In short

• Systemic health-financing failures and out-of-pocket payments drive medical indebtedness and hospital detention in Cameroon.
• Miscommunication, cultural norms and limited insurance deepen vulnerability to unexpected costs.
• Fear of debt leads to delayed care, early discharge and worsening health outcomes.
• Humane, context-sensitive reforms are urgently needed, including stronger insurance, social assistance and the abolition of punitive detention practices.
  

In several African countries, it is not uncommon for patients to be detained in hospitals after discharge because they cannot afford to pay their medical bills. Millions more in Africa still struggle to access or pay for healthcare. An HSRC researcher recently collaborated with international partners to identify the factors that drive hospital detention and medical indebtedness in Cameroon.

Patients waiting to be seen at a hospital in the Far North Region, Cameroon, 2021. Photo: rawpixel

In 2015, the United Nations General Assembly adopted the 2030 Agenda for Sustainable Development, which includes 17 Sustainable Development Goals (SDGs) and 169 targets to guide global action. One of these, SDG 3.8 calls for universal health coverage – the principle that (according to the World Health Organization) everyone should have access to quality health services, when and where they need them, without financial hardship. Yet, according to the latest tracking data (2023), 615-million people in Africa still do not receive the healthcare they need.

A recent study conducted in Fundong, Cameroon, sheds light on how systemic health-financing failures in many African countries have contributed to both the denial of healthcare and the widespread practice of hospital detention. In the study, hospital detention was defined as the refusal to release either living patients after they have been medically discharged or the bodies of deceased patients because their families cannot afford to pay the hospital bills.

As Africa’s largest public social-science institute, the HSRC engages in African research to amplify local expertise, build research capacity, promote cross-country learning on shared challenges and translate findings into practical recommendations that help governments and communities to advance development. HSRC researcher Dr Mathias Alubafi contributed to this study on healthcare in Cameroon. Originally from the study region, Alubafi understands local norms and practices, and his affiliation with the HSRC provided the methodological rigour, supervision and institutional infrastructure needed for high-quality conceptualisation, analysis and writing.

The study setting

The Fundong Health District is in Cameroon’s North West Region, Boyo Division, with an estimated 146,162 people, whose livelihoods depend largely on subsistence farming, small trade and palm-wine tapping. The district’s 27 health facilities (18 public, 2 private for-profit and 7 faith-based) are vital providers, especially the mission hospitals that play an outsized role in rural areas.

The research team conducted qualitative interviews with eight detained, insolvent patients (five of whom were self-employed women) and 26 hospital staff (18 of whom were women from private facilities). Most patients were detained for one to eight weeks, but two cases lasted up to a year. The interviews revealed several common factors that led to indebtedness and detention.

The lived reality of detention

Detained patients were officially discharged but kept inside hospitals because they could not pay. Although unspoken and undisclosed, observations made at facilities across Fundong revealed several impactful institutional practices. Experiences by detained patients included being moved to rooms with little visibility, being watched closely, being called out as “the one who hasn’t paid” and being spoken down to.

Other patients, fearing detention, left hospitals abruptly after treatment, discreetly abandoning personal items such as clothing, toiletries or medical records.

Interpersonal and cultural factors

Patients’ financial vulnerability often stemmed from household dynamics  and prevailing social norms. Many depended on family support that never materialised. Miscommunication about treatment costs fuelled shock at discharge. “They did not tell me how much it was going to cost,” one participant said.

Deep-seated beliefs also discouraged saving for illness, as it is seen as inviting misfortune. “We keep money to be used for good things … If you do that, it means you are inviting sickness to your home,” a participant explained. Religion also played a role, and a male participant noted, “As Muslims, we do not keep money for sickness.”

Organisational and institutional factors

Opaque pricing could further deepen patient debt. At times, patients were not told the expected costs up front. One nurse remarked, “Some patients come here without knowing how much their treatment will cost. They expect to pay later, but by the time they realise the amount they owe, they are overwhelmed by the debt.”

According to the study, health financing in the area mirrored national patterns, where patients spend heavily out-of-pocket (direct, point-of-care payments by households) and where less than 2% of Cameroonians are covered by formal health insurance. Fundong’s Community-Based Health Insurance (CBHI) scheme (a community-based health insurance model with a modest annual premium and partial co-payment coverage) has struggled amid recent conflict in the country.

Since 2016, violent clashes between governmental security forces and separatist armed groups have taken place in the country. Known as the “Anglophone crisis”, this political struggle between the francophone majority and the anglophone minority has disrupted services, livelihoods and trust in institutions.

Community-level factors

Many residents relied on churches, mosques, community leaders and the CBHI scheme for assistance with their hospital bills. However, awareness of how to receive or apply for services was limited. One participant noted that although there was a community-based insurance scheme, “many cannot afford it or don’t know how it works”. Another participant only learned after accruing significant debt that some government help existed. Religious groups sometimes negotiated with medical facilities or contributed funds, but their resources were usually insufficient to cover full bills.

Structural vulnerabilities and consequences of medical debt

The study found that the fear of accruing debt discouraged people from seeking timely care, pushed people towards home remedies or traditional healers, and at times triggered early exits against medical advice. These alternatives can worsen disease severity and, ultimately, treatment costs.

Detention itself imposed physical, emotional, psychological and financial strain, which normalised punitive responses to poverty. Families already at the edge of economic collapse were driven deeper into debt, while the health system’s lack of formal safety nets exacerbated patient suffering.

Towards equitable and humane healthcare  

This study highlighted the urgent need for context-sensitive policy interventions. Key recommendations include:

• Abolishing maternal user fees and reducing the cost of caesarean sections
• Expanding and strengthening health-insurance coverage for vulnerable groups, with comprehensive benefits
• Strengthening and protecting hospital social-assistance funds and allowing flexible, deferred or in-kind payments to prevent detention
• Implementing community-based, culturally sensitive financial-literacy and support programmes to help families plan for, and navigate, health costs
• Replacing punitive hospital-detention practices with humane alternatives such as legal protections, mediation mechanisms and patient-advocate/social-worker support
• Integrating mental-health and psychosocial support into routine hospital care
• Improving health-system financing and governance to ensure sustainable safety nets.

Ultimately, solutions should address not only institutional inefficiencies and communication gaps but also the deeper socio-economic and cultural dynamics that drive financial precarity. By implementing these interconnected and contextually tailored recommendations, policymakers can begin to dismantle the structural causes of medical debt and hospital detention, thereby potentially saving millions of lives, significantly improving global life expectancy and advancing progress towards the SDGs.

Research contacts and acknowledgements

This Review article is based on the paper Trapped by debt: an ethnographic study of medical indebtedness and hospital detention in the Fundong Health District, Cameroon, written by HSRC science writer Jessie-Lee Smith and Dr Mathias Alubafi, a senior research specialist in the HSRC’s Developmental, Capable and Ethical State Division. For more information, contact Dr Alubafi at malubafi@hsrc.ac.za.

Collaborating researchers included Dr Ashangwa Constantine Tanywe (University of Yaoundé, Cameroon), Dr Ngambouk Vitalis Pemunta (Covenant University, Nigeria), Vidarah Nimar and Womma Habiba Hira (University of Gothenburg, Sweden), Dr Maurine Ekun Nyok (University of Hradec Králové, Czechia), Dr Tom Obara Bosire (University of Glasgow, Scotland), Nguyen Ngoc Bich Tram (Budapest Business School, Hungary), and Dr Brendabell Ebanga Njee (African Public Health Organization, United States).

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