The New Humanitarian Annual Report 2021

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Going into debt for health

A fistula patient at the John F. Kennedy Hospital in Monrovia.
(Ansu Konneh/IRIN)

One in four families living in the world’s poorest countries borrows money or sells assets in order to afford health care, according to the most recent issue of the US medical journal "Health Affairs".

The authors calculated almost 26 percent of households representing 3.6 billion people – most often the poorest with little or no health insurance – used "hardship financing" from 2002 to 2004 to cover health costs.

Out-of-pocket payments accounted for 70 percent of health payments in low-income countries compared to less than 15 percent in richer countries, according to an independent 2007 study of global health insurance programmes.

Countries throughout sub-Saharan Africa have tried to varying degrees to follow the authors' call for “prepayment mechanisms that reduce (or for the poor, eliminate) charges at the point of care [to] mitigate the economic risk that out-of-pocket payments pose for families.”

Health fees in West Africa
 SIERRA LEONE: Government weighs “hybrid” health care plan
 WEST AFRICA: Weighing free health care for all
 LIBERIA: Post-conflict dilemma - should health care be free?
 COTE D'IVOIRE: Health care fees up for discussion


Widowed after her husband was killed during Liberia’s civil war, Mary Dewh, a 39-year-old mother of four, told IRIN she alone covers her family’s health care costs. “When my son was hospitalised with malaria two weeks ago and the bill came to US$50, I did not have enough money for him to be discharged from the hospital.” She said a neighbour loaned her money so her son could come home.

In 2007 Liberia tested lifting health care fees for basic care in public health centres, but Solomon Bah, a doctor in the capital Monrovia told IRIN free care is not easy to find now in cities.

“[There is a] little bit of free service in rural communities where people can not afford [health care]. But that is done on a smaller-scale basis. Patients are shouldering their own responsibility to settle their medical bills. The government does not have that much of money to have free medical service for everyone,” said Bah.

The Ministry of Health is undergoing a national review of user fees.


Since 2005 the Ghanaian government has introduced a national health insurance programme, which has enrolled 54 percent of the population as of the end of 2008, according to the government.

In a recent independent evaluation of the insurance programme,  60 percent of those interviewed expressed frustration at delays in enrolment and difficulty buying medicines at pharmacies under the plan, but all surveyed agreed health care costs had fallen.

As of September 2006, only 22 percent of workers in the informal sector had enrolled, according to the government; Seventy percent of Ghana’s work force is in the informal sector.

The government announced in early 2009 a “restructuring” of the insurance programme – which is estimated to cost more than $600 million a year – to improve claims management, increase medical services for communicable diseases, improve access to free maternal care and “better respond to the needs of the population”.

day patients beg the night guards to let them leave at night because
they fear not having enough  money to pay for their hospital stay

Burkina Faso

Since 2005 the government of Burkina Faso has covered health costs for under-five children suffering from severe forms of malaria at the cost of almost $1 million a year, according to Laurent Moyenga who heads the country’s national anti-malarial programme.

In addition, the country has paid more than US$4 million a year since 2006 to women giving birth and for newborn care during their first week of life, said Jeanne Nougtara, the director of family health subsidies in the Ministry of Health. “We cannot cover all illnesses and believe children are at highest risk to deadly diseases in their first seven days,” Nougtara told IRIN.

But even with this help, patients are still struggling, said a health employee from Yalgado Ouédraogo hospital in the capital Ouagadougou, who preferred to remain anonymous. “Every day patients beg the night guards to let them leave at night because they fear not having enough money to pay for their hospital stay.” 


This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information:

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