Mrs. Audu, 33, had just given birth to her first child at the Asokoro General Hospital. She was ecstatic and could not wait to take her newborn home, but her joy was short-lived.
“We’ve been asked to stay here until we can pay,” looking at her newborn, she said, feigning indifference.
“I need Nigerians to help me out,” she said into the voice recorder and looked resigned again.
Mrs. Audu, a low-grade civil servant in the nation’s capital, is one of many new mothers under detention in Nigerian hospitals as a result of their inability to pay their medical bills. Her case is particularly serious; shortly after giving birth, she suffered postpartum hemorrhage.
Up the aisle to the maternity ward of the Asokoro Hospital, a stretch of pregnant women are seen groaning under labor pains and awaiting available beds for delivery.
“All the beds have been occupied in this hospital. The women queue until there’s a bed space available,” a matron who asked to remain anonymous told me. “As soon as you birth your baby, you are discharged to go home, as we need space for others.”
The failure to implement the 2014 National Health Act is a major drawback and reason for the collapse of health facilities, which have turned into trauma centers for most pregnant women.
The act mandates a 1 percent contribution by the federal government from the Consolidated Revenue Fund that will help guarantee a basic minimum health package, which includes free health coverage for pregnant women and children under 5 years of age.
A coalition of about 30 civil society organizations and the ONE Campaign, in an open letter to Nigerian President Muhammadu Buhari, called for more investment in the healthcare sector in Nigeria.
“There is an urgent need to make a quantum leap investment into the health sector in the 2018 budget to at least 7.5 percent of the national budget and demonstrate good faith in implementing the 1 percent Consolidated Revenue Fund towards the Basic Health Care Provision Fund (BHCPF), as stipulated by the National Health Act 2014,” the letter read.
Nana Aisha, 34, was preparing to spend her third night at Asher Hospital, where she had given birth to twins.
The hospital, situated in Kubwa, Abuja, has an emergency ward, a maternity ward and a small pharmacy unit.
She was held against her will due to her inability to pay for a cesarean section arising from complications. Mrs. Aisha had been abandoned and had yet to hear from her husband ever since he pledged to return to make the payments.
Mrs. Aisha was eventually bailed out through the contributions of a women’s empowerment group called Ejilogwu Women Association. She had been a member but had to leave the group due to her inability to keep up with the required monthly contributions.
Hajiya Jummai, who runs the empowerment group, bailed Mrs. Aisha through a microfinance model in which women contribute on a monthly basis to help each other finance their individual businesses or challenges.
“We see a lot of situations like this, that is why we organized ourselves to help each other. We raise money for naming ceremonies, burials and other problems that women face,” Mrs. Jummai said.
The hospital had been charging her for basic equipment used during her treatment such as bandages, bed-space, hand-gloves and a gown. The total amount reached N16,000 (less than $50).
After it became clear that Mrs. Aisha could not pay her fees, the doctor instructed the gateman and the night nurse on duty not to let her out of the hospital. She realized this when she tried to escape.
“We heard that she was detained and her husband had run away because he could not pay the N4000 hospital bill after her delivery, so we gathered money that afternoon and went to bail her,” Mrs. Jummai said.
At the Gwagwalada Specialist Hospital, a government-owned facility, I spoke to Ifeanyi Anih, a medical intern who told me that the hospital management has created a deferral scheme.
“We handle all female genital tract issues, and there are a lot of cases where women come in pregnant and require surgery. We have a system that allows them to do it on credit to enable them pay afterwards, but the more prevalent case is that they don’t return so we turn it into a bad debt. The finance department actually raises some money as a provision for this,” he said.
This is not the same for private hospitals. Folake Animashaun, whose real name has been withheld, works at one of the private clinics and told me that sometimes they gauge the patient before treatment.
“When we give the patient the cost of the treatment, and we realize the patient cannot pay, we don’t treat them. Sometimes you can tell by their body language, the way they begin to look at each other or complain. In cases like this, we just refer them to a general hospital,” she said.
“Sometimes it’s a critical emergency, we pad the patient, give them pain-killers and wait for them to leave. It’s easier to bear a cost of roughly N2,000 in free medications than to conduct a N150,000 surgery and not get the money back.”
She explained to me that the most prevalent cases are pregnant women with complications who have been turned away by the privately owned health centers.
“The largest cases we face here are mostly obstructions during pregnancy. Like when the baby is in the wrong position. We asked them if they can pay for it and they started looking at themselves. The challenge here is that you really can’t treat them for free.
“There is a framework that comes from the Ministry of Health which serves as a guideline for billing patients, and a surgery like that costs about N85,000. Private hospitals collect almost three times that rate.
“The private clinics don’t handle patients who cannot pay. In one case we faced here, they went as far as padding the bleeding woman, gave her one pint of blood and waited for her to leave. She still came here, and yet had no money,” she said.
With less than four percent of the population insured, Nigeria has one of the worst health coverage indicators in the world.
Currently, health insurance covers a number of government workers and big private sector organizations. Hospitals charge the people in this category only 10 percent of the cost of treatment, but the larger population of Nigeria are denied this benefit.
On a daily basis, Nigerian mothers are detained all over the country; the situation poses a grave threat to the country’s ambitions to achieve universal health coverage (UCH) by 2030, a key aspect of the United Nations Sustainable Development Goals.
According to the terms of UCH, access to safe, quality and essential, affordable healthcare services, including medicines and vaccines, should be available for all.
While Nigeria’s President Buhari enjoys medical treatment abroad, Nigerian government hospitals remain detention facilities for new mothers across the country. The irony is that it has become common to see high-ranking public officials bail out detained mothers in what is pitched to the public as an act of compassion.
As the class divide deepens, public hospitals have become the exclusive preserve of the Nigerian middle class while the rich turn to medical facilities abroad. The poor have nowhere to run. The inability of the government to provide free maternal services contribute to the grave maternal mortality indicators in Nigeria as pregnant women seek unorthodox medical options or stay at home, leading to major complications and death.
Audu and Aisha consider themselves lucky to be alive in debt. Other women in similar situations are never admitted and most of them die from complications trying to birth their babies.
Mercy Abang is a United Nations Journalism Fellow, freelance journalist, and media fixer with the Sunday Times of London, BBC, and Al-Jazeera. You can follow her on Twitter @abangmercy.
This article was written as part of the 2017 BudgIT Media Fellowship