Host, Maaza 00:11

Here are some people you’ve never met with whom you might share an unlikely connection: The family of the late George Mwenje Mwangi, they had to make a public appeal to raise funds to pay for the release of his body reportedly detained for five months by a private hospital due to non-payment of a $9,700 bill. A woman who lost one of her twin babies during childbirth because she could not afford her medical bill, her surviving baby was detained for three months in a private hospital during which she commuted daily to breastfeed him before leaving him in the care of nurses. A refugee father from Burundi, his family of seven were reportedly on their way to a UN Refugee office when an accident occurred, and his daughter was killed. He survived but had no means of paying the private hospital bill, he was detained for nonpayment of a $9,000 bill for his treatment.  These stories are shocking enough on their own. But you might be even more shocked to learn that if you live and work in the UK, France or Germany, your tax dollars might have been propping up the health care system that enabled these situations, one that profits from pain and fear.  This is Sick Development, and I’m your host Maaza Seyoum. As an African and an advocate for social justice and health equity, I’ve witnessed and worked for many years to address the persistent inequalities that harm communities around the world. And in this podcast series, we will delve into the clear but complex and often convoluted connections between finance, development and health care seeking to unravel the mechanisms that perpetuate this growing divide. If you’re a listener to the EQUALS podcast, these realities might not be news to you. Sick Development is a standalone mini-series within the larger EQUALS podcast.  Over the next episodes, we are going to examine how a collection of private hospitals in the global south are systematically abusing patients and denying health care causing hardship, suffering and death. And how they are using funds from European governments and the World Bank to do it. Funds that were mandated to fight poverty and achieve development goals. You’ll hear about impossibly expensive treatment, patients being imprisoned for not paying their bills, and healthy patients being pushed to have operations they didn’t need. And you will learn that even death does not offer an escape for many victims. All this happened at private hospitals backed by taxpayers’ money from governments of the UK, France, and Germany, as well as from the World Bank Group and the European Investment Bank. By examining the intersection of power, finance, and healthcare, we aim to ignite conversations that challenge the status quo and inspire transformative change. It is time to demand a future where health is no longer a privilege, but a fundamental human right.

Host, (Words of Eva) 03:25

The most damaging thing that has happened to me is that my longtime love had to marry some other person because I couldn’t escape from this huge financial tangle and get married to him. I developed some mental health problems because of all the stress. I only sleep with the help of medicines. I’m unable to make decisions easily because of all the distress. I still feel trauma from the bad experience.

Host, Maaza 03:57

Those are the words of a young woman named Eva speaking from India, the bill for her mother’s treatment and care came to an astonishing 30 lakh rupees over $36,000. This was four and a half times the maximum charge promised by the senior consultant and the equivalent of more than seven years of Eva and her father’s combined total income. The hospital had refused the family’s government health insurance card without justification and the private health insurance that the same consultant had convinced Eva to buy and had promised would cover the bill refused to reimburse her. At every step of her mother’s treatment Eva said she felt threatened by the consultant who repeatedly told her if you don’t follow my advice in full if anything happens in between, I will not be held responsible Eva used her life savings borrowed from friends took out a loan, as did her father and sold a small family plot of land. When asked if she was comfortable having her story used in this podcast. She said,

Host, (Words of Eva) 05:03

“I’m least bothered about my life. The doctor has already killed all my hopes and aspirations in life, so he cannot kill me anymore. I am financially killed. I’m psychologically damaged and my family life has collapsed. My career is damaged. What else is there to fear?”

Host, Maaza 05:25

The private hospital that ever said ruined her life is only one of many such hospitals that is being funded with money that is supposed to be fighting poverty and achieving the Sustainable Development Goals. Another woman who had a catastrophic dealing with a private hospital was Francisca Wanjiru, two years after her mother died in a private hospital, the hospital was still refusing to release her remains until once you found a way to pay the $43,000 medical bills she could not afford. Wanjiru ended up making a public plea that the hospital releases her mother’s remains as a Christmas present.  Sadly, Eva’s and Francisca’s stories are not unique. In doing research for this podcast, Oxfam learned of countless cases of life changing financial hardship, as well as crimes and malpractice experienced by patients attempting to access treatment and care at private for-profit hospitals.  This podcast is not just about what happened to Eva and why you might have helped pay for it. It is about the role of something called development finance institutions, or DFIs. These are development banks owned or part owned by governments or multilateral development agencies. These institutions fund private sector development, including for profit healthcare, and countries with enormous unmet health needs, extreme health care inequality, and unacceptably high numbers of people being pushed into poverty paying for health care out of pocket. DFIs source their capital from national or international development funds and benefit from government guarantees. They fund development grants with loans, guarantees, equity investments lending through financial intermediaries and blended instruments such as public private partnerships. They are all backed by taxpayers in some form. It is crucial to keep in mind that DFIs seek to make a profit from their investments.  The DFIs we will discuss in this podcast all have a mandate to help deliver the Sustainable Development Goals. These are the global goals that all governments have agreed to advance progress on things like health and education and tackling poverty. The last decade has seen the normalization of a new narrative. That to finance these globally agreed upon goals, including healthcare, scarce public funds must be used to leverage and crowd in trillions of dollars in private finance. It is in this context that the role of DFIs directly financing for profit health companies has gained prominence. But lacking is a clear and evidence theory of change. As to how DFIs investments in for-profit private health care providers will succeed in advancing pro poor and gender equitable access to quality health care without financial hardship.  Over the next several episodes, this podcast will outline the impact of this financial hardship both on individuals living in countries with DFI funded hospitals and on those countries themselves. We will talk about how we got into this mess and how we can get out of it.  This podcast is being released in conjunction with two recent Oxfam research reports: ‘Sick Development’, and ‘First Do No Harm.’ With us today we have the principal author of Sick Development, Oxfam’s Anna Marriott. Firstly, congratulations on the launch of your report. Thank you so much for joining me today. Before we get started, could you please introduce yourself to our listeners?

Guest, Anna 09:12

Thank you. It’s a real pleasure to be here. And yes, this report has been a long time in the making. And it’s been a really tough one. So, it’s a great feeling to have our findings. And I think most importantly, these stories of human suffering and rights violations out there in the public domain for everybody to read.

Host, Maaza 09:37

Thank you. Well, it’s great to have you. And just for people who don’t know yet what is your role at Oxfam?

Guest, Anna 09:43

Yeah, sorry about that. My name is Anna Marriott, I’m Oxfam’s Health Policy Manager and I’ve led Oxfam’s work on universal health care and on issues around financing, privatization and inequality in global health for the last 15 years.

Host, Maaza 10:00

Excellent. So, I’ll dive right in. Anna, in this report, Oxfam has called attention to the issue of privatization and commercialization of health care. How do these development banks or development finance institutions contribute to this trend? And what are the implications for health care affordability and accessibility in low-income countries?

Guest, Anna 10:21

I think in general the role of these development banks has grown over the last couple of decades as this love affair with the private sector being the answer to all of our development problems has also grown. But in health, surprisingly, their role hasn’t actually received that much attention, and certainly not the level of attention that we think it deserves. And, and that’s why these investigations that we’ve carried out, I think are so important. And what we’ve done through our work, and it has been incredibly painstaking and time consuming, is to track billions of dollars of development money from these European governments and the World Bank via these development finance institutions that are being channeled to for-profit health care providers, across low and middle income countries, countries like India, Kenya, Uganda, Brazil, there’s examples in Bangladesh, Mozambique, Nigeria, the list goes on. And collectively, they’ve made over 200 investments in private hospitals, or other for-profit health care providers. And in many cases, these you know, we’re talking about big, well established and very powerful corporations with in some cases incredibly wealthy millionaire and billionaire owners. Begging the very first question of many questions as to why on earth, they’re getting any government bank money in the first place. But with these funds, the development banks are helping these corporations become bigger and more powerful and more dominant in their markets. And with it ever more influential in shaping government health policy.

Host, Maaza 12:13

So was that the driving question in your research, Anna? Asking why big corporations are receiving government backed money to supposedly provide health care to people in low income countries?

Guest, Anna 12:27

The driving questions for our research were, firstly, are these government owned development banks living up to their own promises to deliver universal health coverage, which means very simply, everyone everywhere gets access to health care without financial hardship? And secondly, are they you know, upholding basic obligations to protect human rights? And, you know, on the basis of our investigations and research, we have to answer no to both of those questions.  You know, first, these hospitals are just simply eye wateringly expensive. Actually getting hold of the information for these hospitals was really, really difficult in the majority of cases, which brings massive transparency and accountability issues for patients. But we did have some success finding the costs for maternity services. And I mean, you know Maaza, that the number of women dying in pregnancy and childbirth without skilled assistance is actually alarmingly on the rise again, but these hospitals are way too expensive to make a difference.

Host, Maaza 13:40

Anna, I know you detail the costs of assisted childbirth in the report. But can you provide more detail for the listeners just so it’s clear on how exorbitant the costs are for an average woman who wanted to give birth in one of these private hospitals in the countries you looked at?

Guest, Anna 13:58

We found that the average starting price to give birth in one of these funded hospitals by these development banks would cost at least a year’s entire income for a woman in the poorest 40%. So just, you know, no question just out of reach for ordinary women. And we even found, you know, examples of maternity fees in one hospital for in Uganda, for example, where fees actually increased by an incredible 60% for maternity services, after, you know, immediately after these European governments had invested. So, the idea that they’re helping to bring affordable health care to millions of people is just nonsense. And as you know, just to give some, some more examples during the global pandemic, we saw many of these same hospitals selling intensive care beds only to the highest bidder. So exploiting the fear people were facing with this new disease, the unknown, you know, as we saw across the world, but particularly in lower income countries, desperate searches for life saving care, desperate searches for oxygen, and I was just horrified that for people facing death from the virus, also without access to vaccines, which is something that we also campaigned on development funds were being used to support hospitals that were literally charging 1000s of dollars for emergency care, completely out of reach for the majority of people in countries like Uganda, Mozambique and India. Services that these people could never dream of accessing.  But as you’ve already talked about, Maaza, as well as this being healthcare for the rich, it’s also massively unsafe. You’ve talked about the cases that we found of patients being imprisoned in hospitals. And these I mean, they’re just off the chart horrific. But the scandals just go on and on. We interviewed patients, their relatives and community members in India, for example, and found multiple cases of emergency treatment being denied.

Host, Maaza 16:29

Yeah, so Anna, you know, speaking of the stories, the stories you detail in the report are really shocking, and, and heartbreaking. Can you firstly, tell me what it was like for you to research them throughout this process? And there’s so many stories, but is there one in particular that has really stayed with you?

Guest, Anna 16:50

Yeah, I mean, to be honest, it has been a really traumatic experience for me, digging into these stories, and, and finding out the horror that people are faced, at the hands of these hospitals, especially coming from a country where, you know, despite its challenges, health care is there for you when you need it. In my country, in the UK, we have a universal system that’s free. You don’t have to, you know, you don’t have to fear how much money you’ve got in your pocket, when you when you fall sick, or your kids fall sick. So, so just listening to the stories of people who face absolute horror, and who have to sell everything they own to try and save the life of a loved one, incredibly hard, incredibly hard. I’m not gonna lie to you. As for a particular story, there are actually lots that sit with me every day. I think one of the most unfair is a story of a woman called Kanaklata. And we met her in a in a slum, or an informal settlement, right next door to one of these hospitals funded by the UK Government, the French government, as well as the World Bank. And she told us how the settlement was being bulldozed to make way for a new access road to that hospital. And in the process, as she was gathering her belongings, she actually got crushed in her dwelling, and her friends found her found her body unconscious, and clear, you know, clear injury to her skull. And they, you know, in their desperation, took her to the hospital right next door. And the staff there, asked for money. And they tried to explain to the staff that, you know, this woman was an accident victim, she needed emergency treatment. But then she was also a widow, had very little money, had a daughter, she just couldn’t afford to pay. And the hospital staff just told her that the treatment would cost a lot of money, and you people can’t afford it. And they told them to go and they had to then, you know, risk her life by taking her to a government hospital that was that was further away. And, you know, the fact that that that road, that incident was all for the benefit of that hospital. Yet, in an in an emergency situation, that hospital was unwilling to help that person and, you know, we found multiple cases we were told about multiple cases of people in emergency situations being turned away at the door of these hospitals. And that’s not just morally wrong, that is illegal, that is a violation of fundamental human rights. And this has been perpetrated by hospitals for funded by my taxes and the taxes of people in Germany and France, and all those who are contributing to the finances of the World Bank,

Host, Maaza 20:10

That is just such a terrible story. And, you know, you’ve touched on the fact that, you know, taxpayers are have a role in this, you know, you are very well versed on the DFIs. And for some people that might be the first time they’re hearing about this, why is it important that people learn about DFIs? And how do you think taxpayers should maybe feel about their role in all of this.

Guest, Anna 20:33

So I think I think it’s really important, because these development finance institutions are playing a bigger role. They are, in many ways, untransparent in the way that they operate. And they are not being held to account sufficiently by governments, you know, within the health sector, will seeing that they are making these investments in health care, a sector responsible for delivering human rights, they’re doing it like bankers at arm’s length, and they are not providing proper oversight to ensure that these investments are safe. You know, in fact, over 80% of the investments that we looked at, are being channeled via private equity funds that are sitting in tax havens. And it’s almost impossible to track where this money is going. In fact, you know, we had the case, in in for one of the development finance institutions, the European Investment Bank, who came back to us and said, Actually, we’re not invested in some of these, these ones that you’ve identified. And we then had to explain to them how they were. And then they came back a week later and said, Oh, actually, you’re right, Oxfam, you’re right, we are invested in that hospital. And that is just frightening, that they do not necessarily know where their money is going, let alone have proper oversight of these healthcare facilities to make sure that that rights are not being violated and harm is not being perpetrated. So we must pay more attention to these institutions. And I think we need to start, you know, challenging them having a role in these sectors. I mean, Oxfam is firmly of the view that these development finance institutions should not be investing in for-profit health care providers. That’s just should be out of their remit. It’s not safe, and our evidence is showing that it’s, it’s causing real harm. So that’s why I want people to pay attention. It’s taxpayers money invested in these in these institutions. And these institutions are mandated to fight poverty to promote development. And yet, you know, our research has shown completely the opposite

Host, Maaza 23:02

Gosh, and I’m hoping that later as we get into the series, further in the series, we will give people recommendations of what they can do in their own countries, people who are listening to this and who’s whose tax dollars and pounds are contributing. And I know that in our conversation today, we will talk about what outcomes you’re hoping to see from this report. But I wanted to ask you one thing about COVID-19. Anna, you know, one thing that struck me in the report, given how closely you and I had worked on the response to the COVID-19 pandemic was how much privatization and commercialization of healthcare contributed to exacerbating inequality during the height of the pandemic. And you’ve already spoken a little bit about that today. But you know, can you talk a little bit about what this system means for how unprepared we are for the next inevitable pandemic?

Guest, Anna 23:54

Absolutely. And you’re right, you know, we saw those issues play out with vaccine inequality during COVID. The fact that, you know, profit was put before people’s lives again, and again and again, during the pandemic response. And we’re seeing the same happen again, here. This is, you know, development funds going into health care for the rich. And that leaves the rest of the healthcare system under-prepared for responding to the last pandemic. And if we continue down this route, we will be equally if not more unprepared, for the next inevitable pandemic.  Oxfam is so clear, and has been very, very clear from the outset of COVID. What we need now is governments to work together and prioritize fixing public health care systems. This is the route that has been proven again and again to reach everybody, you know, give people a real genuine choice of seeking health care when they need it. This is what works to bring down the numbers of women dying in and childbirth. This is what works to bring down the number of children dying before their fifth birthday. We need to invest seriously, in those comprehensive primary health care systems, community health workers, and nurses and doctors were facing acute shortages of staff to take care of people. And we need that investment now. We cannot keep waiting. We cannot keep turning our backs on the problems at the public sector and pretend that private health care provides some escape route, it doesn’t. It’s healthcare for the few. We need to we need to be creating systems that work for everybody.

Host, Maaza 25:53

Yes. And it seems like those are the main outcomes that you’re hoping to see from this report the advocacy for a system that provides for everybody, is there any anything else you’d like to add about the outcomes you’re hoping to see from the publication of this report,

Guest, Anna 26:06

First and foremost, we have to see an immediate stop to these investments in for profit, private healthcare, both direct and indirect investments from these development finance institutions has to stop. And that’s what we’re calling on these European governments and the World Bank Group to do straight away. Alongside, you know, what we think is an incredibly important independent investigation into all current and historic investments in health care, and where harm is identified, including, you know, by Oxfam’s research, these governments have to take proactive action to remedy that harm.

Host, Maaza 26:47

And you know, Anna, this is such a comprehensive and detailed report. I know that you’ve also released a methodology note for people who are really interested in how the data was gathered. But can you give our listeners a brief sense of that you’ve already spoken a little bit about how difficult it was to access some of the information? How did you get started on this whole process? Where did you find the information that you compiled and analyzed?

Guest, Anna 27:14

Yeah, it’s a good question. And one of the things we’re really hoping for is that other organizations, academics, anyone who wants to look into this can actually replicate our research, both in their, you know, in their own countries, if there, if there are hospitals in their countries that are receiving of this kind of funding. But also, there are lots and lots of other development finance institutions that we didn’t investigate that we think it’s urgent to look at. So we are really hoping that other people will take this methodology that we have used and, and use it for more investigations. But just to give you a bit of an overview. So our starting place was, you know, the websites of the development finance institutions themselves, some are much better than others. The UK is one, for example, is really structured, quite helpfully, at the other end of the spectrum, I would put Germany, in that it is almost impossible to search on their website for their for their health investments, huge transparency problems, there so really, really difficult to track. Once we got the names of some of the investments, then we you know, it was literally a case of using all the contacts that we have around the world, but also website investigations to find information about these hospitals. We reached out to journalists, we reached out to a whole plethora of people to try and help us find out more about the health care providers. And then you know, as well as academic research that you would normally do in this kind of project. But we then complemented that with, you know, going out and actually interviewing people, and that was really, really an important part of this process, to really get an understanding of the human impact of these investments. And so we did that, working with amazing community health workers in India, that helped us to identify patients who had sought care at these hospitals. And, and, you know, we talked to those people, we talked to those community health workers, and other stakeholders involved in those hospitals. So a whole range of approaches, and I’d really encourage people to read the methodology. Now, if you’re interested in pursuing your own research on this.

Host, Maaza 29:51

There’s clearly so much to talk about and a lot for all of us to learn. Thank you very much, Anna, for joining us on our first episode of Sick Development,’ we really appreciate all the work you and your colleagues have done on these important reports. And I’m so grateful to you for joining me to lay the groundwork as we prepare for the rest of our mini-series. Thank you so much, Anna.

Guest, Anna 30:15

Thank you, Maaza.

Host, Maaza 30:16

And thank you so much to you the listeners. We have had such a great introduction to the report and to some of the harms caused by this model. In the next episode, we will be doing a deep dive into the story of one of the people at the heart of this capitalist fairy tale.

In the meantime, we would love it if you took a moment to leave a review and subscribe to the EQUALS podcast, so you won’t miss the next episode of our mini-series.

Thank you to our Sick Development team storyboarding is by Audra Williams, Production by Simon Maina. Victoria Harnett is our Executive Producer. I’m your host Maaza Seyoum, please look out for our next episode.


The host of this podcast, Maaza Seyoum, is the Senior Advisor Alliances & Strategic Partnerships at Oxfam America.
Our guest, Anna Marriot, is the Senior Policy Adviser at Oxfam in Great Britain.

This podcast miniseries is now available in all podcast platforms.