent Charles Hospital, Prince Louis Rwagasore Clinic, Ngozi Hospital, Gitega Hospital, Muramvya Hospital, Karuzi Hospital, Muyinga Hospital, Bururi Hospital, Matana Hospital and Rumonge Hospital for providing valuable insights and facilitating our research.